Acs0612 Aortoiliac Reconstruction

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Acs0612 Aortoiliac Reconstruction

  1. 1. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 1 12 AORTOILIAC RECONSTRUCTION Mark K. Eskandari, MD, FACS Symptomatic aortoiliac occlusive disease is the consequence Step 1: Incision and Approach of a diffuse atherosclerotic process that is exacerbated A standard lower midline transperitoneal incision allows by smoking, hypertension, hypercholesterolemia, and rapid, direct access. Usually, the incision can be made below diabetes.1–4 The resultant narrowing of the aorta and the iliac the umbilicus and extended to the pubis. vessels impairs circulation into the pelvis and the lower extremities, thereby causing myriad patient complaints. Step 2: Exposure and Control of the Aorta and Iliac Arteries Manifestations range from impotence, claudication (in the Upon entry into the abdominal cavity, exposure of the buttock, the thigh, or the calf), and rest pain (in the forefoot) aortic bifurcation is achieved by retracting the small bowel to ulceration or gangrene. cephalad. A self-retaining retractor, such as an Omni Hemodynamically significant obstruction of blood flow (Omni-Tract Surgical, Minneapolis, MN) or a Bookwalter arising from aortoiliac occlusion may be either segmental (Cardinal Health, V. Mueller, McGaw Park, IL), is often or diffuse. Fortunately, a number of different vascular recon- helpful. The retroperitoneum overlying the aortic bifurcation structions can be performed to reestablish sufficient flow to is then incised in the midline, and the aorta is exposed to the lower body. The choice of a surgical revascularization the level of the inferior mesenteric artery [see 6:11 Repair of approach is based on two factors: (1) anatomic constraints Infrarenal Abdominal Aortic Aneurysms]. Both common iliac and (2) comorbid conditions. Regardless of which technique arteries are exposed, with care taken not to damage the is selected, the preoperative workup and planning are underlying iliac veins and the overlying ureters, which essentially the same. normally cross at the iliac bifurcation. Given that this procedure is best suited for treatment of Preoperative Evaluation localized disease, exposure beyond the iliac bifurcation is rarely necessary. If it appears that the disease process extends Once it has been established that a patient’s symptoms into the external iliac arteries or more proximally in the (e.g., claudication, rest pain, or a nonhealing wound) are attri- infrarenal aorta, another form of treatment, such as butable to hemodynamically significant aortoiliac occlusive aortofemoral bypass (see below), may be indicated. disease, a thorough preoperative evaluation is initiated. Such evaluation typically includes obtaining objective physiologic Step 3: Aortoiliac Endarterectomy documentation of the extent of occlusive disease by measur- Once the aorta and the iliac vessels are exposed, IV heparin ing lower extremity blood flow with arterial waveforms is given for systemic anticoagulation. The vessels are then and ankle-brachial indices. An imaging study is also required to guide revascularization. Percutaneous diagnostic angio- controlled with vascular clamps. As a rule, the iliac vessels graphy is widely used for this purpose; however, technological should be clamped first to reduce the risk of distal emboliza- advancements may allow magnetic resonance angiography tion during placement of the aortic cross-clamp. These to supplant traditional contrast arteriography.5–7 If an extra- vessels should be clamped only enough to prevent retrograde anatomic bypass is anticipated, ancillary tests, including bleeding. They must not be repeatedly clamped and bilateral arm blood pressure measurements and computed unclamped because they are prone to the development of tomography scans of the chest, abdomen, or pelvis, may be flow-limiting intimal flaps or fractured atherosclerotic necessary. A standard cardiac risk assessment is mandatory plaques. before any form of revascularization, and the extent of testing Next, the aorta is incised longitudinally from a point just is tailored to the level of cardiac risk. above the bifurcation (where the aorta is soft) and down into the common iliac artery, in which the disease process extends further. Sometimes the middle sacral or lower lumbar arteries Operative Technique must be oversewn to control back-bleeding. A dissection plane is developed between the media and the adventitia, and aortoiliac endarterectomy a standard endarterectomy of the infrarenal aorta and the Although localized aortoiliac endarterectomy is less more diseased iliac artery is performed. The endarterectomy commonly performed today than it once was, it remains of the contralateral iliac artery is performed by means of useful for a subgroup of patients with focal aortic bifurcation eversion through the aortotomy [see Figure 1]. If the distal disease. The classic candidate for this procedure has minimal termination points in the iliac vessels are irregular or have a disease of the infrarenal abdominal aorta and the external significant step-off, the plaque should be tacked down with iliac arteries but a severely diseased and narrowed aortic two or three 6-0 polypropylene sutures, with the knots tied bifurcation. on the outside of the vessel wall. DOI 10.2310/7800.S06C12 06/08
