Transperitoneal versus Retroperitoneal Suprarenal Cross-Clamping for Repair of Abdominal Aortic Aneurysm with a Hostile Infrarenal Aortic Neck

Article Outline

• Abstract
• Introduction
• Materials and Methods
  • Selection of Patients
  • Surgery
  • Outcome Assessment
  • Statistical Analysis
• Results
  • Long-Term Follow-Up
• Discussion
• References
• Copyright

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60°), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.

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Introduction 

In recent years, endovascular aneurysm repair (EVAR) of the abdominal aorta has emerged as a viable, minimally invasive alternative to open surgery repair. More than 62,000 patients have now been treated with EVAR worldwide.¹ Stent-graft systems were approved in the United States for general clinical use by the Food and Drug Administration (FDA) in 1999. The proximal aortic fixation is arguably the most critical portion of endograft placement. A favorable infrarenal aortic neck increases the likelihood of proximal fixation and seal, which prevents the risk of type I endoleak, increased perigraft flow, and aneurysm rupture.² The suitability for EVAR has ranged 45-66% in different studies.³, ⁴, ⁵ Predictably, increased utility of EVAR is likely to result in more infrarenal abdominal aortic aneurysms (AAAs) harboring complex aortic necks requiring open repair with suprarenal aortic cross-clamping.

Previous randomized studies have reached different conclusions about the potential advantages of the retroperitoneal over the transperitoneal approach for infrarenal AAAs.⁶, ⁷, ⁸ Among the distinct advantages of the retroperitoneal approach are reduced postoperative pulmonary complications, ileus, and fluid requirements. The objective of this study was to compare the results of the transperitoneal and the retroperitoneal approaches for repair of infrarenal AAA with a hostile aortic neck requiring suprarenal cross-clamping as well as the relative frequency of such techniques after incorporating EVAR into our clinical practice.

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Materials and Methods 

Selection of Patients 

From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired at our institution (Fig. 1). There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal approach) and 318 (67%) endovascular repairs. There were 61 patients (38%) with a hostile infrarenal aortic neck that underwent open repair. In 38 cases (24% of the open repairs) suprarenal cross-clamping was performed for a hostile infrarenal neck. This cohort of infrarenal AAAs, including 18 patients (47%) with a transperitoneal approach and 20 patients (53%) with a retroperitoneal approach, formed the study group. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency (Table I). The median aneurysm size was 6.0 cm. Under institutional review board approval, demographics, risk factors, operative reports, and postoperative outcomes were retrospectively analyzed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. For the purpose of evaluating possible trends in type of procedure (open vs. EVAR) and approach (retroperitoneal vs. transperitoneal), the results were separately analyzed for the years 1998-2001 and 2002-2005.

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• Fig. 1 

  Elective infrarenal aortic aneurysms repaired at our institution, January 1998 through September 2005.

Table I. Patient demographics

All patients were routinely evaluated with computed tomography angiography (CTA) of the abdomen and, in some instances, aortography (n = 18). A hostile aortic neck was defined as severe angulation (>60°), short neck (<15 mm), extensive calcification, or circumferential thrombus. A hostile neck anatomy usually precluded EVAR, and an open repair was considered (Fig. 2, Fig. 3). A short aortic neck was the most common morphological feature precluding an endovascular procedure (Table II). In patients considered to be physiologically unfit for open repair, EVAR was a treatment option in spite of hostile neck anatomy. The choice of transperitoneal or retroperitoneal incision in the study cohort with unfavorable aortic necks was at the surgeon's discretion. The cases were performed by seven different surgeons during the study period. Patients with suprarenal AAAs, thoracoabdominal aortic aneurysms, or ruptured aneurysms were excluded from the study.

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• Fig. 2 

  Infrarenal aortic aneurysm with short and angulated neck.

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• Fig. 3 

  Infrarenal aortic aneurysm with circumferential thrombus in the proximal neck just below the renal arteries.

Table II. Assessment of aortic neck morphology

Surgery 

The transperitoneal and retroperitoneal incisions were performed in a standard fashion. Briefly, the transperitoneal approach was performed through a vertical midline incision. The parietal peritoneum was divided up to the ligament of Treitz and the duodenum mobilized and retracted laterally. The retroperitoneum overlying the neck of the aneurysm was divided and the left renal vein gently retracted superiorly. The retroperitoneal exposure of the aorta was achieved through an oblique incision made from the tip of the eleventh or twelfth rib to the lateral rectus border at the paraumbilical level. The patient was placed in a semilateral position but with the hips allowed to rotate back to the supine position. The oblique muscles and the transverse abdominal muscles were divided laterally, and the peritoneum was mobilized to the right and the left kidney reflected anteriorly. The lumbar branch of the left renal vein was divided to facilitate anterior mobilization of the kidney and the renal vein.

