Surgery_Schwartz

Surgery_Schwartz. angioplasty of the renal artery is completed, an angiogram is performed to document the procedural result. Radiographic evidence of either residual stenosis or renal artery dissection constitutes suboptimal angioplasty results, which warrants an immediate renal artery stent placement. Moreover, atherosclerotic involvement of the very proximal renal artery that involves the vessel orifice typically requires stent place-ment. A balloon-expandable stent is typically used and is positioned in such a way that it protrudes into the aorta by 1 to 2 mm. The size of the stent is determined by the size of the renal artery, taking into account a desirable 10% to 20% over-sizing. After the stent deployment, the angiogram is repeated, and upon a satisfactory result, the devices are withdrawn. It is critical to maintain the guidewire access across the renal lesion until satisfactory completion angiogram is obtained. Spasm of the branches of the renal artery will usually respond to nitro-glycerin


Surgery_Schwartz

Surgery_Schwartz. critical to maintain the guidewire access across the renal lesion until satisfactory completion angiogram is obtained. Spasm of the branches of the renal artery will usually respond to nitro-glycerin 100 to 200 μg administered through the guiding sheath directly into the renal artery.While endovascular therapy of renal artery occlusive disease is considerably less invasive than conventional renal artery bypass operation, complications relating to this treat-ment modality can occur. In a study in which Guzman and colleagues compared the complications following renal artery angioplasty and surgical revascularization, the authors noted that major complication rates following endovascular and sur-gical treatment were 17% and 31%, respectively.106 In contrast, significantly greater minor complications were associated with the endovascular cohort, with a minor complication rate of 48% compared with 7% in the surgical group. In a prospective randomized study that compared the clinical


Surgery_Schwartz

Surgery_Schwartz. complications were associated with the endovascular cohort, with a minor complication rate of 48% compared with 7% in the surgical group. In a prospective randomized study that compared the clinical outcome of renal artery balloon angioplasty versus stenting for renal ostial ath-erosclerotic lesion, comparable complications rates were found in the two groups (39% vs. 43%, respectively). However, the incidence of restenosis at 6 months was significantly higher in the balloon angioplasty cohort than the stenting group (48% vs. 14%, respectively). This study underscores the clinical superior-ity of renal stenting compared to renal balloon angioplasty alone in patients with ostial stenosis.107Deterioration in renal function, albeit transient, is a com-mon complication following endovascular renal artery inter-vention. This is most likely the combined result of the use of iodinated contrast and the occurrence of renal parenchymal embolism due to wire and catheter manipulation. In most


Surgery_Schwartz

Surgery_Schwartz. renal artery inter-vention. This is most likely the combined result of the use of iodinated contrast and the occurrence of renal parenchymal embolism due to wire and catheter manipulation. In most cases, this is a temporary problem, as supportive care with adequate fluid hydration is sufficient to reverse the renal dysfunction. However, transient hemodialysis may become necessary in approximately 1% of patients. Other complications include vas-cular access complications (bleeding, hematoma, femoral nerve injury, arteriovenous fistula, and pseudoaneurysm), target ves-sel dissection, perinephric hematoma, early postoperative renal artery thrombosis, and extremity atheroembolism from throm-bus in the aorta or the iliac arteries.Clinical Results of Endovascular InterventionsPercutaneous Transluminal Balloon Angioplasty. FMD of the renal artery is the most common treatment indication for percutaneous transluminal balloon angioplasty. Patients with symptomatic FMD such as hypertension or


Surgery_Schwartz

Surgery_Schwartz. Balloon Angioplasty. FMD of the renal artery is the most common treatment indication for percutaneous transluminal balloon angioplasty. Patients with symptomatic FMD such as hypertension or renal insufficiency usually respond well to renal artery balloon angioplasty alone. In contrast, balloon angioplasty generally is not an effective treat-ment for patients with renal artery stenosis or proximal occlusive disease of the renal artery, due to the high incidence of restenosis with balloon angioplasty alone. In the latter group of patients, primary stent placement is the preferred endovascular treatment. The long-term benefit of renal artery balloon angioplasty in patients with FMD was reported by Surowiec and colleagues.108 They followed 14 patients who underwent 19 interventions on 18 renal artery segments. The technical success rate of balloon angioplasty for FMD was 95%. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years, respectively. Assisted primary patency


Surgery_Schwartz

Surgery_Schwartz. artery segments. The technical success rate of balloon angioplasty for FMD was 95%. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years, respectively. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years, respectively. The restenosis rate was 25% at 8 years. Clinical benefit, as defined by either improved or cured hypertension, was found in 79% of patients overall, with two-thirds of patients having maintained this benefit at 8 years. The authors concluded that balloon angioplasty is highly effective in symptomatic FMD with excellent durable functional benefits.The utility of balloon angioplasty alone in the treatment of renovascular hypertension appears to be limited. van Jaars-veld and associates performed a prospective study in which patients with renal artery stenosis were randomized to either drug therapy or balloon angioplasty treatment.109 A total of 106 patients with 50% diameter stenosis or greater plus hyperten-sion or


Surgery_Schwartz

Surgery_Schwartz. patients with renal artery stenosis were randomized to either drug therapy or balloon angioplasty treatment.109 A total of 106 patients with 50% diameter stenosis or greater plus hyperten-sion or renal insufficiency were randomized in the study. At 3 months, there was no difference in the degree to which blood Brunicardi_Ch23_p0897-p0980.indd 93927/02/19 4:14 PM 940SPECIFIC CONSIDERATIONSPART IIpressure was controlled between the two groups. However, the degree and dose of antihypertensive medications were slightly lowered in the balloon angioplasty group. The above advantage of the angioplasty group completely disappeared at 12 months, making the authors conclude that in the treatment of patients with hypertension and renal artery stenosis, percutaneous trans-luminal balloon angioplasty alone offers minimal advantage over antihypertensive drug therapy.Renal Artery Stenting. Endovascular stent placement is the treatment of choice for patients with symptomatic or high-grade renal


Surgery_Schwartz

Surgery_Schwartz. alone offers minimal advantage over antihypertensive drug therapy.Renal Artery Stenting. Endovascular stent placement is the treatment of choice for patients with symptomatic or high-grade renal artery occlusive disease (Fig. 23-48). This is due in part to the high incidence of restenosis with balloon angioplasty alone, particularly in the setting of ostial stenosis. Renal artery stenting is also indicated for renal artery dissection caused by balloon angioplasty or other catheter-based interventions. Numerous studies have clearly demonstrated the clinical efficacy of renal artery stenting when compared to balloon angioplasty alone in patients with high-grade renal artery stenosis.White and colleagues conducted a study to evaluate the role of renal artery stenting in patients with poorly controlled hyper-tension and renal artery lesions that did not respond well to bal-loon angioplasty alone.110 The technical success of the procedure was 99%. The mean blood pressure values were 173 ±


Surgery_Schwartz

Surgery_Schwartz. controlled hyper-tension and renal artery lesions that did not respond well to bal-loon angioplasty alone.110 The technical success of the procedure was 99%. The mean blood pressure values were 173 ± 25/88 ± 17 mmHg prior to stent implantation and 146 ± 20/77 ± 12 mmHg 6 months after renal artery stenting (P <0.01). Angiographic follow-up with 67 patients (mean 8.7 ± 5 months) demonstrated that restenosis, as defined by 50% or greater luminal narrowing, occurred in 15 patients (19%). The study concluded that renal artery stenting is a highly effective treatment for renovascular hypertension, with a low angiographic restenosis rate. In another similar study, Blum and colleagues prospectively performed renal artery stenting in 68 patients (74 lesions) with ostial renal artery stenosis and suboptimal balloon angioplasty.111 Patients were fol-lowed for a mean of 27 months with measurements of blood pres-sure and serum creatinine, duplex sonography, and intra-arterial angiography.


Surgery_Schwartz

Surgery_Schwartz. and suboptimal balloon angioplasty.111 Patients were fol-lowed for a mean of 27 months with measurements of blood pres-sure and serum creatinine, duplex sonography, and intra-arterial angiography. Five-year patency was 84.5% (mean follow-up, 27 months). Restenosis occurred in 8 of 74 arteries (11%), but after reintervention, the secondary 5-year patency rate was 92.4%. Hypertension was cured or improved in 78% of patients. The authors concluded that primary stent placement is an effec-tive treatment for renal artery stenosis involving the ostium.BAFigure 23-48. Renal artery stenting. A. Focal lesion in the renal artery (arrow). B. Poststenting angiogram reveals a satisfactory result following a renal artery stenting placement (arrow).The clinical utility of renal artery stenting in renal func-tion preservation was analyzed by several studies, which mea-sured serial serum creatinine levels to determine the response of renal function following endovascular intervention.112,113 In a


Surgery_Schwartz

Surgery_Schwartz. func-tion preservation was analyzed by several studies, which mea-sured serial serum creatinine levels to determine the response of renal function following endovascular intervention.112,113 In a study reported by Harden and colleagues who performed 33 renal artery stenting procedures in 32 patients with renal insuf-ficiency, they noted that renal function improved or stabilized in 22 patients (69%).113 In a similar study, Watson and associates evaluated the effect of renal artery stenting on renal function by comparing the slopes of the regression lines derived from the reciprocal of serum creatinine versus time.112 A total of 61 renal stenting procedures were performed in 33 patients, and the authors found that after stent placement, the slopes of the reciprocal of the serum creatinine (1/Scr) were positive in 18 patients and less negative in 7 patients. The study concluded that in patients with chronic renal insufficiency due to obstructive renal artery stenosis, renal artery


Surgery_Schwartz

Surgery_Schwartz. (1/Scr) were positive in 18 patients and less negative in 7 patients. The study concluded that in patients with chronic renal insufficiency due to obstructive renal artery stenosis, renal artery stenting is effective in improv-ing or stabilizing renal function.The clinical outcome of several large clinical studies of renal artery stenting in the treatment of renovascular hyperten-sion or chronic renal insufficiency is shown in Table 23-13. These studies uniformly demonstrated an excellent technical success rate with low incidence of restenosis or procedural-related complications. A similar analysis was reported by Leer-touwer and colleagues who performed a meta-analysis of 14 studies comparing patients with renal arterial stent placement to those who underwent balloon angioplasty alone for renal arterial stenosis.114 The study found that stent placement proved highly successful, with an initial technical success of 98%. The overall cure rate for hypertension was 20%, whereas


Surgery_Schwartz

Surgery_Schwartz. alone for renal arterial stenosis.114 The study found that stent placement proved highly successful, with an initial technical success of 98%. The overall cure rate for hypertension was 20%, whereas hypertension was improved in 49%. Renal function improved in 30% of patients and stabilized in 38% of patients. The restenosis rate at follow-up of 6 to 29 months was 17%. Renal stenting resulted in a higher technical success rate and a lower restenosis rate when compared to balloon angioplasty alone.AORTOILIAC OCCLUSIVE DISEASEThe distal abdominal aorta and the iliac arteries are common sites affected by atherosclerosis. The symptoms and natural history of the atherosclerotic process affecting the aortoiliac Brunicardi_Ch23_p0897-p0980.indd 94027/02/19 4:14 PM 941ARTERIAL DISEASECHAPTER 23arterial segment are influenced by the disease distribution and extent. Atherosclerotic plaques may cause clinical symptoms by restricting blood flow due to luminal obstruction or by embo-lizing


Surgery_Schwartz

Surgery_Schwartz. 23arterial segment are influenced by the disease distribution and extent. Atherosclerotic plaques may cause clinical symptoms by restricting blood flow due to luminal obstruction or by embo-lizing atherosclerotic debris to the lower extremity circulation. If the aortoiliac plaques reach sufficient mass and impinge on the arterial lumen, obstruction of blood flow to lower extremi-ties occurs. Various risk factors exist that can lead to the devel-opment of aortoiliac occlusive disease. Recognition of these factors and understanding of this disease entity will enable phy-sicians to prescribe the appropriate treatment strategy, which may alleviate symptoms and improve quality of life.Diagnostic EvaluationOn clinical examination patients often have weakened femoral pulses and a reduced ABI. Verification of iliac occlusive dis-ease is usually made by color duplex scanning, which reveals either a peak systolic velocity ratio ≥2.5 at the site of stenosis and or a monophasic waveform.


