Peripheral arterial occlusive disease often occurs in a multilevel distribution. This multilevel distribution carries significant therapeutic implications, as the first principle guiding the planning of a successful revascularization remains treating inflow disease prior to further distal procedures, if needed. Inflow procedures address occlusive disease in the aorta and iliac arteries of symptomatic limbs. Symptomatic aortoiliac disease is usually manifested as claudication in the calf with extension to the thigh and buttock area. Rest pain and tissue loss are unusual with isolated aortoiliac disease because significant collaterals often develop to maintain distal perfusion. Limb-threatening ischemia, rest pain, and tissue loss frequently occur when multilevel occlusive disease involves a combined distribution of aortoiliac and infrainguinal disease. Claudication and rest pain may be relieved by treatment of the inflow problem; however, tissue loss may require the addition of a distal revascularization. The Leriche syndrome is a classic symptom complex of aortoiliac disease involving hip and thigh claudication, impotence, and absent femoral pulses. Impotence occurs as flow to the internal pudendal artery is decreased, causing insufficient flow for erectile function. Indications for treatment of inflow disease include disabling claudication, rest pain, or tissue loss.

Advances in endovascular therapy have established angioplasty and stenting as the most common intervention for aortoiliac lesions, especially for Trans-Atlantic Inter-Society Consensus (TASC) A/B lesions. Although the results of endovascular interventions are less durable for TASC C lesions, these options are still acceptable for patients with medical comorbidities. Nevertheless, when endovascular interventions are unsuccessful for these lesions or inadvisable (as for TASC D lesions), operative treatment may be indicated. Surgical procedures performed for aortic and unilateral iliac occlusive disease include endarterectomy, anatomical bypasses such as aorto- or iliofemoral bypasses, or extra-anatomical configurations such as axillofemoral, femorofemoral, or crossover iliofemoral bypasses. In this chapter, we will focus on the surgical techniques and relevant details of ipsilateral and crossover iliofemoral bypasses.

Ipsilateral iliofemoral bypass (Fig. 21.1) may be considered when the aorta and proximal common iliac artery are free of hemodynamically significant disease. When the ipsilateral common iliac artery is occluded but the contralateral iliac circulation is
well preserved, iliofemoral crossover bypass (Fig. 21.2) is a good alternative, especially in high-risk patients because this procedure can avoid cavitary exposure and may be done under regional anesthesia. Crossover iliofemoral bypass is certainly favored when there is heavy scarring or infection in the contralateral femoral region. Careful preoperative evaluation and medical optimization are essential to obtain good outcomes, with an individualized approach considered for each patient.

In the patient with unilateral inflow occlusive disease an iliofemoral bypass is an excellent option, especially for patients who are at increased risk for an abdominal aortic procedure. The operation is performed through a flank approach and a retroperitoneal dissection. The bypass extends from the common iliac artery to the femoral artery typically using an 8-mm Dacron or ePTFE graft. The graft is tunneled in an anatomic position in the retroperitoneum and brought under the inguinal ligament into the groin for anastomosis to the femoral artery. Results are excellent with 5-year patency reported between 75% and 90%.

Extra-anatomic bypasses do not follow the normal anatomic course of the arterial tree. These operations are performed when the risk of an anatomical procedure is excessive due to the patient’s medical condition or infected tissue planes. Crossover iliofemoral
bypass is appropriate for unilateral aortoiliac disease in a patient considered a poor operative risk for an intra-abdominal procedure. The bypass requires a contralateral iliac artery without significant disease to serve as inflow. Blood is routed from the contralateral iliac artery to enhance flow to the femoral artery on the symptomatic side typically with an 8-mm Dacron or externally reinforced ePTFE graft. Progression of disease in the donor iliac artery can occur; however, it is relatively uncommon.

Preoperative preparation should identify and medically optimize the comorbid conditions that could result in serious postoperative complications such as myocardial or cerebrovascular ischemia. In patients who are at high risk for coronary artery occlusive disease, noninvasive testing such as ischemic stress test by dipyridamole thallium scintigraphy or stress echocardiography should be obtained, if indicated. Arterial noninvasive testing such as segmental pressures and waveforms with ankle brachial indices (ABIs) should be obtained to assess the severity of the disease at baseline. Although CT and MR angiography can deliver excellent images of the aortoiliac circulation, multiplanar angiography of the bilateral iliac and femoral arterial system should be considered to evaluate the adequacy of the inflow and distal targets in planning for a successful operation. If there is any doubt about subtle disease of the donor iliac artery, pressure gradients should be measured and endovascular intervention executed as indicated to optimize to donor iliac system before the planned surgical revascularization. For male patients who are sexually active, the possibility of sexual dysfunction should be discussed.