Systemic heparin (100 units/kg) was given intravenously before suprarenal cross-clamping. Also, mannitol was given in seven patients and low-dose dopamine in one patient before aortic cross-clamping. Adjuncts protecting for renal ischemia, such as cold perfusion, were not used. A straight or bifurcated Dacron/polytetrafluoroethylene (PTFE) graft was anastomosed to the infrarenal aorta using the endoaneurysmorrhaphy technique. Systemic heparinization was reversed with protamine sulfate as needed. Incisions were closed in a standard fashion, and postoperative care was initially delivered in the intensive care unit. Pain was controlled with intravenous narcotics or an indwelling epidural catheter. Patients were followed up in the vascular clinic for 14 and 30 days postoperatively.

Outcome Assessment 

The primary outcome measurements analyzed included both intraoperative data and postoperative complications. The intraoperative details reviewed were type of incision and repair, suprarenal cross-clamp time, estimated blood loss, and reoperation. The postoperative complications analyzed were wound hematoma, wound infection, pneumonia, urinary tract infection, myocardial infarction, renal insufficiency, dialysis, deep venous thrombosis, and incisional hernia and pain. Renal insufficiency was defined as a postoperative creatinine level greater than 2.0 mg/dL or a 50% increase above an increased baseline value. Myocardial infarction was defined as an elevation of cardiac enzymes and electrocardiogram changes. Pneumonia was determined radiographically, urinary tract infection required a positive urinary culture, and deep venous thrombosis was diagnosed with duplex ultrasonography. Wound complications were determined by physical examination in both groups. Length of stay and 30-day mortality were also determined. The Social Security Death Index was used for long-term mortality.

Statistical Analysis 

Data are presented as median and range unless otherwise noted. Median was used because of the rather small study population and the noneven distribution of some outcome variables. Statistical comparison between groups was performed by the Student t-test and the Fisher exact test. Survival after surgery was calculated using Kaplan-Meier analysis. Interactions between statistically significant variables were checked. Statistical significance was considered for p < 0.05. STATISTICA (data analysis software system), version 6.1 (StatSoft, Tulsa, OK), was used for statistical calculations.

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Results 

The total number of infrarenal aortic aneurysm repairs increased after 2002 from 212 to 266 (p = 0.002). After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% (n = 16) to 39% (n = 30), while the transperitoneal approach decreased from 81% (n = 68) to 61% (n = 46) during the two time periods (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002 (18/84 to 20/76). Suprarenal cross-clamping was also more common with the retroperitoneal (43%) than the transperitoneal (16%) approach. In the study cohort requiring suprarenal cross-clamping, there were 20 repairs performed with a retroperitoneal incision and 18 repairs with a transperitoneal incision. There was no significant difference in age, sex, aneurysm size, or comorbidities between the transperitoneal and retroperitoneal groups with suprarenal cross-clamping.

Three surgeons performed the majority of cases (28/38). The choice of approach was distributed among these surgeons as follows: surgeon A, 50% retroperitoneal; surgeon B, 46% retroperitoneal; and surgeon C, 67% retroperitoneal. The aortic clamp was placed above both renal arteries in 26 patients, above the left renal artery but below the right in six patients, and above the right renal artery but below the left in one patient. In two patients the clamp was placed above the superior mesenteric artery and in three patients at the supraceliac level. When supravisceral clamping was used, the transperitoneal approach was carried out in two patients and the retroperitoneal approach in three patients.

The intraoperative results and postoperative outcomes are outlined in Table III, Table IV. Blood loss was significantly greater and suprarenal cross-clamp time longer in the transperitoneal group (p = 0.03). There was a higher frequency of bifurcated grafts in the transperitoneal group (61% vs. 45%, nonsignificant). The left renal vein was divided in seven patients in the transperitoneal group (39%).

