Aortofemoral Bypass for Atherosclerotic Aortoiliac Occlusive Disease

Procedure Selection

Numerous options exist for revascularization in patients with AOID. Selection of the most appropriate method depends largely on two factors: the patient’s surgical risk and the extent and distribution of occlusive disease. Aortobifemoral grafting is elected for patients who are relatively free of serious comorbid medical conditions that would make them a high or prohibitive risk for direct abdominal aortic reconstruction. Thus careful preoperative evaluation is important.

For patients with relatively limited areas of disease, particularly unilateral iliac disease, alternative lesser procedures such as percutaneous transluminal angioplasty (PTA) with or without stenting, femorofemoral bypass, or unilateral iliofemoral grafting may be considered. For high-risk patients with bilateral iliac disease or those with relative contraindications to direct aortic reconstruction as a result of technical considerations, such as heavy retroperitoneal scarring or contamination, axillobifemoral extra-anatomic bypass may be chosen. The lower long-term patency rate of these grafts is accepted as a compromise to achieve revascularization in high-risk situations.

Although all of the alternative methods may be helpful or appropriate choices in selected circumstances, aortobifemoral grafting clearly provides superior long-term results in terms of durability and sustained relief of symptoms and thus should be properly regarded as the preferred treatment or gold standard for the management of atherosclerotic AOID, as well as the yardstick to which the results of alternative therapies must be measured.

Aortoiliac endarterectomy formerly was employed in many such patients. Although excellent results may be obtained in patients whose AOID is confined to the distal aorta and common iliac vessels, the majority of patients have diffuse disease and are better managed with aortofemoral graft insertion, which is more expedient and effective in such circumstances.

Operative Management

A broad-spectrum prophylactic antibiotic, such as cefazolin 1 g, is administered intravenously 1 to 2 hours before the operation and continued for 1 or 2 days postoperatively. In patients with an infected open ischemic lesion of an extremity or any other possible source of bacteremia, culture-specific antibiotics are best started several days before the operation.

A radial artery cannula is inserted in all patients for continuous blood pressure monitoring and arterial blood gas determinations. A Swan–Ganz catheter is used in many, but not all, patients, depending on preoperative assessment of cardiac and renal status. Most patients undergoing aortic reconstruction on the author's vascular unit and in many other centers undergo anesthesia by a combination of epidural narcotics and inhalation agents (combined general and epidural technique). Continuation of epidural analgesia in the early postoperative period for pain control has been a significant advance in limiting administration of systemic narcotics and in reducing associated respiratory complications following aortic reconstruction.