1. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74,
Type I : localized to distal abdominal aorta and CIA : Symptoms typically consist of bilateral thigh or buttock claudication and fatigue. Men report diminished penile tumescence and may have complete loss of erectile function. These symptoms in the absence of femoral pulses constitute Leriche’s syndrome.
Type II more widespread intraabdominal disease : This disease pattern affects approximately 25% patients with aortoiliac occlusive disease.
Type III multilevel disease with associated infrainguinal occlusive lesion : affects approximately 65% pattern tend to present with symptoms of advanced ischemia and require revascularization for limb salvage
TASC Trans atlantic intersociety consensus document on management of peripheral arterial disease
Choice based on 1. Affected arterial segment 2. Length of Disease segment 3. Patient characteristic
A, Occlusive disease is limited to the distal aorta and common i;liac arteries. location of typical arteriotomies is indicated by dotted lines. B, The endarterectomy plane is achieved, and atheromatous disease is removed from the level of the proximal aortic clamp to the bifurcation. C, A satisfactory endpoint is attained at the iliac bifurcation, and endarterectomy is carried proximally.Tacking sutures may be necessary to secure an adequate endpoint.
). From a technical standpoint, the atherosclerotic disease should terminate at the iliac bifurcation to obtain satisfactory results and achieve a good endpoint no farther than 1 to 2 cm into the external iliac arteries. Bilateral longitudinal arteriotomies, one extending from the distal aorta into one common iliac artery and the other confined to the common iliac artery, are performed. The proper endarterectomy plane, to the level of the external elastic lamina, should be obtained. Patch closure, either with vein or prosthetic, can be used. Tacking sutures may also be used to secure the distal endpoint.
Aortofemoral graft.A, A segment of diseased aorta isresected, and the distal aortic stumpis oversewn. B, End-to-end proximalanastomosis. C, Completed reconstruction
A retroperitoneal approach may also be used (shoulders and torso rotated 45 degrees to the right, with the hips and extremities maintained as horizontal as possible to facilitate femoral artery exposure). The incision is made obliquely in the left flank, starting at the tip of the twelfth rib toward the midline below the umbilicus. This incision is good for patients with right-sided stomas and previous abdominal surgery, including aortic surgery. The retroperitoneal approach may reduce ileus and postoperative cardiopulmonary stress.
The abdominal aorta is then exposed using a standard infrarenal approach. The transverse colon and greater omentum are retracted cephalad and secured with a wet towel. We prefer to have the entire small bowel eviscerated, covered with a lap pad, and the descending and sigmoid portions of the colon retracted laterally and caudally. Next the parietal peritoneum between the duodenum and the inferior mesenteric vein is incised along the long axis of the aorta. The inferior mesenteric vein may need to be divided for optimal exposure of the proximal aorta. Care is taken to preserve the autonomic nerve fibers on the anterolateral aspect of the aorta down to the left common iliac artery; these are involved in male sexual function. The fourth portion of the duodenum is mobilized, and the dissection is carried to expose the left renal vein as it crosses anterior to the aorta. Distally, the aorta is exposed past the origin of the inferior mesenteric artery. This allows construction of the proximal anastomosis and of the graft limb tunnels.
Bilateral oblique groin incisions are preferred because they are easy to close and provide technical ﬂexibility. The incision is carried partially above the anatomic position of the inguinal ligament to ensure adequate exposure. Lymphatic tissue is divided between clamps to minimize the occurrence of lymphatic leaks. The caudal border of the inguinal ligament is divided to ensure enough space for tunneling of the graft. When performing this, care must be taken to ligate the superfcial circumﬂex vein that courses on top of the distal external iliac artery to avoid injury and bleeding during the creation of the tunnel (Fig. 28-4). The common, superfcial, and profunda femoral arteries should be dissected out and controlled.Sizable branches of the femoral arteries should be controlled with loops and preserved if possible
Creation of the retroperitoneal tunnelto the femoral artery. Care must be taken to place the graft limb underneath the ureter.
