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25 Aortofemoral Bypass
269
retracting the peritoneal sac and its contents to the patient’s right. Proximally, the
left renal artery (LRA) is identied during the early stages of dissection. The lumbar
branch of the LRV crosses over the aorta proximally and is a reliable landmark to
the origin of the LRA.This vein is ligated and divided to provide exposure of the IR
aortic neck; a much larger than normal lumbar branch should prompt concern for a
retro-aortic left RV. In this situation, the aorta should be exposed anterior to the
kidney to avoid ligating the LRV.The left posterolateral wall of the aorta is exposed
to the bifurcation by dividing overlying periaortic fat and lymphatics with an ultrasonic scalpel. The aorta just below the LRA is mobilized for clamping. When SR
control is required, the left diaphragmatic crus (a rm tendinous band crossing the
aorta just proximal to the origin of the LRA) is divided 2–3cm along the axis of the
aorta and the underlying aorta exposed. The origin of the LRA is cleared off, and
index nger dissection anterior and posterior to the aorta creates planes for clamp
placement.
The IMA is identied a few centimeters above the bifurcation and if patent preserved; if not, it is ligated and divided to improve exposure for the right RP tunnel.
The tunnel to the left groin is easily made from this approach, but the right side is
much more difcult and requires great care to avoid inadvertent entry into the peritoneal cavity.
Following vascular reconstruction and hemostasis, any incision made in the left
diaphragm is oversewn and pleural air evacuated through a temporary 16 Fr redrubber catheter with lung insufation. The ribs are reapproximated with looped #1
PDS, while the muscle layers of the abdominal wall and chest are closed separately
with running 0 or 2-0 PDS suture.
This RP approach takes more time than a standard midline celiotomy but is associated with reduced evaporative uid losses, ileus, and incisional pain. It is ideal for
patients with signicant pulmonary dysfunction or a “hostile abdomen” from multiple prior celiotomies and those requiring aortic clamping above the renals.
Redo AFB
Redo AFB is fortunately a rare procedure in the endovascular era. Scar tissue greatly
complicates exposure and tunnel creation. We usually place ureteral stents preoperatively to aid in ureteral identication. Although a RP approach can aid proximal
exposure particularly if SR clamping is necessary, it can make redo groin exposure
much more challenging. Creating a new tunnel to the right groin is undoubtedly the
most difcult part of the procedure with this approach and must be done with great
care to avoid a right ureteral injury or inadvertent entry into the abdomen. In certain
situations where this is not possible to do safely, an aorto-unifemoral bypass to the
left groin can be performed with a femoral-femoral bypass to the right groin. A
descending thoracic aorta to femoral bypass is another option when severe scarring
precludes IR aortic exposure. A two-team approach to redo groin dissections is benecial. Sharp dissection with a #15 blade avoids dulling multiple pairs of scissors,
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A. D. Shepard
and debulking segments of thrombosed graft can help create a space for the new
graft. This operation is quite challenging and should only be undertaken in reasonable risk patients by the most experienced surgeons.
Though uncommonly performed in the modern era of endovascular interventions, AFB remains a very good operation for AIOD with excellent long-term
patency. Commonly encountered complications including groin lymphatic leaks,
venous injury, and ischemic colitis can be avoided by careful preoperative planning
and precise operative execution.
Further Reading
Szilagyi DE, Elliott JP, Smith RF, Reddy DJ, McPharlin M.A thirty-year survey of the reconstruc-
tive surgical treatment of aortoiliac occlusive disease. J Vasc Surg. 1986;3(3):421–36.
Kakkos SK, Haurani MJ, Shepard AD, Nypaver TJ, Reddy DJ, Weaver MR, Lin JC, Haddad
GK.Patterns and outcomes of aortofemoral bypass grafting in the era of endovascular inter-
ventions. Eur J Vasc Endovasc Surg. 2011;42:658–66.
Chiu KWH, Davies PG, Nightingale AW, Bradbury AW, Adam DJ. Review of direct anatomical
open surgical management of atherosclerotic aorto-iliac occlusive disease. Eur J Vasc Endovasc
Surg. 2010;39(4):460–71.
Shepard AD, Tollefson DFJ, Reddy DJ, Evans JR, Elliott JP, Smith RF, Ernst CB. Left ank
retroperitoneal exposure: a technical aid to complex aortic reconstruction. J Vasc Surg.
1991;14(3):283–91.
Chapter 26
Thoraco Femoral Bypass forAorto Iliac
Occlusive Disease
IraklisI.Pipinos andSachinderSinghHans
Indications
Bypass from the descending thoracic aorta to femoral artery is an uncommon primary procedure and should be considered only in good risk patients with a satisfactory cardiopulmonary status in the presence of juxtarenal aortic occlusion with
symptoms of chronic functional claudication or critical limb ischemia. This procedure should be considered only if conventional aortofemoral reconstruction is not
feasible or in patients who have a prior history of multiple abdominal operations,
extensive intra-abdominal scarring, failed prior infrarenal aortic reconstruction,
infected aortic prosthesis, or other retroperitoneal pathology.
