Unilateral Retroperitoneal Iliofemoral Bypass Peter G. Kalman The typical patient with isolated iliac occlusive disease generally has intermittent claudication. Critical ischemia in the form of rest pain, ulceration, or gangrene is usually absent unless multilevel disease exists. There are several management options for symptomatic patients with unilateral iliac occlusive disease ranging from conservative medical management to endovascular catheter-based intervention or open operation. Treatment Algorithm for Iliac Occlusive Disease The initial approach for management of localized iliac disease, if feasible, is usually balloon dilation with percutaneous transluminal angioplasty (PTA). There is little evidence to support routine primary stenting after successful iliac PTA other than for a few specific indications, such as lesion recoil, an eccentric lesion, or a dissection following dilation. In general, the results with PTA are less satisfactory than after open surgical reconstruction, but considering the low morbidity and the option of repeating the procedure, PTA is justified for localized iliac stenoses or short occlusions. The only lesion not amenable to PTA is the less common focal iliac coral-reef plaque, which is best managed by endarterectomy. Extensive iliac endarterectomy is rarely performed in contemporary practice since those times when it was more routinely pursued in the 1960s. The long-term results for localized endarterectomy are excellent; however, most patients with localized disease previously treated by endarterectomy are now treated by PTA. Extensive endarterectomy is tedious and time consuming, and it is associated with greater blood loss than bypass grafting and a risk of sexual dysfunction in male patients. Although aortobifemoral bypass is the gold standard for managing patients with diffuse aortoiliac occlusive disease, other suitable options exist for those with unilateral iliac disease. A femorofemoral bypass is often indicated with extensive unilateral iliac disease in the presence of a normal donor iliac artery in patients in all risk categories. An axillofemoral bypass is indicated in patients with a high anesthetic risk for which a femorofemoral bypass is not possible because of the extent of donor iliac disease. A unilateral iliofemoral bypass is a third option, provided that the aorta and ipsilateral common iliac artery are normal or only minimally diseased. Retroperitoneal Iliofemoral Bypass: Surgical Technique The patient is positioned supine and a wide field, including the abdomen, both groins, and lower extremities, is prepped and draped with the feet are covered in clear plastic bags. The common femoral, superficial femoral, and profunda arteries are isolated through a vertical groin incision and preoperative arteriogram. Exposure of the iliac artery is facilitated by slightly tilting the table with the operative side upward. The retroperitoneal incision for exposure of the iliac artery extends obliquely from the anterior axillary line, in line with the tip of the 10th rib, to the midline approximately 3 to 4 cm below the umbilicus. The medial extent of the incision often can be shortened to the midrectus level in patients with a wide costal margin. Keeping the incision high at this level facilitates ample exposure all the way up to the aortic bifurcation, if necessary. The anterior rectus sheath and rectus muscle are divided using cautery, followed by transection of the external and internal oblique muscles. The retroperitoneal exposure is developed, beginning laterally in the flank after splitting the transversus abdominus muscle in the line of its fibers. The peritoneum is then stripped posteriorly and anteriorly, and the entire envelope of peritoneum is retracted medially, with retraction maintained using a table retractor. The ureter is identified as it crosses the bifurcation of the common iliac artery and is carefully mobilized and retracted medially. Before vascular reconstruction, the patient is systematically anticoagulated with intravenous heparin (75–100 U/kg). Generally, an 8-mm graft is selected for the conduit in normal-sized adults. The proximal anastomosis is performed end to side at a suitable location on the common iliac artery using a running 4–0 or 5–0 polypropylene monofilament suture with a parachute technique. The graft is tunneled under the inguinal ligament, and the distal anastomosis is performed to the selected outflow artery. After reversal of the heparin anticoagulation with protamine and other satisfactory hemostasis is evident, the abdominal wall and groin incisions are closed in a standard fashion. 