Preprocedure planning sets the stage for a successful endovascular intervention. Although not always

indicated, CTA or MRA delineates the location, extent, and degree of stenosis and associated

calcification (Fig. 92-6A). Other considerations include the possible need for a concomitant femoral

endarterectomy. When there is significant common femoral artery disease (>50% stenosis) along with

iliac occlusive disease, a hybrid approach is preferred, where in addition to PTA, a femoral

endarterectomy with patch angioplasty is performed. The endarterectomy should extend as high as

possible under the inguinal ligament into the external iliac artery to facilitate stent deployment into the

proximal endarterectomized segment and avoid its placement in the common femoral artery itself. A

hydrophilic wire with an angled tip, usually a Glidewire (Terumo Interventional Systems, Somerset, NJ)

and a straight or angled catheter for support are utilized to cross the stenosis or occlusion. Common

iliac artery disease is treated through an ipsilateral retrograde approach if the external iliac is open. If

the common iliac artery is occluded, bilateral punctures of the femoral arteries will be necessary to

perform an aortography and to delineate the extent of obstruction (Fig. 92-6B). External iliac disease is

usually approached with a contralateral antegrade approach across the aortic bifurcation. Crossing total

occlusions may be challenging, and reentering the true lumen from the subintimal space can be difficult.

If reentry cannot be achieved from the chosen point of vascular access (e.g., the ipsilateral common

femoral), an attempt may be made from a new access site (e.g., contralateral common femoral or

brachial). For more challenging cases, reentry devices such as the Outback (Cordis Corp., Bridgewater,

NJ) or Pioneer (Medtronic, Fridley, MN) catheters may be used. Once the lesion is successfully crossed

with a wire, the mode of intervention should then be considered. The typical balloon used for common

iliac arteries is 8 to 10 mm, and for external iliac arteries 6 to 8 mm. The principal cause of balloon

angioplasty failure is recoil of the atherosclerotic artery or a flow-limiting dissection. Stents serve as

support to oppose the elastic recoil of the media and adventitia of the artery after angioplasty. They are

also highly effective in sealing dissection planes within the atherosclerotic plaque resulting from the

angioplasty procedure. Stents are also indicated in residual post-balloon stenosis (>30%), residual

gradients (>10 mm Hg), ulcerative plaques that have a high risk of showering debris, and after

recanalization of an occluded artery.

Self-expanding stents come precovered with a sheath and can be introduced into the lesion directly.

Pulling back the sheath allows the compressed stent to assume its expanded form. Self-expanding stents

may be more flexible and less likely to get crushed in the event they are deployed close to or past the

inguinal ligament into the common femoral artery and are, therefore, used more frequently in the

external iliac artery. With self-expanding stents, postdeployment balloon angioplasty is usually needed

to achieve full expansion. These stents are usually chosen 10% to 15% larger than the intended lumen

diameter; undersizing must be avoided as self-expanding stents cannot be dilated past their nominal

diameter.

Balloon expandable stents are sometimes preferred to self-expanding stents in the common iliac

artery, owing to their ease and precision of deployment, their better visibility under fluoroscopy, and

the increased radial force of their design. These stents are usually introduced through a long sheath

passed through the lesion to prevent dislodgment of the stent as it traverses the lesion. The sheath is

pulled back once the stent is in satisfactory position, and the stent is deployed under fluoroscopic

guidance. Balloon expandable stents are usually sized to the diameter of the normal adjacent artery.

Slight undersizing of the stent can be easily managed by further dilating the stent, using a larger

balloon.

The role of primary iliac artery stenting was addressed in the Dutch Iliac Stent Trial.53 Primary

angioplasty was compared to primary stenting. Stents were used in 43% of patients who underwent

primary angioplasty because of poor results with dilatation alone. There was no difference between the

groups at 2 years, with approximately 70% of both groups maintaining iliac artery patency. This result

is in contrast to other studies that found that primary stenting for complex aortoiliac disease decreased

complications and reduced overall long-term failure by up to 39%.54,55 Most interventional vascular

specialists stent iliac lesions primarily.

