AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

In patients with peripheral arterial disease, obstructing plaques caused by atherosclerotic occlusive disease commonly occur in the infrarenal aorta and iliac arteries. Atherosclerotic plaques may induce symptoms either by obstructing blood flow or by breaking apart and embolizing atherosclerotic and/or thrombotic debris to more distal blood vessels. If the plaques are large enough to impinge on the arterial lumen, reduction of blood flow to the extremities occurs. Several risk factors exist for development of the arterial lesions, and recognition of these factors enables physicians to prescribe nonoperative treatment that may alleviate symptoms as well as prolong life.

Surgical treatment of aortoiliac occlusive disease (AIOD) has been well standardized for many years, and the outcomes are quite good. However, the additional techniques of percutaneous transluminal angioplasty (PTA) and stenting have offered more alternatives to open surgery and offer successful techniques to patients who may have been considered at an unacceptably high risk for conventional open surgical repairs. Catheter-based endovascular treatments for AIOD offer the advantages of less morbidity, faster recovery, and shorter hospital stays. In fact, most endovascular interventions today are simply performed as outpatient procedures. This chapter reviews the risk factors for development of atherosclerotic occlusive disease of the aorta and iliac arteries and describes the natural history, diagnosis, and treatment of the disease.

For excellent patient education resources, visit eMedicine's Cholesterol Center. Also, see eMedicine's patient education articles High Cholesterol and Cholesterol FAQs.

History of the Procedure

Before prosthetic grafts for aortic bypasses became available, the first direct surgical reconstructions on the aorta were performed using the technique of thromboendarterectomy (TEA), first described by Dos Santos of Lisbon in 1947. The initial procedure was performed on a patient with superficial femoral artery (SFA) obstruction, and Dos Santos termed the procedure disobliteration. Edwin J. Wylie, MD, adapted this technique to the aortoiliac region and, in 1951, performed the first aortoiliac endarterectomy in the United States. With the discovery of suitable prosthetic graft materials for aortic replacement in the 1960s, surgical treatment of AIOD became available to even more patients.

In 1964, Dotter first performed percutaneous iliac angioplasty using a coaxial system of metal dilators. This procedure proved to have limited application due to the cumbersome nature of the device. However, Dotter's early work paved the way for Grüntzig, who, in 1974, developed a catheter with an inflatable polyvinyl chloride balloon that could be passed over a guidewire. This device became the cornerstone for the percutaneous treatment of arterial occlusive lesions today. In 1985, Julio Palmaz introduced the first stent that helped to improve the results of angioplasty for arterial occlusive disease. Since the advent of angioplasty and stenting, the technology has evolved at an astronomical rate. The design and quality of endovascular devices, as well as the ease and accuracy of performing the procedures, have improved. These improvements have led to improved patient outcomes following endovascular interventions for AIOD.

Problem

AIOD occurs commonly in patients with peripheral arterial disease (PAD). Significant lesions in the aortoiliac arterial segment are exposed easily by palpation of the femoral pulses. Any diminution of the palpable femoral pulse indicates that a more proximal obstruction exists. Obstructive lesions may be present in the infrarenal aorta, common iliac, internal iliac (hypogastric), external iliac, or combinations of any or all of these vessels. Occasionally, degenerated nonstenotic atheromatous disease exists in these vessels and may manifest by atheroembolism to the foot, the "blue toe" or "trash foot" syndrome.

Frequency

At least half of patients with PAD have no symptoms, and, therefore, the exact incidence and prevalence of the condition is unknown. However, the incidence of PAD is known to increase with advancing age so that, by age 70 years, as many as 25% of the US population is affected. Occlusive disease involving the aortoiliac arterial segment occurs commonly in patients with PAD and is second only to occlusive disease of the SFA in frequency.

Etiology

Atherosclerosis is the most common etiology of occlusive plaques in the aorta and iliac arteries. Several risk factors exist for the development of atherosclerotic plaques in the aortoiliac arterial segment. Cigarette smoking and hypercholesterolemia are observed more commonly in patients with AIOD as compared with infrainguinal occlusive disease. In addition, patients with AIOD tend to be younger and less likely to have diabetes.

An uncommon cause of aortic obstruction is Takayasu disease, a nonspecific arteritis that may cause obstruction of the abdominal aorta and its branches. The etiology of Takayasu disease is not known. For the purpose of this chapter, only occlusive lesions caused by atherosclerosis are considered.

Pathophysiology

Atherosclerosis is an extraordinarily complex degenerative disease with no known single cause. However, many variables are known to contribute to the development of atherosclerotic lesions. One popular theory emphasizes that atherosclerosis occurs as a response to arterial injury. Factors that are known to be injurious to the arterial wall include mechanical factors such as hypertension and low wall shear stress, as well as chemical factors such as nicotine, hyperlipidemia, hyperglycemia, and homocysteine.

Lipid accumulation begins in the smooth muscle cells and macrophages that occur as an inflammatory response to endothelial injury, and the "fatty streak" begins to form in the arterial wall. The atheroma consists of differing compositions of cholesterol, cholesterol esters, and triglycerides. Some plaques are unstable, and fissures occur on the surface of the plaque that expose the circulating platelets to the inner elements of the atheroma. Platelet aggregation then is stimulated. Platelets bind to fibrin through activation of the glycoprotein (Gp) IIb/IIIa receptor on the platelets, and a fresh blood clot forms in the area of plaque breakdown. These unstable plaques are prone to atheromatous embolization and/or propagation of clot that eventually can occlude the arterial lumen.