Surgery_Schwartz

Surgery_Schwartz. ABI. Verification of iliac occlusive dis-ease is usually made by color duplex scanning, which reveals either a peak systolic velocity ratio ≥2.5 at the site of stenosis and or a monophasic waveform. Noninvasive tests such as pulse volume recordings (PVRs) of the lower extremity with estima-tion of the thigh-brachial pressure index may be suggestive of aortoiliac disease. MRA and multidetector CTA are increasingly being used to determine the extent and type of obstruction. DSA offers the interventionalist the benefit of making a diagnosis and the option of performing an endovascular treatment in a single session. Angiography provides important information regard-ing distal arterial runoff vessels as well as the patency of the PFA. Presence of pelvic and groin collaterals is important to provide crucial collateral flow in maintaining lower limb viabil-ity. It must be emphasized, however, that patients should be subjected to angiography only if their symptoms warrant surgi-cal


Surgery_Schwartz

Surgery_Schwartz. to provide crucial collateral flow in maintaining lower limb viabil-ity. It must be emphasized, however, that patients should be subjected to angiography only if their symptoms warrant surgi-cal intervention.Differential DiagnosisDegenerative hip or spine disease, lumbar disk herniation, spinal stenosis, diabetic neuropathy, and other neuromuscular problems can produce symptoms that may be mistaken for vas-cular claudication. Such cases can be distinguished from true claudication by the fact that the discomfort from neuromuscular problems is often relieved by sitting or lying down, as opposed to cessation of ambulation. In addition, complaints that are Table 23-13Clinical outcome of renal artery stent placement in the treatment of renovascular hypertension and renal insufficiencyAUTHORYEARPATIENT NO.TECHNICAL SUCCESS (%)FOLLOW-UP (MONTHS)RENAL INSUFFICIENCY (%)RENOVASCULAR HYPERTENSION (%)COMPLICATION (%)RESTENOSIS


Surgery_Schwartz

Surgery_Schwartz. of renovascular hypertension and renal insufficiencyAUTHORYEARPATIENT NO.TECHNICAL SUCCESS (%)FOLLOW-UP (MONTHS)RENAL INSUFFICIENCY (%)RENOVASCULAR HYPERTENSION (%)COMPLICATION (%)RESTENOSIS (%)STABLEIMPROVEDCUREDIMPROVEDIannone1301996 63 991045364351314Harden1261997 32100 63434N/AN/A 313Blum1241997 6810027N/AN/A1662 011White1231997100 99 6N/A20N/AN/A 219Shannon1321998 21100 92943N/AN/A 90Rundback1311998 45 9417N/AN/AN/AN/A 925Dorros128199816310048N/AN/A35111N/AHenry1291999210 9925N/A291961 39Bush1272001 73 8920213813611216N/A = not applicable.experienced upon standing suggest nonvascular causes. When confusion persists, the use of noninvasive vascular laboratory testing modalities, including treadmill exercise, can help estab-lish the diagnosis.Collateral Arterial NetworkThe principal collateral pathways in severe aortoiliac artery occlusive disease or chronic aortic occlusion that may provide blood flow distal to the aortoiliac lesion include: (a) the superior mesenteric artery to


Surgery_Schwartz

Surgery_Schwartz. pathways in severe aortoiliac artery occlusive disease or chronic aortic occlusion that may provide blood flow distal to the aortoiliac lesion include: (a) the superior mesenteric artery to the distal IMA via its superior hemorrhoidal branch to the middle and inferior hemorrhoidals to the internal iliac artery; (b) the lumbar arteries to the superior gluteal artery to the internal iliac system; (c) the lumbar arteries to the lateral and deep circumflex arteries to the CFA; and (d) Winslow’s pathway from the subclavian to the superior epigastric artery to the inferior epigastric artery to the external iliac arteries at the groin (Fig. 23-49). In general, treatment indications for aor-toiliac artery occlusive disease include disabling claudication, ischemic rest pain, nonhealing lower extremity tissue wound, and lower extremity microembolization that arises from aor-toiliac lesions.Disease ClassificationBased on the atherosclerotic disease pattern, aortoiliac occlusive disease can be


Surgery_Schwartz

Surgery_Schwartz. tissue wound, and lower extremity microembolization that arises from aor-toiliac lesions.Disease ClassificationBased on the atherosclerotic disease pattern, aortoiliac occlusive disease can be classified into three types (Fig. 23-50). Type I aortoiliac disease, which occurs in 5% to 10% of patients, is confined to the distal abdominal aorta and common iliac vessels (Fig. 23-51). Due to the localized nature of this type of aortic obstruction and formation of collateral blood flow around the occluded segment, limb-threatening symptoms are rare in the absence of more distal disease (Fig. 23-52). This type of aor-toiliac occlusive disease occurs in a relatively younger group of patients (in their mid-50s), compared with patients who have more femoropopliteal disease. Patients with a type I disease pat-tern have a lower incidence of hypertension and diabetes but a significant frequency of abnormal blood lipid levels, particu-larly type IV hyperlipoproteinemia. Symptoms typically consist of


Surgery_Schwartz

Surgery_Schwartz. pat-tern have a lower incidence of hypertension and diabetes but a significant frequency of abnormal blood lipid levels, particu-larly type IV hyperlipoproteinemia. Symptoms typically consist of bilateral thigh or buttock claudication and fatigue. Men report diminished penile tumescence and may have complete loss of erectile function. These symptoms in the absence of femoral Brunicardi_Ch23_p0897-p0980.indd 94127/02/19 4:14 PM 942SPECIFIC CONSIDERATIONSPART IIFigure 23-50. Aortoiliac disease can be classified into three types. Type I represents focal disease affecting the distal aorta and proxi-mal common iliac artery. Type II represents diffuse aortoiliac dis-ease above the inguinal ligament. Type III represents multisegment occlusive diseases involving aortoiliac and infrainguinal arterial vessels.Figure 23-51. Type I aortoiliac disease is confined to the distal abdominal aorta (long arrow) or proximal common iliac arteries. Due to the localized nature of this type of aortic


Surgery_Schwartz

Surgery_Schwartz. arterial vessels.Figure 23-51. Type I aortoiliac disease is confined to the distal abdominal aorta (long arrow) or proximal common iliac arteries. Due to the localized nature of this type of aortic obstruction and formation of collateral blood flow around the occluded segment (short arrows), limb-threatening symptoms are rare in the absence of more distal disease.Figure 23-49. Pertinent collateral pathways are developed in the event of chronic severe aortoiliac occlusive disease. As illustrated in this multidetector computed tomography angiography, these col-laterals include epigastric arteries (large white arrows), an enlarged inferior mesenteric artery (arrowhead), and enlarged lumbar arter-ies (black arrows).Type IType IIType IIIpulses constitute Leriche’s syndrome. Rest pain is unusual with isolated aortoiliac disease unless distal disease coexists. Occa-sionally patients report a prolonged history of thigh and buttock claudication that recently becomes more severe. It is likely


Surgery_Schwartz

Surgery_Schwartz. with isolated aortoiliac disease unless distal disease coexists. Occa-sionally patients report a prolonged history of thigh and buttock claudication that recently becomes more severe. It is likely that this group has underlying aortoiliac disease that has progressed to acute occlusion of the terminal aorta. Others may present with “trash foot,” which represents microembolization into the distal vascular bed (Fig. 23-53). Type II aortoiliac disease rep-resents a more diffuse atherosclerotic progression that involves predominately the abdominal aorta with disease extension into the common iliac artery. This disease pattern affects approxi-mately 25% patients with aortoiliac occlusive disease. Type III aortoiliac occlusive disease, which affects approximately 65% of patients with aortoiliac occlusive disease, is widespread dis-ease that is seen above and below the inguinal ligament (Fig. 23-54). Patients with “multilevel” disease are older, more com-monly male (with a male-to-female


Surgery_Schwartz

Surgery_Schwartz. occlusive disease, is widespread dis-ease that is seen above and below the inguinal ligament (Fig. 23-54). Patients with “multilevel” disease are older, more com-monly male (with a male-to-female ratio of 6:1), and much more likely to have diabetes, hypertension, and associated atheroscle-rotic disease involving cerebral, coronary, and visceral arter-ies. Progression of the occlusive process is more likely in these patients than in those with localized aortoiliac disease. For these reasons, most patients with a type III pattern tend to present with symptoms of advanced ischemia and require revasculariza-tion for limb salvage rather than for claudication. These patients have a decreased 10-year life expectancy when compared to patients with localized aortoiliac disease.The most commonly used classification system of iliac lesions has been set forth by the TransAtlantic Inter-Society Consensus (TASC) group with recommended treatment options. This lesion classification categorizes the


Surgery_Schwartz

Surgery_Schwartz. used classification system of iliac lesions has been set forth by the TransAtlantic Inter-Society Consensus (TASC) group with recommended treatment options. This lesion classification categorizes the extent of atheroscle-rosis and has suggested a therapeutic approach based on this classification (Table 23-14 and Fig. 23-55).1 According to this consensus document, endovascular therapy is the treatment of choice for type A lesions, and surgery is the treatment of choice for type D lesions. Endovascular treatment is the preferred treat-ment for type B lesions, and surgery is the preferred treatment for good-risk patients with type C lesions. In comparison to the 2000 TASC document, the commission has not only made allowances for treatment of more extensive lesions, but it also takes into account the continuing evolution of endovascular technology and the skills of individual interventionalists when stating that the patient’s comorbidities, fully informed patient preference, and the local


