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This document discusses surgical bypass options for aorto-iliac occlusive disease (AIOD). It defines AIOD and describes the standard TASC classification system. The main indications for surgical intervention are claudication or chronic limb-threatening ischemia. Surgical bypass options described include aortoiliac endarterectomy, aortobifemoral bypass, femorofemoral bypass, axillofemoral bypass, and obturator bypass. Postoperative patency rates for different procedures are provided.
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Aiod
- 1. SURGICAL BYPASS OPTIONS IN AORTO-ILIAC OCCLUSIVE DISEASE F2 PARACH SIRISRIRO 14th Aug 2018
- 3. OUTLINE DEFINITION TYPE STANDARD TREATMENT INDICATION FOR SURGICAL BYPASS SURGICAL BYPASS OPTIONS PATENCY
- 4. DEFINITION • Multilevel atherosclerotic occlusive disease involving the distal aorta, iliac vessels, and common femoral arteries is a common occurring pathology seen often by vascular surgeons. Dalman, Ronald. Operative Techniques in Vascular Surgery (Kindle Locations 8452-8458).
- 5. AIOD TYPE
- 6. TASC 2007
- 7. TASC 2007
- 8. TASC
- 11. ROLE OF OPEN SURGERY < 1-5% Peri-renal thrombus • Small hypoplastic aorta • Eccentric, cauliflour calcification • Multiple failed interventions Mortality: 1-4% - 5yr Patency >90% Morbidity: 20-25%
- 12. CLAUDICATION • Indications for surgical reconstruction for symptomatic AIOD - Disabling claudication - Ischemic rest - pain, and tissue loss. • Claudication is a relative indication for intervention, given the natural history of the disease. • In patients of low surgical risk with disabling symptoms from disease limited to the aortobifemoral segment, surgical bypass is an appropriate option.
- 13. CHRONIC LIMB-THREATENING ISCHEMIA • More signifcant risk of amputation without revascularization • The presence of ischemic rest pain, frank ulceration, or digital gangrene are well-accepted indications for surgical correction of AIOD. • An aortic or iliac source of distal emboli, typically from an ulcerated atheromatous plaque or so-called shaggy aorta operative reconstruction is usually indicated. The goal of intervention is to prevent recurrent distal embolization.
- 14. SURGICAL TREATMENT • long-segment arterial disease such as a long superficial femoral artery occlusion is probably best treated with open bypass from the standpoint of durability of the revascularization. • Direct reconstruction for AIOD : patients with endovascular treatment has failed Extensive disease that an endovascular approach is deemed inadvisable
- 15. • A combination of more proximal aneurysmal disease and common or external iliac occlusive disease • Extensive calcifcation at the aortic bifurcation prone to be at risk for rupture with balloon angioplasty • Disease extending to the CFA with unsuitable for an endovascular approach. • Early recurrence of AIOD after angioplasty or stenting • Signifcant renal failure which endovascular therapy triggers dialysis dependence SURGICAL TREATMENT
- 26. AORTOILIAC ENDARTERECTOMY Appropriate for patients with type I disease, aortoiliac endarterectomy is only infrequently performed today. Advantages include - the lack of prosthetic material, - no infective potential - continuity of antegrade inflow to the hypogastrics. Contraindications include - evidence of aneurysmal change - total occlusion of the aorta to the level of the renal arteries, and extension of the disease into the external iliac and distal vessels.
- 27. AORTOILIAC ENDARTERECTOMY • Endarterectomy is now rarely performed for AIOD • its relative technical difculty, potential for signifcant blood loss • poor durability as well as the clear advantages of bypass grafting in this location.
- 29. AORTOBIFEMORAL BYPASS • Indications • disabling or lifestyle-limiting claudication, rest pain, or tissue loss and TransAtlantic Intersociety Consensus (TASC) D aortoiliac occlusive disease • aortobifemoral bypass may be more appropriate than endovascular revascularization because of improved long- term patency for TASC C disease. • Contraindications • associated with significant cardiopulmonary morbidity. Patients with cardiopulmonary comorbidities prohibitive of general anesthesia are not candidates for this procedure.
