- 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).
- Chronic ischemia: none.
- Acute ischemia: nonsurvivable acidosis.
- Cardiopulmonary comorbidities.
- Prior abdominal surgery.
- If significant comorbidities exist, extra-anatomic bypass (axillary-femoral bypass) is preferred.
- Restoration of adequate blood flow to the pelvis and lower extremities to prevent tissue loss and improve claudication symptoms.
- 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).
- 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.
- 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.
- 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.
- 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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