Surgery_Schwartz

Surgery_Schwartz. the continuing evolution of endovascular technology and the skills of individual interventionalists when stating that the patient’s comorbidities, fully informed patient preference, and the local operator’s long-term success rates Brunicardi_Ch23_p0897-p0980.indd 94227/02/19 4:14 PM 943ARTERIAL DISEASECHAPTER 23Figure 23-52. A. Multidetector computed tomography angiography of the aortoiliac artery circulation in a 63-year-old male with buttock claudication. B. Three-dimensional image reconstruction shows intra-arterial calcification of the aorta (large arrow) and right common iliac artery (small arrow). This is consistent with type I aortoiliac occlusive disease.Figure 23-53. Atherosclerotic disease involving the aortoiliac segment can result in microembolization of the lower leg circulation, resulting in trash foot or digital gangrene of toes.must be considered when making treatment decisions for type B and type C lesions.1,115General Treatment ConsiderationsThere is no effective


Surgery_Schwartz

Surgery_Schwartz. resulting in trash foot or digital gangrene of toes.must be considered when making treatment decisions for type B and type C lesions.1,115General Treatment ConsiderationsThere is no effective medical therapy for the management of aortoiliac disease, but control of risk factors may help slow pro-gression of atherosclerosis. Patients should have hypertension, hyperlipidemia, and diabetes mellitus controlled. They should be advised to stop smoking. Most patients are empirically placed on antiplatelet therapy. A graduated exercise program may improve walking efficiency, endothelial function, and metabolic adaptations in skeletal muscle, but, there is usually minimal improvement in patients with aortoiliac disease who are treated with these measures. Failure to respond to exercise and/or drug therapy should prompt consideration for limb revas-cularization. Patients with buttock claudication and reduced or absent femoral pulses who fail to respond to exercise and drug therapy should be


Surgery_Schwartz

Surgery_Schwartz. therapy should prompt consideration for limb revas-cularization. Patients with buttock claudication and reduced or absent femoral pulses who fail to respond to exercise and drug therapy should be considered for revascularization because they are less likely than patients with more distal lesions to improve without concomitant surgical or endovascular intervention.Brunicardi_Ch23_p0897-p0980.indd 94327/02/19 4:14 PM 944SPECIFIC CONSIDERATIONSPART IIFigure 23-54. Type III aortoiliac occlusive disease is a mul-tilevel disease pattern that affects the aortoiliac segment as well as infrainguinal femoropopliteal vessels. Most patients with this disease pattern tend to present with symptoms of advanced isch-emia and require revascularization for limb salvage rather than for claudication.Table 23-14TASC classification of aortoiliac occlusive lesionsType A lesions• Unilateral or bilateral stenoses of CIA• Unilateral or bilateral single short (≤3 cm) stenosis of EIAType B lesions• Short (≤3


Surgery_Schwartz

Surgery_Schwartz. 23-14TASC classification of aortoiliac occlusive lesionsType A lesions• Unilateral or bilateral stenoses of CIA• Unilateral or bilateral single short (≤3 cm) stenosis of EIAType B lesions• Short (≤3 cm) stenosis of infrarenal aorta• Unilateral CIA occlusion• Single or multiple stenosis totaling 3–10 cm involving the EIA not extending into the CFA• Unilateral EIA occlusion not involving the origins of internal iliac artery or CFAType C lesions• Bilateral CIA occlusions• Bilateral EIA stenoses 3–10 cm long not extending into the CFA• Unilateral EIA stenosis extending into the CFA• Unilateral EIA occlusion that involves the origins of internal iliac artery and/or CFA• Heavily calcified unilateral EIA occlusion with or without involvement of origins of internal iliac artery and/or CFAType D lesions• Infrarenal aortoiliac occlusion• Diffuse disease involving the aorta and both iliac arteries requiring treatment• Diffuse multiple stenoses involving the unilateral CIA, EIA, and


Surgery_Schwartz

Surgery_Schwartz. CFAType D lesions• Infrarenal aortoiliac occlusion• Diffuse disease involving the aorta and both iliac arteries requiring treatment• Diffuse multiple stenoses involving the unilateral CIA, EIA, and CFA• Unilateral occlusions of both CIA and EIA• Bilateral occlusions of EIA• Iliac stenoses in patients with AAA requiring treatment and not amenable to endograft placement or other lesions requiring open aortic or iliac surgeryAAA = abdominal aortic aneurysm; CFA = common femoral artery; CIA = common iliac artery; EIA = external iliac artery.Type A lesionsType B lesionsType D lesionsType C lesionsFigure 23-55. Schematic depiction of the TransAtlantic Inter-Society Consensus classification of aortoiliac occlusive lesions.Surgical Reconstruction of Aortoiliac Occlusive DiseaseAortobifemoral Bypass. Surgical options for treatment of aortoiliac occlusive diseases consist of various configurations of aortobifemoral bypass grafting, various types of extra-anatomic bypass grafts, and aortoiliac


Surgery_Schwartz

Surgery_Schwartz. options for treatment of aortoiliac occlusive diseases consist of various configurations of aortobifemoral bypass grafting, various types of extra-anatomic bypass grafts, and aortoiliac endarterectomy. The procedure performed is determined by several factors, including ana-tomic distribution of the disease, clinical condition of the patient, and personal preference of the surgeon.In most cases, aortobifemoral bypass is performed because patients usually have disease in both iliac systems. Although one side may be more severely affected than the other, progression does occur, and bilateral bypass does not complicate the procedure or add to the physiologic stress of the operation. Aortobifemoral bypass reliably relieves symp-toms, has excellent long-term patency (approximately 70–80% at 10 years), and can be completed with a tolerable periopera-tive mortality (2–3%).Technical Considerations for Aortobifemoral Bypass Both femoral arteries are initially exposed to ensure that they are


Surgery_Schwartz

Surgery_Schwartz. 10 years), and can be completed with a tolerable periopera-tive mortality (2–3%).Technical Considerations for Aortobifemoral Bypass Both femoral arteries are initially exposed to ensure that they are ade-quate for the distal anastomoses. The abdomen is then opened in the midline, the small intestine is retracted to the right, and the posterior peritoneum overlying the aorta is incised. A retro-peritoneal approach may be selected as an alternative in certain situations. This approach involves making a left flank incision and displacing the peritoneum and its contents to the right. Such an approach is contraindicated if the right renal artery is acutely occluded, since visualization from the left flank is very poor. Tunneling of a graft to the right femoral artery is also more 4difficult from a retroperitoneal approach, but can be achieved. The retroperitoneal approach has been reputed to be better toler-ated than midline laparotomy for patients with multiple previ-ous abdominal


Surgery_Schwartz

Surgery_Schwartz. from a retroperitoneal approach, but can be achieved. The retroperitoneal approach has been reputed to be better toler-ated than midline laparotomy for patients with multiple previ-ous abdominal operations and with severe pulmonary disease. Further proposed advantages of the retroperitoneal approach include less gastrointestinal disturbance, decreased third space Brunicardi_Ch23_p0897-p0980.indd 94427/02/19 4:14 PM 945ARTERIAL DISEASECHAPTER 23fluid losses, and ease with which the pararenal aorta can be accessed. There are randomized reports, however, that support and refute the superiority of this approach. A collagen-impreg-nated, knitted Dacron graft is used to perform the proximal aortic anastomosis, which can then be made in either an end-to-end or end-to-side fashion using 3-0 polypropylene suture. The proximal anastomosis should be made as close as possible to the renal arteries to decrease the incidence of restenosis from pro-gression of the atherosclerotic occlusive


Surgery_Schwartz

Surgery_Schwartz. 3-0 polypropylene suture. The proximal anastomosis should be made as close as possible to the renal arteries to decrease the incidence of restenosis from pro-gression of the atherosclerotic occlusive process in the future.An end-to-end proximal aortic anastomosis is necessary in patients with an aortic aneurysm or complete aortic occlu-sion extending up to the renal arteries (Fig. 23-56). Although in theory the end-to-end configuration allows for less turbulence and less chance of competitive flow with still patent host iliac vessels, there have not been consistent results to substantiate differences in patency between end-to-end and end-to-side grafts. Relative indications for an end-to-side proximal aortic anastomosis include the presence of large aberrant renal arter-ies, an unusually large IMA with poor back-bleeding suggesting inadequate collateralization, and/or occlusive disease involv-ing bilateral external iliac arteries. Under such circumstances, end-to-end bypass from the


Surgery_Schwartz

Surgery_Schwartz. large IMA with poor back-bleeding suggesting inadequate collateralization, and/or occlusive disease involv-ing bilateral external iliac arteries. Under such circumstances, end-to-end bypass from the proximal aorta to the femoral level devascularizes the pelvic region because there is no antegrade or retrograde flow in the occluded external iliac arteries to supply the hypogastric arteries. As a result of the pelvic devasculariza-tion, there is an increased incidence of impotence, postoperative colon ischemia, buttock ischemia, and paraplegia secondary to spinal cord ischemia despite the presence of excellent femoral and distal pulses.An end-to-side proximal aortic anastomosis can be associ-ated with certain disadvantages, which include the potential for distal embolization when applying a partially occlusive aortic clamp (Fig. 23-57). Furthermore, the distal aorta often pro-ceeds to total occlusion after an end-to-side anastomosis. There Figure 23-56. In an end-to-end proximal aortic


Surgery_Schwartz

Surgery_Schwartz. partially occlusive aortic clamp (Fig. 23-57). Furthermore, the distal aorta often pro-ceeds to total occlusion after an end-to-side anastomosis. There Figure 23-56. In an end-to-end proximal aortic anastomosis, the aorta is divided in half. The proximal end of the aorta is anasto-mosed to the end of a prosthetic graft, while the distal divided aortic stump is oversewn.Figure 23-57. In an end-to-side aortic anastomosis, the end of a prosthetic graft is connected to the side of an aortic incision.may also be a higher incidence of aortoenteric fistula follow-ing construction of end-to-side proximal anastomoses because the anterior projection makes subsequent tissue coverage and reperitonealization of the graft more difficult. The limbs of the graft are tunneled through the retroperitoneum to the groin, where an end-to-side anastomosis is fashioned between the graft and the bifurcation of the CFA using 5-0 polypropylene suture. Endarterectomy or patch angioplasty of the profunda femo-ris


Surgery_Schwartz

Surgery_Schwartz. the groin, where an end-to-side anastomosis is fashioned between the graft and the bifurcation of the CFA using 5-0 polypropylene suture. Endarterectomy or patch angioplasty of the profunda femo-ris may be required concurrently. Once the anastomoses have been fashioned and the graft thoroughly flushed, the clamps are removed and the surgeon carefully controls the degree of aortic occlusion until full flow is reestablished. During this period, the patient must be carefully monitored for hypotension. Declamp-ing hypotension is a complication of sudden restoration of aortic flow, particularly following prolonged occlusion. Once flow has been reestablished, the peritoneum is carefully reapproximated over the prosthesis to prevent fistulization into the intestine.Despite the presence of multilevel disease in most patients, a properly performed aortobifemoral operation can provide arterial inflow and alleviate claudication symptoms in 70% to 80% of patients; however, 10% to 15% of patients


