Endarterectomy for Atherosclerotic Aortoiliac Occlusive Disease



Endarterectomy for Atherosclerotic Aortoiliac Occlusive Disease



Louis M. Messina and Andres Schanzer


Thromboendarterectomy was the first technique used to treat aortoiliac occlusive disease. Dos Santos performed the first femoral endarterectomy in Lisbon in 1947. Wylie performed the first successful aortoiliac thromboendarterectomy in the United States in 1951. Over the ensuing decades, aortobifemoral bypass grafting using synthetic grafts and, more recently, endovascular stenting have replaced thromboendarterectomy as the primary surgical technique to manage aortoiliac occlusive disease. Nonetheless, aortoiliac endarterectomy can still play an important role in managing these patients under specific clinical circumstances.


Thromboendarterectomy is feasible technically because of the pathologic distribution of atherosclerosis in the arterial wall and relies on the principle that the strength and integrity of the arterial wall depends on the outermost layer of adventitia. Atherosclerotic lesions are confined to the intima and inner media of the arterial wall. In general, the cleavage plane within the deep media is identified relatively easily. To complete an endarterectomy, the transition zone of the plaque from its position within the intima and media to the point at which it resides exclusively within the intima must be identified to feather the distal endpoint.


Aortoiliac endarterectomy has certain distinct advantages over synthetic grafting. It is an autogenous tissue technique. Therefore it is not vulnerable to graft infection. The technique of aortoiliac endarterectomy also permits direct revascularization of the internal iliac arteries in patients who have internal iliac artery stenoses or occlusions and have impotence or buttock claudication. Finally, endarterectomy can also be applied when there is a compelling indication for revascularization, such as critical limb ischemia in the presence of a contaminated operative field. The primary contraindication to aortoiliac endarterectomy is the existence of a degenerated or aneurysmal aortic wall.


Optimal outcome after aortoiliac endarterectomy depends on appropriate patient selection. Ideally, this technique is applied in patients whose aortoiliac occlusive disease terminates at or near the common iliac bifurcation. This pattern of disease is often referred to as type A disease, which is found in 5% to 10% of patients requiring aortic reconstruction for occlusive disease. The type A pattern of occlusive disease is particularly common in young women who have a history of tobacco use. Aortoiliac endarterectomy is also a favored technique in patients who have symptomatic atheroembolism resulting from an aortic lesion if an open technique is used to treat it.



Operative Technique


Operative exposure is obtained thorough a standard xiphoid-to-pubis midline abdominal incision. The incision in the retroperitonum over the aorta is placed toward the right of the midline and continued down along the right common iliac artery. The dissection is undertaken to preserve the periaortic nervi erigentes, which course along the left side of the aorta and left common iliac artery (Figure 1A). Aortoiliac endarterectomy requires complete mobilization of the aorta and iliac artery branches, including all of the lumbar arteries (see Figure 1B). This mobilization must be accomplished relatively atraumatically to minimize the risk of atheroembolization during the procedure.


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FIGURE 1 A, Incision in the retroperitoneum on the surface of the aorta is made to the right of the midline and extended onto the anterior surface of the right common iliac artery to avoid both the inferior mesenteric artery and the nervi erigentes, which cross the proximal left common iliac artery as they descend into the pelvis. B, Complete atraumatic mobilization of the aorta is fundamental to the successful aortoiliac endarterectomy. This includes full mobilization of the posterior aorta and lumbar arteries. A linear aortotomy is made extending just below the renal arteries up to the aortic bifurcation. The aortic atheroma is resected proximally with Metzenbaum scissors and distally at the aortic bifurcation. (From Wylie EJ, Stoney RJ, Ehrenfeld WK: Manual of vascular surgery, New York, 1980, Springer-Verlag.)

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  3. Treatment of Acute Upper Extremity Venous Occlusion
  4. Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy

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Aug 25, 2016 | Posted by in CARDIOLOGY | Comments Off on Endarterectomy for Atherosclerotic Aortoiliac Occlusive Disease

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