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Chapter 31
Iliac andFemoral Artery Endarterectomy
FarahHanifAliMohammad
Surgical Anatomy
Common andExternal Iliac Artery
The aorta bifurcates into common iliac arteries at the level of L4–L5. They descend
down into the pelvis further dividing into external and internal iliac arteries. The
internal dives into the true pelvis, while the external runs medial to the psoas, going
behind the inguinal ligament. It gives off deep circumex and inferior epigastric
branches near the ligament.
Operative Steps toIliac Endarterectomy
The common iliac artery can be exposed via transperitoneal or retroperitoneal exposure (Fig.31.1a). For transperitoneal exposure, the patient is placed supine, and the
entire abdomen and pelvis are prepped. A longitudinal midline incision is made, and
the peritoneum is entered (Fig. 31.1b). The omentum and transverse colon are
reected superiorly, and the small bowel is eviscerated to the right. The posterior
peritoneum is then incised over the aorta lateral to the fourth portion of duodenum.
This is following inferiorly over the iliac bifurcation. The iliac artery is then dissected out and encircled carefully to avoid injury to the iliac vein that runs posterolateral to it. One should be careful in dissecting the peri-adventitial tissue over the
aortic bifurcation and left common iliac artery in males as the sympathetic nerves
for ejaculatory function anatomically located in this region. As you dissect further
F. H. A. Mohammad (*)
Henry Ford Hospital, Detroit, 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_31
313
314
a
F. H. A. Mohammad
distally, the ureter runs adjacent to the iliac bifurcation and should be carefully
retracted laterally. The external and internal iliac veins run posteromedial to their
corresponding arteries. Depending on the extent and location of disease, the vessels
are mobilized in anticipation of an endarterectomy.
If retroperitoneal exposure is planned, then the patient is positioned supine position but with ipsilateral hip elevated to 10° with a rolled sheet bump. An oblique
incision is made extending from lateral border of the rectus muscle to approximately halfway between the subcostal margin and iliac crest in the direction of the
midaxillary line (Fig.31.2). The external and internal oblique muscles are divided
parallel to their axis. The transversus abdominis and transversalis fascia are opened
at the lateral half of the wound. The peritoneum is stripped off the lateral pelvic
wall, and retroperitoneum is entered. The psoas muscle and the iliac vessels that lie
medial to it are exposed. The ureter is left attached to the posterior peritoneum and
retracted medially. Depending on the extent and level of exposure needed, the incision and dissection are carried out accordingly.
Fig. 31.1 (a, b) Midline transperitoneal exposure
b
31 Iliac andFemoral Artery Endarterectomy
315
Fig. 31.1 (continued)
Complications
– Venous and ureteral injury: Careful dissection and orientation to corresponding
veins and course of the ureter in relation to the artery are essential to avoid injury.
Common Femoral Artery
The femoral artery serves as the principal vessel supplying blood to the lower
extremity. Inguinal ligament serves as a transition point between the external iliac
and femoral artery. It lies approximately midway between the anterior superior iliac
spine and the symphysis pubis. Common femoral artery along with the vein which
lies medial to it is enclosed in the femoral sheath. Femoral nerve lies lateral to the
artery. The vessels lie within the femoral triangle which is bounded laterally by the
316
Fig. 31.2 Retroperitoneal
exposure of bifurcation of
left common iliac artery
F. H. A. Mohammad
sartorius muscle, medially by the adductor longus muscle, and superiorly by the
inguinal ligament. Femoral artery gives rise to three supercial branches which
include supercial external pudendal, supercial epigastric, and supercial circumex arteries. These branches may serve as essential collaterals in cases of signicant
iliac occlusive disease. The common femoral then continues onto to become supercial femoral artery after giving off the profunda femoris artery laterally approximately 4 cm distal to the inguinal ligament. There are two groups of supercial
subinguinal lymph nodes that lie in the anterior groin incision and contribute to the
rich plexus of lymphatic channels around the artery. Interruption of these channels
can lead to a lymphocele formation.
ab
31 Iliac andFemoral Artery Endarterectomy
317
Operative Steps toFemoral Endarterectomy
Patient is placed supine, and the lower abdomen up to the level of the umbilicus and
mid-thigh is prepped. Bedside ultrasound to identify the femoral bifurcation allows
accurate planning of the incision. Wide exposure of the femoral artery is best
achieved by a vertical incision. The incision is made midway between the anterior
superior iliac spine and the symphysis pubis. In morbidly obese patients with focal
and short segment disease, a horizontal incision may be used to decrease the risk of
wound complications (Fig. 31.3). Horizontal incision is made parallel along the
inguinal ligament. As the incision is deepened, time should be taken to ligate the
lymphatics to reduce the risk of lymphocele. The fascia forming the femoral sheath
is opened along the medial border of the sartorius. Dissection should then be carried
close the artery to avoid injury to the surrounding nerve and venous structures.
Common femoral artery is dissected proximally usually up to the level of inferior
epigastric artery or until a healthy segment of the common femoral is palpated.
