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Reconstruction in unilateral iliac disease
Reconstruction in Unilateral Iliac Disease THOMAS
Unilateral occlusive disease of the iliac artery is not an uncommon problem in peripheral vascular surgery. Although primary occlusive disease occurs in a single iliac artery, a significant number of such entities result as failures of aortoiliac endarterectomy or bypass graft. Occasionally one limb of a bypass graft may require revision and reconstruction in the late postoperative period. The most frequently adopted method for surgical exposure of the abdominal aorta and iliac vessels is through a long midline abdominal incision frum the xiphoid process of the sternum to the pubic symphysis. Reoperation through the same approach may cause tedious dissection and difficulties in exposure. Orthner [I] in 1923 described an extraperitoneal route to the iliac vessels which has usually provided excellent exposure for unilateral reconstructive procedures without the difficulty associated with long abdominal incisions. The superiority of this incision has not been stressed by vascular surgeons, even though it has been used frequently in renal transplantation and sometimes in urologic procedures. The direct extraperitoneal approach to the terminal abdominal aorta and iliac vessels is obtained through an oblique incision parallel to the inguinal ligament in the ipsilateral side. This brings the surgeon closer to the vessels; less dissection and retraction are necessary, particularly in the obese and in patients previously operated upon. (Figure 1.) Routine abdominal complications, such as paralytic ileus, wound dehiscence, adhesions, and pulmonary complications are kept at a minimum because of the muscle-splitting extraperitoneal incision and lower abdominal location of this approach. I used this approach in fifteen different patients, nine of whom were operated on in the year 1969-1970, with exclusive unilateral iliac Or common femoral vascular lesions. Prior to adopt_. From the Department of Surgery. Veterans Administration 4801 Linwood Boulevard. Kansas City, Missouri 64128.
410
Hospital,
V. THOMAS,
MD, Kansas
City, Missouri
ing this approach for vascular reconstructive procedures, I was impressed with the excellent exposure and simplicity of approach to iliac vessels in personal experiences with several renal transplantations at the Louisville General Hospital, Louisville, Kentucky, from 1967 to 1968. Preoperative arteriograms on four of the patients provide an idea of the vascular lesions selected for this approach. (Figures 2 through 5.) Direct Reconstruction of Unilateral Iliac Disease
The diagnosis of unilateral iliac disease is confirmed by physical examination and aortography. An oblique incision is made approximately two fingerbreadths above and parallel to the inguinal .V.C.t
..j
1
i / Abdominal
\ >
,,+
aorta
lnguinal
lig.
J
Diagrammaticrepresentation of the surgical apFigure 1. proach to reconstruction of unilateral iliac artery disease. The inset shows the skin incision which is made parallel to the inguinaf ligament.
The Amarlcan
Journal
of Surgery
Unilateral
Iliac
Disease
Figure 2. Abdominal aortogram of a patient with bilateral Internal iliac artery occlusion and a short segment of marked narrowing in the left external iliac artery. This was treated with local endarterectomy and patch graft through the retroperitoneal approach. Figure 3. Retrograde aortogkam of the abdominal aorta of this patient revealed a unilateral external iliac artery occlusion. The left internal iliac artery is patent.
ligament, starting at its midpoint and extending to the flank. The external oblique, internal oblique, and transversalis muscles are split in the direction of the fibers, and the retroperitoneal space is entered. The patient is rotated 25 to 30 degrees away from the surgeon to permit displacement of visceral contents from the operative site. The ileoinguinal and ileohypogastric nerves are preserved and retracted medially with the peritoneum. The ureter may be left in place or displaced medially. The spermatic cord is seen at the medial aspect of the incision. A plane is created by blunt dissection anterior and posterior to the aortic bifurcation for application of the occluding clamp. The terminal abdominal aorta is partly occluded using a side-clamp on the desired side. The common iliac artery is divided approximately 1 to 2 cm away from its origin and the distal end ligated. A preclotted 6 or 8 mm Dacron@ tube graft is anastomosed end to end
to the stump of the common iliac artery, using number 4-O synthetic sutures. The proximal stump may require dilatation or endarterectomy before the anastomosis is carried out. The end to end anastomosis proximally provides greater flow and better patency rates. The distal end of the graft is anastomosed end to side to the external iliac or common femoral artery. An end to side anastomosis distally helps to perfuse the internal iliac arteries retrograde and creates a wider anastomosis. (Figure 6.) The muscles and fascia are approximated in layers using number 2-O or 3-O interrupted silk sutures. Nasogastric tube decompression of the stomach is rarely indicated. Twenty-four to thirtysix hours after the procedure, oral feedings are started. Concurrent steps, such as lumbar sympathectomy or nephrectomy, may be carried out through this incision. Those surgeons who prefer thromboendarterectomy over bypass grafts may
Figure 4. Retrograde aortogram of another patient with left external iliac occlusion. The Internal lilac artery on the left communicates through collaterals with a patent common femoral artery. Figure 5. Retrograde abdominal aorta. gram of a young patient with complete occlusion of one external iliac artery. internal iliac vessels on both sides are patent.