Table III. Intraoperative data

Table IV. Mortality and postoperative complications

There were no significant differences in postoperative outcomes (Table IV). Of note is that there were two patients in the retroperitoneal group who required postoperative dialysis. Both of those patients had preoperative renal insuffiency and suprarenal cross-clamping time of 47-50 min. Also, three patients required reoperation because of bleeding (n = 2) and thrombectomy of the lower extremity (n = 1). There was no difference in length of stay between the groups. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group (p = 0.13). One patient had an infrarenal aortic wall rupture when clamping together with a splenic laceration. Coagulopathy, acidosis, and cardiac dysrhythmias did later develop. The other patient needed thrombectomy of the lower extremity and developed acute renal failure and adult respiratory distress syndrome.

Long-Term Follow-Up 

Postoperative incisional pain was reported by one patient in each group, and one patient in the transperitoneal group was found to have an incisional hernia. Life-table analysis did not show any significant difference in long-term survival between the two approaches (Table V) (p = 0.23). The standard error exceeded 10% already at 1-year follow-up, indicating lack of reliability of the estimates. The mean follow-up time was 24 months (range 6-60). There were 17 (85%) deaths in the retroperitoneal group and 14 (78%) deaths in the transperitoneal group after 5 years.

Table V. Kaplan-Meier survival curve for transperitoneal and retroperitoneal approaches (p = 0.23)

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Discussion 

EVAR is now regarded as a reliable alternative to open abdominal aneurysm surgery. Randomized studies in patients anatomically suitable for EVAR and fit for open repair have shown that EVAR offers a short-term benefit over open repair.⁹, ¹⁰ However, EVAR seems to offer no advantage compared to open repair with respect to all-cause mortality after 4 years, but it does result in a better aneurysm-related survival.

The reported overall incidence of endograft use in patients undergoing AAA repair varies from 40% to 66%.³, ⁴, ⁵ In our series, the suitability for EVAR was 67% over the entire study period. The most common reason for exclusion from EVAR is unfavorable neck anatomy.⁴ We found a steady and significant increase in EVAR since 1998. This has been accompanied by greater utilization of the retroperitoneal approach for suprarenal aortic cross-clamping in patients undergoing open surgical repair.

A recent report indicates that open repair of abdominal aneurysm is a more technically challenging procedure today than prior to the advent of endovascular stent grafts.⁴ The complexity of aortic repairs has encompassed a greater frequency of suprarenal cross-clamping, renal vein division, and management of associated iliac aneurysmal and occlusive disease. However, another study did not support the hypothesis that open aortic operations for both aneurysmal and occlusive disease have become more technically difficult as the number of EVAR procedures has increased.⁵

Suprarenal cross-clamping in aortic aneurysm surgery has been associated with a significantly increased incidence of postoperative complications and a relative increase in mortality compared to infrarenal cross-clamping.¹¹, ¹², ¹³ At our institution the frequency of suprarenal cross-clamping has increased over time. Shaw et al.¹⁴ reported that of patients with an unfavorable aortic neck, 25% (12 of 45) required suprarenal clamping. The type of incision for this cohort was not reported, but the duration of proximal suprarenal aortic clamping ranged 24-29 min. When confronted with a difficult periaortic dissection, suprarenal cross-clamping should be considered.¹¹ The retroperitoneal approach has generally been preferred for suprarenal aortic cross-clamping due to the superior access and exposure of the entire suprarenal aorta. More recent studies have shown that suprarenal aortic clamping is safe, facilitates repair, and does not significantly increase mortality.¹⁵, ¹⁶

Over the past 25 years, increasing enthusiasm has developed for the retroperitoneal approach, particularly for more complex aortic lesions.¹⁷, ¹⁸ Relative indications for retroperitoneal exposure include previous multiple abdominal surgeries, horseshoe kidney, or inflammatory aneurysm.¹⁹ The relative indications for transperitoneal exposure include access to a right iliac artery aneurysm or to both renal arteries, left-sided vena cava, coexistent intra-abdominal pathology, or a ruptured AAA. The choice of transperitoneal or retroperitoneal incision in this study cohort was at the surgeon's discretion. We cannot comment in this retrospective review on which exact parameters each individual surgeon used as a basis for the choice of incision. Among the three surgeons performing more than five procedures each, the choice of approach was pretty evenly distributed.