If the atheroma enlarges enough to occupy at least 50% of the arterial lumen, the flow velocity of blood through that stenosis can significantly increase. The oxygen requirements of the lower extremity at rest are low enough that even with a moderate proximal stenosis, no increase in blood flow velocity occurs. During exercise, however, the oxygen debt that occurs in ischemic muscle cannot be relieved because of the proximal obstruction of blood flow; this results in claudication symptoms. In more advanced cases, critical tissue ischemia occurs, and neuropathic rest pain or tissue loss ensues. However, critical limb ischemia is seldom, if ever, caused by AIOD alone. Commonly, in patients with critical limb ischemia, multiple arterial segments are involved in the occlusive atherosclerotic process.

Clinical

The most common symptom of patients with hemodynamically significant aortoiliac disease is claudication. The word claudication stems from the Latin word claudicatio, to limp. The symptom complex of claudication is defined as muscle cramps in the leg(s) that occur following exercise and are relieved by resting. In any individual patient, the exercise distance at which claudication occurs is quite constant. Claudication usually occurs first in the calf muscles, although thigh, hip, and buttocks muscles also can be affected when more extensive proximal lesions are present. Location of the muscle pain (ie, calf vs thigh) does not necessarily correlate with the level of arterial obstruction. However, more proximal symptoms (ie, buttocks or thigh claudication) are generally associated with severe aortoiliac occlusive disease.

Symptoms of buttock claudication can occur in association with erectile dysfunction in patients with absent femoral pulses. This constellation of symptoms is termed Leriche syndrome, named for the surgeon who described the condition in 1923. Leriche syndrome occurs when either preocclusive stenosis or complete occlusion of the infrarenal aorta is present due to severe aortic atherosclerosis. Due to the chronic nature of the occlusive process leading to development of rich collateral vessels that supply the lower extremity, limb-threatening ischemia seldom occurs.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Treatment of patients with PAD has 2 goals. The first and foremost goal is to reduce the risk of vascular events (myocardial infarction, stroke, vascular death) that occur at an alarmingly high rate in patients with PAD. About 30% of patients with PAD die within 5 years, and death usually is due to an ischemic coronary event.

The second goal of treatment is to improve symptoms in those patients with claudication and prevent amputation in patients with critical limb ischemia. Critical limb ischemia is present when patients have symptoms of ischemic rest pain, nonhealing foot ulcers, or gangrene, and its presence mandates urgent evaluation with aortography and endovascular and/or surgical revascularization to prevent limb loss.

At least half of patients with PAD are asymptomatic and are diagnosed only by physical examination and/or measurement of the ankle/brachial index (ABI). An ABI less than 0.9 clearly is abnormal and confirms the diagnosis of PAD. An abnormal ABI should alert the clinician to the fact that this group of patients is at risk for early mortality from cardiovascular causes, ie, myocardial infarction, stroke, other vascular death. The goal for treatment of asymptomatic patients is to reduce the risk of subsequent vascular events.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Three distinct arterial segments distal to the visceral bearing portion of the abdominal aorta may become diseased by atherosclerosis. Type I atherosclerosis involves the infrarenal aorta and common iliac arteries only. This pattern of atherosclerosis is present in about 5-10% of patients with PAD and occurs more commonly in women. The vessels distal to the common iliac arteries usually are generally normal or only minimally diseased. Type II atherosclerosis involves the infrarenal aorta, common and external iliac arteries, and may extend into the common femoral arteries. This pattern is observed in 35% of patients with PAD. Type III atherosclerosis is the most severe form and, unfortunately, also the most common. This pattern of atherosclerosis involves the infrarenal aorta, iliac, femoral, popliteal, and tibial arteries.

Diabetes mellitus is a risk factor that results in a characteristic pattern of atherosclerotic lesions in patients with PAD. The proximal inflow (aorta, iliac) arteries tend be normal. However, the femoropopliteal segment (including the profunda femoris artery), and especially the proximal tibial arteries, are usually severely diseased. Fortunately, the distal tibial and plantar vessels may be normal, enabling successful arterial reconstruction for limb-threatening ischemia.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

At least 50% of patients with PAD may be asymptomatic. Because natural history data are poor for iliac stenosis, surgical and/or endovascular intervention should not be considered if patients truly are asymptomatic. Surgical intervention for limb-threatening ischemia is accepted universally, unless the limb is deemed nonviable. Determining whether or not to intervene in a patient with mild claudication may not be as straightforward. An important role exists for conservative therapy in patients with AIOD. Although surgical therapy usually alleviates symptoms, the patient must be apprised of the operative risk of mortality (2-3%) as well as anticipated outcomes over time. Since the advent of catheter-based treatments for AIOD, asymptomatic patients are often treated prophylactically with either angioplasty or stenting of iliac arterial lesions that are discovered during coronary angiography. This practice of drive-by angioplasty should not be recommended.

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Examine a serum lipid profile that includes total cholesterol, low-density lipoprotein (LDL) cholesterol, high-density lipoprotein (HDL) cholesterol, and triglycerides (TG). Furthermore, in younger patients or those with a strong family history of atherosclerosis at any early age, lipoprotein (a) and homocysteine levels should be determined.
• If a history of diabetes exists, a glycosylated hemoglobin level (Hgb A1c) should be checked. Excellent control of diabetes reduces long-term complications, and the American Diabetic Association (ADA) currently recommends that the Hgb A1c be less than 7%.
• If a patient has a history of thrombosis in any venous or arterial segment or a family history of a clotting disorder, an evaluation for hypercoagulability is necessary. Tests include routine prothrombin time, partial thromboplastin time, platelet count, factor V-Leiden, factor II (prothrombin) C-20210a, anticardiolipin antibody, baseline protein C, protein S, and antithrombin III levels.

