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Aorto-Iliac Disease

Khalil Qato PGY-2

Integrated Vascular Surgery Residency
Lenox Hill Hospital
Aorto-iliac disease
• Atherosclerotic plaque in
infrarenal aorta and iliac
• Induce symptoms by:
– Obstructing blood flow
– Embolizing atherosclerotic or
thrombotic debris to more
distal vessels
• Typically begins at aortic bifurcation and
common iliac artery origins and progresses
proximally and distally over time
• May extend to level of renal arteries
– 1/3 of pts with aortic occlusion develop renal
artery thrombosis during a period of 5-10 yrs
• Isolated AI disease
– Younger
– Higher incidence of smoking and HLD
– Male = Female
• Multilevel disease
– Older
– Male > Female
– Have concomitant CVD, CAD and Visceral
Presenting Symptoms
• Range of symptoms from mild claudication to severe forms
of CLI
• Isolated Aorto Iliac disease
– Intermittent claudication of calf muscles alone or involvement
of thigh, hip or buttock
– 30% of male pts have difficulty achieving and maintaining
erection due to inadequate perfusion to internal pudendal
• Leriche Syndrome:
– Thigh, hip, buttock claudication
– Atrophy of leg muscles
– Impotence
– Reduced femoral pulses
Noninvasive hemodynamic
• Segmental systolic blood pressure
• Pulse volume recordings
• Difference of at least 20mm Hg between
brachial pressure and proximal thigh pressure
reflects significant stenosis in aorta or iliac a.
• Reduction in pressure between thigh and
ankle consistent with comcomitant SFA,
popliteal, or tibial outflow disease
• Duplex
– Inferior to other imagine techniques
• CT-A
• Angiography: “Gold Standard”
– When lesion in aorta amenable to percutaneous
therapy identified by imagine, Angio performed
Indications For Treatment
• Disabling claudication, Ischemic Rest Pain,
Tissue Loss
• Claudication:
– Only 20-30% require operation within 5 years
– 1 yr mortality: 5%
– 1 yr rate of limb loss: 1%
Classification – Transatlantic Inter-
society consensus (TASC)
• Lesions in aorto-iliac axis were categorized
according to location, extension and

• Also included implications for treatment

• A-D
TASC II (2007)
Therapeutic Options
• Open
– Direct Revascularization
• Aortic endarterectomy
• Anatomic Bypasses
– Aorto-biiliac
– Aorto-bifemoral
– Extra-anatomic bypasses
• Axillo femoral
• Fem-fem
• Endovascular
– Stenting
Aorto-Iliac Endarterectomy
Patient Selection
• Infection
• Young patients or small vessels
• Pts with Erectile Dysfunction due to proximal
hypogastric occlusive disease
– Higher rates of restored sexual function
• Most feasible in focal stenotic lesions in large-caliber,
high-flow vessels
• Fallen out of favor due to technical difficulty, significant
blood loss, poor durability, advancement of
endovascular therapy
Atherosclerotic disease limited to
distal aorta and bifurcation Completion Angiogram
Endarterectomy Technique
• Direct debulking technique that takes advantage of
pathologic localization of atherosclerosis to
• Longitudinal arteriotomy
– Allows direct visualization of both endpoints as well as
endarterectomized surface
• 3 cleavage planes in operative setting:
– Subintimal
– Transmedial
– Subadventitial
• Subintimal predisposes to subsequent thrombosis
• Transmedial/Subadventital preferred
Endarterectomy Technique
• Residual outer layer generally of sufficient
mechanical strength to hold surgical sutures
and to resist disruption or enlargement

