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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, most 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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OPERATIVE PREPARATION
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The abdominal, inguinal, and upper thigh hair is removed by clippers. The skin is prepped and draped according to the surgeon's specifications. Then a time-out is performed.
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INCISION AND EXPOSURE
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A linear incision is made in each groin over the femoral artery (FIGURE 1), and the common femoral, profunda femoris, and superficial femoral arteries are carefully isolated. The groin incisions are performed first to minimize heat loss from an open abdomen. It is important to dissect at least several centimeters of the profunda femoris to evaluate the presence of disease in this vessel, especially if indicated on preoperative imaging. If it is significantly involved, profunda endarterectomy or a profundoplasty should be considered because this procedure appears to increase the longevity of graft function, especially if it is the main runoff vessel. 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.
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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. A retroperitoneal tunnel is then made overlying the iliac artery and extending into the femoral incision (FIGURE 4) by blunt finger dissection from above as well as from below, under the inguinal ...