Imaging Studies

• Contrast aortography is not always required, unless interventional therapy (PTA/stent or surgical revascularization) is planned. Serum creatinine is checked to validate a baseline level prior to the use of contrast agents that may be nephrotoxic.
• Computerized tomographic arteriography (CTA) is an excellent modality for planning operative or endovascular treatments. CTA has the advantage of producing 3-dimensional images of the arterial system that are as accurate as those of conventional catheter arteriography. However, iodinated contrast agent is still required to obtain the images in CTA, although direct arterial cannulation is not needed.
• As an alternative to conventional angiography, the surgeon may consider magnetic resonance angiography (MRA) or arterial duplex mapping as definitive imaging studies for planning surgery. MRA is overly sensitive and may show significant arterial stenoses that are simply not present.

Other Tests

• The Doppler-derived ABI is a simple office-based examination that confirms the diagnosis of PAD if the value is less than 0.9. The ABI also can grade the severity of PAD. Note that Doppler-derived segmental arterial pressures do not reflect the severity of AIOD accurately.
• • In addition, the ABI is not very sensitive in identifying patients with mild occlusive lesions in the aortoiliac segment. A treadmill exercise stress test should be recommended for those patients with mild iliac occlusive disease who have symptoms suggestive of claudication even though the ABI is normal at rest. Following exercise, the blood flow through stenotic vessels increases and the pressure decline across these lesions is augmented.
  • Moreover, if the blood pressure cuff is unable to compress the vessels adequately, the Doppler-derived pressures may be falsely elevated. This may occur in patients with diabetes or end-stage renal disease. In the event that supranormal (falsely elevated) Doppler-derived pressures are encountered, pulse volume recordings (PVR) may be useful in evaluating leg perfusion. The PVR waveform reflects the volume of blood in the leg during an individual cardiac cycle. A normal waveform demonstrates a brisk upstroke, a sharp systolic peak, and a downstroke with a dicrotic notch. With significant PAD, the dicrotic notch is lost, the slope of the upstroke and downstroke decline, the amplitude of the waveform is reduced, and the contour of the systolic peak is more rounded.
• Because an association of coronary disease in patients with PAD exists, obtain an electrocardiogram even in patients without cardiac history.
• For those patients being considered for an intra-abdominal aortic procedure, pulmonary function tests are important if a history of obstructive pulmonary disease or dyspnea is present. Many times the surgical approach needs to be altered based on the results of this preoperative evaluation.
• If a patient has a history of thrombosis in any venous or arterial segment or a family history of a clotting disorder, an evaluation for hypercoagulability is necessary. Tests include routine prothrombin time, activated partial thromboplastin time, platelet count, factor V-Leiden, factor II (prothrombin) C-20210a, anticardiolipin antibody, protein C and protein S levels, and antithrombin III.
• An intensive preoperative cardiac evaluation is reserved for patients with newly onset angina pectoris, unstable angina pectoris, or evidence of ventricular dysfunction based on dobutamine stress echocardiogram. Adenosine thallium perfusion tests are not routinely performed because of the high sensitivity and low specificity.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

The 2 goals for the clinician treating AIOD are (1) improving symptoms and (2) reducing the associated risk of myocardial infarction, stroke, and vascular death. Three fundamental principles are involved in the treatment of symptomatic PAD due to AIOD.

First, the risk factors must be identified and aggressively treated. The 2 most important risk factors for PAD are cigarette smoking and diabetes. Complete cessation of smoking is mandatory. Carefully regulate serum glucose. The goal for adequate glucose control is an Hgb A1c level lower than 7%. The goal of hypertension control should be blood pressures lower than 140/90 mm Hg. Finally, the LDL cholesterol level should be reduced to less than 100 mg%. This usually can be accomplished with the use of hepatic 3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). In addition to modification of risk factors, patients with AIOD should receive lifelong antiplatelet therapy to reduce the risk of myocardial infarction, stroke, and vascular death.

Secondly, initiate a walking exercise program. No fewer than 28 prospective randomized clinical trials attest to the efficacy of walking exercise to treat claudication (Weitz, 2000; Gardner, 1995). Every trial has demonstrated improvements in walking distance from 180-340%. Supervised walking programs usually produce better results than unsupervised exercise. Walking exercise even has been compared to angioplasty and found to produce superior results. Walking exercise improves symptoms of claudication because the muscle enzymes involved in oxygen extraction and utilization become more efficient over time.

Finally, 2 Food and Drug Administration (FDA)–approved pharmacologic agents may improve the symptoms of claudication caused by lower extremity arterial occlusive disease. Pentoxifylline is a methyl xanthine derivative that acts as a hemorheologic agent, lowering blood viscosity. Unfortunately, pentoxifylline only is effective in 30-40% of patients and must be taken 3 times daily. If it is effective, walking distances only improve modestly. Cilostazol, on the other hand, is a newer agent that belongs to the class of phosphodiesterase III inhibitors and has been shown to be more effective statistically than either pentoxifylline or placebo. The mechanism of action is not well understood. Adverse effects may include headache and loose stools, but the medication generally is well tolerated. It should not be used in patients with significant congestive heart failure.

Surgical therapy

Direct arterial reconstruction on the diseased aortoiliac arterial segment is well established. Aortoiliac endarterectomy (TEA) and aortobifemoral bypass (AFB) are the 2 traditional means of surgically treating AIOD. Both procedures have similar risk and results, and the outcomes have stood the test of time. In 1966, Blaisdell introduced axillofemoral bypass as an extra-anatomic technique for improving inflow to the lower extremities without the need for an abdominal procedure. More recently, with the advent of arterial stents, endovascular repair of aortoiliac lesions has become a reasonable alternative to consider if the pathologic anatomy is suitable.