  2. 2. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 2 instead. Before closure is completed, the vessels should be flushed and back-bled to diminish the risk of distal embo- lization to the legs upon reestablishment of inline flow. The adequacy of the repair is confirmed primarily by the palpation of normal femoral pulses in the groins. Step 5: Closure of the Retroperitoneum Before abdominal closure, the retroperitoneum is closed with an absorbable suture so as to isolate the repair from the gastrointestinal tract. This step reduces the risk of an aortoenteric fistula. iliofemoral bypass Iliofemoral bypass, already an uncommon procedure, has now largely been supplanted by advances in percutaneous endoluminal techniques. Nevertheless, it is still used on occasion and thus is worth knowing. One limitation on the application of iliofemoral bypass is that aortoiliac occlusive disease typically causes diffuse aortic and bilateral iliac artery narrowing. For this operation to be successful, there must be a relatively disease-free common iliac artery that can provide unimpeded inflow. Accordingly, iliofemoral bypass is most suitable for those rare patients who have isolated unilateral external iliac artery disease. Step 1: Incision and Approach The patient is placed in the supine position, and two incisions are made [see Figure 2]. The common iliac artery is approached through a lower-quadrant retroperitoneal inci- sion positioned medial to the lateral border of the rectus muscle. The femoral artery is approached through a standard vertical groin incision. Step 2: Exposure of the Iliac and Femoral Arteries Once the retroperitoneum is entered, the visceral contents and the ureter are bluntly dissected away from the psoas muscle medially. This dissection, which takes place through a mostly bloodless field, yields full exposure of the targeted common iliac artery and its bifurcation into the external and internal iliac arteries. It should proceed far enough to Figure 1 Aortoiliac endarterectomy. Plaque is removed allow control of the arteries with vascular clamps. Care must through a longitudinal aortotomy. be taken not to damage the underlying iliac veins. In par- ticular, no attempt should be made to isolate these vessels circumferentially, which can lead to troublesome bleeding. Occasionally, endarterectomy results in a very thin residual The vertical incision in the groin permits full exposure wall, or the distal termination points are too steep to fix of the common femoral artery and its bifurcation into the with tacking sutures alone. In such cases, the best recourse superficial femoral artery and the profunda femoris. Unlike is to replace this section of the aorta and the common the iliac arteries, the femoral artery and its branches may be iliac vessels with a short standard bifurcated prosthetic circumferentially dissected. interposition graft. Proximally, the graft is sewn to the Step 3: Tunneling of the Bypass Graft infrarenal aorta in an end-to-end fashion. Distally, the two limbs are sewn to the two common iliac arteries in the same Once the inflow and outflow vessels are adequately exposed, manner. the bypass graft is tunneled from the retroperitoneum to the groin, passing beneath the ureter and the inguinal ligament. Step 4: Repair of Arteriotomy During tunneling, care must be taken not to avulse the The arteriotomy can be closed either primarily or with a bridging epigastric vein found just cephalad and posterior patch, depending on the size of the aorta and the iliac vessels. to the inguinal ligament. Typically, a prosthetic graft 8 to Primary closure is preferred, but if it appears that such 10 mm in diameter is used; however, autogenous material closure will significantly narrow the aorta or the iliac artery, (e.g., a segment of the greater saphenous vein) may be used a patch (either prosthetic or autogenous) should be used if desired. 06/08
  3. 3. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 3 Figure 2 Iliofemoral bypass. (a) A low retroperitoneal incision and an ipsilateral groin incision are made for exposure of the inflow and outflow bypass vessels. Dashed lines denote skin incision. (b) The graft is tunneled beneath the ureter and the inguinal ligament. 06/08