Anterior to posterior clamping may be necessary in the presence of a soft anterior but calcifed posterior aortic wall.Appropriate atraumatic vascular clamps are selected, and after sufcient time is allowed for the heparin to circulate, the aorta is clamped frst proximally or distally at the site of least disease to avoid dislodgement and potential distal embolization ofplaque. Te distal clamp is usually placed above or below the inferior mesenteric artery. The proximal clamp is placed justbelow the renal arteries if the disease pattern does not obligate suprarenal clamping, with as little dissection of the renal arteryorigins as possible
Aortogram showing occlusion of the aorta below the level of the renal arteries (a). In this case the proximal anastomosis of an aorto-bifemoral bypass should be end to end (b). If there is continuity with the inferior mesenteric artery or internal iliac arteries, then an end-to-side anastomosis (c) may be preferable
The standard anastomosis is constructed using a 3-0 running polypropylene suture run from both the posterior and the anteriormidline clockwise and counterclockwise, and it is tied in the lateral aspect of the aorta. Thromboendarterectomy of the proximal aortic cuff up to the proximal clamp can be performed in cases of signifcant disease at the site of theintended proximal graft anastomosis. In this event, an interrupted, pledgetedsuture technique is recommended because of the thinness and possible fragility of the remaining adventitia of the endarterectomized aortic wall
Graft limbs are then passed down into the femoral region with the aid of the previously placed Penrose drains and a large DeBakey aortic clamp. Care is taken to avoid twisting the graft limbs. The femoral anastomosis must ensure good ﬂow to the profunda femoris arteries Because of this, the profunda arteries should be evaluated by both preoperative imaging and intraoperatively by passage of 3.5- to 4.0-mm dilators at the time of anastomosis to ensure that no significant stenotic lesion are present. A standard end-to-side anastomosis to the common femoral artery is performed
INCISION AND EXPOSURE Femoral-femoral bypass depends on the ability of one “donor” iliac artery to supply enough blood flow to perfuse both the donor and the “recipient” legs Oblique, groin-crease incisions may be used, but longitudinal groin incisions centered over the femoral arteries and beginning approximately at the inguinal ligament provide the most flexibility and are preferred by most surgeons. Incision length depends on patient habitus.
ANASTOMOSIS Systemic heparin or another suitable anticoagulant is administered, and in most cases a longitudinally oriented or slightly oblique arteriotomy is created in a convenient place for anastomosis. Making the anastomosis on a more distal portion of the femoral system, such as the deep or superficial femoral artery, may be dictated by local anatomy and may reduce the tendency of the graft to kink in the sagittal plane in patients with protuberant abdomens. As with most end-toside anastomoses, arteriotomies are made about three times as long as the graft diameter. The graft ends are spatulated by placing a curved hemostat on the graft and then using a scalpel to cut the ePTFE graft along the inside of the hemostat curve. An end-to-side graft to artery anastomosis is then created using running 5-0 or 6-0 polypropylene or CV-5 or CV-6 polytetrafluoroethylene (PTFE) suture. The donor-side anastomosis is usually performed first, although either side may be completed first and the anastomoses may be performed simultaneously
Triphasic brachial artery Doppler waveform and a blood pressure nomore than 10 mm Hg lower in the proposed donor arm than in the contralateral arm.
A, the donor axillary artery is exposed using a transverse incision inferior to the clavicle and the artery is controlled from the clavicle medially to the pectoralis minor muscle laterally. B,the graft is tunneled posterior to the pectoralis minor muscle and then subcutaneously in the midaxillary line
The graft is generally tunneled in the midaxillary line and lateral abdomen from the donor axillary artery to the ipsilateral femoral recipient artery. C, a femoral-femoral graft is first placed, followed by the anastomosis of the distal axillofemoral graft limb tothe ipsilateral hood of the femoral-femoral graft. D,the distal axillofemoral graft limb is anastomosed to the femoral artery followed by the anastomosis of the ipsilateral side of a femoral-femoral graft to the hood of the axillofemoral graft
SURGICAL BYPASS OPTIONS IN
AORTO-ILIAC OCCLUSIVE DISEASE
F2 PARACH SIRISRIRO
14th Aug 2018
INDICATION FOR SURGICAL BYPASS
SURGICAL BYPASS OPTIONS
• Multilevel atherosclerotic occlusive
disease involving the distal aorta,
iliac vessels, and common
femoral arteries is a common
occurring pathology seen often by
Dalman, Ronald. Operative Techniques in Vascular Surgery (Kindle Locations 8452-8458).
ROLE OF OPEN SURGERY
• Small hypoplastic
• Eccentric, cauliflour
• Multiple failed
Mortality: 1-4% - 5yr Patency >90%
• Indications for surgical reconstruction for symptomatic AIOD
- Disabling claudication
- Ischemic rest
- pain, and tissue loss.
• Claudication is a relative indication for intervention, given the natural
history of the disease.
• In patients of low surgical risk with disabling symptoms from disease
limited to the aortobifemoral segment, surgical bypass is an
CHRONIC LIMB-THREATENING ISCHEMIA
• More signifcant risk of amputation without revascularization
• The presence of ischemic rest pain, frank ulceration, or digital
gangrene are well-accepted indications for surgical correction of
• An aortic or iliac source of distal emboli, typically from an
ulcerated atheromatous plaque or so-called shaggy aorta
operative reconstruction is usually indicated.
The goal of intervention is to prevent recurrent distal
• long-segment arterial disease
such as a long superficial femoral artery occlusion
is probably best treated with open bypass from the
standpoint of durability of the revascularization.