TEA of the aorta and iliac arteries was the first reconstructive procedure performed for AIOD. The concept is simple. A dissection plane exists between the arterial media and the obstructing plaque. When the appropriate plane is entered, the arterial intima, plaque, and internal elastic lamina of the media are removed as a single specimen. Early in the experience, surgeons were concerned that the remaining portion of arterial wall was not sturdy enough to hold blood under arterial pressure. However, with more experience, it became clear that the remaining portion of the vessel (external elastic lamina of the media and adventitia) following TEA provided a secure and durable conduit with excellent long-term patency. When aortoiliac TEA is used to treat patients with type I atherosclerotic occlusive disease, the patency rates are excellent. However, the results are not as good when TEA is applied to patients with more extensive distal occlusive lesions in the external iliac and femoral arteries.

Today, aortoiliac TEA is not used as commonly as AFB, primarily because the procedure is best suited for patients with type I atherosclerosis, occlusive disease limited to the infrarenal aorta and common iliac arteries (Image 1). Patients with type 1 atherosclerosis comprise the minority of patients with PAD. Furthermore, younger surgeons may not have had proper exposure to the technique of aortoiliac TEA during their training and therefore do not have appropriate experience using the procedure to treat AIOD.

Aortoiliac TEA has significant advantages over conventional AFB for the treatment of AIOD. First and most obvious is that prosthetic material is not needed to perform the arterial reconstruction. Even for the most experienced surgeons, aortic prosthetic graft infections occur in 0.5-3% of patients following AFB. The mortality rate associated with the treatment of aortic graft infection ranges from 11-27%. In addition, a similar rate is observed for early amputation following aortic graft infection.

Many patients undergo aortoiliac TEA not for the indication of removing the plaques that obstruct blood flow, but rather to remove the source of atheroembolism causing blue toe syndrome. Aortoiliac TEA is ideally suited for this indication because the offending degenerated atheroma is removed, leaving a clean, glistening surface that soon is covered by new functional endothelium.

The only significant disadvantage of TEA compared to AFB is that a larger, more meticulous dissection is required to expose and control the branches of the infrarenal aorta. For this reason, some surgeons may opt for AFB even if the occlusive process is limited to the infrarenal aorta and common iliac arteries.

Finally, aortoiliac TEA should not be performed if occlusive plaques involve the more distal external iliac and femoral arteries. The "tail" of the atheroma in the common iliac artery may extend into the orifice of the external iliac artery, and this tongue usually is removed easily during the course of the procedure. However, if diffuse disease exists in the more distal external iliac and femoral arteries, AFB is a more suitable alternative.

AFB is the most common open surgical alternative used to treat AIOD. In the early experience of aortic surgery, unilateral AFB or even aortoiliac bypass (AIB) often was performed to limit the extent of the procedure. However, as more experience was gained with these operations, using the common femoral arteries as the outflow target clearly produced better long-term patency results. Unilateral AFB is performed infrequently today because the extremity that was neglected initially seldom truly is healthy and invariably demonstrates symptoms from progressive atherosclerosis. Therefore, performing AFB bilaterally to avoid the need for subsequent inflow operative procedures on the limb that demonstrates less extensive occlusive disease is appropriate.

The original approach to AFB was transabdominal. As an alternative approach, retroperitoneal exposure of the aorta can be used to avoid entering the peritoneum. Some authors have advocated this approach based upon a theoretical advantage of fewer pulmonary problems, more rapid resolution of postoperative ileus, and fewer days in the hospital. Other studies have not supported this proposed benefit.

In some circumstances, a bypass serving both legs can be constructed using a single common iliac artery as the donor site. This procedure can be performed through either a transperitoneal or retroperitoneal approach.

For higher-risk patients who are less likely to tolerate an abdominal operation, extra-anatomic bypass was developed in the mid 1960s. Axillobifemoral bypass provided an extracavitary means of improving blood flow to the lower extremities. This procedure proved especially useful in the treatment of aortic graft infections. However, the long-term patency of extra-anatomic bypass is distinctly inferior to conventional aortobifemoral bypass.

With the advent of PTA and stents, excellent minimally invasive alternatives to conventional open reconstructive surgery now are available. If applied to the appropriate anatomical problem, the results of iliac angioplasty/stent placement rival open surgical results For isolated segmental common iliac artery stenoses, angioplasty/stenting rivals open surgical results (TASC Working Group, 2000). However, for occlusive disease that diffusely involves the aortoiliac segment, direct open surgical repair still offers the best long-term outcome. However, through catheter-based treatments (angioplasty/stenting), patients with significant operative risk due to comorbid diseases can be offered therapy.

Preoperative details

Because most patients with AIOD are older than 50 years, finding associated ischemic heart disease is not uncommon, even if classic anginal symptoms are not present. Hertzer and colleagues found that most patients undergoing aortic operations for arterial occlusive disease had diseased coronary arteries when coronary arteriography was performed. Moreover, Porter and associates found a significant incidence of occlusive plaques in the carotid arteries in a similar group of patients. Clearly, AIOD does not exist in a vacuum. However, despite the association of coronary and extracranial arterial occlusive disease with PAD, every patient clearly does not need an extensive preoperative evaluation prior to undergoing aortic surgery.

Preoperative cardiac evaluations are reserved for patients with either an abnormal finding on ECG and/or a history of new-onset or unstable angina or with symptoms of ventricular dysfunction (orthopnea, dyspnea on exertion). Patients who have had coronary angioplasty or bypass or who have a history of stable angina on appropriate medication probably do not need a preoperative cardiac evaluation, unless a change has occurred in either exercise tolerance or anginal pattern.

Immediately before the induction of anesthesia, the anesthesiologist places an epidural catheter. Although the catheter is not used during the procedure, the analgesic relief provided by instillation of narcotic and local anesthetic agents in the postoperative period is invaluable.

In addition, a systemic dose of perioperative cephalosporin antibiotic is administered intravenously before the skin incision is made. The antibiotic is continued postoperatively for 24-28 hours to lower the risk of graft infection.