Occasionally, the disease extends into the external iliac artery in which partial division of the inguinal ligament assists in exposure. In case of signicant proximal
disease, hybrid approach can be taken with iliac artery stenting or angioplasty. The
dissection distally extends to expose the femoral bifurcation. Depending on the
extent of the disease, the proximal segments of SFA and profunda femoris may be
dissected. Once adequate proximal and distal control is obtained, patient is heparinized, and clamps are placed. Artery is then opened, and endarterectomy is performed
and patched with autogenous vein or bovine pericardium. The wound should be
closed in multiple layers to close the dead space.
Trans. incision
Ver tical incision
Sartorius
Fig. 31.3 (a, b) Exposure of common femoral artery and its bifurcation
C.F.A.
Common
fem. vein
S.F. A
D.F. A
318
F. H. A. Mohammad
Complications
– Wound complications: Groin wound complications including dehiscence, infec-
tion, lymphocele, and hematoma can be devastating. Gentle tissue handling and
aggressive ligation of lymphatics are key to avoid wound problems.
Chapter 32
Femoral-Popliteal Bypass Graft
AbdulKaderNatour andLoayKabbani
Introduction
It’s estimated that 30 million North Americans are affected by peripheral artery
disease (PAD), with a prevalence of almost 30% in people older than 70years [1–2].
PAD signicantly affects the quality of life and constitutes a major burden for
healthcare-related expenditures [3–4]. Femoral-popliteal (FP) PAD symptoms can
range from asymptomatic to claudication and to critical limb ischemia (CLI) [5].
The optimal approach to treating FP atherosclerotic disease remains controversial
[6]. Although the use of endovascular treatment has been increasing over the past
decades, there remain a signicant number of patients best treated with open surgery. The indications for infrainguinal bypass include the presence of CLI manifested by tissue loss, rest pain, or gangrene. Persistent lifestyle-limiting claudication
after medical therapy is also a relative indication.
A. K. Natour
Henry Ford Hospital, Detroit, MI, USA
e-mail: anatour1@hfhs.org
L. Kabbani (*)
Department of Surgery, Henry Ford Hospital, Detroit, MI, USA
Wayne State University, Detroit, MI, USA
Michigan State University, Detroit, MI, USA
Henry Ford Hospital, Heart and Vascular Institute, Detroit, MI, USA
e-mail: lkabban1@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_32
319
320
A. K. Natour and L. Kabbani
Surgical Anatomy
Common Femoral Artery
The common femoral artery (CFA) is the continuation of the external iliac artery at
the level of the inguinal ligament. It’s located in the femoral triangle, a wedgeshaped area situated within the superomedial aspect of the anterior thigh. The femoral triangle is bounded superiorly by the inguinal ligament, medially by the adductor
longus muscle, and laterally by the sartorius muscle (Fig.32.1). Within the femoral
triangle, the anatomical relationship from medial to lateral is femoral vein, CFA,
and femoral nerve (Fig.32.1). The vein and artery are contained within a fascial
covering called a fascial sheath while the nerve is not. The CFA branches in the
femoral triangle into the profunda femoris and supercial femoral artery (SFA). The
latter exits at the adductor hiatus to continue as the popliteal artery.
Popliteal Artery
The popliteal fossa is located at the back of the knee joint dened anteriorly by the
upper tibia, femur, and popliteus muscle; laterally by biceps femoris and gastrocnemius muscles; and medially by semitendinosus and semimembranosus muscles.
Fig. 32.1 Groin incision
in the femoral triangle
Incision
Fem. nerve
Fem. art.
Vein
Add. long.
Sartorius
c
h
32 Femoral-Popliteal Bypass Graft
321
The SFA artery exits the adductor hiatus at the apex of the popliteal fossa where it
becomes the popliteal artery. The popliteal artery ends at the lower border of the
popliteus muscle, where it branches into the anterior tibial artery and the tibioperoneal trunk.
Preoperative Planning
Traditionally, angiography has been the gold standard imaging modality. However,
computed tomographic angiography has been used more frequently to assess the
thigh vessels.
Proximal Anastomotic Site Assessment andSelection
Traditionally, the CFA is the inow vessel of choice. If the CFA exhibits signicant
atherosclerotic disease, consideration of CFA endarterectomy is prudent. The profunda femoris or SFA provide effective sites when appropriately selected and have
the added benet of shortening the conduit length used. In reoperative procedures,
access to the CFA may be limited, and the SFA or profunda femoris could serve as
alternate inow site (Figs.32.2, 32.3, and 32.4).
Fig. 32.2 Opening of the
deep fascia over the
femoral vessels
Inguinal lymp
nodes
Distal ext. ilia
art. and vein
Groin incision
Sartorius
322
Fig. 32.3 Opening of the
femoral sheath
A. K. Natour and L. Kabbani
circumflex
Lat.
art. & vein
Femoral sheath
incised
Profunda
femoris
Sartorius
Fig. 32.4 Exposure of the femoral artery, its branches, and accompanying veins
Sup. femoral
art.