- 30. AORTOBIFEMORAL BYPASS • Incision The infrarenal abdominal aorta Long midline incision provides the best exposure and is preferred.
- 31. AORTOBIFEMORAL BYPASS • Incision : A retroperitoneal approach
- 32. • Exposure of the Abdominal Aorta AORTOBIFEMORAL BYPASS
- 33. AORTOBIFEMORAL BYPASS • EXPOSURE OF THE FEMORAL ARTERIES
- 34. AORTOBIFEMORAL BYPASS • EXPOSURE OF THE DISTAL PROFUNDA • Profundaplasty may need to be performed at the same time as aorto-bifemoral grafting, • To perform this adequately, at least 2 to 3 cm of the profunda must be exposed.
- 35. TUNNEL CONSTRUCTION • Tunnels are made by gentle blunt dissection, with the index fingers, simultaneously from the groins and the aortic bifurcation. • Care must be made to construct the tunnel underneath the ureters and thus avoid possible hydronephrosis.
- 36. CLAMP PLACEMENT
- 38. PROXIMAL GRAFT ANASTOMOSIS • END-TO-END AORTIC ANASTOMOSIS • The graft is cut 3 to 4 cm from its bifurcation to construct a prosthesis with a short body or stem. • This confguration facilitates retroperitoneal closure over the graft and allows separation of the anastomosis from the duodenum. • It also diminishes the takeoff angle of the limb, which prevents kinking and potential graft limb thrombosis.
- 39. PROXIMAL GRAFT ANASTOMOSIS • END-TO-SIDE AORTIC ANASTOMOSIS • Totally occluding an aortic segment with proximal and distal by aortic clamps • The anastomosis is placed as cephalad as possible by cutting the graft with a bevel of approximately 60 degrees (anterior posterior) that extends close to the aortic bifurcation.
- 41. OTHER OPERATIVE CONSIDERATIONS • External Iliac Anastomosis an aortobiiliac bypass remains advantageous in • Patients with hostile groin creases from prior surgery or radiation therapy Patients with obese, diabetic patients with an intertriginous rash at the inguinal crease and patent external iliac arteries.
- 42. COMPLICATION
- 43. AORTOILIAC DISEASE: OPEN EXTRAANATOMIC BYPASS • Extraanatomic procedures were developed as alternatives to direct aortofemoral bypass for patients - at high risk for direct aortic surgery - presenting with a “hostile” abdomen, - an infection of the native aortoiliac arterial system - prior prosthetic replacement of the aortoiliac system
- 44. FEMOROFEMORAL BYPASS Femorofemoral bypass has been a frequently applied procedure in patients with dominant unilateral iliac artery disease
- 45. FEMOROFEMORAL BYPASS Anastomoses to the common femoral artery may extend onto the deep or superficial femoral This decision is most often made after exposure, inspection, and palpation of the femoral arteries
- 46. AXILLOFEMORAL BYPASS (1)excessively high physiologic risk for direct aortic repair (2) patients with infected native aortas or aortic grafts or the closely related problem of aortoenteric fstulas, (3)a hostile abdomen, generally with multiple previous surgeries, active intra- abdominal infection, (4)presence of intestinal or urinary stomas.