Intraoperative details

Both of the conventional surgical procedures used to treat AIOD (TEA and AFB) are performed through either a longitudinal midline or transverse intra-abdominal incision and even may be performed via a retroperitoneal exposure to the aorta. More dissection is needed with TEA. Total circumferential mobilization of the infrarenal aorta and common iliac arteries is required in order to perform aortoiliac TEA. The proximal extent of the dissection is the level of the renal arteries as long as the occlusive plaques do not extend proximally and impinge on the orifices of these vessels. If occlusive disease extends cephalad to the renal arteries, the dissection must be carried proximally to the origin of the superior mesenteric artery (SMA) to allow placement of the aortic occluding clamp at the base of this vessel.

An alternative approach for suprarenal control of the aorta is placement of the aortic cross clamp above the level of the celiac axis, a maneuver that is not difficult and is quite familiar to vascular surgeons. The lumbar, middle sacral, and inferior mesenteric (IMA) arteries must be managed using vessel loops to control back bleeding when the aorta is opened. Take care to identify and preserve any accessory renal arterial branches that may be present in as many as 20% of patients. In addition, the proximal portion of the external iliac and hypogastric arteries should be dissected adequately to allow placement of occluding clamps on these vessels distal enough from the origin to view the proximal portion of the external iliac artery

The difficult portion of the dissection occurs around the distal aorta and proximal common iliac arteries. The inferior vena cava and common iliac veins may be quite adherent to the arteries at this point, and care must be taken to avoid injury to these veins. After the dissection is completed, 5000 units of intravenous heparin are administered prior to arterial occlusion.

The distal clamps are placed first to reduce the incidence of atheroembolism that may occur following application of the aortic clamp. The aorta is incised longitudinally extending from 2 cm distal to the aortic occluding clamp proximally to 2 cm proximal to the aortic bifurcation distally. Place the line of incision on the right side of the anterior surface of the aorta to avoid the origin of the IMA. The endarterectomy plane easily is established where the atheromatous disease is most severe. Grasp the plaque and gently push away the remaining arterial wall. The dissection is continued distally until the bifurcation is reached, and the appropriate plane is continued into the orifice of each common iliac artery.

The iliac artery may be incised longitudinally (if the length of the common iliac is long), or even transversely, directly over the common iliac bifurcation. The author prefers a longitudinal incision extending from the proximal common iliac artery 2 cm from the origin to the iliac bifurcation because it affords the surgeon a better view of the endarterectomized surface and the endarterectomy endpoint. A bridge of arterial wall is preserved between the abdominal aortic incision and the common iliac incisions.

Once the entire plaque is mobilized in the common iliac, the entire specimen may be pulled in a cephalad direction and removed entirely as a single specimen resembling a pair of pants. Take care to examine the distal endpoint in the iliac artery. A tongue of atheroma may continue into the origin of the external iliac and hypogastric arteries. This tail of atheroma must be excised in a more superficial plane to avoid extending the endarterectomy into the deeper plane used to perform TEA. The plane of the atheroma actually is easy to discern because the atheroma usually is a darker yellow color and has a different consistency than the more normal adherent intima.

After any remaining plaque and/or strands of media are removed, the arteriotomies are closed with continuous polypropylene sutures. If the aorta is small (<2 cm), a prosthetic, zero-porosity Dacron patch is used to avoid narrowing that may occur during primary closure of a longitudinal arteriotomy. Once blood flow has been restored, femoral pulses should be palpated to confirm the presence of adequate inflow.

A similar aortic exposure is used to perform AFB. In addition, the common femoral, proximal superficial femoral, and proximal profunda femoris arteries are mobilized through longitudinal groin incisions that are made just lateral to the femoral pulse. If the pulse is not present, the proper line of incision is found by measuring 3-4 finger breadths lateral to the pubic tubercle.

Cover the skin in a povidone-iodine–impregnated plastic drape to help avoid skin contact with the prosthetic graft. The infrarenal aorta immediately adjacent to the renal arteries is mobilized. Circumferential mobilization of the aorta is not necessary. The common femoral artery and its branches are mobilized from the inguinal ligament to the bifurcation, exposing enough superficial femoral and profunda femoris arteries to allow placement of an arterial occluding clamp.

The aortic anastomosis may be performed in either an end-to-end or an end-to-side configuration using continuous polypropylene suture. Although partial occluding aortic clamps have been used when performing end-to-side anastomoses, a better view of the aortic lumen is obtained with the use of proximal and distal clamps that totally occlude the aorta.

If the aorta is filled with atherosclerotic debris that appears loose and may embolize when flow is restored, perform an end-to-end aortic anastomosis and oversew the distal aorta. The configuration of the proximal anastomosis is not as important as its location. The anastomosis to the aorta must be placed near the renal arteries to help avoid recurrent atheromatous and/or aneurysmal disease that may involve infrarenal aorta that remains proximal to the aortic anastomosis.

Once the proximal anastomosis is completed and no bleeding is present, the limbs of the prosthetic graft are passed carefully through retroperitoneal tunnels that were made before the patient received intravenous heparin. The tunnels are made directly anterior to the iliac arteries and posterior to the ureters. The circumflex iliac veins must be avoided during creation of the tunnel and passage of the graft limbs. Partial incision of the inguinal ligament may aid in constructing the tunnel and identifying these large troublesome veins.

The common femoral artery is incised longitudinally, and a conventional end-to-side femoral anastomosis is performed using continuous polypropylene suture. Take care to examine the origins of the 2 outflow branches (SFA and profunda) of the common femoral artery. Not uncommonly, the SFA has significant occlusive disease. If the SFA is occluded, any stenosis in the proximal portion of the profunda must be repaired to insure adequate long-term patency of the aortic graft limb. If the common femoral artery is severely diseased, limited local TEA may need to be performed to facilitate an adequate femoral anastomosis.