There have been three randomized studies for infrarenal AAA repair that have reached different conclusions about the potential advantages of retroperitoneal over transperitoneal incisions.⁶, ⁷, ⁸ Cambria et al.⁶ found no difference in the incisions in terms of aortic cross-clamp times, transfusion requirements, or degree of hypothermia. The incidence of respiratory complications was identical in both groups. Other aspects of postoperative recovery, including recovery of gastrointestinal function, the requirement for narcotics, metabolic parameters of operative stress, the incidence of major and minor complications, and the duration of hospital stay, were similar for both approaches. Sicard et al.⁷ showed that the retroperitoneal approach for abdominal aortic surgery was associated with fewer postoperative complications, shorter stays in the hospital and intensive care unit, and lower cost. In long-term follow-up, the retroperitoneal incision group reported more incisional pain, but no difference was found in incisional hernias or bulges. In another randomized study, Sieunarine et al.⁸ found no significant difference between the two approaches regarding operating time, cross-clamp time, blood loss, analgesia requirements, gastrointestinal function, mortality, and length of stay. In the long-term follow-up, there were significantly more wound problems, including bulging, hernias, and wound pain, in the retroperitoneal group. Long-term mortality was similar in both groups.

A retrospective review including patients with aneurysmal and occlusive disease reported decreased intensive care unit time, postoperative ileus, volume of intraoperative crystalloid, and total length of stay in the retroperitoneal incision group compared to the transperitoneal group.²⁰ In the era of EVAR, a more recent study showed that a modified retroperitoneal approach, predominantly used for patients with difficult anatomy and medical comorbidities, had operative mortality and complications comparable to the transperitoneal approach.¹⁴

The two patients who needed dialysis in our study had preoperative renal insuffiency and prolonged perioperative suprarenal aortic cross-clamping. It seems that if suprarenal clamp duration is brief, patients with normal preoperative creatinine levels exhibit no increase or a marginal increase in creatinine levels after aortic surgery.²¹ Suprarenal aortic clamping less than 50 min appears safe and well tolerated in this group of patients. There was no difference in incisional pain or the incidence of hernia between the approaches. We find it important with the retroperitoneal incision to place it in line with the ribs to avoid injury to the intercostal nerves, avoid long extension into the intercostal space, and ensure careful suture closure of the incision.

The survival after 5 years was only 15% for the retroperitoneal group and 22% for the transperitoneal group (nonsignificant). This survival proportion is low compared to previous series of elective infrarenal AAA. Five-year survival after successful AAA repair in modern series is approximately 70% compared with approximately 80% in the age-matched and gender-matched general population.²² We did not find a good explanation for the low survival other than a possibly sicker patient cohort compared to the general infrarenal aortic aneurysm population.

Endovascular repair with a hostile aortic neck is already being challenged. In recent years, selected patients with aortic necks less than 15 mm have been treated in our practice with endografts with suprarenal fixation. Fenestrated endografts may extend the treatment options for infrarenal AAAs with aortic necks unsuitable for standard endovascular repair. Early data show a trend toward higher mortality of selected patients with fenestrated endografts than for standard stent graft repair, but the mortality rate is comparable to open repair.²³ Clinical evaluation of the outcomes and durability of this technology certainly needs to be further monitored before being accepted as part of routine practice.

The major limitations of the current study are the retrospective nature and the rather limited number of patients undergoing suprarenal cross-clamping. However, we find the surgical approach important to discuss for this cohort of patients, considering the few previous studies and the increasing numbers of EVARs. The study is nonrandomized, which implies that unrecognized factors that might modify outcome have been unequally distributed between the two approaches. Certainly, a multicenter randomized clinical trial might better determine the best approach for these patients.

In conclusion, our cohort with a hostile infrarenal aortic neck unsuitable for EVAR and requiring suprarenal cross-clamping seems to benefit more from a retroperitoneal than a transperitoneal approach. Advantages of the retroperitoneal approach include less perioperative blood loss and shorter suprarenal cross-clamp time, which may explain the trend toward better 30-day survival compared to the transperitoneal approach.