Surgery_Schwartz

Surgery_Schwartz. disease in most patients, a properly performed aortobifemoral operation can provide arterial inflow and alleviate claudication symptoms in 70% to 80% of patients; however, 10% to 15% of patients will require simultaneous outflow reconstruction to address distal ischemia and facilitate limb salvage. The advantage of concomitant distal revascularization is avoidance of reoperation in a scarred groin. As a rule, if the profunda femoris can accept a 4-mm probe and if a No. 3 Fogarty embolectomy catheter can be passed distally for 20 cm or more, the PFA will be sufficient for outflow, and concomitant distal revascularization is not necessary.Aortic Endarterectomy. Aortoiliac endarterectomy is rarely performed because it is associated with greater blood loss and greater sexual dysfunction and is more difficult to perform. Long-term patency is comparable with aortobifemoral grafting, and thus it remains a reasonable option in cases in which the risk of infection of a graft is excessive


Surgery_Schwartz

Surgery_Schwartz. and is more difficult to perform. Long-term patency is comparable with aortobifemoral grafting, and thus it remains a reasonable option in cases in which the risk of infection of a graft is excessive because it involves no pros-thetic tissue. Aortoiliac endarterectomy was useful when disease was localized to either the aorta or common iliac arteries; how-ever, at present, aortoiliac PTA, stents, and other catheter-based therapies have become first-line treatment in this scenario. End-arterectomy should not be performed if the aorta is aneurysmal because of continued aneurysmal degeneration of the endarter-ectomized segment. If there is total occlusion of the aorta to the level of the renal arteries, aortic transection several centime-ters below the renal arteries with thrombectomy of the aortic cuff followed by graft insertion is easier and more expeditious when compared to endarterectomy. Involvement of the external iliac artery makes aortic endarterectomy more difficult to com-plete


Surgery_Schwartz

Surgery_Schwartz. cuff followed by graft insertion is easier and more expeditious when compared to endarterectomy. Involvement of the external iliac artery makes aortic endarterectomy more difficult to com-plete because of decreased vessel diameter, increased length, and exposure issues. The ability to establish an appropriate Brunicardi_Ch23_p0897-p0980.indd 94527/02/19 4:14 PM 946SPECIFIC CONSIDERATIONSPART IIendarterectomy plane is compromised due to the muscular and inherently adherent nature of the media in this location. There is a higher incidence of early thrombosis and late failure with extended aortoiliofemoral endarterectomy when compared to bypass grafting as a result of recurrent stenosis.Axillofemoral Bypass. An axillofemoral bypass is an extra-anatomic reconstruction that derives arterial inflow from the axillary artery to the femoral artery. This is a treatment option for patients with medical comorbidities that prohibit an abdominal vascular reconstruction. It may be performed


Surgery_Schwartz

Surgery_Schwartz. inflow from the axillary artery to the femoral artery. This is a treatment option for patients with medical comorbidities that prohibit an abdominal vascular reconstruction. It may be performed under local anesthesia and is used for limb salvage. Extra-anatomic bypasses have lower patency when compared to aortobifemo-ral and, therefore, are seldom recommended for claudication. Before performing this operation, the surgeon should check pulses and blood pressure in both arms to ensure that there is no obvious disease affecting flow through the axillary system. Angiography of the axillosubclavian vasculature is not neces-sary, but can be helpful if performed at the time of aortography. The axillary artery is exposed below the clavicle, and a 6to 8-mm externally reinforced PTFE graft is tunneled subcutane-ously down the lateral chest wall and lateral abdomen to the groin. It is anastomosed ipsilaterally at the CFA bifurcation into the SFA and PFA. A femorofemoral crossover graft using a


Surgery_Schwartz

Surgery_Schwartz. subcutane-ously down the lateral chest wall and lateral abdomen to the groin. It is anastomosed ipsilaterally at the CFA bifurcation into the SFA and PFA. A femorofemoral crossover graft using a 6to 8-mm externally reinforced PTFE graft is then used to revascularize the opposite extremity if necessary. Reported patency rates over 5 years vary from 30% to 80%.116 Paradoxi-cally, although it is a less complex procedure than aortofemoral grafting, the mortality rate is higher (10%), reflecting the com-promised medical status of these patients.Iliofemoral Bypass. One option for patients with unilateral occlusion of the distal common iliac or external iliac arteries is iliofemoral grafting (Fig. 23-58). Long-term patency is compa-rable to aortounifemoral bypass, and because the procedure can be performed using a retroperitoneal approach without clamping the aorta, the perioperative mortality is less.116Femorofemoral Bypass. A femorofemoral bypass is another option for patients with


Surgery_Schwartz

Surgery_Schwartz. can be performed using a retroperitoneal approach without clamping the aorta, the perioperative mortality is less.116Femorofemoral Bypass. A femorofemoral bypass is another option for patients with unilateral stenosis or occlusion of the common or external iliac artery who have rest pain, tissue loss, BAFigure 23-58. A. Skin markings showing the incisions of an ilio-femoral bypass. B. A prosthetic bypass graft is used for an iliofemo-ral artery bypass in which the proximal anastomosis is connected to the common iliac artery (long arrow) while the distal anastomosis is connected to the common femoral artery (short arrow).or intractable claudication. The primary (assisted) patency at 5 years is reported to be 60% to 70%, and although this is inferior when compared to aortofemoral bypass, there are physi-ologic benefits, especially for patients with multiple comorbidi-ties because it is not necessary to cross-clamp the aorta.117 There are no studies supporting the superiority of


Surgery_Schwartz

Surgery_Schwartz. there are physi-ologic benefits, especially for patients with multiple comorbidi-ties because it is not necessary to cross-clamp the aorta.117 There are no studies supporting the superiority of unsupported or exter-nally supported PTFE over Dacron for choice of conduit. The fear of the recipient extremity stealing blood from the extremity ipsilateral to the donor limb is not realized unless the donor iliac artery and donor outflow arteries are diseased. Depending on the skills of the interventionalist or surgeon, many iliac lesions classified as TASC B, C, or D can now be addressed using an endovascular approach, thus obviating the need to perform a femorofemoral bypass. Additionally, femorofemoral bypass can be used as an adjuvant procedure after iliac inflow has been optimized with endovascular methods.Obturator Bypass. An obturator bypass is used to recon-struct arterial anatomy in patients with groin sepsis resulting from prior prosthetic grafting, intra-arterial drug abuse, groin


Surgery_Schwartz

Surgery_Schwartz. methods.Obturator Bypass. An obturator bypass is used to recon-struct arterial anatomy in patients with groin sepsis resulting from prior prosthetic grafting, intra-arterial drug abuse, groin neoplasm, or damage from prior groin irradiation. This bypass can originate from the common iliac artery, external iliac artery, or uninvolved limb of an aortobifemoral bypass. A conduit of Dacron, PTFE, or autologous vein is tunneled through the anteromedial portion of the obturator membrane to the distal superficial femoral artery or popliteal artery. The obturator membrane must be divided sharply so as avoid injury to adja-cent structures, and care must be taken to identify the obturator artery and nerve that pass posterolaterally. After the bypass is completed and the wounds isolated, the infected area is entered, the involved arteries are debrided to healthy tissue, and vascu-larized muscle flaps are mobilized to cover the ligated ends. There have been varied results in terms of patency and


Surgery_Schwartz

Surgery_Schwartz. area is entered, the involved arteries are debrided to healthy tissue, and vascu-larized muscle flaps are mobilized to cover the ligated ends. There have been varied results in terms of patency and limb salvage for obturator bypass. Some authors have reported 57% 5-year patency and 77% 5-year limb salvage rates, whereas others have shown a high rate of reinfection and low patency requiring reintervention.118,119Thoracofemoral Bypass. The indications for thoracofemoral bypass are (a) multiple prior surgeries with a failed infrarenal aortic reconstruction and (b) infected aortic prosthesis. This pro-cedure is more physiologically demanding than other extra-ana-tomic reconstructions because the patient must not only tolerate clamping the descending thoracic aorta but also performance of a left thoracotomy. The graft is tunneled to the left CFA from the left thorax posterior to the left kidney in the anterior axillary line using a small incision in the periphery of the diaphragm and an


Surgery_Schwartz

Surgery_Schwartz. left thoracotomy. The graft is tunneled to the left CFA from the left thorax posterior to the left kidney in the anterior axillary line using a small incision in the periphery of the diaphragm and an incision in the left inguinal ligament to gain access to the extraperitoneal space from below. The right limb is tunneled in the space of Retzius in an attempt to decrease kinking that is more likely to occur with subcutaneous, suprapubic tunneling. Thoracofemoral bypass has long-term patency comparable to aortofemoral bypass.Complications of Surgical Aortoiliac ReconstructionWith current surgical techniques and conduits, early postopera-tive hemorrhage is unusual and occurs in 1% to 2%, which is usually the result of technical oversight or coagulation abnor-mality.120 Acute limb ischemia occurring after aortoiliac surgery may be the result of acute thrombosis or distal thromboembo-lism. The surgeon can prevent thromboembolic events by (a) avoiding excessive manipulation of the aorta, (b)


Surgery_Schwartz

Surgery_Schwartz. after aortoiliac surgery may be the result of acute thrombosis or distal thromboembo-lism. The surgeon can prevent thromboembolic events by (a) avoiding excessive manipulation of the aorta, (b) ensuring Brunicardi_Ch23_p0897-p0980.indd 94627/02/19 4:14 PM 947ARTERIAL DISEASECHAPTER 23adequate systemic heparinization, (c) judicious placement of vascular clamps, and (d) thorough flushing prior to restoring blood flow. Acute thrombosis of an aortofemoral graft limb in the early perioperative period occurs in 1% to 3% of patients.120 Thrombectomy of the graft limb is performed through a trans-verse opening in the hood of the graft at the femoral anastomo-sis. With this approach, it is possible to inspect the interior of the anastomosis and pass embolectomy catheters distally to clear the superficial femoral and profunda arteries. Various complica-tions may be encountered following aortoiliac or aortobifemoral reconstruction (Table 23-15).Intestinal ischemia following aortic


Surgery_Schwartz

Surgery_Schwartz. clear the superficial femoral and profunda arteries. Various complica-tions may be encountered following aortoiliac or aortobifemoral reconstruction (Table 23-15).Intestinal ischemia following aortic reconstruction occurs in approximately 2% of cases; however, with colonoscopy mucosal ischemia, which is a milder form, is seen more fre-quently. The surgeon can identify patients who require con-comitant revascularization of the IMA, hypogastric arteries, or mesenteric arteries by examining the preoperative arteriogram for the presence of associated occlusive lesions in the celiac axis, the superior mesenteric arteries, or both. Likewise, patients with a patent and enlarged IMA or a history of prior colonic resections will benefit from IMA reimplantation.In a comprehensive review of 747 patients who had aor-toiliac operations for occlusive disease, secondary operations for late complications such as reocclusion, pseudoaneurysms, and infection were necessary in 21% over a 22-year