  4. 4. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 4 Step 4: Proximal Anastomosis to the Iliac Artery occlusive disease. This operation is still favored by many, and With the bypass graft in position, the patient undergoes it yields excellent long-term patency. systemic anticoagulation with IV heparin. The common, Step 1: Incision and Approach external, and internal iliac arteries are controlled with vascular clamps. The proximal anastomosis is then performed Typically, the patient is placed in the supine position, and to the selected common iliac artery. If practicable, the the operation is performed through a midline laparotomy and anastomosis should be an end-to-side one so as to preserve two longitudinal groin incisions. A self-retaining retractor is antegrade flow into the internal iliac artery. recommended to facilitate exposure of the infrarenal aorta. Alternatively, the infrarenal aorta may be exposed via a left Troubleshooting Occasionally, the common iliac artery retroperitoneal incision extending obliquely from the lateral is too diseased to clamp or to use as an inflow source. In such border of the rectus muscle, at the level of the umbilicus, to cases, the infrarenal aorta may be clamped instead or used as the tip of the 11th rib. For this approach, the patient is placed the site of the proximal anastomosis. in a right semilateral decubitus position with the assistance of an inflatable beanbag. The hips are rotated so that they are Step 5: Distal Anastomosis to the Femoral Artery flat on the bed, providing easy access to the groins. Vascular clamps are placed on the common femoral artery and its branches, and the distal anastomosis is performed in Step 2: Exposure of the Aorta an end-to-side manner. The configuration of the longitudinal Upon entry into the abdominal cavity, the fourth portion arteriotomy depends on the presence and extent of disease of the duodenum is dissected free of its retroperitoneal attach- in the femoral arteries. If both the superficial femoral artery ments, and the small bowel is retracted to the right of and the profunda femoris are relatively free of disease, the the aorta. The self-retaining retractor may then be placed to arteriotomy should extend from the common femoral artery facilitate exposure. Next, the retroperitoneum overlying the into the superficial femoral artery. If, however, the superficial infrarenal aorta is incised in the midline to expose the vessel, femoral artery is occluded or heavily diseased, the arteriotomy should extend down into the profunda femoris [see Figure 3]. ideally in a location that is not heavily diseased or calcified. In either case, an end-to-side anastomosis is fashioned. Unlike the dissection required in a localized endarterectomy Before completion of the bypass, the inflow vessel is flushed [see Aortoiliac Endarterectomy, above], this dissection is and the outflow vessel back-bled to reduce the risk of distal primarily between the renal arteries and the inferior mesen- embolization to the legs. teric artery. In most cases, the dissection need not be extended downward below the aortic bifurcation into the iliac aortofemoral bypass arteries. Before the application of percutaneous balloon angioplasty When this operation is performed through a left and stenting, aortofemoral bypass grafting was the revascular- retroperitoneal incision, the external and internal oblique ization operation of choice for patients with diffuse aortoiliac muscles and the transversus abdominis are divided, and Figure 3 Iliofemoral bypass. (a) When concomitant superficial femoral artery disease is present, the distal anastomosis is performed to a longitudinal arteriotomy that extends onto the proximal profunda femoris. (b) The heel of the hood of the graft is anastomosed to the common femoral artery. (c) The tip of the graft is extended down the profunda femoris. 06/08
  5. 5. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 5 the retroperitoneum is entered. Complete exposure of the Once a configuration for the anastomosis has been chosen, infrarenal aorta is obtained by mobilizing the abdominal con- IV heparin is given for systemic anticoagulation. The graft tents, the left kidney, and the left ureter medially after blunt is trimmed so that its bifurcation lies close to the proximal dissection along the anterior border of the psoas muscle. anastomosis. The infrarenal aorta is controlled, most com- monly with vascular clamps above and below the site of the Troubleshooting In those cases in which aortofemoral intended anastomosis. Control of the aorta with a partially bypass is being done for a patient with complete infrarenal occluding vascular clamp may be attempted, but the size of aortic occlusion, the operative approach is modified to allow the vessel and the coexistence of aortic disease typically make placement of a vascular clamp above the renal arteries. The this difficult or impossible to accomplish. dissection is carried cephalad by retracting the small bowel If an end-to-side anastomosis is to be performed, a mesentery and the superior mesenteric artery to the right. longitudinal aortotomy is made and the graft is sewn in place The left renal vein is found anterior to the aorta at the in a spatulated fashion. The toe of the graft is oriented level of the renal arteries. Generally, this vein need not be cephalad [see Figure 4]. The anastomosis should be spatulated divided to expose the suprarenal aorta. Rather, it should be steeply so that it is not too bulky in the retroperitoneum thoroughly dissected and encircled with a vessel loop so and can be covered at the end of the procedure. Before that it can be