Plate 157

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.

See Plate 153.

See Plate 153.

See Plate 153.

See Plate 153.

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).

An aortic clamp is then used to clamp the aorta proximally just below the renal arteries (Figure 4). A second aortic clamp is placed horizontally to occlude the iliac vessels and the lumbar arteries, as depicted in Figures 4 and 5. A small vascular clamp should be applied to the inferior mesenteric artery. It is important to have the distal aorta freed sufficiently that this clamp can be placed far posteriorly to avoid interference with the arteriotomy and the anastomosis. A linear arteriotomy is made in the aorta to a point just above the inferior mesentery artery takeoff (Figure 5). An attempt is made to preserve that vessel if at all possible. The graft is beveled (Figure 6A), and an end-to-side anastomosis is then created (Figures 6B, 7, 8, and 9) with a running 000 vascular suture, beginning at the inferior margin of the arteriotomy with a mattress suture, much as described in Plate 153. The running suture then is carried up each side of the arteriotomy, and finally the anastomosis is completed in the middle of the arteriotomy on the operator's side.

Many vascular surgeons prefer a direct end-of-aorta to end-of-graft anastomosis. In this technique, the aorta is dissected free circumferentially at the same level below the renal arteries and between lumbar vessels. Care must be taken to identify the caval and lumbar vessels during this dissection. A pair of vascular clamps are applied and the aorta is transected, leaving an adequate cuff for anastomosis proximally while oversewing the distal cuff with a 000 vascular suture.

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