Preoperative Evaluation
Risk stratication with noninvasive cardiac stress test, 2D echocardiogram, and pulmonary functional test should be performed prior to the operation. Evaluation of the
descending thoracic aorta using thin section CTA of the chest/abdomen/pelvis and
bilateral lower extremity should be performed. Contraindications include aneurysmal disease or extensive calcication of descending thoracic aorta or inability to
tolerate single lung ventilation. Relative contraindications include advanced chronic
obstructive pulmonary disease and prior thoracotomy.
I. I. Pipinos
Department of Surgery, University of Nebraska Medical Center, Omaha, NE, USA
e-mail: ipipinos@unmc.edu
S. S. Hans (*)
Vascular and Endovascular Services, Henry Ford Macomb Hospital,
Clinton Twp, MI, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_26
271
272
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I. I. Pipinos and S. S. Hans
Positioning
The patient is positioned on the operating table with a vacuum bean bag extending
from the shoulders to the proximal thigh. Following induction of general anesthesia
and placement of a double lumen endotracheal tube, the left hemithorax is placed at
an angle of 45°–65° on the operating table while maintaining the pelvis as at as
possible to allow access to both groin areas. The left arm is supported on an arm rest.
And a silicone roll is placed under the right axilla to prevent brachial plexus injury
(Fig.26.1). Air is evacuated from the bean bag. Pillow rests are placed under the
knees and between the legs to prevent hyperextension with the patient’s legs secured
to the operating table with a safety strap. In the event full thoracotomy becomes
necessary, left scapula and thoracic spine should be included in the operative eld.
Fig. 26.1 Patient
positioned after double
lumen endotracheal
intubation in a 45°–60°
right lateral decubitus
position, with the left arm
secured over an arm rest.
The pelvis is placed as at
as possible to allow access
of both groins for exposure
of the femoral vessels. The
left thorax is exposed
sufciently to allow a
posterolateral
mini-thoracotomy
e
26 Thoraco Femoral Bypass forAorto Iliac Occlusive Disease
273
Groin Incisions andRetroperitoneal Tunnels
The femoral arteries are dissected rst in both groins to reduce the length of time,
and the left chest cavities open thereby reducing the heat loss. The right femoral
artery is exposed through a standard vertical incision extending to just above the
inguinal ligament (groin crease). As the pelvis is tilted to the right, the femoral
exposure is facilitated by rotating the operating table slightly toward the left. The
left groin incision is extended approximately 8–10cm cephalad above the inguinal
ligament (inguinal crease). At the cephalad end of the left groin incision, the retroperitoneum is accessed, thus helping the creation of the tunnel, connecting the left
groin to the left chest. An 8–10cm long incision is carried to the aponeurosis of the
external oblique and the internal oblique muscles on the left extending parallel to
the inguinal ligament and 2–3cm cephalad to its caudal border. The internal oblique
muscles are divided, and transverse muscle and transverse fascia are opened in the
lateral aspect of the incision (Fig.26.2). The retroperitoneal space is then entered
medial to the iliac crest and anterior superior iliac spine making this the caudal portion of the retroperitoneal tunnel for the passage of the graft.
Rectus abdominis muscle
Transversus abdominis muscl
Inguinal ligament
Common femoral
artery
Fig. 26.2 Exposure of femoral artery is carried out rst. On the left side, the excision is extended
10cm above the inguinal ligament and an additional 10cm incision through the aponeurosis of the
external oblique and internal oblique muscles on the left extending parallel to the inguinal ligament
and approximately 2cm cephalad to its caudal border. The internal oblique muscles are divided in
the direction of their bers, and transverse abdominis muscle and transverse fascia are opened to
the lateral aspect of the incision. This incision is used for the creation of the retroperitoneal tunnel
to the left chest. When bifurcated graft is used, this incision is also used to route the right limb of
the graft from its retroperitoneal location to a preperitoneal channel and into the right groin
274
S
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I. I. Pipinos and S. S. Hans
Exposure oftheThoracic Aorta
The operating table is tilted to the patient’s right side and a limited posterolateral
thoracotomy (mini thoracotomy) through the eight intercostal space to expose the
descending thoracic aorta. The exposure can also be obtained from the seventh or
ninth intercostal space depending on the position of the patient and body habitus.