Postoperative details

In the past, all patients were monitored in an intensive care environment for the first 24-48 hours following an aortic operation. In the last decade, it has become increasingly common for patients undergoing operations for occlusive disease to avoid the ICU and have their postoperative care on a regular surgical floor.

For patients with hemodynamic concerns, systemic arterial as well as pulmonary capillary wedge (PCWP) pressures help to plan intravenous fluid requirements. In addition, hourly urinary output through a bladder catheter is recorded. Although significant blood loss is not common, the hematocrit is monitored every 6-12 hours during the first 24 hours.

If the operation has proceeded smoothly, perform extubation at the end of the procedure. Preoperative pulmonary function tests help to predict which patients are likely to develop postoperative respiratory problems. When the forced expiratory volume in 1 second (FEV₁) is less than 1000 cc, one can anticipate difficult respiratory problems associated with conventional aortic surgical approaches through midline incisions. For such cases, a transverse intra-abdominal or retroperitoneal incision may help to reduce postoperative respiratory complications.

Most large fluid shifts occur following aortic surgery and are related to the size of the dissection and the length of the operation as well as the amount of intraoperative blood loss. Patients tend to gain significant "wet weight" during the first 48 hours postoperatively. By the beginning of the third postoperative day, mobilization of the excess water back into the intravascular compartment begins to occur. Urine output increases, PCWP rises, and hematocrit may drift downward.

Also monitor the perfusion to the lower extremities carefully. If pedal pulses cannot be palpated due to SFA occlusive disease, monitor Doppler flow as well as ABI. After successful revascularization, ABI should increase by at least 15%.

Follow-up

In general, results of the treatment for AIOD are excellent, but patients still need follow-up care at regular intervals. See patients every 3-6 months for the first year and every 6-12 months thereafter. If a prosthetic graft has been implanted, a lifelong risk of graft infection exists that the patient must recognize. Moreover, oral antibiotic prophylaxis is appropriate before dental procedures, urologic instrumentation, sigmoidoscopy, or other gastrointestinal surgical procedures.

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Several complications are related both to aortoiliac TEA and AFB, and others are associated only with one or the other. Perioperative thrombosis may be a complication of either procedure and generally is related to technical problems. For example, a plaque that dissects, causing restriction in blood flow and subsequent thrombosis, may occur as a complication of either procedure. Visualization of endarterectomy endpoints and suturing of plaques that may elevate when blood flow is restored may help to reduce the risk of dissection and subsequent thrombosis.

Intraoperative atheroembolism is another complication that may occur during surgical dissection and mobilization of the vessels or following release of the occluding clamps during reperfusion. Meticulous dissection during mobilization of the arteries is imperative. Furthermore, placement of the distal occluding clamps before application of the proximal clamps may help to reduce the risk of atheroembolism that is inherent during any aortic operation.

Injury to adjacent structures (ie, duodenum, inferior vena cava, iliac veins, ureters) usually is easy to avoid with careful technique. However, care must be used with mechanical retractors to avoid inadvertent injury to adjacent structures. Care is necessary both in the retroperitoneum and in the groin to avoid injury to nerves adjacent to major vessels.

Careful closure of groin wounds is necessary in order to avoid a lymphocele, which can lead to graft infection.

A specific complication related to the use of prosthetic material for AFB is development of aortic graft infection, which occurs in 0.5-3% of cases. Usually, presentation of the infection follows the aortic procedure by a significant length of time (20-24 mo). Most commonly, a complication of healing in the groin wound is the first sign that a serious, life-threatening and limb-threatening problem must be dealt with.

Graft infections can be classified into 2 groups, depending on the etiologic microbial involved. The more virulent organisms (ie, Staphylococcus aureus, gram-negative bacilli) usually are responsible for causing a more severe type of clinical infection. When systemic signs of sepsis occur with graft infection, a virulent organism is present.

On the other hand, a significant number of graft infections are caused by Staphylococcus epidermidis. These infections are much more indolent, and the extent of graft involvement may be harder to determine. Even with the most skilled physician, the mortality rate following treatment of aortic graft infection is 11-27%. Moreover, the risk of amputation following graft infection is almost as high.

Major complications rates associated with catheter-based treatments (PTA/stents) for aortoiliac occlusive disease range from 2.3-17%. The problem can occur in the target vessel, the access site, or even other arteries that are far removed anatomically (ie, atheroembolism). These complications include dissection, acute thrombosis, atheroembolism, and even arterial perforation. Complications related to the contrast agent (ie, anaphylaxis [rarely] or contrast-induced renal dysfunction) are uncommon.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Outcomes following aortic operations for AIOD are measured in terms of operative mortality rates and patency of the arterial reconstruction over time. These outcomes are similar for both aortoiliac TEA or AFB. The operative mortality rate (30-d) is 2-3%. Long-term patency is excellent too. The patency rate at 5 years following AFB or TEA is 85-90%. If patients continue to smoke, however, these excellent patency rates are reduced by half.

Outcomes for extra-anatomic (axillofemoral/femoral-femoral) bypasses clearly are not as good as either AFB or aortoiliac TEA. Operative mortality rates for extra-anatomic bypass might be expected to be better than AFB due to the extracavitary nature of these procedures and the fact that aortic occlusion is not required during the course of the operation. However, an operative mortality rate of 0-4% for femorofemoral bypass and 2-11% for axillobifemoral bypass is a reflection of the selected patients in whom these procedures are performed. Five-year primary patency of extra-anatomic bypasses performed for AIOD ranges from 19-50% for axillobifemoral bypass and 44-85% for femoral-femoral bypass.