Volume
122,
September
1971
411
Thomas
Figure 6. lntraoperative erterlogram of a patient with a bypass graft from the common iliac to the distal external iliac artery, carried out through a retroperitoneal approach. Figure 7. Aortogram of a patient treated by an alternative extraperitoneal approach applicable to extremely poor risk patients. The bypass graft from one common femoral artery to the other is carried through a suprapubic subcuteneous tunnel.
find this approach more convenient than the abdominal one for unilateral iliac disease. None of the fifteen patients in this series had any major complications, This approach was used to get proximal control of the external iliac artery and the ipsilateral limb of the aortofemoral graft when large false aneurysms developed distally in two patients. Another patient in this group had an arteriovenous fistula in the groin secondary to old trauma, and proximal control of the iliac vessels was obtained through an extraperitoneal approach. It was found to be a valuable step in two patients in the Louisville General Hospital with gunshot wounds of the groin and a large expanding pulsatile hematoma in whom the initial procedure was to obtain control of the proximal blood flow. Indirect
Femorofemoral
Bypass
The direct reconstruction is usually carried out with the patient under general anesthesia, but spinal anesthesia may be used also. On rare occasions a patient may not be a good risk for general or spinal anesthesia, and the unilateral iliac occlusion can be bypassed with the patient receiving local infiltration of anesthetics. The femoral arteries are exposed through 5 to 6 cm long incisions in both groins, and blood is bypassed to the diseased side by the use of a prosthetic or autogenous graft placed through a subcutaneous tunnel. (Figure 7.1 Comments
The extraperitoneal flank approach used for a variety of clinical situations,
412
is being the most
frequent of which is probably renal transplantation, as described by Starzl and co-workers [Z]. Urologists have used this approach to expose the distal ureters. Gynecologists have utilized it for ligation of the hypogastric vessels for control of pelvic hemorrhage, as reported by Byron et al [a]. Others have found it useful for infusion of chemotherapeutic agents in pelvic neoplasms. Smyth [.4] has reported the use of this method for ligation of internal iliac vessels in patients with ruptured gluteal artery aneurysms. In the presence of intraperitoneal inflammatory process and iliac occlusion, this approach may be preferable to prevent infection of a prosthetic graft. Suppurative processes in the groin also will forbid the use of a vascular anastomosis; therefore, a graft from the iliac artery may be brought out through the obturator foramen into the distal superficial femoral artery. Although the major occlusive disease involves only the iliac vessels on one side, as in the cases under consideration here, I have preferred the use of bypass grafts as an expedient and equally effective method as described in another communication [5]. Nine of the operations performed at the Veterans Administration Hospital in Kansas City, Missouri, were carried out by the resident staff under supervision, and have yielded excellent results. The relatively smooth and short postoperative course as well as the early recuperation of these patients has been impressive in comparison to that of patients undergoing transperitoneal reconstruction. This approach is not advisable when there is bilateral iliac or distal aortic involvement because of the lack of exposure for satisfactory
Unilateral
control of the abdominal aorta and the contralatera1 iliac vessel. Summary
The extraperitoneal approach is a preferable method in patients with unilateral iliac disease or failure of one limb of a graft from previous surgical reconstruction. Technically the approach is simple and postoperative complications are fewer. Femorofemoral bypass is an alternate method that may be carried out using local anesthesia in poor risk patients.
Volume
122,
September
1971
iliac
Disease
References 1. Orthner I: Treatment of inoperable cancer of the uterus, Wien K/in Wschr 36: 54, 1923. 2. Starzl TE, Marchiaro TL, Dickinson TC, Rifkind D, Storing ton OG, Wadder WR: Technique of renal homotransplantation. Arch Surg 89: 87, 1964. 3. Byron RL Jr, Yonemoto RH, Rihimaki DU, Freeman RK: Retroperitoneal ligation of hypogastric arteries for pelvic hemorrhage. Ann Surg 33: 25, 1967. 4. Smyth NPD: Gluteal artery rupture. Ann Surg 167: 273, 1968. 5. Thomas TV: Role of thromboendarterectomy and bypass graft in occlusive vascular disorders. Surgery 66: 965, 1969.