• May need to reconstruct wall with a patch or

interposition graft
– Usually if plaque is extensively calcified
Aortobifemoral Bypass
• Pre-op: Adequate IV Access, A-line, Foley, Pre-
op Antibiotics, General endotracheal
• Intra-op: Normothermia should be
maintained throughout procedure to reduce
significant organ dysfunction and operative
• Femoral vessels exposed first to reduce time during
which abdomen is open and viscera are exposed:
– Bilateral longitudinal, oblique incisions
• Extent of exposure dictated by severity of disease and
level of reconstruction
• Distal extent:
– Circumferential control of proximal SFA and Profunda
• Proximal Extent:
– Inferior epigastric and circumflex iliac branches mark
transition from Ext Iliac to CFA
– Circumflex femoral arterial branch frequently arises from
posterior aspect of distal CFA
• Blunt digital dissection posterior to the
inguinal ligament
– Inguinal ligament can be partially divided
posteriorly to prevent graft limb thrombosis
• Tunnels should track directly along the
anterior aspect of the external iliac artery
– Care taken to elevate all soft tissues to ensure
ureters remain anterior
Infrarenal aortic exposure
• Transperitoneal approach
– Longitudinal midline laparotomy (Xiphoid to
• Transverse Colon is retracted Cephalad
• Small bowel shifted to patients right side
• Ligament of treitz taken down
• Duodenum mobilized to right allowing access
to infrarenal aorta
Infra renal aortic exposure
• Retroperitoneal tissue overlying the aorta
dissected superiorly to level of left renal vein
– Lymphatic vessels within retroperitoneal
lymphatic network ligated
• Extensive dissection anterior to aortic
bifurcation and proximal left iliac artery
should be avoided because autonomic nerve
plexus regulating erection and ejaculation in
men sweeps over aorta
Infra renal aortic exposure
• If thrombus or significant aortic calcification
extend to level of renal a. can dissect
proximally to supra-renal level to allow safe
proximal clamp placement
• Alternatively:
– Intraluminal balloon deployment
– Supraceliac clamping via gastrohepatic ligament
Aortobifemoral Bypass
• When Vessel exposed and tunnel creation
• IV bolus of Heparin given (70-100U/Kg)
• Activated Clotting time maintained between
250-350 second range
Clamp Placement
• Aorta palpated to identify optimal sites for
• Atraumatic vascular clamps selected
• Soft anterior but calcified posterior wall:
anterior to posterior clamping
• Proximal Clamp: just below renal arteries
• Distal Clamp: above or below IMA
Anastamoses – End to End
• End-to-end and end-to-side are acceptable
• End to end:
– Facilitates thromboendarterectomy or proximal stump
– Allows a better in-line flow pattern, less turbulence
and more favorable hemodynamic characteristics
– Lower rates of proximal suture line pseudoaneurysm
and better long-term patency shown in some studies
– Stapling/Oversowing the distal aorta with end-to-end
technique has benefit of reducing risk of clamp-
induced emboli to lower extremities
End-to-End Anastamosis
• Aorta transected several inches below proximal
• Distal aorta oversewn in two layers with running
monofilament suture
• If necessary, complete thromboendarterectomy
of infrarenal neck carried out
– Facilitates suture placement and creation of widely
patent proximal anastamosis
• Division of L renal vein usually unnecessary but
acceptable if additional exposure required
Anastamosis – End to side
• Patients with occluded or severely diseased
external iliac arteries but patent common and
internal iliac a.
– Interruption of forward aortic flow may result in
loss of critical pelvic perfusion
– No retrograde flow from the external iliac a.
normally in end to end configuration
• Preservation of large IMA, important
accessory renal a.
End-to-side anastamosis technique
• 3-cm longitudinal aortotomy as close to renal
• After completion of abdominal portion of
procedure, graft limbs are clamped with soft-
jaw insert clamps and flushed with
heparanized saline
• Graft passed through retroperitoneal tunnels
End-to-side Anastamosis
Graft Selection
• Bifurcated graft appropriately sized to match
aorta and femoral vessels
• Polytetrafluoroethylene (PTFE)
• Knitted Polyester (Dacron)
• Male:
– 18 by 9mm or 16 by 8mm
• Female:
– 14 by 7mm or 12 by 6mm
• Digital manipulation from above and below
• Care taken to maintain a course anterior to
the iliac vessels but posterior to the ureters
• Left Tunnel:
– Passes beneath the sigmoid mesentery and
slightly more laterally in an effort to avoid
disruption of autonomic nerve plexus
Distal anastamosis
• Longitudinal arteriotomy limited to distal CFA
– Extension across profunda femoris artery origin
and profundoplasty may be necessary
• Beveled end-to-side fashion with 5-0 prolene
• Important to alert anesthetic team before
