L’approccio agli aneurismi infiammatori iuxtarenali

Abstract

The incidence of inflammatory abdominal aortic aneurysm (IAAA) in a late review of the literature is estimated about 2-15% overall aortic aneurysms.

In our data this type of aneurysm is 3,6 overall aortic aneurysms treated. In the majority of the cases, IAAA is juxtarenal or infrarenal .

Ethiopathogenesis of IAAA till today is not certain. Recent ipothesis on IAAA attribute the same ethiopathogenesis in both atherosclerotic and inflammatory aneurysm. The interaction of genetic, environmental and infective factors should be able to determine an autoimmune inflammatory reaction of variable severity. 80% of the patients suffering from IAAA present abdominal or lumbar pain, loss of weight and increase of the RC sedimentation velocity. The AAAI’s natural history goes to ru p t u re. Entrapment of nearstending organs totally involved in the fibrotic process is the most frequent complications. Usually these is a compression of the ure t e re and the duodenum with consequenced hydroureteronefrosis and bowel obstruction .

Preoperative diagnosis is possible; CT scan and MRI guarantee and accuracy about 90%. Intraoperatively the external wall of IAAA appears whitish and translucent and always there are tenacious adhesion given by the avventital wound’s inflammation. Confirm is given by the histological examination of the aneurysmatic wall and peravventitial tissues.

Our experience and a late review of the literature concord e that surgical indication for the treatment of IAAA is the same for the atherosclerotic one.

This convinction is supported by the fact that the diagnostic methodical evolution and the improvement in mininva s i ve surgical tecnique lowe red perioperating morbility and mortality. We prefere, according with many authors, retroperitoneal approach to iuxtarenal IAAA, instead of standard i zed tra n speritoneal access with xifo-pubical or tra s versal under costal incision. This approach offers some advantages as eaiser exposition of aorta, whose postero-later wall is hardy ever involved in inflammatory process, little duodenum’s and left renal vein’s manipulation and low incidence of paralytic ileum and respirato  disease.

Endovascolar surgery hasn’t in this moment any role in iuxtarenal IAAA’t reatment because this type of aneurysm has inadequate proximal neck. In the next future, probably, endovascular repair will be possible using a new type of endografts with renal legs. Often surgical treatment is inadequate to control retroperitorenal fibrosis and so surgeon has to use perioperating pharmacolocical therapy.