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Extraperitoneal aortoiliac disobliteration with plaque cracker
Extraperitoneal Aortoiliac Disobliteration with Plaque Cracker Harry H. LeVeen,
MD, Brooklyn, New York
Carlos Diaz, MD, Brooklyn, New York Moon Wai Ip, MD, Brooklyn, New York
Many surgeons have abandoned the use of disobliteration of the aorta, iliac, and femoral arteries because the operations are time-consuming, extensive, and involve considerable loss of blood. These surgeons contend that there is a greater morbidity and mortality associated with this procedure than with the simpler bypass procedure. We have simplified this type of surgery to the point where the operation can be performed rapidly and without blood loss. The principal changes of our approach were use of the plaque cracker [I] and performance of the endarterectomy in the unopened vessel between isolation clamps. An opening into the vessel is made only to extract the dissected material lying free in the vessel lumen between the clamps. Although the name “endarterectomy” is widely used, the manner in which this procedure is done varies so widely that when the operation is done by different people, it becomes totally dissimilar. Therefore, “disobliteration,” the term used by the British, seems more applicable since it has neither anatomic nor procedural connotations but refers merely to the end result. The present paper describes technics developed over a twenty year period and the results found in 245 patients. The introduction of the plaque cracker in 1969 greatly simplified the procedure, and during the 1as.t five years, all aortic reconstructive surgery has been done using the extraperitoneal approach. Clinical Methods
The aorta is approached via an extraperitoneal incision. The left side of the body is propped up at a 45 degree angle from the tabletop. The patient is placed over the break in the table, so that his torso can be gently hyperextended to widen the interval between the ribs and the pelvic crest. The incision begins at the tip of the eleventh rib and extends downward towards the symphysis pubis. A few inches above the femoral point, the incision is turned downward over the thigh to expose the femoral artery. (Figure 1A.) From the Departments of Surgery, Veterans Administration Hospital, and the State University of New York, Downstate Medical Center, Brooklyn, New York. Peprint requests should be addressed to Han-yH. LeVeen, MD, Department Of Surgery, Veterans Administration Hospital, Brooklyn, New York 11209. Presented at th!?Sixth Annual Meeting of ths Society for Clinical Vascular Surgery. Palm Springs, California, April l-5. 1978.
Volume 136, August 1978
If additional room is required, the incision is extended upward to just below the costal margin from the eleventh rib. The muscles are split where practical and they are otherwise transected to expose the properitoneal fat which is pushed medially with the peritoneum for exploration of the aorta. The aorta should not be cleaned in its entirety, but it should be exposed. (Figure 1B.) The disobliteration technic employs the intimal guillotine (plaque cracker) [I] which has dull blades that deliver a measured impact to the outside of the ,vessel by a spring-loaded hammer. The impact transects the intima on the inside of the unopened vessel and does not cause significant injury to the outer elastic adventitia. The transected intima is then milked distally, or proximally, and the vessel is disobliterated. The exact order in which this milking maneuver is performed is important, since an excessive quantity of intima cannot be milked into any one segment of vessel in case the vessel becomes overexpanded to the point of rupture. Since all of the intima is removed through one small transverse arteriotomy, the removal must be done sequentially. Blood loss is prevented by dissecting unopened segments of vessel. The operation is begun by circumferentiall,y dissecting the aorta for application of the plaque cracker. (Figure 2A.) Similarly, both common iliac arteries are circumferentially dissected near their takeoff from the aorta for the same purpose. The right common iliac artery is clamped just above its bifurcation, which is a short distance below the point. where the plaque cracker will transect the intima in the right common iliac artery. (Figure 2B.) The left common iliac artery is cross-clamped just proximal to its bifurcation. (Figure 2C.) The plaque cracker is first placed on the aorta, and the intima is transected. (Figure 2D.) The transected intima is squeezed for 1 or 2 cm distally (Figure 2E), and an occlusive cross clamp, such as a Satinsky clamp, is placed across the emptied segment of the aorta. (Figure 3A.) The entire area to be endarterectomized is now contained between cross clamps. Next, the intima of the left common iliac artery is severed just beneath the bifurcation. (Figure 3B.) It is milked as far distally as is compatible with distension of the distal vessel with endarterectomized material. After mobilizing this proximal stump, the plaque cracker is placed just proximal to the distal occluding clamp of the left common iliac artery. (Figure 3C.) The transected plaque is then milked proximally. (Figure 3D.) Having mobilized the plaque within the left common iliac artery, a transverse arteriotomy is made 1 and 2 cm beneath the aortic bifurcation. The proximal portion of the mobilized plaque is extracted through the endarterectomy opening (Figure 4A), and the remainder
221
LeVeen, Diaz, and Ip
Figure 1. A, an in&ion is made a few inches above the femoral point and turned downward over the thigh to expose the femoral artery: 6, the aorta is exposed.