Endovascular techniques (ie, PTA, stent placement) offer alternatives to conventional surgical repair. Therefore, understanding the outcomes offered with such interventions is important. Although isolated stenosis of the infrarenal aorta or common iliac artery is uncommon, this lesion is suited ideally to PTA and/or stent placement. With localized, segmental occlusive disease in the aorta, initial technical success can be achieved in 95% of cases, with 5-year patency rates of 80-87% using PTA. Initial success rates using PTA for iliac lesions are 93-97%, with 5-year patency rates of 54-85%. These results seem to be improved when arterial stents are used either primarily or as an adjunct to PTA for the treatment of iliac artery stenosis.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

No controversy exists regarding the appropriate surgical procedure to treat AIOD. Use TEA only in cases of type I atherosclerosis. TEA also is an excellent option for those patients with blue toe syndrome from severe ulcerogenic aortoiliac atherosclerosis that involves only the infrarenal aorta and common iliac arteries.

Some authors have advocated performing the aortic procedure through a retroperitoneal rather than an intra-abdominal approach. Unfortunately, despite some excellent work in this area, outcomes are similar whether the procedure is performed in a retroperitoneal or transabdominal fashion.

A more controversial area is whether proximal occlusive disease should be treated nonoperatively, using angioplasty and stent placement rather than the more invasive aortic operation. It seems clear that angioplasty and/or stent placement is a suitable alternative for patients with very focal occlusive disease in the common iliac artery but offers a poor alternative for more diffuse disease that involves the external iliac artery. Furthermore, the patency results for patients who have had total occlusions in the iliac arteries treated by endovascular therapy are definitely inferior to conventional surgical results.

The current controversy involves the appropriate place for minimally invasive treatment of AIOD. Laparoscopically assisted AFBs have been performed both in animals and humans with satisfactory results. However, a significant learning curve seems to be involved, and no long-term follow-up data are available for review.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Type I atherosclerosis with occlusive disease limited to the infrarenal aorta and common iliac arteries.
	View Full Size Image
Media type:  Image

Media file 2:  Large collateral vessels confirm hemodynamic significance of left common iliac stenosis.
	View Full Size Image
Media type:  Image

Media file 3:  Successful treatment of focal high-grade left common iliac stenosis with Palmaz stent.
	View Full Size Image
Media type:  Image