Covered balloon-expandable (iCast, Atrium Medical Corp, Hudson, NH) and self-expanding stents

(Viabahn, W.L. Gore and Associates, Flagstaff, AZ) have been introduced and are purported to offer a

longer patency rate by controlling neointimal hyperplasia that may grow through the interstices of a

noncovered stent, especially in TASC C and D lesions.56,57 Covered stents may also be useful for

ulcerated plaques, because they are thought to reduce the chance of distal atheromatous embolism and

for heavily calcified or tortuous iliac arteries that are more prone to rupture with balloon inflation.58

Endovascular stent grafts, similar to those used in the treatment of abdominal aortic aneurysms, have

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been evaluated for the treatment of AIOD.59 In one series, the 4-year primary and secondary patency

rates were 66% and 72%, respectively. Although these rates are inferior to conventional open

reconstruction, they suggest that endovascular reconstruction affords a reasonable alternative when

open procedures are high risk or contraindicated.

Intravascular ultrasound is a modality used during an intervention, rather than as an initial diagnostic

tool. It is helpful in sizing iliac stenoses to choose the appropriate-size balloon and stent.38

Lesions just above the aortic bifurcation are usually complex, exophytic, and calcific, and usually

involve both common iliac arteries. Safe and effective intervention in this situation typically requires

the use of two stents, one in each iliac artery, that partially project into the aorta so that they “kiss” in

the distal aorta (Fig. 92-6C). Theoretically, treating only one common iliac artery orifice (i.e., the lesion

is close to the aortic bifurcation) can result in plaque shifting during the angioplasty, causing a new

obstruction in the contralateral lumen. Treating both sides simultaneously avoids this complication.

Complications of Endovascular Interventions

Access site complications are the most common. These include access site hematomas and

retroperitoneal bleeding (4% to 17%), pseudoaneurysms (0.5% to 3%), arterial dissection (2% to 5%),

and distal embolism (1% to 11%). In experienced hands, these complications are infrequent and can

usually be remedied with ultrasound-guided therapy (compression or thrombin injection), intraluminal

stenting, or thrombolytic therapy.60 Contrast-induced nephropathy, however, is a particularly troubling

complication, especially in patients with preexisting renal insufficiency.61 Low osmolality or

isoosmolality agents should be used in patients with moderate renal insufficiency. Avoidance of volume

depletion, non–steroidal anti-inflammatory drugs, and possibly volume expansion should be

considered.62

The most serious intraoperative complication is arterial rupture during angioplasty (0.5% to 3%).60

This is seen as active extravasation on the postintervention angiogram. Treatment is quick passage and

reinflation of the balloon to occlude the rupture site and maintain hemodynamic control and then either

deployment of a covered stent across the rupture site or open repair in the operating room.

Outcome of Endovascular Interventions

Initial technical success is quite high, in the order of 98%, for TASC A and B lesions. TASC C and D

lesions may not be as amenable to endovascular intervention. Surveillance with ABIs and possible

duplex ultrasound play a major role in maintaining patency in these patients. The primary patency of

iliac artery stenting is 70% at 5 years, but this can improve to 85% with close surveillance and

reintervention as necessary (Table 92-2).60,63–65 Late failures are related to the initial extent of

atherosclerosis and the diameter of the treated vessels.66

Open Surgical Management

6 Aortobifemoral (or aortofemoral for short) bypass has been the standard open surgical procedure for

treating AIOD for decades. Five-year patency rates are in excess of 95%, which is unmatched by any

endovascular procedure.67,68 However, direct revascularization of the aortoiliac segment is currently

reserved for patients with advanced (TASC C or D) occlusive disease, for whom the risk of surgery is

acceptable and a durable long-term result is expected.

Description of the Aortofemoral Bypass Operation

Aortofemoral bypass remains the reference standard for reconstruction of advanced AIOD (Fig. 92-7).69

The operation begins with bilateral groin incisions to expose the common, superficial, and deep femoral

arteries. Starting the operation in the groins then moving to the abdomen minimizes the duration the

abdomen is open. This limits fluid loss and hypothermia, and decreases the risk of graft infection. If the

femoral arteries are severely atherosclerotic, the external iliac just above the inguinal ligament is often

a soft, disease-free segment that is amenable to safe clamping. The profunda femoris (deep femoral)

artery is a critical collateral pathway for the entire lower extremity. If disease is present at its origin,

exposure beyond this segment with division of the overlying lateral circumflex femoral vein may be

necessary for complete endarterectomy.