- 47. AXILLOFEMORAL BYPASS • SELECTION OF A DONOR ARTERY • The versatility of the axillofemoral bypass depends on • The ability of one axillosubclavian artery to supply enough blood flow to adequately perfuse both the donor arm and one (axillounifemoral bypass) or more often both (axillobifemoral bypass) legs. • Avoid in - presence of intestinal or urinary stomas - placement of an axillofemoral bypass based on the side of an existing arteriovenous hemoaccess fistula, since this might provoke or worsen existing steal symptoms
- 50. OBTURATOR BYPASS - maintain perfusion of the leg after dealing with arterial infection in the groin. - requires tunnelling a graft from the iliac arterial system through the obturator fossa in the pelvis to the infrainguinal arterial system
- 51. OBTURATOR BYPASS • The primary indication for this procedure is arterial infection in the femoral triangle • patient in the supine position with the entire ipsilateral leg circumferentially prepped and draped • The incision should be in the anteromedial part of the obturator membrane to avoid the obturator nerve and artery. • The graft is usually placed in the potential space between the adductor magnus posteriorly and the adductor longus and brevis anteriorly,
- 52. PATENCY
- 53. PATENCY
- 54. THANK YOU
Hinweis der Redaktion
- 1. Rutherford's Vascular Surgery and Endovascular Therapy, Chapter 74,
- Type I : localized to distal abdominal aorta and CIA : Symptoms typically consist of bilateral thigh or buttock claudication and fatigue. Men report diminished penile tumescence and may have complete loss of erectile function. These symptoms in the absence of femoral pulses constitute Leriche’s syndrome. Type II more widespread intraabdominal disease : This disease pattern affects approximately 25% patients with aortoiliac occlusive disease. Type III multilevel disease with associated infrainguinal occlusive lesion : affects approximately 65% pattern tend to present with symptoms of advanced ischemia and require revascularization for limb salvage
- TASC Trans atlantic intersociety consensus document on management of peripheral arterial disease
- Choice based on 1. Affected arterial segment 2. Length of Disease segment 3. Patient characteristic
- A, Occlusive disease is limited to the distal aorta and common i;liac arteries. location of typical arteriotomies is indicated by dotted lines. B, The endarterectomy plane is achieved, and atheromatous disease is removed from the level of the proximal aortic clamp to the bifurcation. C, A satisfactory endpoint is attained at the iliac bifurcation, and endarterectomy is carried proximally. Tacking sutures may be necessary to secure an adequate endpoint.
- ). From a technical standpoint, the atherosclerotic disease should terminate at the iliac bifurcation to obtain satisfactory results and achieve a good endpoint no farther than 1 to 2 cm into the external iliac arteries. Bilateral longitudinal arteriotomies, one extending from the distal aorta into one common iliac artery and the other confined to the common iliac artery, are performed. The proper endarterectomy plane, to the level of the external elastic lamina, should be obtained. Patch closure, either with vein or prosthetic, can be used. Tacking sutures may also be used to secure the distal endpoint.
- Aortofemoral graft. A, A segment of diseased aorta is resected, and the distal aortic stump is oversewn. B, End-to-end proximal anastomosis. C, Completed reconstruction
- A retroperitoneal approach may also be used (shoulders and torso rotated 45 degrees to the right, with the hips and extremities maintained as horizontal as possible to facilitate femoral artery exposure). The incision is made obliquely in the left flank, starting at the tip of the twelfth rib toward the midline below the umbilicus. This incision is good for patients with right-sided stomas and previous abdominal surgery, including aortic surgery. The retroperitoneal approach may reduce ileus and postoperative cardiopulmonary stress.
- The abdominal aorta is then exposed using a standard infrarenal approach. The transverse colon and greater omentum are retracted cephalad and secured with a wet towel. We prefer to have the entire small bowel eviscerated, covered with a lap pad, and the descending and sigmoid portions of the colon retracted laterally and caudally. Next the parietal peritoneum between the duodenum and the inferior mesenteric vein is incised along the long axis of the aorta. The inferior mesenteric vein may need to be divided for optimal exposure of the proximal aorta. Care is taken to preserve the autonomic nerve fibers on the anterolateral aspect of the aorta down to the left common iliac artery; these are involved in male sexual function. The fourth portion of the duodenum is mobilized, and the dissection is carried to expose the left renal vein as it crosses anterior to the aorta. Distally, the aorta is exposed past the origin of the inferior mesenteric artery. This allows construction of the proximal anastomosis and of the graft limb tunnels.
- Bilateral oblique groin incisions are preferred because they are easy to close and provide technical flexibility. The incision is carried partially above the anatomic position of the inguinal ligament to ensure adequate exposure. Lymphatic tissue is divided between clamps to minimize the occurrence of lymphatic leaks. The caudal border of the inguinal ligament is divided to ensure enough space for tunneling of the graft. When performing this, care must be taken to ligate the superfcial circumflex vein that courses on top of the distal external iliac artery to avoid injury and bleeding during the creation of the tunnel (Fig. 28-4). The common, superfcial, and profunda femoral arteries should be dissected out and controlled. Sizable branches of the femoral arteries should be controlled with loops and preserved if possible
- Creation of the retroperitoneal tunnel to the femoral artery. Care must be taken to place the graft limb underneath the ureter.
