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  • Significant chronic lower extremity ischemia.
    • Lifestyle-limiting claudication, tissue loss, and rest pain.
    • Risk factor modification partially helpful.
  • Acute lower extremity ischemia.
    • Thrombosed aortoiliac system.
  • Infected aortic graft (prior abdominal aortic graft for aneurysmal or occlusive disease).
  • Abdominal aortic aneurysm with iliac disease (occlusive or aneurysmal).

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Absolute

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  • Chronic ischemia: none.
  • Acute ischemia: nonsurvivable acidosis.

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Relative

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  • Cardiopulmonary comorbidities.
  • Prior abdominal surgery.
  • If significant comorbidities exist, extra-anatomic bypass (axillary-femoral bypass) is preferred.

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Expected Benefits

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  • Restoration of adequate blood flow to the pelvis and lower extremities to prevent tissue loss and improve claudication symptoms.

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Potential Risks

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  • Cardiac compromise is common, as more than one third of patients have significant coronary artery disease.
  • Respiratory compromise can occur with abdominal approaches.
  • Renal dysfunction can occur due to perioperative hemodynamic variation, preoperative intravenous contrast dye administration, and suprarenal aortic cross-clamping.
  • Although rare, significant morbidity can occur with graft infections, which can appear late (months to years postoperatively).

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  • An Omni rectractor is preferred.
  • Polytetrafluoroethylene (PTFE) or Dacron bifurcated aortic grafts for aortobifemoral bypass or a ringed PTFE graft for axillary (bi)femoral bypass.
  • Vascular clamps and instruments.
  • Tunneling device if axillary-femoral bypass is to be performed.
  • Doppler ultrasonography is useful to document lower extremity pulses before and after bypass.

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  • Thorough preoperative workup is essential before recommending aortic surgery.
    • Claudication or rest pain symptoms need to be distinguished from other causes of lower extremity pain.
    • Likewise, tissue loss must be attributable to ischemia, at least in part.
  • Screening for peripheral occlusive disease should include ankle-brachial indices (ABIs).
    • Diabetic patients may have calcified vessels, resulting in inaccurate ABIs.
  • The gold standard for diagnosis is aortography with evaluation of runoff vessels in the lower extremities.
  • CT angiography of the aorta and lower extremity arteries is now frequently used to evaluate aortic and iliac occlusive and aneurysmal disease.
  • MR angiography is preferred in patients with renal dysfunction but can overestimate occlusive disease.
  • Patient selection is based on preoperative cardiopulmonary testing.
    • Significant cardiac disease can be present in up to 50% of patients.
    • Appropriate cardiac testing, including stress testing, echocardiography, and cardiac catheterization, should be considered in appropriate patients.

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  • The patient should be supine and prepared from mid chest to the feet.
    • The abdomen is entered through a midline incision.
    • Groin incisions can be transverse but more often are longitudinal.

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Aortobifemoral Bypass

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  • Figure 36–1: Exposure of the retroperitoneum and aorta.
    • After a midline laparotomy, the small bowel is retracted to the patient's right side and the transverse colon is lifted superiorly, exposing the ligament of Treitz.
    • The ligament of Treitz is taken down sharply and the duodenum retracted to the right.
    • The retroperitoneum is opened over the aorta, taking care to avoid injuring the duodenum and preserving enough retroperitoneum for later closure.
  • Figure 36–2: Control ...

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