• Direct reconstruction for AIOD :
patients with endovascular treatment has failed
Extensive disease that an endovascular approach is deemed
• A combination of more proximal aneurysmal disease and common or
iliac occlusive disease
• Extensive calcifcation at the aortic bifurcation prone to be at risk for
rupture with balloon angioplasty
• Disease extending to the CFA with unsuitable for an endovascular
• Early recurrence of AIOD after angioplasty or stenting
• Signifcant renal failure which endovascular therapy triggers dialysis
Appropriate for patients with type I disease, aortoiliac endarterectomy is only
infrequently performed today.
- the lack of prosthetic material,
- no infective potential
- continuity of antegrade inflow to the hypogastrics.
- evidence of aneurysmal change
- total occlusion of the aorta to the level of the renal arteries,
and extension of the disease into the external iliac and distal vessels.
• Endarterectomy is now rarely performed for AIOD
• its relative technical difculty,
potential for signifcant blood loss
• poor durability as well as the clear advantages of
bypass grafting in this location.
• disabling or lifestyle-limiting claudication, rest pain, or tissue
loss and TransAtlantic Intersociety Consensus (TASC) D
aortoiliac occlusive disease
• aortobifemoral bypass may be more appropriate than
endovascular revascularization because of improved long-
term patency for TASC C disease.
• associated with significant cardiopulmonary morbidity.
Patients with cardiopulmonary comorbidities prohibitive of
general anesthesia are not candidates for this procedure.
The infrarenal abdominal
aorta Long midline incision
provides the best exposure
and is preferred.
• Incision : A retroperitoneal approach
• Exposure of the Abdominal Aorta
• EXPOSURE OF THE FEMORAL ARTERIES
• EXPOSURE OF THE DISTAL
• Profundaplasty may need to be
performed at the same time as
• To perform this adequately, at
least 2 to 3 cm of the profunda
must be exposed.
• Tunnels are made by gentle blunt
with the index fingers, simultaneously
from the groins and the aortic bifurcation.
• Care must be made to construct the
tunnel underneath the ureters and thus
avoid possible hydronephrosis.
PROXIMAL GRAFT ANASTOMOSIS
• END-TO-END AORTIC ANASTOMOSIS
• The graft is cut 3 to 4 cm from its bifurcation to
construct a prosthesis with a short body or stem.
• This confguration facilitates retroperitoneal
closure over the graft and allows separation of
the anastomosis from the duodenum.
• It also diminishes the takeoff angle of the limb,
which prevents kinking and potential graft limb
• END-TO-SIDE AORTIC
• Totally occluding an aortic
segment with proximal and distal
by aortic clamps
• The anastomosis is placed as
as possible by cutting the graft
with a bevel of approximately 60
degrees (anterior posterior) that
extends close to the aortic
OTHER OPERATIVE CONSIDERATIONS
• External Iliac Anastomosis
an aortobiiliac bypass remains advantageous in
• Patients with hostile groin creases from prior surgery
or radiation therapy
Patients with obese, diabetic patients with an
intertriginous rash at the inguinal crease and patent
external iliac arteries.
AORTOILIAC DISEASE: OPEN
• Extraanatomic procedures were developed as
alternatives to direct aortofemoral bypass for
- at high risk for direct aortic surgery
- presenting with a “hostile” abdomen,
- an infection of the native aortoiliac arterial
- prior prosthetic replacement of the aortoiliac
has been a frequently
procedure in patients with
dominant unilateral iliac
Anastomoses to the
common femoral artery
may extend onto the
deep or superficial
This decision is most
often made after
exposure, inspection, and
palpation of the femoral
(1)excessively high physiologic
risk for direct aortic repair
(2) patients with infected native
aortas or aortic grafts or the
closely related problem of
(3)a hostile abdomen, generally
with multiple previous
surgeries, active intra-
(4)presence of intestinal or
• SELECTION OF A DONOR ARTERY
• The versatility of the axillofemoral bypass depends on
• The ability of one axillosubclavian artery to supply enough
blood flow to adequately perfuse both the donor arm and one
(axillounifemoral bypass) or more often both (axillobifemoral
• Avoid in - presence of intestinal or urinary stomas
- placement of an axillofemoral bypass based on the
side of an existing arteriovenous hemoaccess fistula, since this
might provoke or worsen existing steal symptoms
- maintain perfusion of the
leg after dealing with
arterial infection in the
- requires tunnelling a graft
from the iliac arterial
system through the
obturator fossa in the pelvis
to the infrainguinal arterial
• The primary indication for this procedure is arterial infection
in the femoral triangle
• patient in the supine position with the entire ipsilateral leg
circumferentially prepped and draped
• The incision should be in the anteromedial part of the
obturator membrane to avoid the obturator nerve and artery.
• The graft is usually placed in the potential space between the
adductor magnus posteriorly and the adductor longus and