retracted cephalad and caudad. Sometimes an adrenal or gonadal vein draining into the left renal vein must be ligated and divided to give the renal vein added mobility. With the left renal vein retracted caudad, the suprarenal aorta is dissected. Step 3: Exposure of the Femoral Artery A vertical groin incision provides full exposure of the common femoral artery and its bifurcation into the superficial femoral artery and the profunda femoris. The femoral artery and its branches should be circumferentially dissected to give the surgeon an unobstructed view for placement of the vascular clamps. Step 4: Tunneling of the Bypass Graft Once the inflow and outflow vessels are adequately exposed, the bypass graft—typically, a bifurcated prosthetic graft measuring 14x7 mm or 16x8 mm—is tunneled from the abdomen to the groins. Its course should pass beneath the ureter and the inguinal ligament. To create the tunnel, one index finger, oriented so that its dorsum faces the vessel wall, is inserted in the midline incision and advanced caudad down to the groin. Simultaneously, the other index finger, oriented so that its volar aspect faces the common femoral artery, is inserted into a groin incision and advanced cephalad until the two fingers meet. As with an iliofemoral bypass graft, care must be taken not to avulse the bridging epigastric vein found just cephalad and posterior to the inguinal ligament. With one of the two fingers held in place, a Silastic tube or vessel loop is passed through the tunnel. The limbs of the graft are attached to the tube or loop and passed through the tunnel down to the groins. Step 5: Proximal Anastomosis to the Aorta The proximal aortic anastomosis can be done in either an end-to-end or an end-to-side configuration. An end-to-side beveled anastomosis is preferable for (1) patients with a small (< 1.5 cm) infrarenal aorta and (2) patients with severe occlusive disease of both external iliac arteries in whom it is desirable to preserve flow into the pelvic circulation via the internal iliac arteries. An end-to-end anastomosis is preferable for (1) patients with occlusive iliac disease and a concomitant aortic aneurysm and (2) patients undergoing revascularization for chronic total aortic occlusion. The latter configuration is also less bulky and easier to cover and isolate from the gastrointestinal (GI) tract at the conclusion of the Figure 4 Aortofemoral bypass. Shown is an end-to-side operation. proximal anastomosis. 06/08
  6. 6. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 6 completion of the anastomosis, the graft is flushed and A heavily calcified infrarenal aorta encountered at the back-bled. time of operation presents a difficult problem. In most cases, If an end-to-end anastomosis is to be performed, a small the infrarenal aorta can still be used, but the proximal anas- portion of the aorta is resected to allow the graft to fit neatly tomosis should be performed in an end-to-end configuration. into the retroperitoneum. In some cases, back-bleeding Even in the most calcified aortas, the region 1 to 2 cm below lumbar arteries in the region of the resected aorta must the renal arteries is often soft enough to allow an anastomosis be oversewn. The distal stump is oversewn with 2-0 or 3-0 to be fashioned. If this is not the case, there are two alterna- polypropylene in two rows; the first row is done with a con- tives: (1) suprarenal aortic control and endarterectomy of the tinuous suture in a horizontal mattress stitch and the second infrarenal aorta just below the renal ostia before the proximal with a continuous suture in a baseball stitch [see Figure 5]. anastomosis and (2) conversion to a thoracofemoral bypass graft [see Thoracofemoral Bypass, below]. Troubleshooting Vascular control of the aorta is achieved differently when chronic infrarenal aortic occlusion Step 6: Distal Anastomosis to the Femoral Artery is present. In this setting, placement of a vascular clamp just Vascular clamps are placed on the common femoral artery below the renal arteries may squeeze atherosclerotic debris up and its branches, and the distal anastomosis is performed. into the renal arteries. To prevent this, the vascular clamp As with an iliofemoral bypass, the configuration of the longi- should be placed between the superior mesenteric artery and tudinal arteriotomy depends on the existence of disease in the the renal arteries. Once the distal clamp is in place, the aorta femoral arteries. If both the superficial femoral artery and the is opened below the renal arteries and the atherosclerotic plug profunda femoris are relatively free of disease, the arteriotomy is removed. The suprarenal clamp can then be moved to just should extend from the common femoral artery into the below the renal arteries, and the proximal anastomosis can be superficial femoral artery. If, however, the superficial femoral fashioned as already described (see above). artery is occluded or heavily diseased, the arteriotomy should Figure 5 Aortofemoral bypass. Shown is an end-to-end proximal anastomosis. (a) A segment of diseased aorta is resected, and the distal aortic stump is oversewn. (b) The proximal end of the graft is sutured to the open infrarenal aorta. (c) The distal anastomoses are completed in an end-to-side fashion. 06/08