The latissimus dorsi muscle is spared by developing superior and inferior skin aps
to allow posterior retraction of the muscle thus reducing postoperative pain. The
intercostal muscles are incised along the superior of the border of the inferior rib of
the selected rib, and the pleural cavities entered carefully avoiding injury to the
underlying lung parenchyma. A rib spreader is inserted and opened gradually to
prevent fracture of the ribs. Additional exposure if required can be obtained by
resection of the cephalad rib or transecting it at the posterior aspect of the incision.
The left lung is deated, and inferior pulmonary ligament is taken down to the level
of inferior pulmonary vein. The lung is retracted into upper thorax, and 2-0 silk
sutures are placed and tied using “gure-of-eight” technique at the center of the
diaphragm and are brought through the anterior and inferior chest wall and secured
to retract the diaphragm to aid in satisfactory exposure of the distal descending
thoracic aorta. The visceral pleura covering the distal descending thoracic aorta is
incised, and approximately a 6cm segment of the thoracic aorta is exposed above
the diaphragm (Fig.26.3). The site of proximal aortic anastomosis is selected in a
segment free of atherosclerotic disease. The aorta is dissected circumferentially, and
both proximally and distally and umbilical tapes or silastic vessel loops are passed
to help place the proximal clamp in the aorta. The site of proximal anastomosis
should be high enough above the crus of the diaphragm to avoid kinking of the
proximal graft following tunneling of the graft.
Fig. 26.3 An eight
intercostal space
thoracotomy is performed
sparing the sartorius and
latissimus dorsi muscle.
The left lung is deated,
and the distal aorta is
exposed by dividing the
overlying the pleura for
3–4in
Descend. thoracic
aorta
Lung
Rib spreader 8th IC
26 Thoraco Femoral Bypass forAorto Iliac Occlusive Disease
275
Tunneling oftheGraft
A retroperitoneal tunnel is created to facilitate the passage of the graft from the
thorax to the groins. A 2cm incision is made in the posteromedial aspect of the left
hemidiaphragm over the ribs through the open chest cavity. The site of aortotomy
and the exit site of the graft are aligned carefully so that thoracic portion of graft
curves smoothly without any kink. The left hand is placed through the left retroperitoneal tunnel incision, and the dissection proceeds cephalad along the left retroperitoneal plane in a slow and deliberate manner. The dissection plane proceeds cephalad
and medially anterior to the external iliac vessels and the psoas major muscles posterior to the left kidney and posteromedial to the spleen and meets the right hand as
its ngers slide posterior to the spleen starting from the left hemithorax. A large
tunneler (DeBakey, Gore, or Garrett) is then guided through the tunnel, and an
umbilical tape is laid to facilitate the passage of the graft. In a patient necessitating
the use of bifurcated graft, the shaft and its two limbs are tunneled through the retroperitoneal channel and are tunneled through the left retroperitoneal channel and
brought through through the left retroperitoneal incision. Following this, a preperitoneal channel is made that enables the right limb of the graft to reach the right groin
incision. A simultaneous blunt nger dissection is utilized to create this second
tunnel between the left suprainguinal area, retroperitoneal space, and the groin. This
tunnel courses immediately posterior to the rectus abdominis muscle in an anterior
and cephalad plane to the urinary bladder in the preperitoneal space. The right
inguinal ligament is partially divided in its medial aspect to allow the passage of the
right limb of the graft without compression. Another option is to rst perform the
thoracic aorta to left femoral bypass using a straight tube graft (8–10mm in diameter) and then perform a standard crossover femoral-femoral graft using an 8mm in
diameter conduit from the hood of the rst graft and anastomosed to the common
femoral artery with the tunnel in a subcutaneous location.
Choice ofGraft
A partially occluding side-biting clamp such as Cobra (Savantia Medical, Sialkot
Pakistan) or Lemole-Strong clamp (Becton Dickinson Franklin Lakes, NJ USA) can
be applied to distal thoracic aorta as it helps maintain antegrade blood ow through
the aorta during performance of the proximal anastomosis. This limits the severity
of ischemia to lower torso, anterior spinal artery, and visceral arteries. If a partially
occluding side-biting clamp is not feasible due to the small size of the aorta, the
aorta may be clamped completely by a vertically placed angled vascular clamp
superiorly (complete occlusion) and an angled vascular clamp inferiorly to control
the intercostal artery bleeding. Prior to aortic clamping, systemic heparin (100units
IU/kg) is administered intravenously by the anesthesia team, and ACT is monitored
between the range of 250 and 300s. An appropriately sized graft is selected to match
the size of the aorta and femoral arteries. A 16 × 8mm or 14 × 7mm bifurcated graft
276
aortic anast.
aortic clamp
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I. I. Pipinos and S. S. Hans
is most commonly used. In patients with a straight graft from the aorta to femoral
artery, 8–10mm graft is selected, and from left to right crossover femoral- femoral
graft, an 8mm graft is preferred.
