Only patients with severe and debilitating occlusive disease of the aortoiliac segment should be considered for surgery. In general, these patients will have claudication that is progressing or disabling. Patients with rest pain, ulceration, or gangrene who fall in the limb salvage group may require surgery to preserve limb function. These patients are generally elderly and have associated generalized arteriosclerosis with a high incidence of coronary disease and hypertension. In addition, the majority are long-time smokers, and it is not unusual for limitation of pulmonary function to be present. The risks associated with these factors must be carefully weighed against the benefits expected from a successful surgical procedure. The careful selection of patients is of the utmost importance.
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 freed by entering the retroperitoneal space. The posterior peritoneum is divided, and the duodenum is mobilized until the renal vein is identified. Sharp and blunt dissection then 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. Additionally, if the left renal vein is not visualized, it may lie beneath the aorta and be injured by such a dissection. Heparin is injected intra-arterially to protect the distal extremities from thrombosis, as outlined for resection of abdominal aortic aneurysm (Plate 154).