clamp release, given blood pressure drop with
Adjunctive Profundoplasty
• Profunda typically arises as a posterolateral
branch off terminal CFA
• Profunda and SFA Disease limits outflow
• In patients with AI, SFA, And Profunda causing
CLI, a concomitant profundoplasty may be
sufficeint to sustain patency of inflow graft and
salvage limb
• Common practice to extend hood of distal
anastamosis over the origin of the profunda
femoris a. to enhance graft outflow, particularly if
SFA is occluded or severely diseased
Retroperitoneal approach
• Advantageous in patients with
– a history of multiple prior abdominal operations
– Abdominal wall stoma
– Concurrent renal or mesenteric arterial disease
– Severe cardiopulmonary disease
• Disadvantages:
– Difficulty in accessing R renal and iliac arteries and
R groin
Retroperitoneal approach
• Technique:
– Pt placed on inflatable beanbag in partial R Lateral
decubitus position with flank extension
– Hips are rotated as far posteriorly as possible to
maximize exposure to R femoral a.
– Oblique incision from L lateral border of rectus
abdominus to posterior axillary line
– Lateral 3rd of 11th rib excised
– Retroperitoneal plane is identified and peritoneal
contents mobilized anteriorly to reveal L iliac a. and
infrarenal aorta
External Iliac Anastamosis
• CFA anastamosis preferred:
– Technically easier
– Long term patency improved over AI grafts
• Aortobiiliac bypass advantageous for:
– Patients with hostile groin creases from prior
surgery or radiation therapy
– Obese, Diabetic patients wth rash at inguinal
• Endarterectomy:
– 5 year patency rates: 95%
– 10 yr patency: 85-90%
– Peri-operative mortality: 1%
• Aorto-bifemoral bypass:
– Peri-operative mortality: 1%
– 5 year patency: 85-97%
– 10 yr patency: 72-90%
– Age a significant predictor of outcome
• >60: 5 yr patency 95%
• <60: 66%
• More aggressive form of atherosclerosis?
• Conflicting results on gender difference
• NO major difference in durability between
– transperitoneal or retroperitoneal techniques
– End-to-end or end-to-side anastomotic techniques
– Indications of claudication and CLI
• Pts with multi-level disease
– Lesser degree of symptom reduction
– 10 yr survival as low as 50%
• Isolated AI Disease
– Life expectancy not different from normal age- and
sex-matched counterparts
Outcomes in endovascular era
• Decrease in patency rates for both ABFB and
Iliofemoral bypass when results compared by
decade of publication
– Greater operative complexity
– Decreased experience of recently trained
surgeons in open aortic reconstruction
Early Complications
Early Complications
• Overall Morbidity 17-32%
• Cardiac complications most common cause of
– Hemodynamic stress a/w major vascular surgery
– Fluid shifts during early post-op period
• Pulmonary complications:
– COPD, smoking hx, poor pre-op nutritional status
– Pain control, appropriate diuresis and pulmonary
toilet important to prevent pneumonia
Early Complications
• Acute Renal failure
– Uncomon in Pts with normal pre-op renal fxn
– Adequate hydration and avoiding repetitive aortic
cross-clamping and peri-op hypotension
preventive measures
– Pts with pre-op Cr >1.8 much higher risk for
Early Complications
• Spinal Cord Ischemia
– Careful preservation of hypogastric perfusion
– Gentle technique to minimize risk of atheroemboli
and avoidance of perioperative and postoperative
– Uncomon 0.3% of AI reconstructions
Intestinal Ischemia
• 2% of cases
• Usually the rectosigmoid segment
– Sacrifice of main collateral perfusion
– Perioperative hypotension
– Atheroemboli
• If compromised bowel perfusion recognized
intraoperatively , IMA reimplantation indicated
– Doppler flow along antimesenteric border, IMA stump
pressure, IV Fluorescein
• If post-operatively, perform sigmoidoscopy
Late Complications
Late complications
• Graft Thrombosis
– 30% of cases in which grafts observed 10 yrs or
– Occlusion of entire graft usually due to placing
proximal anastamosis inappropriately low
• Unilateral limb thrombosis
– Progressive intimal hyperplasia and distal
anastamosis or progression of outflow disease
Late complications - Pseudoaneurysm
• Less common in modern practice
• 1-5% of cases
• Due to weakening in the suture line as a result of
structural fatigue or fabric degeneration
• Infection
– Staphylococcus predominant organisms
• Femoral anastomotic pseudoaneurysm
– Most common
– Slowly enlarging, asymptomatic groin bulge
• Proximal anastamotic pseudoaneurysms often found
incidentally or after rupture
Late Complication
• Aorto-enteric fistula
– Erosion of proximal aortic suture line through the
third or fourth portion of duodenum
– Fistula between iliac anastamoses into small
bowel or colon
– Dx: CT, Endoscopy, Angiogram
– Triad: GI Bleed, Sepsis, Abdominal pain
– Tx: Extra-anatomic bypass and graft excision