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
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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.
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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.
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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.
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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.
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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.
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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.
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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.)
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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.
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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
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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.
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