of the plaque is then expressed by squeezing the common iliac artery to move the transected plaque up the iliac artery and through the arteriotomy opening. The plaque is expressed in much the same way in which one would squeeze toothpaste from a tube. Next, the intima of the right common iliac artery is transected with the plaque cracker, which is placed as close as possible to the aortic bifurcation. (Figure 4B.) The aortic intima is milked upward from the right common iliac artery (Figure 4C) and from the transected stump of the left common iliac artery by the same squeezing and milking procedure that was previously used. The segment is mobilized upward as far as possible and directed into the left common iliac artery by putting a clamp up the left common iliac artery and grasping the mobilized intima and pulling it downward. (Figure 5A.) At the same time, the previously transected and mobilized aortic intima located above is squeezed downward until the entire aortic segment has been pushed into the iliac artery and extracted through the transverse arteriotomy. Similarly, the right common iliac artery is emptied down to its bifurcation, but not beyond, since visibility is poor. (Figure 5B.) The material in the right common iliac artery is delivered over to the left common iliac artery and removed. (Figure 5C.) If the material in the right internal iliac artery is not accessible and a portion remains together with material in the right external iliac artery, it must be removed using a right-sided approach. This can be accomplished via a low McBurney type incision, an incision that follows the external iliac artery upward, or an incision that runs parallel to the inguinal ligament but is 4 cm above it. The left external iliac artery should be emptied by transecting the plaque low down and milking it upward. Because of the length of the external iliac artery, it should not be emptied in a single piece, but rather in two segments. An occlusive clamp is placed as low down as possible on the left internal iliac artery and the left external iliac artery. It is then advisable
222
to transect this intima of the external iliac artery just distal to the bifurcation of the common iliac artery. Material in the internal iliac artery is best removed by a finger fracture technic as far distally as can be managed. Thereafter, the intima is transected at the midportion of the external iliac artery, and this segment is removed. Subsequently, the intima in the distal part of the external iliac artery is removed. If it is necessary to empty the femoral artery, this should be done only to the profunda femori. These plaques are mobilized by milking, and they are removed through a transverse arteriotomy in the common femoral artery. A series of soft brushes that are graded in size and bristle stiffness can be used to brush the vessels to free any small
pieces of residual intima. The interior of the vessel is also irrigated after the brushes have been used.
Results A total of 245 patients were treated during the twenty year period from 1956 to 1976. A plaque cracker has been used in almost all these operations within the past eight years; however, the number of patients treated in this manner now exceeds 131. (Figure 6.) Since 1972 the extraperitoneal approach has gradually replaced the intraperitoneal abdominal approach. (Figure 6.) Long-term follow-up data were available only for seventy-two patients Three of these seventy-two patients (4.2 per cent) died after surgery. Short-term patency (6 weeks) in sixty-two of the seventy patients was 88 per cent, whereas long-term patency (1 to 4 years) in forty-eight of sixty-four patients was 75 per cent. The operative time for aortic cross clamping ranged from 12 to 26 minutes (average, 19 minutes); thus, the operation can be performed rapidly. TheAmerican
Journal of Surgery
Extraperitoneal
Aortoiliac
ihobliteration
Figure 2. A, the aorta is circumferential/y dissected for the application of the plaque cracker; B, the right common iliac artery is clamped just above its bifurcation; C, the left common iliac artery is cross-clamped just proximal to its bifurcation; D, the plaque cracker is placed on the aorta and the intima is transected; E, the transected intima is squeezed for 1 or 2 cm distally.
