Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease

Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease

Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease A n n e t t e Seagraves, M . D . , and R o b e r ...

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Isolated hypogastric artery revascularization after previous bypass for aortoiliac occlusive disease A n n e t t e Seagraves, M . D . , and R o b e r t B. R u t h e r f o r d , M . D . ,

Denver, Colo.

Patients with recurrent buttock claudication and/or impotence occurring after aortoiliac reconstruction, whose resting and postexercise vascular laboratory values are normal, represent an uncommon and poorly recognized problem resulting from occlusion of the bypassed iliac segments and ischemia isolated to the distribution of the hypogastric artery. This paradox and its solution are exemplified by two patients reported herein. In each instance flow was reestablished after thromboendarterectomy of the proximal hypogastric artery by connecting the artery to the fimctioning bypass. (J VASC SURG 1987;5:

,~72-4.)

Bypass surgery performed to treat aortoiliac occlusive disease understandably focuses on the relief o f incapacitating ischemic limb pain or the prevention o f major amputation. Such bypass procedures may also relieve impotence, but in certain circumstances they may not only fail to relieve but even produce sexual dysfunction. 1-6 Typically, patients are followed up after bypass o f aortoiliac occlusive disease by evaluation o f leg symptoms and by measurement o f ankle systolic pressures. However, despite normal resting and postexercise ankle pressures, such patients can have recurrent buttock claudication and even impotence. Recognition and management o f this rare paradox have received little attention in the literature. This report describes two cases in which recurrent symptoms after aortofemoral bypass surgery were ultimately relieved by isolated hypogastric artery revascularization. CASE REPORTS

Case 1. A 47-year-old man was admitted with claudication and impotence after two previous proximal reconstructions performed elsewhere--an aortobi-iliac and a right aortofemoral bypass--had failed. Aortography showed the infrarenal aorta and the above-mentioned grafts to be occluded, but retrograde flow was observed up the external iliac to the hypogastric arteries. Aortobifemoral bypass was performed after thrombectomy of the infrarenal aorta on Feb. 27, 1976. Both claudication and From the Department of Surgery, Universityof Colorado Health Sciences Center. Reprint requests: Robert B. Rutherford, M.D., Professor of Surgery, Vascular Surgery Section, University of Colorado Health Sciences Center, 4200 East Ninth Ave. (Box C312), Denver, CO 80262. 472

impotence were relieved postoperatively and resting and postexercise ankle pressures were normal. Four years later the patient had left buttock claudication and impotence. Pedal pulses were readily palpable and the ankle pressures were again normal at rest and after treadmill exercise. Aortography revealed occlusion of the distal iliac segments. The branches of the left hypogastric artery filled from above via a branch of the superior ruesenteric artery and from below through the medial femoral circumflex branch of the left profunda femoris artery. Patency of the hypogastric artery was shown from the point of its first branch distally. On May 22, 1980, through an oblique left lower quadrant incision and a retroperitoneal approach, the heft iliac bifurcation was exposed, mobilized, and controlled with tapes. Through a lateral arteriotomy in the occluded iliac artery, a thromboendarterectomy of the hypogastric artery was easily performed with brisk backflow. A button w~ ~fashioned from the back wall of the iliac artery including the hypogastric orifice, and this was anastomosed to the posterior aspect of the left limb of the aortobifemoral graft. Postoperatively, the buttock claudication and impotence were relieved and remained so at the time of last followup 2 years ago. Case 2. A 52-year-old woman had right lower extremity claudication 7 years after an aortoiliac bypass was performed to treat occlusive disease. The patient had an occluded right graft limb and a femorofemoral bypass was performed. Four years later she had ischemia of the right great toe, which was thought to be embolic in nature. Arteriography showed an irregular stenosis at the distal femorofemoral anastomosis. Transluminal angioplasry was unsuccessful in dilating this segment; therefore, direct revision was carried out and an exophytic mural thrombus was removed in the process. Ankle pressures returned to normal and the ischemic lesion on the toe healed within 2 months. When the patient was again able to walk, she noticed right buttock claudication. Aortography again re-

