Chapter 36. Operative Management of Aortoiliac Occlusive Disease

• 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).

Absolute

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

Relative

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

Expected Benefits

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

Potential Risks

• 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.

Aortobifemoral Bypass

• 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 ...