Figure 3. A, an occlusive cross clamp is placed across the emptied segment of the aorta; B, the intima of the ieft common iliac ariery is severed just beneath the biltrrcatton; C, the plaque cracker is placed just proximal to the distal occluding clamp of the teft common iliac artery; D, the transected plaque is milked proximally.
Volume 136, August 1978
Figure 4. A, the proximal portion of the mobilized plaque Is extracted through the endarterectomy openhtg; B, the intima of the right common iliac artery is transected with the plaque cracker; C, the aortic intima Is milked upward from the right common iliac artery.
LeVeen,
Diaz, and Ip
Figure 6. The results of 245 patients who underwent aortoiliofemoral endarterectomles.
JMo55
‘77
Figure 5. A, the aortlc intlma is directed into the left common iliac artery by putting a clamp up the left common lilac artery; B, the right common Iliac artery Is also emptied; C, the material in the right common Iliac artery is delivered to the left common Iliac artery and removed.
Comments
One contraindication to the use of the plaque cracker is a calcified aorta. Patients with considerable calcification should not undergo this type of reconstructive surgery. The adventitia is usually too thin to allow for sewing, and leakage by perforation of calcified spicules is a serious problem. A modicum.of calcium can be handled, but the intima should not be sectioned in a calcified area. Although autogenous tissue is more desirable when reconstructing the artery than when using synthetic materials, the decision to use synthetics is often based on operative time and expected morbidity. Our experience shows that the operation can be done safely and rapidly and results in good long-term patency. With the increasing use of synthetic bypass grafts, several late complications have become apparent. One is aneurysm at the suture line. This has been estimated to occur in 2 to 5 per cent of all patients. These aneurysms are not easily accessible, and because of previous scarring, they are difficult to treat. They sometimes become manifest only at the time of rupture. Another serious complication is instability of the neointima that covers the interior of the prosthesis and leakage and occlusion of the graft because of a hematoma between the cloth and the fibrous sheath surrounding it. Also, duodenal tistulas have occurred from erosion of the aortic graft through
224
the duodenum. These are difficult to prevent because the prosthesis cannot always be wrapped with tissue after a bypass that is done for removal of an aneurysm. The remnants of the wall of the aneurysm are used to cover the cloth of the prosthesis. Late localization of an infection can also occur should sepsis develop with bacteremia from any cause. The synthetic artery is like an artificial heart valve or a valve injured by rheumatic fever: it is always susceptible to infection. Such considerations are, of course, inconsequential if the patient dies from excessive surgery and blood loss during endarterectomy. If disobliteration of the aorta and iliac vessels can be done quickly and safely, it becomes the procedure of choice. The retroperitoneal approach avoids postoperative morbidity. The patients are out of bed the following day and do not suffer gastrointestinal or pulmonary complications. It is safe, since the possibility of bowel injury and postoperative wound dehiscence with evisceration is minimized. The approach gives adequate exposure for surgery. Summary
Disobliteration of the aorta and iliac arteries through an extraperitoneal approach is described. An intimal guillotine (plaque cracker) is used to transect the intima of the unopened vessel. The intima is then milked down to a transverse arteriotomy in the left common iliac artery, through which all of the discarded intima is removed. Since the intima is dissected free before opening the vessels, blood loss is minimal. The procedure is rapid and requires only an average of 19 minutes of aortic cross clamping. Our operative mortality was 4.2 per cent and the long-term patency rate 75 per cent. Reference 1. LeVeen HH, Diaz C, Christoudias G: The postendarterectomy intimal flap. Arch Surg 107: 664, 1973.