  7. 7. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 7 extend downward into the profunda femoris. In either case, position. Because single-lung ventilation will be necessary an end-to-side anastomosis is indicated. Before completion of when the proximal anastomosis is done, either a double- the bypass, the inflow vessel is flushed and the outflow vessel lumen endotracheal tube or a bronchial blocker must be back-bled to diminish the risk of distal embolization to the used. Placement of an orogastric tube to decompress the legs. stomach helps keep the diaphragm down during exposure of the descending thoracic aorta. Step 7: Closure of the Retroperitoneum Before abdominal closure, the retroperitoneum is closed Step 1: Incision and Exposure of the Descending Thoracic with an absorbable suture to isolate the repair from the Aorta GI tract and reduce the risk of an aortoenteric fistula. The The descending thoracic aorta is approached through a ureters should be visualized and preserved. Careless closure left posterior lateral thoracotomy at the level of the seventh of the retroperitoneum can lead to laceration or entrapment or eighth interspace. Additional exposure can be gained of the ureter, particularly the right ureter. Every attempt by resecting part of the rib and using a self-retaining should be made to cover the graft. If the retroperitoneum is table-mounted retractor. With the left lung decompressed, too thin or the graft too bulky, an omental pedicle flap may the parietal pleura overlying the descending thoracic aorta is be used. incised. The aorta is cleanly dissected, with care taken not to damage the esophagus, which lies medially. Having an thoracofemoral bypass orogastric tube in place is advantageous in this regard: the A thoracofemoral bypass is ideal for a small subgroup esophagus can easily be located by palpating the tube. of patients, comprising (1) those with an occluded old Any intercostal vessels in the region of the anticipated aortofemoral bypass graft, (2) those with a so-called lead-pipe aortotomy can be preserved and controlled at the time of the calcified infrarenal aorta that is unusable as an inflow anastomosis. source, and (3) those with a so-called hostile abdomen (i.e., those with an ileal conduit, an ileostomy or colostomy, or a Step 2: Exposure of the Femoral Artery previous aortic graft infection). Candidates for this procedure Full exposure of the common femoral artery and its bifur- must have adequate pulmonary reserve and be able to cation into the superficial femoral artery and the profunda tolerate a thoracotomy. They must also be informed of and femoris is obtained via a standard groin incision. accept the low but real risk of paralysis. The patient is placed in a right semilateral decubitus Step 3: Tunneling of the Bypass Graft position so that the hips are nearly flat on the table and the The tunnel for the prosthetic graft has two components: torso is slightly rotated to the patient’s right [see Figure 6]. An (1) a left retroperitoneal tunnel and (2) a subcutaneous tunnel axillary roll and an inflatable beanbag will help maintain this over the pubis. Usually, a tube prosthetic graft is sutured to Figure 6 Thoracofemoral bypass. The patient is positioned so that the hips are flat, but the torso is slightly rotated to the patient’s right. Three incisions are made: a left posterolateral thoracotomy and two groin incisions. Dashed lines denote skin incision. 06/08
  8. 8. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 8 a bifurcated graft before being tunneled through the retro- anastomosis is fashioned. Exposure can be enhanced by peritoneum. The retroperitoneal tunnel is started in the chest ventilating the right lung and attaching the orogastric tube to by making a 1 cm hole in the posterior lateral aspect of the suction to decompress the stomach. Before completion of the left diaphragm. An index finger is inserted through this hole anastomosis, the aorta is flushed and back-bled. and advanced caudad into the retroperitoneum as far as it can go. The other index finger is inserted through the left groin Troubleshooting Partial aortic control with a side- incision, oriented directly over the external iliac artery, and biting vascular clamp is successful in most cases, but it is not advanced cephalad into the retroperitoneum [see Figure 7]. recommended when the descending thoracic aorta is heavily Care is taken not to avulse the bridging epigastric vein found diseased and calcified or when preoperative imaging posterior and inferior to the inguinal ligament. In most cases, studies show thrombus in this location. If an intercostal artery the left retroperitoneal tunnel must then be completed by cannot be temporarily controlled with clamps, it can be using a long, hollow metal tunneling device such as the Gore oversewn from the inside of the aorta to prevent nuisance Tunneler (W. L. Gore & Associates, Inc., Tempe, AZ). Once back-bleeding. this tunnel is completed, the graft is passed through it in such a way that the bifurcated limbs are brought caudad down into Step 5: Distal Anastomosis to the Femoral Artery the left groin wound. Vascular clamps are placed on the common femoral artery Next, the subcutaneous tunnel from the left groin to the and its branches, and an end-to-side anastomosis is fashioned right groin is bluntly fashioned anterior to the pubis. It should distally. Again, the configuration of the longitudinal arteri- not be oriented superior to the pubis because of the risk of otomy depends on the existence of disease in the femoral injury to an overdistended bladder. To minimize this risk, an arteries. If both the superficial femoral artery and the pro- indwelling urinary catheter is advocated. The subcutaneous funda femoris are relatively free of disease, the arteriotomy tunnel is used to pass the right limb of the graft over to the should extend from the common femoral artery into the right groin. It is not uncommon for the bifurcation of the superficial femoral artery. If, however, the superficial femoral prosthetic graft to lie just cephalad to the left groin wound. artery is occluded or heavily diseased, the arteriotomy should extend downward into the profunda femoris. Before comple- Step 4: Proximal Anastomosis to the Descending Thoracic tion of the bypass, the inflow vessel is flushed and the outflow Aorta vessel is back-bled. Once the graft has been tunneled, the patient undergoes systemic anticoagulation with IV heparin. The descending Step 6: Closure of the Chest thoracic aorta is controlled either with a side-biting clamp or Once the proximal anastomosis is complete, the left lung is with two completely occluding aortic clamps placed in close reinflated. At the conclusion of the operation, the chest is proximity to each other. In the latter case, one or two closed in a standard fashion over two chest tubes. The prox- intercostal arteries may have to be temporarily controlled as imal anastomosis should be covered with either a prosthetic well. A longitudinal aortotomy is then made along the left patch or bovine pericardium to diminish the risk of an aorto- lateral aspect of the thoracic aorta, and a beveled end-to-side pulmonary fistula. Figure 7 Thoracofemoral bypass. A left retroperitoneal tunnel is fashioned for passage of the prosthetic graft downward to the groin. (The right arm of the graft is subsequently passed to the right groin via a subcutaneous tunnel anterior to the pubis.) 06/08
  9. 9. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 9 axillofemoral bypass Step 4: Proximal Anastomosis to the Axillary Artery Axillofemoral bypass is ideally suited to elderly patients With the long graft in place, IV heparin is given for who cannot tolerate an aortic operation. The hemodynamic systemic anticoagulation. The pectoralis minor may be changes occurring during the operation are minimal, and retracted laterally to provide additional exposure. The axillary recovery from the three small incisions used is substantially artery is controlled with vascular clamps, with care taken not quicker than that from a laparotomy or a thoracotomy. to include any part of the brachial plexus lying nearby. Because hemodynamically significant occlusive disease is A longitudinal arteriotomy is made along the length of the less common in the right innominate artery than in the left axillary artery. The proximal anastomosis is then fashioned in subclavian artery, the right axillary is more often used as an end-to-side configuration. The anastomosis must lie the inflow vessel than the left axillary artery. Such occlusion medial to the medial border of the pectoralis minor. This is can easily be identified preoperatively by measuring blood critical for preventing avulsion of the graft from the axillary pressure in both arms. The sterile field includes both groins, artery when the patient fully abducts the arm postoperatively. the appropriate side of the chest (usually the right) up to Before the anastomosis is completed, it is flushed and the neck, and the appropriate flank (again, usually the right). back-bled. Once blood flow to the arm is reestablished, the It need not include the entire inflow arm; however, the graft should be positioned so that it lies parallel to the axillary arm should be abducted 90° and positioned on an arm artery for a length of 2 to 3 cm before diving deep and board. caudad. Step 1: Incision and Exposure of the Axillary Artery Step 5: Distal Anastomosis to the Femoral Artery The patient is placed in the supine position. The axillary The distal anastomosis to the femoral arteries is performed artery is approached through a horizontal 6 cm infraclavicular as described earlier [see Thoracofemoral Bypass, above]. Some controversy remains over the formation of the short incision placed approximately 2 cm below the inferior border crossover graft from the axillary bypass graft to the contralat- of the clavicle. Dissection is carried through the subcutane- eral femoral artery. My practice