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Unilateral Retroperitoneal Iliofemoral Bypass Peter G. Kalman The typical patient with isolated iliac occlusive disease generally has intermittent claudication. Critical ischemia in the form of rest pain, ulceration, or gangrene is usually absent unless multilevel disease exists. There are several management options for symptomatic patients with unilateral iliac occlusive disease ranging from conservative medical management to endovascular catheter-based intervention or open operation. Treatment Algorithm for Iliac Occlusive Disease The initial approach for management of localized iliac disease, if feasible, is usually balloon dilation with percutaneous transluminal angioplasty (PTA). There is little evidence to support routine primary stenting after successful iliac PTA other than for a few specific indications, such as lesion recoil, an eccentric lesion, or a dissection following dilation. In general, the results with PTA are less satisfactory than after open surgical reconstruction, but considering the low morbidity and the option of repeating the procedure, PTA is justified for localized iliac stenoses or short occlusions. The only lesion not amenable to PTA is the less common focal iliac coral-reef plaque, which is best managed by endarterectomy. Extensive iliac endarterectomy is rarely performed in contemporary practice since those times when it was more routinely pursued in the 1960s. The long-term results for localized endarterectomy are excellent; however, most patients with localized disease previously treated by endarterectomy are now treated by PTA. Extensive endarterectomy is tedious and time consuming, and it is associated with greater blood loss than bypass grafting and a risk of sexual dysfunction in male patients. Although aortobifemoral bypass is the gold standard for managing patients with diffuse aortoiliac occlusive disease, other suitable options exist for those with unilateral iliac disease. A femorofemoral bypass is often indicated with extensive unilateral iliac disease in the presence of a normal donor iliac artery in patients in all risk categories. An axillofemoral bypass is indicated in patients with a high anesthetic risk for which a femorofemoral bypass is not possible because of the extent of donor iliac disease. A unilateral iliofemoral bypass is a third option, provided that the aorta and ipsilateral common iliac artery are normal or only minimally diseased. Retroperitoneal Iliofemoral Bypass: Surgical Technique The patient is positioned supine and a wide field, including the abdomen, both groins, and lower extremities, is prepped and draped with the feet are covered in clear plastic bags. The common femoral, superficial femoral, and profunda arteries are isolated through a vertical groin incision and preoperative arteriogram. Exposure of the iliac artery is facilitated by slightly tilting the table with the operative side upward. The retroperitoneal incision for exposure of the iliac artery extends obliquely from the anterior axillary line, in line with the tip of the 10th rib, to the midline approximately 3 to 4 cm below the umbilicus. The medial extent of the incision often can be shortened to the midrectus level in patients with a wide costal margin. Keeping the incision high at this level facilitates ample exposure all the way up to the aortic bifurcation, if necessary. The anterior rectus sheath and rectus muscle are divided using cautery, followed by transection of the external and internal oblique muscles. The retroperitoneal exposure is developed, beginning laterally in the flank after splitting the transversus abdominus muscle in the line of its fibers. The peritoneum is then stripped posteriorly and anteriorly, and the entire envelope of peritoneum is retracted medially, with retraction maintained using a table retractor. The ureter is identified as it crosses the bifurcation of the common iliac artery and is carefully mobilized and retracted medially. Before vascular reconstruction, the patient is systematically anticoagulated with intravenous heparin (75–100 U/kg). Generally, an 8-mm graft is selected for the conduit in normal-sized adults. The proximal anastomosis is performed end to side at a suitable location on the common iliac artery using a running 4–0 or 5–0 polypropylene monofilament suture with a parachute technique. The graft is tunneled under the inguinal ligament, and the distal anastomosis is performed to the selected outflow artery. After reversal of the heparin anticoagulation with protamine and other satisfactory hemostasis is evident, the abdominal wall and groin incisions are closed in a standard fashion. Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Technical Aspects of Percutaneous Carotid Angioplasty and Stenting for Arteriosclerotic Disease Management of Acute Limb Ischemia Complicating Aortic Reconstruction Treatment of Dyslipidemia and Hypertriglyceridemia Intraoperative Assessment of the Technical Adequacy of Carotid Endarterectomy Stay updated, free articles. Join our Telegram channel Join