The American Journal of Surgery
MD, Brooklyn, New York
Carlos Diaz, MD, Brooklyn, New York Moon Wai Ip, MD, Brooklyn, New York
Many surgeons have abandoned the use of disobliteration of the aorta, iliac, and femoral arteries because the operations are time-consuming, extensive, and involve considerable loss of blood. These surgeons contend that there is a greater morbidity and mortality associated with this procedure than with the simpler bypass procedure. We have simplified this type of surgery to the point where the operation can be performed rapidly and without blood loss. The principal changes of our approach were use of the plaque cracker [I] and performance of the endarterectomy in the unopened vessel between isolation clamps. An opening into the vessel is made only to extract the dissected material lying free in the vessel lumen between the clamps. Although the name “endarterectomy” is widely used, the manner in which this procedure is done varies so widely that when the operation is done by different people, it becomes totally dissimilar. Therefore, “disobliteration,” the term used by the British, seems more applicable since it has neither anatomic nor procedural connotations but refers merely to the end result. The present paper describes technics developed over a twenty year period and the results found in 245 patients. The introduction of the plaque cracker in 1969 greatly simplified the procedure, and during the 1as.t five years, all aortic reconstructive surgery has been done using the extraperitoneal approach. Clinical Methods
The aorta is approached via an extraperitoneal incision. The left side of the body is propped up at a 45 degree angle from the tabletop. The patient is placed over the break in the table, so that his torso can be gently hyperextended to widen the interval between the ribs and the pelvic crest. The incision begins at the tip of the eleventh rib and extends downward towards the symphysis pubis. A few inches above the femoral point, the incision is turned downward over the thigh to expose the femoral artery. (Figure 1A.) From the Departments of Surgery, Veterans Administration Hospital, and the State University of New York, Downstate Medical Center, Brooklyn, New York. Peprint requests should be addressed to Han-yH. LeVeen, MD, Department Of Surgery, Veterans Administration Hospital, Brooklyn, New York 11209. Presented at th!?Sixth Annual Meeting of ths Society for Clinical Vascular Surgery. Palm Springs, California, April l-5. 1978.
Volume 136, August 1978
If additional room is required, the incision is extended upward to just below the costal margin from the eleventh rib. The muscles are split where practical and they are otherwise transected to expose the properitoneal fat which is pushed medially with the peritoneum for exploration of the aorta. The aorta should not be cleaned in its entirety, but it should be exposed. (Figure 1B.) The disobliteration technic employs the intimal guillotine (plaque cracker) [I] which has dull blades that deliver a measured impact to the outside of the ,vessel by a spring-loaded hammer. The impact transects the intima on the inside of the unopened vessel and does not cause significant injury to the outer elastic adventitia. The transected intima is then milked distally, or proximally, and the vessel is disobliterated. The exact order in which this milking maneuver is performed is important, since an excessive quantity of intima cannot be milked into any one segment of vessel in case the vessel becomes overexpanded to the point of rupture. Since all of the intima is removed through one small transverse arteriotomy, the removal must be done sequentially. Blood loss is prevented by dissecting unopened segments of vessel. The operation is begun by circumferentiall,y dissecting the aorta for application of the plaque cracker. (Figure 2A.) Similarly, both common iliac arteries are circumferentially dissected near their takeoff from the aorta for the same purpose. The right common iliac artery is clamped just above its bifurcation, which is a short distance below the point. where the plaque cracker will transect the intima in the right common iliac artery. (Figure 2B.) The left common iliac artery is cross-clamped just proximal to its bifurcation. (Figure 2C.) The plaque cracker is first placed on the aorta, and the intima is transected. (Figure 2D.) The transected intima is squeezed for 1 or 2 cm distally (Figure 2E), and an occlusive cross clamp, such as a Satinsky clamp, is placed across the emptied segment of the aorta. (Figure 3A.) The entire area to be endarterectomized is now contained between cross clamps. Next, the intima of the left common iliac artery is severed just beneath the bifurcation. (Figure 3B.) It is milked as far distally as is compatible with distension of the distal vessel with endarterectomized material. After mobilizing this proximal stump, the plaque cracker is placed just proximal to the distal occluding clamp of the left common iliac artery. (Figure 3C.) The transected plaque is then milked proximally. (Figure 3D.) Having mobilized the plaque within the left common iliac artery, a transverse arteriotomy is made 1 and 2 cm beneath the aortic bifurcation. The proximal portion of the mobilized plaque is extracted through the endarterectomy opening (Figure 4A), and the remainder
221
LeVeen, Diaz, and Ip
Figure 1. A, an in&ion is made a few inches above the femoral point and turned downward over the thigh to expose the femoral artery: 6, the aorta is exposed.