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References 

1. Rutherford RB, Krupski WC. Current status of open versus endovascular stent-graft repair of abdominal aortic aneurysm. J Vasc Surg. 2004;39:1129–1139
   • View In Article
   • Full Text
   • Full-Text PDF (185 KB)
   • CrossRef
2. Dillavou ED, Muluk SC, Rhee RY, et al. Does hostile neck anatomy preclude successful endovascular aortic aneurysm repair?. J Vasc Surg. 2003;38:657–663
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (267 KB)
   • CrossRef
3. Carpenter JP, Baum RA, Barker CF, et al. Impact of exclusion criteria on patient selection for endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2001;34:1050–1054
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (67 KB)
   • CrossRef
4. Costin JA, Watson DR, Duff SB, Edmonson-Holt A, Shaffer L, Blossom GB. Evaluation of the complexity of open abdominal aneurysm repair in the era of endovascular stent grafting. J Vasc Surg. 2006;43:915–920
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (90 KB)
   • CrossRef
5. Patel AP, Langan EM, Taylor SM, et al. Has the emergence of endovascular treatment for aneurysmal and occlusive aortic disease increased the complexity and difficulty of open aortic operations?. Ann Vasc Surg. 2004;18:212–217
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (547 KB)
   • CrossRef
6. Cambria RP, Brewster DC, Abbott WM, et al. Transperitoneal versus retroperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg. 1990;11:314–324
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (1546 KB)
   • CrossRef
7. Sicard GA, Reilly JM, Rubin BG, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg. 1995;21:174–181
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (1079 KB)
   • CrossRef
8. Sieunarine K, Lawrence-Brown MM, Goodman MA. Comparison of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early and late results. Cardiovasc Surg. 1997;5:71–76
   • View In Article
   • MEDLINE
   • CrossRef
9. EVAR Trial Participants . Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet. 2005;365:2179–2186
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (109 KB)
   • CrossRef
10. Prinssen M, Verhoeven EL, Buth J, et al. Dutch Randomized Endovascular Aneurysm Management (DREAM)Trial Group A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004;351:1607–1618
    • View In Article
    • CrossRef
11. Breckwoldt WL, Mackey WC, Belkin M, O'Donnell TF. The effect of suprarenal cross-clamping on abdominal aortic aneurysm repair. Arch Surg. 1992;127:520–524
    • View In Article
    • MEDLINE
12. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part II. Variables predicting morbidity and mortality. J Vasc Surg. 1989;9:437–447
    • View In Article
    • Abstract
    • Full Text
    • CrossRef
13. Ayari R, Paraskevas N, Rosset E, Ede B, Branchereau A. Juxtarenal aneurysm. Comparative study with infrarenal abdominal aortic aneurysm and proposition of a new classification. Eur J Vasc Endovasc Surg. 2001;22:169–174
    • View In Article
    • Abstract
    • Full-Text PDF (145 KB)
    • CrossRef
14. Shaw PM, Veith FJ, Lipsitz EC, et al. Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms. J Vasc Surg. 2003;38:504–510
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (240 KB)
    • CrossRef
15. El-Sabrout RA, Reul GJ. Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms. Tex. Heart Inst J. 2001;28:254–264
    • View In Article
16. Giulini SM, Bonardelli S, Portolani N, et al. Suprarenal aortic cross-clamping in elective abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg. 2000;20:286–289
    • View In Article
    • Abstract
    • Full-Text PDF (83 KB)
    • CrossRef
17. Ricotta JJ, Williams GM. Endarterectomy of the upper abdominal aorta and visceral arteries through an extraperitoneal approach. Ann Surg. 1980;192:633–638
    • View In Article
    • MEDLINE
    • CrossRef
18. Shepard AD, Tollefson DF, Reddy DJ, et al. Left flank retroperitoneal exposure: a technical aid to complex aortic reconstruction. J Vasc Surg. 1991;14:283–291
    • View In Article
    • Abstract
    • Full Text
    • Full-Text PDF (876 KB)
    • CrossRef
19. Rutherford RB. Abdominal aortic and iliac aneurysms. In:  Schermerhorn ML,  Cronenwett JL editor. Vascular Surgery. 6th ed.. Philadelphia: Elsevier Saunders; 2005;p. 1408–1452
    • View In Article
20. Arko FR, Bohannon WT, Mettauer M, et al. Retroperitoneal approach for aortic surgery: is it worth it?. Cardiovasc Surg. 2001;9:20–26
    • View In Article
    • MEDLINE
    • CrossRef
21. Wahlberg E, Dimuzio PJ, Stoney RJ. Aortic clamping during elective operations for infrarenal disease: the influence of clamping time on renal function. J Vasc Surg. 2002;36:13–18
    • View In Article
    • Abstract
    • Full-Text PDF (182 KB)
    • CrossRef
22. Norman PE, Semmens JB, Lawrence-Brown MM. Long-term relative survival following surgery for abdominal aortic aneurysm: a review. Cardiovasc Surg. 2001;9:219–224
    • View In Article
    • MEDLINE
    • CrossRef
23. Semmens JB, Lawrence-Brown MM, Hartley DE, Allen YB, Green R, Nadkarni S. Outcomes of fenestrated endografts in the treatment of abdominal aortic aneurysm in Western Australia (1997-2004). J Endovasc Ther. 2006;13:320–329
    • View In Article
    • MEDLINE
    • CrossRef