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INDICATIONS

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Only patients with severe and debilitating occlusive disease of the aortoiliac segment should be considered for surgery. Initial management of aortoiliac occlusive disease is often via endovascular methods. In general, these patients will have claudication that is progressing or disabling. Patients with rest pain, ulceration, or gangrene may require surgery to preserve limb function. These patients are generally elderly and have associated generalized atherosclerosis with a high incidence of coronary artery disease and hypertension. In addition, the majority are long-time smokers, and it is not unusual for them to have impaired pulmonary function. The risks associated with these comorbidities must be carefully weighed against the benefits expected from a successful surgical procedure. The careful selection of patients is of the utmost importance.

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PREOPERATIVE PREPARATION

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See preceding Chapter 135, Resection of Abdominal Aortic Aneurysm.

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ANESTHESIA

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See preceding Chapter 135.

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POSITION

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See preceding Chapter 135.

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OPERATIVE PREPARATION

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See preceding Chapter 135.

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INCISION AND EXPOSURE

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A midline incision is made from the xiphoid to the pubis to afford maximum exposure (figure 1). The abdomen is explored for the presence of other pathology, and the intra-abdominal arterial tree is carefully assessed. Figure 2 demonstrates typical aortoiliac occlusive disease. The aorta is exposed by entering the retroperitoneal space. The posterior peritoneum is divided, and the fourth portion of the duodenum is mobilized until the renal vein is identified. Sharp and blunt dissection is used to clear the aorta on its anterior, lateral, and medial surfaces (figure 3). It is usually not necessary to encircle the aorta or to free it completely; this often leads to troublesome bleeding from lumbar arteries and veins. In addition, if the left renal vein is not visualized, it may lie behind the aorta and be injured by such a dissection.

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DETAILS OF PROCEDURE

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An aortic clamp is used to clamp the aorta proximally just below the renal arteries (figure 4). A second aortic clamp is placed tangentially to occlude the iliac vessels and the lumbar arteries, as depicted in figures 4 and 5. It is important to have the distal aorta freed sufficiently so that this clamp can be placed far posteriorly to avoid interference with the arteriotomy and the anastomosis. A small vascular clamp should be applied to the inferior mesenteric artery, close to its origin, so as not to impair collateral circulation to the left colon. A linear arteriotomy is made in the aorta to a point just above the inferior mesentery artery takeoff (figure 5). An attempt is made to preserve that vessel if at all possible. The graft is beveled (figure 6a), and an end-to-side anastomosis is then created (figures ...

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