of the plaque is then expressed by squeezing the common iliac artery to move the transected plaque up the iliac artery and through the arteriotomy opening. The plaque is expressed in much the same way in which one would squeeze toothpaste from a tube. Next, the intima of the right common iliac artery is transected with the plaque cracker, which is placed as close as possible to the aortic bifurcation. (Figure 4B.) The aortic intima is milked upward from the right common iliac artery (Figure 4C) and from the transected stump of the left common iliac artery by the same squeezing and milking procedure that was previously used. The segment is mobilized upward as far as possible and directed into the left common iliac artery by putting a clamp up the left common iliac artery and grasping the mobilized intima and pulling it downward. (Figure 5A.) At the same time, the previously transected and mobilized aortic intima located above is squeezed downward until the entire aortic segment has been pushed into the iliac artery and extracted through the transverse arteriotomy. Similarly, the right common iliac artery is emptied down to its bifurcation, but not beyond, since visibility is poor. (Figure 5B.) The material in the right common iliac artery is delivered over to the left common iliac artery and removed. (Figure 5C.) If the material in the right internal iliac artery is not accessible and a portion remains together with material in the right external iliac artery, it must be removed using a right-sided approach. This can be accomplished via a low McBurney type incision, an incision that follows the external iliac artery upward, or an incision that runs parallel to the inguinal ligament but is 4 cm above it. The left external iliac artery should be emptied by transecting the plaque low down and milking it upward. Because of the length of the external iliac artery, it should not be emptied in a single piece, but rather in two segments. An occlusive clamp is placed as low down as possible on the left internal iliac artery and the left external iliac artery. It is then advisable
222
to transect this intima of the external iliac artery just distal to the bifurcation of the common iliac artery. Material in the internal iliac artery is best removed by a finger fracture technic as far distally as can be managed. Thereafter, the intima is transected at the midportion of the external iliac artery, and this segment is removed. Subsequently, the intima in the distal part of the external iliac artery is removed. If it is necessary to empty the femoral artery, this should be done only to the profunda femori. These plaques are mobilized by milking, and they are removed through a transverse arteriotomy in the common femoral artery. A series of soft brushes that are graded in size and bristle stiffness can be used to brush the vessels to free any small
pieces of residual intima. The interior of the vessel is also irrigated after the brushes have been used.
Results A total of 245 patients were treated during the twenty year period from 1956 to 1976. A plaque cracker has been used in almost all these operations within the past eight years; however, the number of patients treated in this manner now exceeds 131. (Figure 6.) Since 1972 the extraperitoneal approach has gradually replaced the intraperitoneal abdominal approach. (Figure 6.) Long-term follow-up data were available only for seventy-two patients Three of these seventy-two patients (4.2 per cent) died after surgery. Short-term patency (6 weeks) in sixty-two of the seventy patients was 88 per cent, whereas long-term patency (1 to 4 years) in forty-eight of sixty-four patients was 75 per cent. The operative time for aortic cross clamping ranged from 12 to 26 minutes (average, 19 minutes); thus, the operation can be performed rapidly. TheAmerican
Journal of Surgery
Extraperitoneal
Aortoiliac
ihobliteration
Figure 2. A, the aorta is circumferential/y dissected for the application of the plaque cracker; B, the right common iliac artery is clamped just above its bifurcation; C, the left common iliac artery is cross-clamped just proximal to its bifurcation; D, the plaque cracker is placed on the aorta and the intima is transected; E, the transected intima is squeezed for 1 or 2 cm distally.
