Introduction

Patients with aortoiliac lesions due to atherosclerosis can be classified into three distinct types:

– Type I: Lesions confined to the aorta and common iliacs. These patients typically experience intermittent claudication to varying degrees, with severe ischemia occurring only in cases of atheroembolism to leg arteries. This type mainly affects young adults with dyslipidemia and a low incidence of associated diseases.

– Type II: Lesions confined to the abdomen but extending to the external iliacs. In these cases, claudication for shorter distances is observed.

– Type III: Associated with more diffuse lesions, also involving the infrainguinal segment. These patients are usually elderly and have a high prevalence of all risk factors for atherosclerosis and other associated diseases. They constitute the majority of candidates for surgical treatment.

Atherosclerotic plaque tends to be more developed in the posterior wall of the aorta. Removing this plaque typically facilitates proximal anastomosis between the aorta and synthetic prostheses. In cases of clamping above the kidneys, care must be taken to avoid atheroembolism to the kidneys.

With ischemia, there is a slow and progressive growth of collateral circulation, occurring through connections between:

– Superior mesenteric, inferior mesenteric, and internal iliacs;

– Intercostal/lumbar, internal iliac, and circumflex iliac;

– Inferior mesenteric, internal iliac;

– Internal iliac, deep femoral.

In cases of claudication for short distances, rest pain, or risk of limb loss, the possibility of losing this collateral circulation should be considered or patients of Type III, who have associated disease in the infrainguinal segment. Sudden worsening usually results from thrombosis of previous stenosis.

Indications for Surgical Treatment

The classic indication comprises patients at imminent risk of limb loss, presenting with rest pain accompanied or not by trophic lesions. However, recent excellent long-term results achieved by surgical treatment have expanded indications to include patients with disabling claudication or vasculogenic vascular impotence, especially young individuals with low surgical risk.

Aortobifemoral Bypass

Most commonly used in aortoiliac revascularization.

– Incision: Xiphopubic.

– Access: Transperitoneal. No need for lumbar ligature.

– Technique: The aorta is exposed in its anterior and lateral portion up to the left renal vein. This exposure should be done longitudinally and to the right of the aorta to avoid injury to the pre-aortic nerve plexus, minimizing sexual dysfunction in male patients postoperatively. The aorta is dissected in its infra-renal portion enough to place the arterial clamp.

Aortoiliac Endarterectomy

Continuously being abandoned for several reasons:

– Very laborious, requiring more extensive vessel dissection;

– Higher risk of damage to periarterial nerve plexuses;

– Longer operative time;

– Greater blood loss;

– Higher rate of complications in the immediate post-op period;

– Lower long-term success rate.

Iliacofemoral Bypass

Used when the goal is revascularization of only one limb.

– Incision: There are two, actually. The first one is oblique, semi-parallel to the inguinal ligament for retroperitoneal access, and the longitudinal inguinotomy.