The abdominal aorta is usually exposed via a midline, transperitoneal, inframesocolic approach. The

transverse colon is retracted cephalad, the ligament of Treitz taken down, and the duodenum (third and

fourth portions) mobilized to the right. The left renal vein is identified in the retroperitoneum and

serves as the most cephalad limit of exposure in most cases (0.3% of patients have a retroaortic left

2637

renal vein).70 The anterior surface of the aorta is then exposed from lower border of the left renal vein

to just below the IMA. Numerous lymphatics are usually encountered in the para-aortic retroperitoneal

space. These should be ligated to decrease the chances of a chyle leak. The left renal vein is mobilized if

more proximal aortic control is needed; this is performed by ligating the adrenal, gonadal, and lumbar

branches. It is generally unnecessary to divide the renal vein. Distal control of the aorta is dictated by

the extent of disease. When exposing sites for distal control, the location of the hypogastric plexus and

the presacral nerves, which course anterior to the aorta and travel caudally over the aortic bifurcation

and origin of the left common iliac artery, needs to be kept in mind. Injury to these nerves can result in

erectile dysfunction in men while injury to the sympathetic chain can cause retrograde ejaculation.

Retroperitoneal tunnels are then developed between the exposed infrarenal aorta and the groins by

means of blunt finger dissection. The tunnels are directed posterior to the ureters to avoid postoperative

obstructive uropathy from entrapment of the ureter between the graft limb and the native iliac artery. A

retroperitoneal approach to the aorta via a left flank incision is an accepted alternative, especially in

those patients with “hostile” abdomens; however, it makes creation of the tunnel for the right limb of

the bypass graft slightly more challenging.71

A bifurcated vascular prosthesis of appropriate size is selected, typically a presealed knitted Dacron or

a polytetrafluoroethylene graft, and the patient is heparinized. With an occluding clamp below the renal

arteries and another just above the IMA, the proximal anastomosis between the graft and the aorta is

performed in either an end-to-end or end-to-side fashion. Though most vascular surgeons prefer an endto-end anastomosis for technical simplicity, the end-to-side technique has been found to be just as good,

depending on the pattern of occlusive lesions and need to perfuse patent hypogastric arteries.72 The

proximal anastomosis is placed as close to the renal arteries as practical to prevent future compromise

of the bypass resulting from progression of atherosclerosis in the remaining infrarenal cuff. The limbs of

the prosthesis are then delivered through the retroperitoneal tunnels into the groins. The distal

anastomoses are performed to the common femoral arteries and should be carried onto the profunda

femoral arteries if there is any disease at the femoral bifurcation. Common femoral and profunda

femoris origin endarterectomy may be needed and should be carried out prior to the anastomosis.

Maintaining good outflow through the profunda femoris is very important as many of these patients

have concomitant superficial femoral arterial disease, which may compromise long-term graft patency.

In the rare patient with tissue loss secondary to multilevel disease (AIOD associated with an occluded

superficial femoral artery and compromised deep femoral collaterals), a concomitant distal bypass

(femoropopliteal–tibial) may also be required.

Endarterectomy

Endarterectomy was more commonly performed in the era before reliable vascular prosthetic conduits

were available. The high success rates of angioplasty and stenting for the more limited disease patterns

amenable to endarterectomy have rendered aortoiliac endarterectomy essentially obsolete in most

current practices.

Table 92-2 Results of Endovascular Interventions

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Figure 92-9. A: Ipsilateral infraclavicular incision and bilateral femoral incision locations for extra-anatomic axillary to bifemoral

artery bypass. B: Image demonstrates unilateral axillary to ipsilateral femoral artery bypass graft with cross-femoral to femoral

artery bypass graft.

Extra-Anatomic Bypass

Patients who are at high risk for open aortic surgery due to either physiologic or anatomic constraints

and are not endovascular candidates may be better served with extra-anatomic reconstruction. Although

these operations are less risky, they have a documented lower patency rate and are, therefore, reserved

for patients with CLI and generally not performed for intermittent claudication.

Axillofemoral extra-anatomic reconstruction has been used for revascularization in poor-risk patients

and in those with a “hostile” abdomen and has been reported to be an acceptable alternative to

aortofemoral bypass (Fig. 92-9).73 The axillary artery supplying the arm with the higher brachial blood

pressure is chosen as the inflow vessel, usually the right side. The operative sequence starts with

exposure of the most proximal portion of the axillary artery through an infraclavicular, pectoralis major

muscle-splitting incision. The common, superficial, and deep femoral arteries are then dissected through

bilateral groin incisions. An externally supported polytetrafluoroethylene graft is then passed behind the

pectoralis major muscle and through a subcutaneous tunnel in the anterior axillary line, connecting the

axillary incision with the ipsilateral groin incision. Next, a cross-femoral limb of the graft is delivered

through a subcutaneous suprapubic tunnel connecting the two groins. An anastomosis between the

proximal axillary artery and the prosthesis is then constructed in an end-graft–to–side-of-artery fashion.