413
Unilateral occlusive disease of the iliac artery is not an uncommon problem in peripheral vascular surgery. Although primary occlusive disease occurs in a single iliac artery, a significant number of such entities result as failures of aortoiliac endarterectomy or bypass graft. Occasionally one limb of a bypass graft may require revision and reconstruction in the late postoperative period. The most frequently adopted method for surgical exposure of the abdominal aorta and iliac vessels is through a long midline abdominal incision frum the xiphoid process of the sternum to the pubic symphysis. Reoperation through the same approach may cause tedious dissection and difficulties in exposure. Orthner [I] in 1923 described an extraperitoneal route to the iliac vessels which has usually provided excellent exposure for unilateral reconstructive procedures without the difficulty associated with long abdominal incisions. The superiority of this incision has not been stressed by vascular surgeons, even though it has been used frequently in renal transplantation and sometimes in urologic procedures. The direct extraperitoneal approach to the terminal abdominal aorta and iliac vessels is obtained through an oblique incision parallel to the inguinal ligament in the ipsilateral side. This brings the surgeon closer to the vessels; less dissection and retraction are necessary, particularly in the obese and in patients previously operated upon. (Figure 1.) Routine abdominal complications, such as paralytic ileus, wound dehiscence, adhesions, and pulmonary complications are kept at a minimum because of the muscle-splitting extraperitoneal incision and lower abdominal location of this approach. I used this approach in fifteen different patients, nine of whom were operated on in the year 1969-1970, with exclusive unilateral iliac Or common femoral vascular lesions. Prior to adopt_. From the Department of Surgery. Veterans Administration 4801 Linwood Boulevard. Kansas City, Missouri 64128.
410
Hospital,
V. THOMAS,
MD, Kansas
City, Missouri
ing this approach for vascular reconstructive procedures, I was impressed with the excellent exposure and simplicity of approach to iliac vessels in personal experiences with several renal transplantations at the Louisville General Hospital, Louisville, Kentucky, from 1967 to 1968. Preoperative arteriograms on four of the patients provide an idea of the vascular lesions selected for this approach. (Figures 2 through 5.) Direct Reconstruction of Unilateral Iliac Disease
The diagnosis of unilateral iliac disease is confirmed by physical examination and aortography. An oblique incision is made approximately two fingerbreadths above and parallel to the inguinal .V.C.t
..j
1
i / Abdominal
\ >
,,+
aorta
lnguinal
lig.
J
Diagrammaticrepresentation of the surgical apFigure 1. proach to reconstruction of unilateral iliac artery disease. The inset shows the skin incision which is made parallel to the inguinaf ligament.
The Amarlcan
Journal
of Surgery
Unilateral
Iliac
Disease
Figure 2. Abdominal aortogram of a patient with bilateral Internal iliac artery occlusion and a short segment of marked narrowing in the left external iliac artery. This was treated with local endarterectomy and patch graft through the retroperitoneal approach. Figure 3. Retrograde aortogkam of the abdominal aorta of this patient revealed a unilateral external iliac artery occlusion. The left internal iliac artery is patent.
ligament, starting at its midpoint and extending to the flank. The external oblique, internal oblique, and transversalis muscles are split in the direction of the fibers, and the retroperitoneal space is entered. The patient is rotated 25 to 30 degrees away from the surgeon to permit displacement of visceral contents from the operative site. The ileoinguinal and ileohypogastric nerves are preserved and retracted medially with the peritoneum. The ureter may be left in place or displaced medially. The spermatic cord is seen at the medial aspect of the incision. A plane is created by blunt dissection anterior and posterior to the aortic bifurcation for application of the occluding clamp. The terminal abdominal aorta is partly occluded using a side-clamp on the desired side. The common iliac artery is divided approximately 1 to 2 cm away from its origin and the distal end ligated. A preclotted 6 or 8 mm Dacron@ tube graft is anastomosed end to end
to the stump of the common iliac artery, using number 4-O synthetic sutures. The proximal stump may require dilatation or endarterectomy before the anastomosis is carried out. The end to end anastomosis proximally provides greater flow and better patency rates. The distal end of the graft is anastomosed end to side to the external iliac or common femoral artery. An end to side anastomosis distally helps to perfuse the internal iliac arteries retrograde and creates a wider anastomosis. (Figure 6.) The muscles and fascia are approximated in layers using number 2-O or 3-O interrupted silk sutures. Nasogastric tube decompression of the stomach is rarely indicated. Twenty-four to thirtysix hours after the procedure, oral feedings are started. Concurrent steps, such as lumbar sympathectomy or nephrectomy, may be carried out through this incision. Those surgeons who prefer thromboendarterectomy over bypass grafts may
Figure 4. Retrograde aortogram of another patient with left external iliac occlusion. The Internal lilac artery on the left communicates through collaterals with a patent common femoral artery. Figure 5. Retrograde abdominal aorta. gram of a young patient with complete occlusion of one external iliac artery. internal iliac vessels on both sides are patent.