Volume 5 Number 3 March 1987

vealed occlusion of the right limb of the graft but also showed a widdy patent femorofemoral graft with good bilateral runoff. There was collateral filling of the branches of the right internal lilac artery, suggesting proximal paten W. Through an oblique right lower quadrant incision and retroperitoneal approach, the hypogastric artery was mobilized and thromboendarterectomy performed in a similar fashion to the first case. The occluded right limb of the aortoiliac bypass was a calcified cord and not suitable for thrombectomy and use as inflow for the reconstruction. The bifurcation of this graft was quite high and further mobilization to expose the upper graft was not technically feasible. Therefore, the next most accessible inflow source, the right half of the femorofemoral bypass, was approached ventrally from within the abdomen, aided by a downward extension of the original incision. A 6 mm polytetrafluo.'thylene graft was anastomosed end to side to the undersurface of this graft and then joined in an end-to-end fashion to the hypogastric artery; again the anastomosis was made to a button of posterior iliac wall surrounding the hypogastric orifice. Postoperatively, the patient's buttock claudication was relieved and at 1-year follow-up, she was asymptomatic. DISCUSSION The effects on pelvic hemodynamics of bypass l,~ucedures to treat aortoiliac occlusive disease have attracted considerable interest. The significance of sexual dysfunction in relation to occlusive lesions in the aortoiliac segment and its branches and the effects of various reconstructive procedures on this dysfunction have been well clarified. H-~2 Insufficient arterial inflow to the penis results in either an inability to obtain or maintain an erection. This functional ischemia can result from obstructive lesions proxi" ~ally in the aortoiliac segment, occlusive disease of the hypogastric artery itself, or obliterative lesions in the distal branches of the internal pudendal artery. It has been well established that when neurologic pathways are intact, the ability to achieve an erection is largely determined by the adequacy of arterial inflow, although the role of the damming of venous outflow in achieving tumescence has been given considerable emphasis. May, DeWeese, and Rob ~ emphasized the importance of maintaining hypogastric arterial blood flow during arterial reconstruction for aortoiliac occlusive disease to avoid postoperative impotence. When the aortoiliac segment is bypassed, the severity and distribution of occlusive lesions and the configuration of the proximal anastomosis must be taken into consideration if the goals of restoring potency or not causing impotence are to be achieved. Pierce et al.~2 performed intraoperative measurements of

Hypogastric artery revascularization 473

penile pressure during aortobifemoral bypass and with various arteries and graft limbs occluded to emphasize the importance of these considerations. They showed that ultimate loss of potency occurred ~vice as often after end-to-end as after end-to-side proximal anastomosis. Flanigan et al. 9 showed that careful examination of the preoperative aortogram with these factors in mind allows one to perform proximal reconstruction without loss of impotence in most cases. Although much attention has been paid to impotence, little has been said about buttock claudication as an isolated symptom. Billet, Dagher, and QueraP 3 suggested that in selected cases consideration be given to reimplantation of the hypogastric artery, onto one limb of an aortobifemoral graft or that revascularization be achieved by interposition graft. However, it has not been well recognized that the bypassed diseased iliac segment may ultimately occlude, leaving the tissues supplied by the hypogastric artery fed only through collateral vessels coming proximally from the lumbar vessels or distally from the circumflex iliac branches of the profunda femoris artery. If these vessels are occluded or have been interrupted during previous reconstructive procedures, collateral flow will not prove adequate to prevent buttock claudication or impotence in male patients. Thus, patients who have recurrent or residual buttock claudication occurring after aortobit~moral bypass despite good pedal pulses and ankle pressures should alert the surgeon to the possibility of isolated ischemia of hypogastric artery distribution. The potential benefit and technique of isolated hypogastric artery revascularization also deserve recognition. Feasibility can be established by conventional arteriography by means of sequentially delayed exposures or by digital subtraction technique after proximal arterial injection. The main occlusive lesion is usually- localized to the origin of the hypogastric artery and can be easily disoblitcrated along with a short segment of thrombus that has propagated up to the first branch. A widely patent anastomosis can be fashioned with the use of a button of the posterior wall of the iliac artery, to enlarge the anastomosis. Inflow may be obtained from any nearby source, although a patent bifurcation graft limb is the best choice when present. The procedure can be carried out through a simple retroperitoneal approach, which causes little morbidity. REFERENCES

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