Surgery_Schwartz

Surgery_Schwartz. 747 patients who had aor-toiliac operations for occlusive disease, secondary operations for late complications such as reocclusion, pseudoaneurysms, and infection were necessary in 21% over a 22-year period.121 The most frequent late complication is graft thrombosis. Limb occlusion occurs in 5% to 10% of patients within 5 years of the index operation and in 15% to 30% of patients ≥10 years after the index operation. Anastomotic pseudoaneurysms occur in 1% and 5% of femoral anastomoses in patients with aortofemo-ral grafts. Predisposing factors to pseudoaneurysm formation Table 23-15Perioperative complications of aortobifemoral bypass graftingMedical Complications• Perioperative myocardial infarction• Respiratory failure• Ischemia-induced renal failure• Bleeding from intravenous heparinization• StrokeProcedure-Related ComplicationsEarly• Declamping shock• Graft thrombosis• Retroperitoneal bleeding• Groin hematoma• Bowel ischemia/infarction• Peripheral embolization• Erectile


Surgery_Schwartz

Surgery_Schwartz. heparinization• StrokeProcedure-Related ComplicationsEarly• Declamping shock• Graft thrombosis• Retroperitoneal bleeding• Groin hematoma• Bowel ischemia/infarction• Peripheral embolization• Erectile dysfunction• Lymphatic leak• Chylous ascites• ParaplegiaLate• Graft infection• Anastomotic pseudoaneurysm• Aortoenteric fistula• Aortourinary fistula• Graft thrombosisinclude progression of degenerative changes within the host artery, excessive tension at the anastomosis, and infection.121 Due to the associated risks of thrombosis, distal emboliza-tion, infection, and rupture, anastomotic aneurysms should be repaired expeditiously.Infection following aortoiliac reconstruction is a devastat-ing complication that occurs in 1% of cases. Femoral anastomo-ses of aortofemoral reconstructions and axillofemoral bypasses are prone to infection. Use of prophylactic antibiotics and metic-ulous surgical technique are vital in preventing contamination of the graft at the time of implantation. If


Surgery_Schwartz

Surgery_Schwartz. axillofemoral bypasses are prone to infection. Use of prophylactic antibiotics and metic-ulous surgical technique are vital in preventing contamination of the graft at the time of implantation. If infection appears local-ized to a single groin, graft preservation and local measures such as antibiotic irrigation, aggressive debridement, and soft tissue coverage with rotational muscle flaps may prove successful. Most patients with infected aortoiliofemoral reconstructions usually require graft excision and revascularization via remote uncontaminated routes or the use of in situ replacement to clear the infective process and maintain limb viability. Aortoenteric fistula and associated gastrointestinal hemorrhage are devas-tating complications, with a 50% incidence of death or limb loss. The incidence of aortoenteric fistula formation appears to be higher after an end-to-side proximal anastomosis because it is more difficult to cover the prosthesis with viable tissue and avoid contact


Surgery_Schwartz

Surgery_Schwartz. incidence of aortoenteric fistula formation appears to be higher after an end-to-side proximal anastomosis because it is more difficult to cover the prosthesis with viable tissue and avoid contact with the gastrointestinal tract with this configu-ration.121 Treatment of aortoenteric fistula requires resection of all prosthetic material, closure of the infrarenal abdominal aorta, repair of the gastrointestinal tract, and revascularization by means of an extra-anatomic graft.Endovascular Treatment for Aortic DiseaseAlthough aortofemoral bypass surgery has excellent long-term patency and can be performed with low mortality rates, there are patients who are unable to withstand the physiologic stress of longer open procedures performed under general anesthe-sia, which require aortic cross-clamping and which are associ-ated with greater blood loss. These patients are more suited to endovascular interventions despite the decreased durability and requirement for more frequent


Surgery_Schwartz

Surgery_Schwartz. cross-clamping and which are associ-ated with greater blood loss. These patients are more suited to endovascular interventions despite the decreased durability and requirement for more frequent reinterventions.Focal Aortic Stenosis. The endovascular technique used to treat infrarenal aortic stenoses is similar to that used for iliac artery disease. Bilateral CFA access is established followed by insertion of a 6-French sheath. The lesion is crossed using a hydrophilic wire and a supporting selective catheter and then changed for a stiffer guidewire. A self-expanding nitinol stent or a balloon-expandable stent mounted on a larger-caliber angio-plasty balloon is implanted followed by adequate postdilation. At the physician’s discretion, “kissing” stents, simultaneous bilateral proximal iliac stents, are deployed if the lesion is in the distal aorta in the proximity of the aortic bifurcation. The role of covered stents such as cuffs made for endoluminal AAA repair has not been rigorously


Surgery_Schwartz

Surgery_Schwartz. stents, are deployed if the lesion is in the distal aorta in the proximity of the aortic bifurcation. The role of covered stents such as cuffs made for endoluminal AAA repair has not been rigorously studied. The aortic diameter should be sized with a calibrated catheter during the angiography or by preintervention CT scanning to avoid undersizing. Balloon size will range from 12 to 18 mm in most cases. A single stent is generally sufficient in most cases. Concentric aortic stenosis may encroach upon the IMA, and coverage of this vessel may be unavoidable. Care should be taken to use low inflation pres-sures (5 mmHg) to minimize the risk of aortic rupture. Patient complaints of back or abdominal pain during balloon infla-tion should be taken seriously as they may suggest impending rupture. In case of a calcified small-caliber, hypoplastic aorta (≤12 mm, typically in female patients), it is recommended to Brunicardi_Ch23_p0897-p0980.indd 94727/02/19 4:14 PM 948SPECIFIC


Surgery_Schwartz

Surgery_Schwartz. rupture. In case of a calcified small-caliber, hypoplastic aorta (≤12 mm, typically in female patients), it is recommended to Brunicardi_Ch23_p0897-p0980.indd 94727/02/19 4:14 PM 948SPECIFIC CONSIDERATIONSPART IIuse smaller diameter stents. To achieve clinical improvement, these patients can be recanalized to an aortic diameter of 8 or 9 mm. Distal embolization is one of the potential complications of endovascular treatment for aortic stenoses. Full hepariniza-tion, meticulous technique during wire and catheter manipula-tions, and primary stenting reduce the risk of this complication. Since calcified aortic stenoses are prone to rupture during dila-tion, it is recommended to be cognizant of the extent of the calcification with preoperative CT scans. In case of aortic rup-ture, as long as wire access has been maintained, an occlusion balloon can be inflated proximal to the disrupted segment to achieve hemostasis, and the rupture can be covered with a stent graft or repaired with


Surgery_Schwartz

Surgery_Schwartz. as wire access has been maintained, an occlusion balloon can be inflated proximal to the disrupted segment to achieve hemostasis, and the rupture can be covered with a stent graft or repaired with open surgery.Occlusive Lesions of the Aortic Bifurcation. Occlusive lesions are treated with the kissing balloon technique to avoid dislodging aortic plaque. Two angioplasty balloons of equal size are positioned across the ostia of the common iliac arteries, using a retrograde approach, and inflated. Simultaneous bal-loon dilatation at the origins of both common iliac arteries is advocated, even in the presence of unilateral lesion, to protect the contralateral common iliac artery from dissection or plaque embolization. Calcified lesions that typically occur at the aor-tic bifurcation are not amenable to balloon dilatation and fre-quently require that a distal aortic reconstruction be performed using “kissing stents.” Fears that the proximal ends of the stents that extend into the distal


Surgery_Schwartz

Surgery_Schwartz. amenable to balloon dilatation and fre-quently require that a distal aortic reconstruction be performed using “kissing stents.” Fears that the proximal ends of the stents that extend into the distal aorta will become a nidus for throm-bus formation or cause hemolysis have not been realized. The results are difficult to interpret because these bifurcation lesions are usually included in studies with iliac artery lesions. Patency rates for aortic bifurcation PTA range from 76% to 92% at 3 years. The largest series reported to date includes 79 patients with aortic bifurcation lesions. The cumulative clinical success rate at a mean of 4 years was 93%.122 Stents have also been used to reconstruct the aortic bifurcation with high success rates. The kissing stent technique is well suited for orificial lesions. Technical success with kissing stents at the aortic bifurcation has been reported to be 95% to 100%.123 In the largest series reported, the primary patency at 3 years was


Surgery_Schwartz

Surgery_Schwartz. for orificial lesions. Technical success with kissing stents at the aortic bifurcation has been reported to be 95% to 100%.123 In the largest series reported, the primary patency at 3 years was 79%.124Endovascular Treatment for Iliac Artery DiseasePercutaneous Transluminal Angioplasty. PTA is most use-ful in the treatment of isolated iliac stenoses of less than 4 cm in length. When used for stenoses rather than occlusion, a 2-year patency of 86% can be achieved.125 The complication rate is approximately 2%, consisting of distal embolization, medial dissection, and acute thrombosis.Technical Considerations for Iliac Interventions Crossing a high-grade stenosis or occlusion can be challenging in the iliac arteries. It is vital to image the lesion well because multiple views and use of the image intensifier will frequently uncover the anatomic reason for the difficulty. Frequently, the difficulty is the result of vessel tortuosity that cannot be appreciated on the original view. Use of


Surgery_Schwartz

Surgery_Schwartz. image intensifier will frequently uncover the anatomic reason for the difficulty. Frequently, the difficulty is the result of vessel tortuosity that cannot be appreciated on the original view. Use of an angled hydrophilic guidewire and an angled catheter can provide steering and add extra support for the wire trying to cross the lesion. Patience, persistence, and periodic reimaging will facilitate the crossing of a lesion in the great majority of cases. Guidewire traversal must be achieved for performance of endovascular iliac intervention. Over 90% of iliac occlusions can be passed with simple guidewire tech-niques. The preferred approach for recanalizing a common iliac artery occlusion is retrograde passage of devices from an ipsi-lateral CFA puncture because, in this manner, distance to the lesion is short and access is straighter. A stenosis is normally crossed using a combination of a soft-tip 0.035-inch guidewire (i.e., Bentson-type wire) or hydrophilic wire and a 5-French


Surgery_Schwartz

Surgery_Schwartz. to the lesion is short and access is straighter. A stenosis is normally crossed using a combination of a soft-tip 0.035-inch guidewire (i.e., Bentson-type wire) or hydrophilic wire and a 5-French straight or selective catheter. One of the hazards of retrograde recanalization is that the guidewire stays in a subintimal loca-tion and cannot be redirected into the true lumen at the aortic bifurcation. There are several approaches that can be used to achieve reentry of total chronic occlusions. Specialized cath-eters allow passage of a needle and guidewire across the intima distal to the occlusion. Intravascular ultrasound can be used for true lumen reentry under fluoroscopic guidance. Another method of achieving true lumen reentry involves performing the recanalization from an antegrade contralateral CFA approach. A 4-French Berenstein catheter (Cordis Corp., Miami Lakes, FL) is used to probe the occlusion. The lesion can be crossed in most instances (5–20% failure rate) with a