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

• Antiplatelet Trialists'' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy--I: Prevention of death, myocardial infarction, and stroke by prolonged antiplatelet therapy in various categories of patients. BMJ. Jan 8 1994;308(6921):81-106. [Medline].
• Baker JD. Physiologic studies to document severity of aortoiliac occlusive disease. In: Ernst CB, Stanley JC, eds. Current Therapy in Vascular Surgery. 4th ed. St. Louis, Mo:. Mosby-Year Book, Inc;2001.
• Ballard JL, Bergan JJ, Singh P, et al. Aortoiliac stent deployment versus surgical reconstruction: analysis of outcome and cost. J Vasc Surg. Jul 1998;28(1):94-101; discussion 101-3. [Medline].
• Ballard JL, Sparks SR, Taylor FC, et al. Complications of iliac artery stent deployment. J Vasc Surg. Oct 1996;24(4):545-53; discussion 553-5. [Medline].
• Barbera L, Mumme A, Metin S, et al. Operative results and outcome of twenty-four totally laparoscopic vascular procedures for aortoiliac occlusive disease. J Vasc Surg. Jul 1998;28(1):136-42. [Medline].
• Blaisdell FW, Hall AD. Axillary femoral bypass for lower extremity ischemia. Surgery. 1963;54:563.
• Bosch JL, Hunink MG. Meta-analysis of the results of percutaneous transluminal angioplasty and stent placement for aortoiliac occlusive disease. Radiology. Jul 1997;204(1):87-96. [Medline].
• Brewster DC, Darling RC. Optimal methods of aortoiliac reconstruction. Surgery. Dec 1978;84(6):739-48. [Medline].
• Brewster DC. Current controversies in the management of aortoiliac occlusive disease. J Vasc Surg. Feb 1997;25(2):365-79. [Medline].
• Cambria RP, Brewster DC, Abbott WM, et al. Transperitoneal versus retroperitoneal approach for aortic reconstruction: a randomized prospective study. J Vasc Surg. Feb 1990;11(2):314-24; discussion 324-5. [Medline].
• Criqui MH, Fronek A, Barrett-Connor E. The prevalence of peripheral arterial disease in a defined population. Circulation. Mar 1985;71(3):510-5. [Medline].
• Criqui MH, Langer RD, Fronek A. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med. Feb 6 1992;326(6):381-6. [Medline].
• DeBakey ME, Cooley DA, Crawford ES. Clinical application of a new flexible knitted Dacron arterial substitute. Am J Surg. 1958;24:862.
• Donaldson MC, Louras JC, Bucknam CA. Axillofemoral bypass: a tool with a limited role. J Vasc Surg. May 1986;3(5):757-63. [Medline].
• Dos Santos JC. Sur la desobstruction des thrombus arterielles anciennes. Mem Acad Chir. 1947;73:409.
• Dotter C, Judkins M. Transluminal treatment of arteriosclerotic obstruction: Description of a new technique and a preliminary report of its application. Circulation. 1964;30:654-70.
• Ernst E, Fialka V. A review of the clinical effectiveness of exercise therapy for intermittent claudication. Arch Intern Med. Oct 25 1993;153(20):2357-60. [Medline].
• Funovics MA, Lackner B, Cejna M, et al. Predictors of long-term results after treatment of iliac artery obliteration by transluminal angioplasty and stent deployment. Cardiovasc Intervent Radiol. Sep-Oct 2002;25(5):397-402.
• Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. JAMA. Sep 27 1995;274(12):975-80. [Medline].
• Gruntzig A, Hopff H. [Percutaneous recanalization after chronic arterial occlusion with a new dilator-catheter (modification of the Dotter technique) (author''s transl)]. Dtsch Med Wochenschr. Dec 6 1974;99(49):2502-10, 2511. [Medline].
• Harrington ME, Harrington EB, Haimov M, et al. Iliofemoral versus femorofemoral bypass: the case for an individualized approach. J Vasc Surg. Dec 1992;16(6):841-52; discussion 852-4. [Medline].
• Hiatt WR, Hoag S, Hamman RF. Effect of diagnostic criteria on the prevalence of peripheral arterial disease. The San Luis Valley Diabetes Study. Circulation. Mar 1 1995;91(5):1472-9. [Medline].
• Jackson MR, Clagett GP. Antithrombotic therapy in peripheral arterial occlusive disease. Chest. Jan 2001;119(1 Suppl):283S-299S. [Medline].
• Legemate DA, Teeuwen C, Hoeneveld H, Eikelboom BC. Value of duplex scanning compared with angiography and pressure measurement in the assessment of aortoiliac arterial lesions. Br J Surg. Aug 1991;78(8):1003-8. [Medline].
• Malone JM, Moore WS, Goldstone J. The natural history of bilateral aortofemoral bypass grafts for ischemia of the lower extremities. Arch Surg. Nov 1975;110(11):1300-6. [Medline].
• McKenna M, Wolfson S, Kuller L. The ratio of ankle and arm arterial pressure as an independent predictor of mortality. Atherosclerosis. Apr 1991;87(2-3):119-28. [Medline].
• Messina LM. Endarterectomy for atherosclerotic aortoiliac occlusive disease. In: Ernst CB, Stanley JC, eds. Current Therapy in Vascular Surgery. 4th ed. St. Louis, Mo:. Mosby-Year Book, Inc;2001:381-4.
• Newman AB, Siscovick DS, Manolio TA, et al. Ankle-arm index as a marker of atherosclerosis in the Cardiovascular Health Study. Cardiovascular Heart Study (CHS) Collaborative Research Group. Circulation. Sep 1993;88(3):837-45. [Medline].
• Palmaz JC, Sibbitt RR, Reuter SR, et al. Expandable intraluminal graft: a preliminary study. Work in progress. Radiology. Jul 1985;156(1):73-7. [Medline].
• Passman MA, Taylor LM, Moneta GL, et al. Comparison of axillofemoral and aortofemoral bypass for aortoiliac occlusive disease. J Vasc Surg. Feb 1996;23(2):263-9; discussion 269-71. [Medline].
• Pentecost MJ, Criqui MH, Dorros G, et al. Guidelines for peripheral percutaneous transluminal angioplasty of the abdominal aorta and lower extremity vessels. A statement for health professionals from a special writing group of the Councils on Cardiovascular Radiology, Arteriosclerosis, Cardio. Circulation. Jan 1994;89(1):511-31. [Medline].
• Prendiville EJ, Burke PE, Colgan MP, et al. The profunda femoris: a durable outflow vessel in aortofemoral surgery. J Vasc Surg. Jul 1992;16(1):23-9. [Medline].
• Regensteiner JG, Steiner JF, Hiatt WR. Exercise training improves functional status in patients with peripheral arterial disease. J Vasc Surg. Jan 1996;23(1):104-15. [Medline].
• Ross R. The pathogenesis of atherosclerosis--an update. N Engl J Med. Feb 20 1986;314(8):488-500. [Medline].
• Said S, Mall J, Peter F, Muller JM. Laparoscopic aortofemoral bypass grafting: human cadaveric and initial clinical experiences. J Vasc Surg. Apr 1999;29(4):639-48. [Medline].
• Schafer AL. Antiplatelet therapy. Am J Med. Aug 1996;101(2):199-209. [Medline].
• Schneider PA. Endovascular or open surgery for aortoiliac occlusive disease?. Cardiovasc Surg. Aug 2002;10(4):378-82.
• Sharp WJ, Hoballah JJ, Mohan CR, et al. The management of the infected aortic prosthesis: a current decade of experience. J Vasc Surg. May 1994;19(5):844-50. [Medline].
• Stoney RJ, Reilly LM. Endarterectomy for aortoiliac occlusive disease. In: Ernst CB, Stanley JC, eds. Current Therapy in Vascular Surgery. St. Louis, Mo:. Mosby-Year Book, Inc;1987:157.
• Szilagyi DE, Elliott JP, Smith RF. A thirty-year survey of the reconstructive surgical treatment of aortoiliac occlusive disease. J Vasc Surg. Mar 1986;3(3):421-36. [Medline].
• Szilagyi DE, Smith RF, Elliott JP, Vrandecic MP. Infection in arterial reconstruction with synthetic grafts. Ann Surg. Sep 1972;176(3):321-33. [Medline].
• TASC Working Group. Endovascular procedures for intermittent claudication. J Vasc Surg. 2000;31:S97-S112.
• Taylor Jr LM, Moneta GL, Porter JM. Natural history and non-operative treatment of chronic lower extremity ischemia. Vasc Surg. 2000;928-43.
• Weitz JI, Byrne J, Clagett GP. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation. Dec 1 1996;94(11):3026-49. [Medline].
• Wylie EJ. Thromboendarterectomy for arteriosclerotic thrombosis of major arteries. Surgery. 1952;23:275-292.
• Yeager RA, Moneta GL, Taylor LM, et al. Improving survival and limb salvage in patients with aortic graft infection. Am J Surg. May 1990;159(5):466-9. [Medline].
• el-Massry S, Saad E, Sauvage LR, et al. Axillofemoral bypass with externally supported, knitted Dacron grafts: a follow-up through twelve years. J Vasc Surg. Jan 1993;17(1):107-14; discussion 114-5. [Medline].

Article Last Updated: Sep 29, 2006