This operation for aorto-iliac occlusive disease is less frequently performed since the advent of effective percutaneous balloon angioplasty with or without stent placement.

Incisions

Full length midline to expose the abdominal aorta and vertical groin to expose the common femoral arteries on each side.

Procedure

• After a full laparotomy, expose the aorta from below the left renal vein as in an aneurysm repair.
• Divide the peritoneum over the aorta continuing down to expose both common iliac arteries.
• Palpate the aorta and the iliac arteries to determine the extent of the disease and select the site of proximal anastomosis, avoiding large calcified plaques. The aortic segment between left renal vein and the inferior mesentesic artery is best.
• If there is total aortic occlusion, transect it and construct an end-to-end anastomosis with the proximal graft. Otherwise, an end to side onlay anastomosis is preferable to preserve perfusion of the internal iliac arteries.
• After systemic heparinization, aortic control is achieved with vascular clamps.
• A pulsatile inferior mesenteric artery with wide ostia should be preserved.
• Select a bifurcated dacron graft of appropriate size and trim the excess of the body of the graft leaving only few centimeters to avoid kinking of its limbs.
• Construct the proximal anastomosis using synthetic non-absorbable sutures.
• On completion of the aortic anastomosis, apply clamps to each limb of the graft and release the aortic clamp to test its integrity.
• Expose the common femoral artery below the inguinal ligament and place separate rubber slings around common femoral, superficial femoral and profunda femoral arteries.
• Make tunnels retroperitoneally and under the inguinal ligaments, through which to pass the limbs of the graft to the groin incisions. It is preferable to make these tunnels prior to heparinisation.
• Apply clamps to the common, superficial and profunda femoral arteries and make a longitudinal arteriotomy above the bifurcation. The distal anastomoses of graft to femoral arteries are completed in an end to side fashion. Each limb is flushed before completing the anastomosis.

• After completion clamps are released sequentially to avoid declamping shock.
• Finally, the circulation to both feet is checked.

Intraoperative Problems

Aortic clamps can cause fracture of calcified plaques and tear the wall of aorta. This can be controlled by higher application of the aortic clamp and buttress suturing using dacron pledgets.

Main Postoperative Complications

Are similar to those occurring after aortic aneurysm repair.

Back Forward