Surgery_Schwartz

Surgery_Schwartz. contralateral CFA approach. A 4-French Berenstein catheter (Cordis Corp., Miami Lakes, FL) is used to probe the occlusion. The lesion can be crossed in most instances (5–20% failure rate) with a hydrophilic guidewire or occasionally with its stiffer back end. As soon as the guidewire has crossed the obstruction and lies within the ipsilateral exter-nal iliac artery lumen, it is snared and partially pulled out of the ipsilateral CFA. A short catheter is then inserted in a retrograde fashion over the wire end into the abdominal aorta proximal to the lesion. The hydrophilic guidewire is then exchanged for a stiffer Amplatz (Boston Scientific, Natick, MA) guidewire to facilitate iliac stenting.Obtaining arterial access when there are absent femoral pulsations is aided by the use of ultrasound guidance and “road-map” imaging software, which is available on modern angio-graphic equipment. When the lesion is successfully crossed, balloons of an appropriate size and length are selected for


Surgery_Schwartz

Surgery_Schwartz. guidance and “road-map” imaging software, which is available on modern angio-graphic equipment. When the lesion is successfully crossed, balloons of an appropriate size and length are selected for the angioplasty. Most common iliac arteries will accommodate 8to 10-mm diameter balloons, whereas most external iliac arteries will accommodate 6to 8-mm diameter balloons. Inflation is performed with caution, especially if there is heavy calcifica-tion, and should be guided by patient discomfort, pressure gauge readings, and changes in balloon outline.If guidewire traversal is straightforward, consideration should be given to the presence of an acute thrombosis that may benefit from catheter-directed thrombolysis. If guidewire traversal is challenging, it is unlikely that catheter-directed thrombolysis will be beneficial. Stents should be placed after inadequate angioplasty. Stents are warranted when there is a greater than 30% residual stenosis, when there is a flow-limiting dissection, or


Surgery_Schwartz

Surgery_Schwartz. will be beneficial. Stents should be placed after inadequate angioplasty. Stents are warranted when there is a greater than 30% residual stenosis, when there is a flow-limiting dissection, or when there is a pressure gradient of ≥5 mmHg across the treated segment. Placement of stents can precipitate distal embolization in up to 10%, especially if lesions are friable and vulnerable to manipulation. Routine primary stent place-ment is not recommended because it has not been found to be superior to selective stenting in terms of outcomes or cost.Primary Stenting Versus Selective Stenting in Iliac Arteries. Primary stenting rather than selective stenting should be considered for longer iliac lesions and for all TASC C and D lesions. The primary patency rates at 1, 2, and 3 years were 96%, 90%, and 72%, respectively, for longer lesions (>5 cm) that were primarily stented versus 46%, 46%, and 28%, respectively, with selective stenting.126 Primary stenting is generally advocated for chronic


Surgery_Schwartz

Surgery_Schwartz. and 72%, respectively, for longer lesions (>5 cm) that were primarily stented versus 46%, 46%, and 28%, respectively, with selective stenting.126 Primary stenting is generally advocated for chronic iliac artery occlusions, recur-rent stenosis after previous iliac PTA, and complex stenoses with eccentric, calcified, ulcerated plaques or plaques with spontaneous dissection. All of these lesions are prone to distal Brunicardi_Ch23_p0897-p0980.indd 94827/02/19 4:14 PM 949ARTERIAL DISEASECHAPTER 23embolization during manipulation of wires and angioplasty balloons. Distal embolization with isolated PTA is not com-mon for uncomplicated lesions, but can occur in up to 24% of cases, when treating ulcerated plaques, aortoiliac bifurca-tion lesions, or iliac occlusions. It is believed that direct stent placement without predilation significantly reduces the risk of distal embolization by trapping potentially embologenic material between the arterial wall and the stent mesh. While PTA has


Surgery_Schwartz

Surgery_Schwartz. stent placement without predilation significantly reduces the risk of distal embolization by trapping potentially embologenic material between the arterial wall and the stent mesh. While PTA has demonstrated excellent results in focal stenoses of the abdominal aorta and iliacs, primary stenting in these locations is safe, improves patency rates, reduces the degree of resteno-sis when compared with PTA alone, and decreases the risk of distal embolization. Additional potential advantages of direct stenting include shorter procedural time and less radiation exposure. The Dutch Iliac Stent Trial has provided evidence that refutes the superiority of primary stenting over angio-plasty alone.151 Most interventionalists continue to perform angioplasty first and stent selectively for inadequate results. The approach to aortoiliac stenting is intuitive. Individual judgment and experience are important in the decision-making process, and there are lesions with unstable morphology such as long


Surgery_Schwartz

Surgery_Schwartz. results. The approach to aortoiliac stenting is intuitive. Individual judgment and experience are important in the decision-making process, and there are lesions with unstable morphology such as long occlusions, ulceration, and dissection that warrant pri-mary stenting.Stent Graft Placement for Aortoiliac Interventions. Stent grafts have been used to treat complex iliac lesions in an attempt to exclude these sources of embolization. A recent report sug-gested that the use of stent grafts was beneficial for TASC C and D lesions.127 Bosiers and colleagues published a series of 91 limbs with diseased iliacs that they treated with 107 stent grafts. They reported successful deployment in all patients with-out distal embolization or vessel rupture and a primary patency rate of 91.1% at 1 year.128 The authors commented about their concerns of causing embolization during placement of the stent grafts and recommended that once an occlusion was traversed with the guidewire, to gently predilate


Surgery_Schwartz

Surgery_Schwartz. The authors commented about their concerns of causing embolization during placement of the stent grafts and recommended that once an occlusion was traversed with the guidewire, to gently predilate with a 5-mm balloon, followed by smooth stent graft insertion into the newly created channel. The role of stent grafts in aortoiliac occlusive disease has not been fully elucidated yet.Complications of Endovascular Aortoiliac InterventionsIliac artery angioplasty is associated with a 2% to 4% major complication rate and 4% to 15% minor complication rate. Many of these minor complications are related to the arterial puncture site. The most frequent complications relate to access site cannulation. Hemorrhage can range from the more common access site hematoma to the rarer retroperitoneal and intraperi-toneal hemorrhage. Distal embolization occurs in 2% to 10% of iliac PTA and stenting procedures.120 Percutaneous catheter aspiration should be the initial treatment for calf vessel embo-lization,


Surgery_Schwartz

Surgery_Schwartz. hemorrhage. Distal embolization occurs in 2% to 10% of iliac PTA and stenting procedures.120 Percutaneous catheter aspiration should be the initial treatment for calf vessel embo-lization, but, for larger emboli, such as those that lodge in the profunda femoris or common femoral arteries, surgical embo-lectomy may be required because the embolic material contains atherosclerotic plaque, which is not amenable to transcatheter aspiration or catheter-directed thrombolysis. The incidence of pseudoaneurysm formation at the puncture site is 0.5%. The treatment of choice for pseudoaneurysms >2 cm in diameter is percutaneous thrombin injection under ultrasound guidance. Arterial rupture may complicate the procedure in 0.3% of cases. Tamponade of the ruptured artery with an occlusion balloon should be performed, and a covered stent should be placed. In case of failure, surgical treatment is required.Clinical Results Comparing Surgical and Endovascular Treatment of Aortoiliac DiseaseThe


Surgery_Schwartz

Surgery_Schwartz. should be performed, and a covered stent should be placed. In case of failure, surgical treatment is required.Clinical Results Comparing Surgical and Endovascular Treatment of Aortoiliac DiseaseThe mortality risk of aortobifemoral bypass in patients with iso-lated, localized aortoiliac disease is relatively low, whereas for patients with concomitant atherosclerosis in coronary, carotid, and visceral vessels, mortality and morbidity are higher. For this reason, the cumulative long-term survival rate for patients receiving aortoiliac reconstruction remains 10 to 15 years less than anticipated for a normal ageand sex-matched population. Twenty-five percent to 30% of patients with concomitant ath-erosclerosis in other vascular distributions are dead within 5 years, and 50% to 60% will have died by 10 years.129Compared with conventional aortobifemoral bypass, common iliac angioplasty was shown to have a 10% to 20% lower overall patency rate. It should be noted that these results were


Surgery_Schwartz

Surgery_Schwartz. died by 10 years.129Compared with conventional aortobifemoral bypass, common iliac angioplasty was shown to have a 10% to 20% lower overall patency rate. It should be noted that these results were reported in early trials that used older generations of endovascular equipment. With continued progress and newer angioplasty balloons and stenting practices, more comparable outcomes are being reported. Review of the literature confirms that there is an 85% to 90% graft patency rate at 5 years and a 70% to 75% graft patency rate at 10 years after aortobifemo-ral reconstruction.127 Due in part to factors including continued refinements in anesthetic management, intraoperative monitor-ing, and postoperative intensive care, low perioperative mortal-ity rates for aortobifemoral bypass can be achieved commonly in today’s clinical practice. The most recent systematic review and meta-analysis of 5358 patients who underwent direct open bypass or endovascular treatment for aortoiliac occlusive


Surgery_Schwartz

Surgery_Schwartz. commonly in today’s clinical practice. The most recent systematic review and meta-analysis of 5358 patients who underwent direct open bypass or endovascular treatment for aortoiliac occlusive dis-ease demonstrated superior durability for open bypass, although with longer length of stay and increased risk for complications and mortality, when compared to the endovascular approach.130 In this study, poor preoperative runoff was greater in the open bypass group (50.0% vs. 24.6%). Mean length of hospital stay was 13 days for open bypass versus 4 days for endovascular treatment procedures. The open bypass group experienced more complications (18.0% vs. 13.4%) and greater 30-day mortality (2.6% vs. 0.7%). At 1, 3, and 5 years, pooled primary patency rates were greater in the open bypass group (94.8% vs. 86.0%, 86.0% vs. 80.0%, and 82.7% vs. 71.4%, respectively); the same was true for secondary patency (95.7% vs. 90.0%, 91.5% vs. 86.5%, and 91.0% vs. 82.5%, respectively).Despite its lower


Surgery_Schwartz

Surgery_Schwartz. (94.8% vs. 86.0%, 86.0% vs. 80.0%, and 82.7% vs. 71.4%, respectively); the same was true for secondary patency (95.7% vs. 90.0%, 91.5% vs. 86.5%, and 91.0% vs. 82.5%, respectively).Despite its lower long-term success, common iliac angio-plasty is a useful procedure in patients with focal disease and mild symptoms in whom a major surgical revascularization is not justified. Angioplasty of the iliac vessels can be a useful adjunct to distal surgical bypass as well, increasing the success of dis-tal revascularization and eliminating the risks associated with aortoiliac bypass. Thus, with long-term patency less than, but comparable to, open surgical bypass, and with more favorable morbidity rates, iliac angioplasty has become a well-accepted modality of treatment for iliac occlusive disease. Ideal iliac angioplasty lesions are nonocclusive and short. Patency after intervention is better when lesions occur in larger diameter ves-sels, when stenoses rather than occlusions are treated, when