is to place the proximal ous tissue, the fascia overlying the pectoralis major is incised, anastomosis of the crossover femorofemoral anastomosis on and the muscle is bluntly dissected along the length of the hood (or distal anastomosis) of the axillofemoral bypass its fibers. The dissection plane should remain medial to the graft [see Figure 8]. Others prefer to use a commercially pectoralis minor. available bifurcated axillofemoral prosthetic graft or to place Next, the axillary vein is encountered and retracted caudad, the crossover graft more proximally along the length of the and the underlying axillary artery is visualized. The axillary axillofemoral graft. artery is cleanly dissected, with care taken not to retract or damage the brachial plexus lying deep and superior to the artery. For full exposure of the axillary artery, the thoraco- acromial artery may have to be ligated at its origin. For easier retraction, the axillary artery may be encircled with vessel loops. Step 2: Exposure of the Femoral Artery The femoral artery and its bifurcation into the superficial femoral and profunda femoris arteries are approached through a standard groin incision. Step 3: Tunneling of the Bypass Graft Once the inflow and outflow vessels are adequately exposed, a prosthetic graft 80 to 100 cm long and 8 or 10 mm in diameter is tunneled from the axillary incision, anterior to the pectoralis minor, and down to the flank. The use of a long, hollow metal tunneler is recommended at this point. To facilitate tunneling, a single counterincision is made in the midaxillary line over the sixth or seventh intercostal space. From this counterincision, the graft is tunneled along the flank, over the iliac crest, anterior to the anterior superior iliac process, and into the ipsilateral groin wound. Except for the portions in the axilla and the groin, the entire graft should lie in a subcutaneous plane. Next, a subcutaneous tunnel from the ipsilateral groin to the contralateral groin is bluntly fashioned anterior to the Figure 8 Axillofemoral bypass. Shown is the recommended pubis to allow passage of a second prosthetic graft (a short configuration for the short femorofemoral crossover graft crossover graft 8 mm in diameter). This tunnel should not be originating from the long axillofemoral graft. The femoro- oriented superior to the pubis because of the risk of injury to femoral graft originated from the hood of the axillofemoral an overdistended bladder. graft. 06/08
  10. 10. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 10 femorofemoral bypass 6. Buttock claudication, resulting from disruption of inline A femorofemoral crossover bypass is well suited to patients flow to the pelvic circulation (all) who have unilateral complete occlusion or a diffusely diseased 7. Aortoduodenal fistula, resulting from incomplete iliac system but have a relatively normal contralateral iliac coverage of an aortic graft (aortofemoral and iliofemoral system. It is performed with the patient supine and is con- bypass) ducted in essentially the same fashion as an axillofemoral 8. Renal failure, resulting from acute tubular necrosis or bypass, but without the axillary anastomosis. embolization when a suprarenal aortic clamp is used (thoracofemoral bypass and aortobifemoral bypass) endovascular therapy 9. Arm paralysis, resulting from injury to the deep The use of percutaneous balloon angioplasty and stenting and superiorly oriented brachial plexus (axillofemoral for the treatment of peripheral vascular disease has grown bypass) exponentially since its introduction in the 1990s. With regard 10. Respiratory failure resulting from effusion or hemo- to short-term results, patients clearly experience less pain, thorax after a left thoracotomy or from inadvertent recover more quickly, and regain function earlier. Initially, pneumothorax during exposure of the axillary artery there was some question about the durability of stenting; (thoracofemoral bypass, axillofemoral bypass) however, data from longer follow-up periods indicate that this approach is an acceptable alternative for patients with focal Outcome Evaluation aortoiliac occlusive disease.8–10 Regardless of which operation is performed to treat aortoiliac occlusive disease, the subsequent outcome should Complications be immediate relief of presenting symptoms—for example, Certain complications are associated with all of the revas- reduced claudication, resolution of rest pain, or improved cularization procedures discussed, such as bleeding, distal distal wound healing. Unfortunately, overall long-term sur- embolization, graft thrombosis, and graft infection. Late graft vival in patients with symptomatic aortoiliac occlusive disease infection, recurrent disease, and pseudoaneurysm formation is not improved by operative management and is typically 10 are known long-term complications as well. In addition, the to 15 years less than that in a normal age-matched group. Not following complications are unique to one or more of the surprisingly, by far the most significant long-term cause of procedures but do not arise