Volume
122,
September
1971
411
Thomas
Figure 6. lntraoperative erterlogram of a patient with a bypass graft from the common iliac to the distal external iliac artery, carried out through a retroperitoneal approach. Figure 7. Aortogram of a patient treated by an alternative extraperitoneal approach applicable to extremely poor risk patients. The bypass graft from one common femoral artery to the other is carried through a suprapubic subcuteneous tunnel.
find this approach more convenient than the abdominal one for unilateral iliac disease. None of the fifteen patients in this series had any major complications, This approach was used to get proximal control of the external iliac artery and the ipsilateral limb of the aortofemoral graft when large false aneurysms developed distally in two patients. Another patient in this group had an arteriovenous fistula in the groin secondary to old trauma, and proximal control of the iliac vessels was obtained through an extraperitoneal approach. It was found to be a valuable step in two patients in the Louisville General Hospital with gunshot wounds of the groin and a large expanding pulsatile hematoma in whom the initial procedure was to obtain control of the proximal blood flow. Indirect
Femorofemoral
Bypass
The direct reconstruction is usually carried out with the patient under general anesthesia, but spinal anesthesia may be used also. On rare occasions a patient may not be a good risk for general or spinal anesthesia, and the unilateral iliac occlusion can be bypassed with the patient receiving local infiltration of anesthetics. The femoral arteries are exposed through 5 to 6 cm long incisions in both groins, and blood is bypassed to the diseased side by the use of a prosthetic or autogenous graft placed through a subcutaneous tunnel. (Figure 7.1 Comments
The extraperitoneal flank approach used for a variety of clinical situations,
412
is being the most
frequent of which is probably renal transplantation, as described by Starzl and co-workers [Z]. Urologists have used this approach to expose the distal ureters. Gynecologists have utilized it for ligation of the hypogastric vessels for control of pelvic hemorrhage, as reported by Byron et al [a]. Others have found it useful for infusion of chemotherapeutic agents in pelvic neoplasms. Smyth [.4] has reported the use of this method for ligation of internal iliac vessels in patients with ruptured gluteal artery aneurysms. In the presence of intraperitoneal inflammatory process and iliac occlusion, this approach may be preferable to prevent infection of a prosthetic graft. Suppurative processes in the groin also will forbid the use of a vascular anastomosis; therefore, a graft from the iliac artery may be brought out through the obturator foramen into the distal superficial femoral artery. Although the major occlusive disease involves only the iliac vessels on one side, as in the cases under consideration here, I have preferred the use of bypass grafts as an expedient and equally effective method as described in another communication [5]. Nine of the operations performed at the Veterans Administration Hospital in Kansas City, Missouri, were carried out by the resident staff under supervision, and have yielded excellent results. The relatively smooth and short postoperative course as well as the early recuperation of these patients has been impressive in comparison to that of patients undergoing transperitoneal reconstruction. This approach is not advisable when there is bilateral iliac or distal aortic involvement because of the lack of exposure for satisfactory
Unilateral
control of the abdominal aorta and the contralatera1 iliac vessel. Summary
The extraperitoneal approach is a preferable method in patients with unilateral iliac disease or failure of one limb of a graft from previous surgical reconstruction. Technically the approach is simple and postoperative complications are fewer. Femorofemoral bypass is an alternate method that may be carried out using local anesthesia in poor risk patients.
Volume
122,
September
1971
iliac
Disease
References 1. Orthner I: Treatment of inoperable cancer of the uterus, Wien K/in Wschr 36: 54, 1923. 2. Starzl TE, Marchiaro TL, Dickinson TC, Rifkind D, Storing ton OG, Wadder WR: Technique of renal homotransplantation. Arch Surg 89: 87, 1964. 3. Byron RL Jr, Yonemoto RH, Rihimaki DU, Freeman RK: Retroperitoneal ligation of hypogastric arteries for pelvic hemorrhage. Ann Surg 33: 25, 1967. 4. Smyth NPD: Gluteal artery rupture. Ann Surg 167: 273, 1968. 5. Thomas TV: Role of thromboendarterectomy and bypass graft in occlusive vascular disorders. Surgery 66: 965, 1969.
413