Surgery_Schwartz

Surgery_Schwartz. Ideal iliac angioplasty lesions are nonocclusive and short. Patency after intervention is better when lesions occur in larger diameter ves-sels, when stenoses rather than occlusions are treated, when run-off vessels are patent, and when the indication for intervention is lifestyle-limiting claudication rather than critical limb ischemia.Becker and colleagues estimated a 5-year patency rate of 72% in an analysis of 2697 cases of iliac angioplasty and noted a better patency (79%) in claudicants.131 Less favorable results are obtained with long stenoses, external iliac stenoses, and tan-dem lesions. The reported technical and initial clinical success of balloon angioplasty in iliac artery stenoses exceeds 90% in 5Brunicardi_Ch23_p0897-p0980.indd 94927/02/19 4:14 PM 950SPECIFIC CONSIDERATIONSPART IImost series, and the 5-year patency rates range from 54% to 92%. The reported technical and initial clinical success of bal-loon angioplasty in iliac artery occlusions ranges from 78% to


Surgery_Schwartz

Surgery_Schwartz. series, and the 5-year patency rates range from 54% to 92%. The reported technical and initial clinical success of bal-loon angioplasty in iliac artery occlusions ranges from 78% to 98%, and the 3-year patency rates range from 48% to 85%.131,132Factors reported to affect the patency of aortoiliac endovas-cular interventions adversely include quality of runoff vessels, severity of ischemia, and length of diseased segments treated. Likewise, as vessel diameter and flow rates change, so do suc-cess rates after angioplasty. It was reported in the literature that location of the lesion at the external iliac artery adversely affects both primary and assisted-primary patency. Following angio-plasty of the common iliac artery, patency rates were 81% and 52% at 1 and 6 years, respectively; whereas, after external iliac artery angioplasty, they were 74% and 48% at 1 and 4 years, respectively.133 Although some literature supports location of the lesion in the external iliac artery as a factor


Surgery_Schwartz

Surgery_Schwartz. after external iliac artery angioplasty, they were 74% and 48% at 1 and 4 years, respectively.133 Although some literature supports location of the lesion in the external iliac artery as a factor that adversely affects both primary and assisted-primary patency, this has not been a universal finding. Female patients are also reported to have lower patency rates than males following iliac PTA, with or without stent placement in the external iliac artery.134Stenting of the iliac arteries provides a durable and curative treatment, with a 3-year patency rate of 41% to 92% for stenosis and a 3-year patency rate of 64% to 85% and 4-year patency rate of 54% to 78% for occlusions.132 A meta-analysis of 2116 patients by Bosch and Hunink showed that aortoiliac stenting resulted in a 39% improvement in long-term patency compared to balloon angioplasty, despite the fact that complication rates and 30-day mortality rates did not differ significantly.135 Park and colleagues presented long-term


Surgery_Schwartz

Surgery_Schwartz. in long-term patency compared to balloon angioplasty, despite the fact that complication rates and 30-day mortality rates did not differ significantly.135 Park and colleagues presented long-term follow-up results in a cohort of patients with all four TASC types of iliac lesions. The authors presented primary patency rates of 87%, 83%, 61%, and 49% at 3, 5, 7, and 10 years, respectively, after the index intervention.136 Leville and colleagues achieved primary and secondary patency rates of 76% and 90%, respectively, after 3 years, in a cohort of patients who received stents for iliac occlusions.137 The authors postulated that endovascular treatment for iliac occlusive dis-ease should be extended to type C and D lesions, because they observed no detectable differences between the four TASC clas-sifications in terms of primary and secondary patency rates.137 They concluded that presence of TASC C and D lesions should not preclude endovascular treatment and believe that endovas-cular


Surgery_Schwartz

Surgery_Schwartz. clas-sifications in terms of primary and secondary patency rates.137 They concluded that presence of TASC C and D lesions should not preclude endovascular treatment and believe that endovas-cular attempts should be exhausted before open surgical repair of iliac occlusions is attempted because of the decreased periop-erative morbidity and good midterm durability.Not all results have been in favor of stenting, and at present, universal primary stenting cannot be recommended. Although stents are often used to improve the outcome of PTA, there is no general consensus that stenting should be mandatory in all iliac lesions. Complex, ulcerated iliac lesions with high embologenic potential or recanalized chronic iliac occlusions may be an exception. In the Dutch Iliac Stent Trial, primary stenting did not prove to be superior to iliac angioplasty and selective stenting.138 The researchers in this prospective ran-domized multicenter study concluded that balloon angioplasty with selective


Surgery_Schwartz

Surgery_Schwartz. did not prove to be superior to iliac angioplasty and selective stenting.138 The researchers in this prospective ran-domized multicenter study concluded that balloon angioplasty with selective stenting had comparable 2-year patency rates with primary stenting (77% and 78%, respectively). It must be noted, however, that it was necessary to stent 43% of the patients in the PTA treatment group due to unsatisfactory angioplasty results. The 5-year outcomes between the two groups were also similar, with 82% and 80% of the treated iliac segments remaining free of the need for new revascularization procedures after a mean follow-up of 5.6 ± 1.3 years.138LOWER EXTREMITY ARTERIAL OCCLUSIVE DISEASEThe symptoms of lower extremity occlusive disease are classi-fied into two large categories: acute limb ischemia (ALI) and chronic limb ischemia (CLI). Ninety percent of acute ischemia cases are either thrombotic or embolic. Frequently, sudden onset of limb-threatening ischemia may be the result of


Surgery_Schwartz

Surgery_Schwartz. ischemia (ALI) and chronic limb ischemia (CLI). Ninety percent of acute ischemia cases are either thrombotic or embolic. Frequently, sudden onset of limb-threatening ischemia may be the result of acute exacerbation of the preexisting atherosclerotic disease. Chronic ischemia is largely due to atherosclerotic changes of the lower extremity that manifest from asymptomatic to limb-threatening gangrene. As the population ages, the prevalence of chronic occlusive disease of the lower extremity is increasing, and it significantly influences lifestyle, morbidity, and mortality. In addition, multiple comorbid conditions increase risks of surgical procedures. Endovascular interventions become an important alternative in treating lower extremity occlusive disease. How-ever, despite rapidly evolving endovascular technology, lower extremity endovascular intervention continues to be one of the most controversial areas of endovascular therapy.EpidemiologyIn a detailed review of the literature,


Surgery_Schwartz

Surgery_Schwartz. endovascular technology, lower extremity endovascular intervention continues to be one of the most controversial areas of endovascular therapy.EpidemiologyIn a detailed review of the literature, McDaniel and Cronenwett concluded that claudication occurred in 1.8% of patients under 60 years of age, 3.7% of patients between 60 and 70 years of age, and 5.2% of patients over 70 years of age.139 Leng and his colleagues scanned 784 subjects using ultrasound in a random sample of men and women age 56 to 77 years. Of the subjects who were scanned, 64% demonstrated atherosclerotic plaque.140 However, a large number of patients had occlusive disease with-out significant symptoms. In a study by Schroll and Munck, only 19% of patients with peripheral vascular disease were symptomatic.141 Using ABIs, Stoffers and colleagues scanned 3171 individuals between the ages of 45 and 75 and identified that 6.9% of patients had ABIs <0.95, only 22% of whom had symptoms.142 In addition, they demonstrated


Surgery_Schwartz

Surgery_Schwartz. Stoffers and colleagues scanned 3171 individuals between the ages of 45 and 75 and identified that 6.9% of patients had ABIs <0.95, only 22% of whom had symptoms.142 In addition, they demonstrated that concomitant cardiovascular and cerebrovascular diseases were three to four times higher among the group with asymptomatic peripheral vascular diseases than those without peripheral vascular disease. Furthermore, they confirmed that 68% of all peripheral arterial obstructive diseases were unknown to the primary care physi-cian, and this group mainly represented less advanced cases of atherosclerosis. However, among patients with an ABI ratio <0.75, 42% were unknown to the primary physicians.Diagnostic EvaluationThe diagnosis of lower extremity occlusive disease is often made based on a focused history and physical examination and confirmed by the imaging studies. A well-performed physi-cal examination often reveals the site of lesions by detecting changes in pulses, temperature, and


Surgery_Schwartz

Surgery_Schwartz. history and physical examination and confirmed by the imaging studies. A well-performed physi-cal examination often reveals the site of lesions by detecting changes in pulses, temperature, and appearances. The bedside ABIs using blood pressure cuff also aid in diagnosis. Various clinical signs and symptoms are useful to differentiate condi-tions of viable, threatened, and irreversible limb ischemia caused by arterial insufficiency (Table 23-16).Noninvasive studies are important in documenting the severity of occlusive disease objectively. Ultrasound Dopplers measuring ABIs and segmental pressures are widely used in North America and Europe. Normal ABI is greater than 1.0. In patients with claudication, ABIs decrease to 0.5 to 0.9 and to even lower levels in patients with rest pain or tissue loss. Seg-mental pressures are helpful in identifying the level of involve-ment. Decrease in segmental pressure between two segments indicates significant disease. Ultrasound duplex scans are used


Surgery_Schwartz

Surgery_Schwartz. loss. Seg-mental pressures are helpful in identifying the level of involve-ment. Decrease in segmental pressure between two segments indicates significant disease. Ultrasound duplex scans are used Brunicardi_Ch23_p0897-p0980.indd 95027/02/19 4:14 PM 951ARTERIAL DISEASECHAPTER 23Table 23-16Signs and symptoms of acute limb ischemiaDESCRIPTIONCATEGORYVIABLETHREATENEDIRREVERSIBLEClinical descriptionNot immediately threatenedSalvageable if promptly treatedMajor tissue loss, amputation unavoidableCapillary returnIntactIntact, slowAbsent (marbling)Muscle weaknessNoneMild, partialProfound, paralysis (rigor)Sensory lossNoneMild, incompleteProfound anestheticArteriovenous Doppler findingAudibleInaudible or audibleInaudibleto identify the site of lesion by revealing flow disturbance and velocity changes. A meta-analysis of 71 studies by Koelemay and associates confirmed that duplex scanning is accurate for assessing arterial occlusive disease in patients suffering from claudication or


Surgery_Schwartz

Surgery_Schwartz. changes. A meta-analysis of 71 studies by Koelemay and associates confirmed that duplex scanning is accurate for assessing arterial occlusive disease in patients suffering from claudication or critical ischemia with an accumulative sensitiv-ity of 80% and specificity of over 95%.143 Adding an ultrasound contrast agent further increases the sensitivity and specificity of ultrasound technology. Other noninvasive imaging technolo-gies, such as MRA and CTA, are rapidly evolving and gaining popularity in the diagnosis of lower extremity occlusive disease (Figs. 23-59 and 23-60).Contrast angiography remains the gold standard imaging study. Using contrast angiography, interventionists can locate and size the anatomic significant lesions and measure the pres-sure gradient across the lesion, as well as plan for potential inter-vention. Angiography is, however, semi-invasive and should be confined to patients for whom surgical or percutaneous inter-vention is contemplated. Patients with