- Anterior to posterior clamping may be necessary in the presence of a soft anterior but calcifed posterior aortic wall. Appropriate atraumatic vascular clamps are selected, and after sufcient time is allowed for the heparin to circulate, the aorta is clamped frst proximally or distally at the site of least disease to avoid dislodgement and potential distal embolization of plaque. Te distal clamp is usually placed above or below the inferior mesenteric artery. The proximal clamp is placed just below the renal arteries if the disease pattern does not obligate suprarenal clamping, with as little dissection of the renal artery origins as possible
- Aortogram showing occlusion of the aorta below the level of the renal arteries (a). In this case the proximal anastomosis of an aorto-bifemoral bypass should be end to end (b). If there is continuity with the inferior mesenteric artery or internal iliac arteries, then an end-to-side anastomosis (c) may be preferable
- The standard anastomosis is constructed using a 3-0 running polypropylene suture run from both the posterior and the anterior midline clockwise and counterclockwise, and it is tied in the lateral aspect of the aorta. Thromboendarterectomy of the proximal aortic cuff up to the proximal clamp can be performed in cases of signifcant disease at the site of the intended proximal graft anastomosis. In this event, an interrupted, pledgeted suture technique is recommended because of the thinness and possible fragility of the remaining adventitia of the endarterectomized aortic wall
- Graft limbs are then passed down into the femoral region with the aid of the previously placed Penrose drains and a large DeBakey aortic clamp. Care is taken to avoid twisting the graft limbs. The femoral anastomosis must ensure good flow to the profunda femoris arteries Because of this, the profunda arteries should be evaluated by both preoperative imaging and intraoperatively by passage of 3.5- to 4.0-mm dilators at the time of anastomosis to ensure that no significant stenotic lesion are present. A standard end-to-side anastomosis to the common femoral artery is performed
- INCISION AND EXPOSURE Femoral-femoral bypass depends on the ability of one “donor” iliac artery to supply enough blood flow to perfuse both the donor and the “recipient” legs Oblique, groin-crease incisions may be used, but longitudinal groin incisions centered over the femoral arteries and beginning approximately at the inguinal ligament provide the most flexibility and are preferred by most surgeons. Incision length depends on patient habitus.
- ANASTOMOSIS Systemic heparin or another suitable anticoagulant is administered, and in most cases a longitudinally oriented or slightly oblique arteriotomy is created in a convenient place for anastomosis. Making the anastomosis on a more distal portion of the femoral system, such as the deep or superficial femoral artery, may be dictated by local anatomy and may reduce the tendency of the graft to kink in the sagittal plane in patients with protuberant abdomens. As with most end-toside anastomoses, arteriotomies are made about three times as long as the graft diameter. The graft ends are spatulated by placing a curved hemostat on the graft and then using a scalpel to cut the ePTFE graft along the inside of the hemostat curve. An end-to-side graft to artery anastomosis is then created using running 5-0 or 6-0 polypropylene or CV-5 or CV-6 polytetrafluoroethylene (PTFE) suture. The donor-side anastomosis is usually performed first, although either side may be completed first and the anastomoses may be performed simultaneously
- Triphasic brachial artery Doppler waveform and a blood pressure no more than 10 mm Hg lower in the proposed donor arm than in the contralateral arm.
- A, the donor axillary artery is exposed using a transverse incision inferior to the clavicle and the artery is controlled from the clavicle medially to the pectoralis minor muscle laterally. B,the graft is tunneled posterior to the pectoralis minor muscle and then subcutaneously in the midaxillary line
- The graft is generally tunneled in the midaxillary line and lateral abdomen from the donor axillary artery to the ipsilateral femoral recipient artery. C, a femoral-femoral graft is first placed, followed by the anastomosis of the distal axillofemoral graft limb to the ipsilateral hood of the femoral-femoral graft. D,the distal axillofemoral graft limb is anastomosed to the femoral artery followed by the anastomosis of the ipsilateral side of a femoral-femoral graft to the hood of the axillofemoral graft