Operative Approach

The infrarenal abdominal aorta may be exposed for aortofemoral reconstruction by a variety of approaches. A long midline vertical incision is employed most often and is generally preferred because it is rapidly made, is easy to close, and affords maximal exposure and technical flexibility in most patients. A retroperitoneal approach may also be used, if desired. For this method, the patient is positioned with the shoulders and torso rotated approximately 45 degrees toward the right, while the hips and extremities are maintained as horizontal as possible to facilitate exposure of the femoral arteries in each groin. An oblique left flank incision beginning at the tip of the twelfth rib and carried toward the midline just below the umbilicus is used.

A retroperitoneal approach is potentially advantageous in patients who have had multiple prior abdominal operations or, particularly, for reoperative aortic procedures. This approach is also often useful for obese patients or those with right-sided intestinal stomas. Advocates also believe that a retroperitoneal approach causes less postoperative ileus, decreased fluid losses, and reduced cardiopulmonary stresses postoperatively. However, many of these potential benefits are not conclusively established. The author prefers a transperitoneal midline approach, primarily because of the easier and generally superior exposure of the femoral arteries that it allows. A retroperitoneal approach is reserved for some of the specific technical indications outlined earlier.

Bilateral groin incisions are made to expose both femoral arteries. Any lymph nodes or lymphatic tissue is best divided between clamps and then suture ligated to minimize the possibility of a postoperative lymphatic leak with its associated risk of wound or graft infection. The posterior aspect of the inguinal ligament is partially divided directly over the femoral artery to ensure ample space for tunneling the graft without compression. Dissection is carried to just beyond the femoral artery bifurcations, and the proximal aspect of both superficial and deep femoral artery branches are encircled with silicone elastic (Silastic) loops. If preoperative arteriograms or palpation at the time of operation suggests significant occlusive disease involving the proximal deep femoral artery branch, more distal exposure of this vessel for at least another 2 to 3 cm is required to allow concomitant profundaplasty at the time of distal graft anastomosis. This method usually necessitates dividing and ligating one or more branches of the deep femoral vein that typically cross the anterior surface of the proximal profunda femoris artery.

Tunnel Construction

After the aortic and femoral artery dissection are completed, retroperitoneal tunnels between the two fields of dissection are made for subsequent passage of each graft limb. Such tunnels are best made by gentle blunt dissection with the index finger of each hand simultaneously from the groins and the area of the aortic bifurcation (Figure 1). Dissection should be kept on a plane directly anterior to the common and external iliac vessels to ensure that the graft is subsequently placed posterior to the ureter. This detail is important because passage of graft anterior to the ureter can lead to later compression and obstruction of the ureter and hydronephrosis. After appropriate tunnels have been created to both groins, a long blunt-tipped clamp is placed through the tunnel, and a Penrose drain is drawn through the tunnel. Elevation on both ends of this facilitates later passage of the graft limbs to the site of distal graft anastomosis.

Stay updated, free articles. Join our Telegram channel

Join