Graft material such as Dacron or PTFE is equally suitable as conduits. The aortotomy is created, and the body of the graft is sized accordingly and divided. When
a bifurcated graft is used for reconstruction, the body of the graft is kept as long as
possible to make certain that the limbs of the graft can reach the right femoral artery
without tension. If the graft cannot reach the right groin, excess graft from the contralateral limb can be divided and used to construct a composite right limb (graftgraft composite). A tension-free aortic anastomosis performed using 2-0 or 3-0 CV
polypropylene suture in a continuous fashion (Fig.26.4). Following completion of
proximal anastomosis, vascular clamp is applied to the body of the graft, and aortic
clamps are released to check for any leaks.
Tunneling of the graft from the left chest to the left groin is carefully performed
with a help of a tunneler. The opening of the diaphragm should be adequate so that
the graft is not compressed during its passage. The correct orientation and tension
of the graft limb should be maintained to prevent graft kinking or twisting. When a
End to side
with dacron
graft
Fig. 26.4 The proximal anastomosis is performed using a partially occluding clamp. A running
suture is acceptable if the quality of the aorta is satisfactory. Interrupted sutures with Teon pledgets can be used to control bleeding if aorta is not optimal for a continuous suture anastomosis
Partially
occluding
26 Thoraco Femoral Bypass forAorto Iliac Occlusive Disease
277
bifurcated graft is required the right limb of the graft is brought around the left retroperitoneum with a gentle curve into the preperitoneal space behind the rectus
abdominis muscle anterior to the urinary bladder (retropubic space). The right femoral anastomosis is then completed. In patients with a previously failed axillobifemoral or aorto-bifemoral graft, the distal anastomosis is thoracic aorto- femoral
graft which may require anastomosis to the profunda femoral arteries (deep femoral
artery) or anastomosis to the most distal limbs of the remote graft. Profunda femoris
artery (deep femoral artery) is the most suitable artery as an outow for performance of the thoracic aorta to femoral bypass as external iliac artery and supercial
femoral arteries are frequently diseased in this group of patients. Occasionally,
common femoral endarterectomy and extensive profundo plasty with patch angioplasty may be necessary to perform a satisfactory distal anastomosis.
Heparin is reversed with protamine sulfate depending upon the results of
ACT. The thoracic and femoral incisions are closed in layers. A large chest tube
(36F) is placed through the incision caudal to the thoracotomy incision, and its tip
is positioned to the apex of the chest cavity. The lung is reinated, and the ribs are
approximated with using absorbable sutures in a gure-of-eight conguration. The
chest wall muscles are closed in layers, and the skin is closed with sutures and
staples.
Complications
Reoperation for bleeding, respiratory failure, postoperative MI, and uncommonly
renal failure and paraplegia may develop. In patients in whom total clamping of the
aorta is required because of its small size for performance of proximal anastomosis,
the incidence of ischemia to the torso and spinal cord ischemia is quite low as proximal anastomosis can be completed in about 8 to 10min.
Chapter 27
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Mesenteric Artery Bypass
andReconstruction
TimothyJ.Nypaver
Indications forMesenteric Artery Bypass
Chronic Mesenteric Ischemia
Open mesenteric bypasses or reconstructions are procedures performed in the management of chronic mesenteric ischemia (CMI), symptomatic with manifestations
of postprandial abdominal pain, weight loss, food fear, early satiety, or diarrhea in
association with signicant mesenteric artery occlusive disease. The diagnosis
requires a high index of suspicion as there is typically a signicant delay (greater
than 10months) from onset of symptoms to denitive diagnosis and treatment. The
mesenteric circulation is a high-resistance vascular bed which typically requires
multivessel involvement for symptom development. Occasionally, single-vessel disease, specically of the superior mesenteric artery (SMA), may be severe enough
for patients to develop chronic mesenteric symptoms related to CMI.Atherosclerosis
is the primary etiology in 95–98% of cases with the remaining including bromuscular dysplasia, aortic dissection, or trauma. It has been demonstrated that asymptomatic disease rarely progresses to symptomatic disease; thus, the indications for
intervention exist only for symptomatic mesenteric artery occlusive disease. The
goals of treatment are as follows: relief of pain, restoration of normal weight, and
improvement in survival with the reduction in risk of bowel ischemia. Like many
other vascular disease beds, the management of symptomatic mesenteric artery
occlusive disease is primarily performed employing endovascular means of treatment. Approximately 77% of overall cases are now treated endovascularly, with
open operations reserved for an anatomic disease pattern not amenable to
T. J. Nypaver (*)
Division of Vascular Surgery, Henry Ford Hospital, Detroit, MI, USA
e-mail: TNYPAVE1@hfhs.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
S. S. Hans et al. (eds.), Primary and Repeat Arterial Reconstructions,
https://doi.org/10.1007/978-3-031-13897-3_27
279
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