with the others: death in these patients is atherosclerotic cardiac disease, 1. Injury to the ureters, resulting from their position which underscores the importance of a thorough preoperative overlying the iliac vessels (aortoiliac endarterectomy, cardiac evaluation. iliofemoral bypass, axillofemoral bypass) In general, direct aortoiliac reconstructions (i.e., endarter- 2. Impotence, resulting from damage to the autonomic ectomy, aortofemoral bypass, and thoracofemoral bypass) nerve fibers around the origin of the left common iliac have an expected patency rate of 85 to 90% at 5 years and 70 artery (aortoiliac endarterectomy, iliofemoral bypass, to 75% at 10 years.11–13 When these operations are performed axillofemoral bypass) at experienced centers on patients who are considered to be 3. Bleeding or deep vein thrombosis, related to trauma to good risk candidates, mortality is typically less than 3%.14,15 the underlying iliac venous structures (all) Femorofemoral bypass and axillobifemoral bypass have 4. Paraplegia, resulting from the sacrifice of intercostal expected 5-year patency rates of 70 to 75% and 60 to 85%, vessels supplying the anterior spinal artery (thoraco- respectively.16–19 Coexistent superficial femoral artery disease femoral bypass) in the recipient vessels has a detrimental effect on the long- 5. Colonic ischemia or infarction, resulting from hindered term patency of these bypasses.20 Long-term anticoagulation primary flow via the inferior mesenteric artery or with warfarin may improve the patency for an axillobifemoral collateral vessels from the hypogastric arteries (all) bypass graft. References 1. Witteman JC, Grobbee DE, Valkenburg 4. Faries PL, LoGerfo FW, Hook SC, et al. alternative to automated-table techniques. HA, et al. Cigarette smoking and the The impact of diabetes on arterial recon- AJR Am J Roentgenol 2002;179:1583. development and progression of aortic structions for multilevel arterial occlusive 8. Back MR, Novotney M, Roth SM, et al. atherosclerosis: a 9-year population-based disease. Am J Surg 2001;181:251. Utility of duplex surveillance following iliac follow-up study in women. Circulation 5. Morasch MD, Collins J, Pereles FS, et al. artery angioplasty and primary stenting. 1993;88:2156. Lower extremity stepping-table magnetic J Endovasc Ther 2001;8:629. 2. McGill HC Jr, McMahan CA, Malcom GT, resonance angiography with multilevel 9. Sanchez LA, Wain RA, Veith FJ, et al. et al. Effects of serum lipoproteins and contrast timing and segmented contrast Endovascular grafting for aortoiliac occlusive smoking on atherosclerosis in young men infusion. J Vasc Surg 2003;37:62. disease. Semin Vasc Surg 1997;10:297. and women. The PDAY Research Group. 6. Loewe C, Schoder M, Rand T, et al. 10. Gray BH, Sullivan TM. Aortoiliac occlusive Pathobiological determinants of athero- Peripheral vascular occlusive disease: disease: surgical versus interventional sclerosis in youth. Arterioscler Thromb Vasc evaluation with contrast-enhanced moving- therapy. Curr Interv Cardiol Rep 2001;3: Biol 1997;17:95. bed MR angiography versus digital sub- 109. 3. Van Der Meer IM, De Maat MP, Hak AE, traction angiography in 106 patients. AJR 11. Kalman PG. Thoracofemoral bypass: et al. C-reactive protein predicts progression Am J Roentgenol 2002;179:1013. proximal exposure and tunneling. Semin of atherosclerosis measured at various sites 7. Pandharipande PV, Lee VS, Reuss PM, Vasc Surg 2000;13:65. in the arterial tree: the Rotterdam study. et al. Two-station bolus-chase MR angio- 12. Nash T. Aortoiliac occlusive vascular Stroke 2002;33:2750. graphy with a stationery table: a simple disease: a prospective study of patients 06/08
  11. 11. © 2008 BC Decker Inc ACS Surgery: Principles and Practice 6 VASCULAR SYSTEM 12 AORTOILIAC RECONSTRUCTION — 11 treated by endarterectomy and bypass aortofemoral bypass for aortoiliac occlusive 19. Naylor AR, Ah-See AK, Engeset J. procedures. Aust N Z J Surg 1979;49:223. disease. J Vasc Surg 1996;23:263. Axillofemoral bypass as a limb salvage 13. Brewster DC. Clinical and anatomical 16. Martin D, Katz SG. Axillofemoral bypass procedure in high risk patients with aortoiliac considerations for surgery in aortoiliac for aortoiliac occlusive disease. Am J Surg disease. Br J Surg 1990;77:659. disease and results of surgical treatment. 2000;180:100. 20. Criado E, Burnham SJ, Tinsley EA Jr, et al. Circulation 1991;83:I42. 17. Taylor LM Jr, Moneta GL, McConnell D, Femorofemoral bypass graft: analysis of 14. de Vries SO, Hunink MG. Results of aortic et al. Axillofemoral grafting with externally patency and factors influencing long-term bifurcation grafts for aortoiliac occlusive supported polytetrafluoroethylene. Arch outcome. J Vasc Surg 1993;18:495. disease: a meta-analysis. J Vasc Surg Surg 1994;129:588. 1997;26:558. 18. Rutherford RB, Patt A, Pearce WH. Extra- Acknowledgment 15. Passman MA, Taylor LM, Moneta GL, anatomic bypass: a closer view. J Vasc Surg et al. Comparison of axillofemoral and 1987;6:437. Figures 1 through 8 Alice Y. Chen. 06/08

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