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Aiod

Bypass option

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Aiod

  1. 1. SURGICAL BYPASS OPTIONS IN AORTO-ILIAC OCCLUSIVE DISEASE F2 PARACH SIRISRIRO 14th Aug 2018
  2. 2. REFERENCE Textbook
  3. 3. OUTLINE DEFINITION TYPE STANDARD TREATMENT INDICATION FOR SURGICAL BYPASS SURGICAL BYPASS OPTIONS PATENCY
  4. 4. DEFINITION • Multilevel atherosclerotic occlusive disease involving the distal aorta, iliac vessels, and common femoral arteries is a common occurring pathology seen often by vascular surgeons. Dalman, Ronald. Operative Techniques in Vascular Surgery (Kindle Locations 8452-8458).
  5. 5. AIOD TYPE
  6. 6. TASC 2007
  7. 7. TASC 2007
  8. 8. TASC
  9. 9. SURGICAL INTERVENTION
  10. 10. ROLE OF OPEN SURGERY < 1-5% Peri-renal thrombus • Small hypoplastic aorta • Eccentric, cauliflour calcification • Multiple failed interventions Mortality: 1-4% - 5yr Patency >90% Morbidity: 20-25%
  11. 11. CLAUDICATION • 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 appropriate option.
  12. 12. 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 AIOD. • 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 embolization.
  13. 13. SURGICAL TREATMENT • 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 inadvisable
  14. 14. • A combination of more proximal aneurysmal disease and common or external 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 approach. • Early recurrence of AIOD after angioplasty or stenting • Signifcant renal failure which endovascular therapy triggers dialysis dependence SURGICAL TREATMENT
  15. 15. PROCEDURE SELECTION
  16. 16. AORTOILIAC ENDARTERECTOMY
  17. 17. AORTOILIAC ENDARTERECTOMY Appropriate for patients with type I disease, aortoiliac endarterectomy is only infrequently performed today. Advantages include - the lack of prosthetic material, - no infective potential - continuity of antegrade inflow to the hypogastrics. Contraindications include - 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.
  18. 18. AORTOILIAC ENDARTERECTOMY • 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.
  19. 19. AORTOBIFEMORAL BYPASS
  20. 20. AORTOBIFEMORAL BYPASS • Indications • 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. • Contraindications • associated with significant cardiopulmonary morbidity. Patients with cardiopulmonary comorbidities prohibitive of general anesthesia are not candidates for this procedure.
  21. 21. AORTOBIFEMORAL BYPASS • Incision The infrarenal abdominal aorta Long midline incision provides the best exposure and is preferred.
  22. 22. AORTOBIFEMORAL BYPASS • Incision : A retroperitoneal approach
  23. 23. • Exposure of the Abdominal Aorta AORTOBIFEMORAL BYPASS
  24. 24. AORTOBIFEMORAL BYPASS • EXPOSURE OF THE FEMORAL ARTERIES
  25. 25. AORTOBIFEMORAL BYPASS • EXPOSURE OF THE DISTAL PROFUNDA • Profundaplasty may need to be performed at the same time as aorto-bifemoral grafting, • To perform this adequately, at least 2 to 3 cm of the profunda must be exposed.
  26. 26. TUNNEL CONSTRUCTION • Tunnels are made by gentle blunt dissection, 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.
  27. 27. CLAMP PLACEMENT
  28. 28. PROXIMAL GRAFT ANASTOMOSIS
  29. 29. 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 thrombosis.
  30. 30. PROXIMAL GRAFT ANASTOMOSIS • END-TO-SIDE AORTIC ANASTOMOSIS • Totally occluding an aortic segment with proximal and distal by aortic clamps • The anastomosis is placed as cephalad as possible by cutting the graft with a bevel of approximately 60 degrees (anterior posterior) that extends close to the aortic bifurcation.
  31. 31. FEMORAL ANASTOMOSIS
  32. 32. 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.
  33. 33. COMPLICATION
  34. 34. AORTOILIAC DISEASE: OPEN EXTRAANATOMIC BYPASS • Extraanatomic procedures were developed as alternatives to direct aortofemoral bypass for patients - at high risk for direct aortic surgery - presenting with a “hostile” abdomen, - an infection of the native aortoiliac arterial system - prior prosthetic replacement of the aortoiliac system
  35. 35. FEMOROFEMORAL BYPASS Femorofemoral bypass has been a frequently applied procedure in patients with dominant unilateral iliac artery disease
  36. 36. FEMOROFEMORAL BYPASS Anastomoses to the common femoral artery may extend onto the deep or superficial femoral This decision is most often made after exposure, inspection, and palpation of the femoral arteries
  37. 37. AXILLOFEMORAL BYPASS (1)excessively high physiologic risk for direct aortic repair (2) patients with infected native aortas or aortic grafts or the closely related problem of aortoenteric fstulas, (3)a hostile abdomen, generally with multiple previous surgeries, active intra- abdominal infection, (4)presence of intestinal or urinary stomas.
  38. 38. AXILLOFEMORAL BYPASS • 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 bypass) legs. • 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
  39. 39. AXILLOFEMORAL BYPASS
  40. 40. AXILLOFEMORAL BYPASS
  41. 41. OBTURATOR BYPASS - maintain perfusion of the leg after dealing with arterial infection in the groin. - requires tunnelling a graft from the iliac arterial system through the obturator fossa in the pelvis to the infrainguinal arterial system
  42. 42. OBTURATOR BYPASS • 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 brevis anteriorly,
  43. 43. PATENCY
  44. 44. PATENCY
  45. 45. THANK YOU

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