Figure 3. A, an occlusive cross clamp is placed across the emptied segment of the aorta; B, the intima of the ieft common iliac ariery is severed just beneath the biltrrcatton; C, the plaque cracker is placed just proximal to the distal occluding clamp of the teft common iliac artery; D, the transected plaque is milked proximally.
Volume 136, August 1978
Figure 4. A, the proximal portion of the mobilized plaque Is extracted through the endarterectomy openhtg; B, the intima of the right common iliac artery is transected with the plaque cracker; C, the aortic intima Is milked upward from the right common iliac artery.
LeVeen,
Diaz, and Ip
Figure 6. The results of 245 patients who underwent aortoiliofemoral endarterectomles.
JMo55
‘77
Figure 5. A, the aortlc intlma is directed into the left common iliac artery by putting a clamp up the left common lilac artery; B, the right common Iliac artery Is also emptied; C, the material in the right common Iliac artery is delivered to the left common Iliac artery and removed.
Comments
One contraindication to the use of the plaque cracker is a calcified aorta. Patients with considerable calcification should not undergo this type of reconstructive surgery. The adventitia is usually too thin to allow for sewing, and leakage by perforation of calcified spicules is a serious problem. A modicum.of calcium can be handled, but the intima should not be sectioned in a calcified area. Although autogenous tissue is more desirable when reconstructing the artery than when using synthetic materials, the decision to use synthetics is often based on operative time and expected morbidity. Our experience shows that the operation can be done safely and rapidly and results in good long-term patency. With the increasing use of synthetic bypass grafts, several late complications have become apparent. One is aneurysm at the suture line. This has been estimated to occur in 2 to 5 per cent of all patients. These aneurysms are not easily accessible, and because of previous scarring, they are difficult to treat. They sometimes become manifest only at the time of rupture. Another serious complication is instability of the neointima that covers the interior of the prosthesis and leakage and occlusion of the graft because of a hematoma between the cloth and the fibrous sheath surrounding it. Also, duodenal tistulas have occurred from erosion of the aortic graft through
224
the duodenum. These are difficult to prevent because the prosthesis cannot always be wrapped with tissue after a bypass that is done for removal of an aneurysm. The remnants of the wall of the aneurysm are used to cover the cloth of the prosthesis. Late localization of an infection can also occur should sepsis develop with bacteremia from any cause. The synthetic artery is like an artificial heart valve or a valve injured by rheumatic fever: it is always susceptible to infection. Such considerations are, of course, inconsequential if the patient dies from excessive surgery and blood loss during endarterectomy. If disobliteration of the aorta and iliac vessels can be done quickly and safely, it becomes the procedure of choice. The retroperitoneal approach avoids postoperative morbidity. The patients are out of bed the following day and do not suffer gastrointestinal or pulmonary complications. It is safe, since the possibility of bowel injury and postoperative wound dehiscence with evisceration is minimized. The approach gives adequate exposure for surgery. Summary
Disobliteration of the aorta and iliac arteries through an extraperitoneal approach is described. An intimal guillotine (plaque cracker) is used to transect the intima of the unopened vessel. The intima is then milked down to a transverse arteriotomy in the left common iliac artery, through which all of the discarded intima is removed. Since the intima is dissected free before opening the vessels, blood loss is minimal. The procedure is rapid and requires only an average of 19 minutes of aortic cross clamping. Our operative mortality was 4.2 per cent and the long-term patency rate 75 per cent. Reference 1. LeVeen HH, Diaz C, Christoudias G: The postendarterectomy intimal flap. Arch Surg 107: 664, 1973.
The American Journal of Surgery