Merits of and Technical Tips for Supra-Mesenteric Aortic Cross Clamping

Abstract

Supra-celiac aortic cross clamping is often utilized during aortic reconstruction for aneurysmal/occlusive disease involving the pararenal aorta. However, this may be accompanied a myriad of complications related to hemodynamic disturbances, cardiopulmonary compromise and hepatic ischemia. Supra-mesenteric aortic cross clamping may be an excellent option in selected patients with suitable anatomy to minimize or avoid these complications. Herein, the merits of and technical tips for supra-mesenteric aortic cross clamping are discussed.

Keywords: Aorta; Arterial bypass; Celiac artery; Clamping; Superior mesenteric artery.

Fig. 1

(A) The superior mesenteric artery (SMA), right renal artery (RRA) left renal artery (LRA) are encircled with vessel loops and left renal vein (LRV) with a yellow plasma tubing. An aortic clamp is positioned on supra-mesenteric aorta. (B) In the same patient, the LRV is retracted with a renal retractor blade and aortic cross clamp applied on the supra-mesenteric aorta providing uninhibited access to the pararenal aorta.

Fig. 2

The left crus of the diaphragm is held between a pair of forces before it is divided with electrocautery, while the aorta is pushed to the right using a sucker tip to avoid any thermal injury to the aorta. SMA, superior mesenteric artery; LRV, left renal vein.

Fig. 3

(A, B) Both the superior mesenteric artery (SMA) and celiac axis are isolated and dissected free. Red loops encircle the bilateral renal arteries. (C) Surgical graft is in place.

Fig. 4

(A) The paravisceral aorta and superior mesenteric artery (SMA) are exposed by a transperitoneal retropancreatic approach. (B) Pararenal aortic endarterectomy is performed via a longitudinal aortotomy which is closed primarily (arrow). The aortic clamp was moved down to the infrarenal aorta, the aorta transected and a prosthetic graft sewn in end-to-end.