The distal anastomoses are performed end-to-side to the common femoral arteries and may be carried

over or onto the deep femoral arteries to ensure adequate graft outflow. Providing flow through both

femoral arteries (axillobifemoral bypass) rather than one ipsilateral artery (axillounifemoral) has been

shown to increase flow velocities within the long main shaft of the graft and improve long-term patency

of the bypass.73 The generally accepted lower patency of the axillofemoral bypass makes it better

2639

reserved for patients with advanced aortoiliac disease who are poor surgical risks with a reduced life

expectancy or those with a “hostile” abdomen.74 For high-risk patients with diffuse advanced disease

limited to one iliac artery, cross-femoral (or femoral artery–to–femoral artery) bypass or an iliofemoral

bypass is a good option.75

Outcomes

The excellent durability of aortofemoral bypass is related to the large caliber and high flow rates of the

vessels involved. Results of direct surgical revascularization are listed in (Table 92-3). Aortofemoral

bypass has excellent primary graft patency rates of approximately 85% to 95% at 5 years and 75% to

88% at 10 years. Factors associated with lower long-term patency of these grafts include female sex (in

part due to smaller vessel size), multilevel arterial occlusive disease, and young age (<50 years) where

premature and aggressive atherosclerosis is usually present.76,77 The most common cause of failure of

surgical reconstructions is the progression of atherosclerosis or the development of anastomotic

neointimal hyperplasia.78 Axillofemoral grafts by comparison have patency rates of only 60% at 3 years.

Femoral–femoral grafts are intermediate in performance with a 5-year patency of 50% to 60%.

Table 92-3 Results of Direct Surgical Revascularization

Complications

As previously stated, aortofemoral grafting is considered the gold standard for the treatment of AIOD.

Due to advancements in anesthesia and surgical critical care, aortofemoral bypass can be performed

with perioperative mortality and morbidity below 5%, respectively67 (Table 92-3). The perioperative

morbidity and mortality for axillofemoral bypass is similar but is performed, in general, on a much

higher risk population of patients.

Early Complications

Postoperative cardiac events have decreased to less than 5%. This is due to diligent preoperative

screening and following the excellent perioperative guidelines promoted by numerous professional

societies including the use of aspirin, statins, and perioperative beta-blockers.

Pulmonary complications are not infrequent, occurring in up to 7% of patients. Adequate pain control

with epidural anesthesia to facilitate pulmonary toilet and avoiding volume overload can help reduce

these complications.

Atheroemboli can occur during the procedure, manifesting as end organ ischemia of the skin, pelvis,

spinal cord, and bowel. Attention to detail during arterial clamping and flushing out the graft before

unclamping can minimize this complication.

Ischemic colitis and pelvic ischemia are rare and can be minimized by planning a procedure that

maintains pelvic perfusion and blood flow to the IMA when collateral flow is insufficient to maintain

left colon viability. Selective reimplantation of the IMA can be performed when poor IMA perfusion is

anticipated or demonstrated. Ischemic colitis may require colectomy for treatment, but this is

associated with a 50% mortality.

Acute renal injury can result from either atheroembolism from aortic clamping close to the renal

arteries or from corticomedullary renal shunting induced by the acute increase in afterload attendant

with aortic clamping.

Other possible complications include wound complications, particularly in the groin (lymphocele,

lymphocutaneous fistula, wound infection), postoperative hemorrhage, erectile dysfunction in men,

bowel injury, pancreatitis from retraction injury, and spinal cord ischemia. Wound complications can

be particularly troublesome for axillofemoral and femoral–femoral bypasses because of the

subcutaneous location of these prosthetic grafts.

Late Complications

Graft thrombosis that is largely due to progression of native atherosclerotic disease either proximal or

distal to the graft, or to anastomotic neointimal hyperplasia.

2640

Pseudoaneurysms from material fatigue, suture fracture, artery wall degeneration, or occult infection.

Graft infections. A graft enteric fistula (most frequently to the third/fourth portions of the overlying

duodenum) may present as a gastrointestinal bleed. Every gastrointestinal bleed in a patient with a

history of aortofemoral bypass or other aortic reconstruction should be considered to be an

aortoenteric fistula until proven otherwise.

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