Surgery_Schwartz

Surgery_Schwartz. as well as plan for potential inter-vention. Angiography is, however, semi-invasive and should be confined to patients for whom surgical or percutaneous inter-vention is contemplated. Patients with borderline renal function may need to have alternate contrast agents, such as gadolinium or carbon dioxide, to avoid contrast-induced nephrotoxicity.Differential DiagnosisArterial insufficiency frequently leads to muscle ischemic pain involving the lower extremity muscles, particularly during exer-cise. Intermittent claudication is pain affecting the calf and, less commonly, the thigh and buttock that is induced by exercise and relieved by rest. Symptom severity varies from mild to severe. Intermittent claudication occurs as a result of muscle ischemia during exercise caused by obstruction to arterial flow. Regarding the differential diagnosis of intermittent claudication, there are a variety of neurologic, musculoskeletal, and venous conditions that may produce symptoms of calf pain (Table


Surgery_Schwartz

Surgery_Schwartz. flow. Regarding the differential diagnosis of intermittent claudication, there are a variety of neurologic, musculoskeletal, and venous conditions that may produce symptoms of calf pain (Table 23-17). Addi-tionally, various nonatherosclerotic conditions can also cause symptoms consistent with intermittent lower extremity claudi-cation (Table 23-18). Nocturnal calf muscle spasms or night cramps are not indicative of arterial disease. They are common but are difficult to diagnose with certainty. Foot ulceration is not always the result of arterial insufficiency. Ischemic ulcers occur on the toes or lateral side of the foot and are painful. By com-parison, venous ulcers, which are also common, occur above the medial malleolus, usually in an area with the skin changes of lipodermatosclerosis, and cause mild discomfort. Neuropathic ulcers are usually found on weight-bearing surfaces, have thick calluses, and are pain free. Ulcers may be the result of more than one etiology. Rest pain must


Surgery_Schwartz

Surgery_Schwartz. and cause mild discomfort. Neuropathic ulcers are usually found on weight-bearing surfaces, have thick calluses, and are pain free. Ulcers may be the result of more than one etiology. Rest pain must be distinguished from periph-eral neuropathy, which is prevalent in diabetic patients. Patients with diabetic neuropathy tend to have decreased vibration and Figure 23-59. High-resolution computed tomography angiogra-phy of a patient with normal right lower extremity arterial circu-lation. Distal occlusive disease is noted in the left tibial arteries (arrow).position sense and decreased reflexes. Spinal stenosis causes pain that is exacerbated with standing and back extension.Lower Extremity Occlusive Disease ClassificationLower extremity occlusive disease may range from exhibiting no symptoms to limb-threatening gangrene. There are two major classifications developed based on the clinical presentations.Brunicardi_Ch23_p0897-p0980.indd 95127/02/19 4:15 PM 952SPECIFIC


Surgery_Schwartz

Surgery_Schwartz. no symptoms to limb-threatening gangrene. There are two major classifications developed based on the clinical presentations.Brunicardi_Ch23_p0897-p0980.indd 95127/02/19 4:15 PM 952SPECIFIC CONSIDERATIONSPART IIFigure 23-60. Multidetector computed tomography angiography of a patient with an (A) infrapopliteal arterial circulation and (B) pedal arterial circulation. The high spatial resolution and image quality of these images shows three patent infrapopliteal runoff vessels and patent pedal vessels at the foot level.BAThe Fontaine classification uses four stages: Fontaine I is the stage when patients are asymptomatic; Fontaine II is when they have mild (IIa) or severe (IIb) claudication; Fon-taine III is when they have ischemic rest pain; and Fontaine IV is when patients suffer tissue loss, such as ulceration or gangrene (Table 23-19).144The Rutherford classification has four grades (0–III) and seven categories (0–6). Asymptomatic patients are classi-fied into category 0;


Surgery_Schwartz

Surgery_Schwartz. tissue loss, such as ulceration or gangrene (Table 23-19).144The Rutherford classification has four grades (0–III) and seven categories (0–6). Asymptomatic patients are classi-fied into category 0; claudicants are stratified into grade I and divided into three categories based on the severity of the symp-toms; patients with rest pain belong to grade II and category 4; and patients with tissue loss are classified into grade III and categories 5 and 6 based on the significance of the tissue loss.2 These clinical classifications help to establish uniform standards in evaluating and reporting the results of diagnostic measure-ments and therapeutic interventions (Table 23-19).The most clinically useful classification of lower extrem-ity atherosclerotic disease should be based on the morphologic character of the lesions. The TASC taskforce published a guide-line separating lower extremity arterial diseases into femoropop-liteal and infrapopliteal lesions (Table 23-20). This guideline is


Surgery_Schwartz

Surgery_Schwartz. character of the lesions. The TASC taskforce published a guide-line separating lower extremity arterial diseases into femoropop-liteal and infrapopliteal lesions (Table 23-20). This guideline is particularly useful in determining intervention strategies based on the disease classifications. Based on the guideline, femoro-popliteal lesions are divided into four types: A, B, C, and D. Type A lesions are single focal lesions less than 3 cm in length and do not involve the origins of the SFA or the distal popliteal artery. Type B lesions are single lesions 3 to 5 cm in length not involving the distal popliteal artery or multiple or heavily calci-fied lesions less than 3 cm in length. Type C lesions are multiple stenoses or occlusions greater than 15 cm in length or recurrent stenoses or occlusions that need treatment after two endovascu-lar interventions. Type D lesions are those with complete occlu-sion of CFA, SFA, or popliteal artery.115In a similar fashion, infrapopliteal arterial


Surgery_Schwartz

Surgery_Schwartz. that need treatment after two endovascu-lar interventions. Type D lesions are those with complete occlu-sion of CFA, SFA, or popliteal artery.115In a similar fashion, infrapopliteal arterial diseases are classified into four types based on TASC guideline (Fig. 23-61). Type A lesions are single lesions less than 1 cm in length not involving the trifurcation. Type B lesions are multiple lesions less than 1 cm in length or single lesions shorter than 1 cm involving the trifurcation. Type C lesions are lesions that exten-sively involve trifurcation or 1to 4-cm stenotic or 1to 2-cm occlusive lesions. Type D lesions are occlusions longer than 2 cm or diffuse lesions.115Etiology of Acute Limb IschemiaALI is defined as sudden loss of limb perfusion, and the term is applicable up to 2 weeks after an initiating event. While the instances of acute leg ischemia caused by emboli have decreased due to more effective treatment of rheumatic fever and atrial fibrillation, the incidence of thrombotic


Surgery_Schwartz

Surgery_Schwartz. an initiating event. While the instances of acute leg ischemia caused by emboli have decreased due to more effective treatment of rheumatic fever and atrial fibrillation, the incidence of thrombotic acute leg ischemia has increased. Even with the extensive use of newer endovascular techniques including thrombolysis, most published series report a 10% to 30% 30-day amputation rate.115 The short-term mortal-ity of patients presenting with acute ischemia is 15% to 20%. The most common etiologies of ALI include embolism, native vessel thrombosis, reconstruction thrombosis, trauma, and com-plications of peripheral aneurysm. Most cases of lower extrem-ity ALI are the result of thrombosis of a prosthetic conduit. This stems from increased use of prosthetic conduits to address CLI.Presenting symptoms in ALI are pain and loss of sensory or motor function. The abruptness and time of onset of the pain, its location and intensity, and change in severity over time should all be taken into


Surgery_Schwartz

Surgery_Schwartz. symptoms in ALI are pain and loss of sensory or motor function. The abruptness and time of onset of the pain, its location and intensity, and change in severity over time should all be taken into consideration. The duration and inten-sity of the pain and presence of motor or sensory changes are very important in clinical decision making and urgency of revas-cularization. Thrombolysis may be less effective for thrombosis of ≥2 weeks in duration compared with acute thrombosis.145Arterial Embolism. The heart is the most common source of distal emboli, which accounts for more than 90% of peripheral arterial embolic events. Atrial fibrillation is the most common source. Sudden cardioversion results in the dilated noncon-tractile atrial appendage regaining contractile activity, which can dislodge the contained thrombus. Other cardiac sources include mural thrombus overlying a myocardial infarction or thrombus forming within a dilated left ventricular aneurysm. Mural thrombi can also develop


Surgery_Schwartz

Surgery_Schwartz. the contained thrombus. Other cardiac sources include mural thrombus overlying a myocardial infarction or thrombus forming within a dilated left ventricular aneurysm. Mural thrombi can also develop within a ventricle dilated by Brunicardi_Ch23_p0897-p0980.indd 95227/02/19 4:15 PM 953ARTERIAL DISEASECHAPTER 23Table 23-17Differential diagnosis of intermittent claudicationCONDITIONLOCATION OF PAIN OR DISCOMFORTCHARACTERISTIC DISCOMFORTONSET RELATIVE TO EXERCISEEFFECT OF RESTEFFECT OF BODY POSITIONOTHER CHARACTERISTICSIntermittent claudication (calf)Calf musclesCramping painAfter same degree of exerciseQuickly relievedNoneReproducibleChronic compartment syndromeCalf musclesTight, bursting painAfter much exercise (e.g., jogging)Subsides very slowlyRelief speeded by elevationTypically heavy-muscled athletesVenous claudicationEntire leg, but usually worse in thigh and groinTight, bursting painAfter walkingSubsides slowlyRelief speeded by elevationHistory of iliofemoral deep venous


Surgery_Schwartz

Surgery_Schwartz. heavy-muscled athletesVenous claudicationEntire leg, but usually worse in thigh and groinTight, bursting painAfter walkingSubsides slowlyRelief speeded by elevationHistory of iliofemoral deep venous thrombosis, signs of venous congestion, edemaNerve root compression (e.g., herniated disk)Radiates down leg, usually posteriorlySharp lancinating painSoon, if not immediately after onsetNot quickly relieved (also often present at rest)Relief may be aided by adjusting back positionHistory of back problemsSymptomatic Baker’s cystBehind knee, down calfSwelling, soreness, tendernessWith exercisePresent at restNoneNot intermittentIntermittent claudication (hip, thigh, buttock)Hip, thigh, buttocksAching discomfort, weaknessAfter same degree of exerciseQuickly relievedNoneReproducibleHip arthritisHip, thigh, buttocksAching discomfortAfter variable degree of exerciseNot quickly relieved (and may be present at rest)More comfortable sitting, weight taken off legsVariable, may relate to activity


Surgery_Schwartz

Surgery_Schwartz. thigh, buttocksAching discomfortAfter variable degree of exerciseNot quickly relieved (and may be present at rest)More comfortable sitting, weight taken off legsVariable, may relate to activity level, weather changesSpinal cord compressionHip, thigh, buttocks (follows dermatome)Weakness more than painAfter walking or standing for same length of timeRelieved by stopping only if position changedRelief by lumbar spine flexion (sitting or stooping forward) pressureFrequent history of back problems, provoked by increased intra-abdominal pressureIntermittent claudication (foot)Foot, archSevere deep pain and numbnessAfter same degree of exerciseQuickly relievedNoneReproducibleArthritic, inflammatory processFoot, archAching painAfter variable degree of exerciseNot quickly relieved (and may be present at rest)May be relieved by not bearing weightVariable, may relate to activity levelBrunicardi_Ch23_p0897-p0980.indd 95327/02/19 4:15 PM 954SPECIFIC CONSIDERATIONSPART IITable