Aorto-Iliac Disease:

-Identify suitable level

-location of renals

-end-to-end if possible: better in-line flow, easier closure of retroperitoneum, decreased infection/fistula rates/esp if w/ aneurysm

***will need patent external iliacs for above as this will allow for pelvic blood supply

IF w/o patent external iliacs- end to side anastomosis. Forward flow will continue to perfuse pelvis

Steps:

Expose femorals via b/l oblique incisions (expose to inguinal ligament)

                Control inferior epigastrics and circumflex iliacs

Dissect to superficial and deep femoral arteries. Determine if endarterectomy/ patch is required. Get vascular control

Expose abdominal aorta via midline, transperitoneal incision

Ligament of treitzà mobilize duodenum

Proximal control (depending on level of disease may be supraceliac, through gastrohepatic ligament)

Proximal endarterectomy, then quick flash. Aim for as close to renals as possible to prevent progression to remnant infrarenal neck

Distally, identify a soft landing spot. APPROACH LATERALLY to prevent nerve injury (sweep these upwards)

                 Minimize dissection to prevent injury to iliac veins, hypogastric plexus, and presacral nerves        (travel ANTERIOR; impotence, premature ejaculation)

Tunnel to the groin. Proceed directly anterior to vessels to avoid ureteral injury

Identify proximal landing zone

Heparinize

Excise portion of aorta (2-4cm) superior to IMA (allows for back bleed). Oversow or staple end of aorta. If not excising, identify soft region for side anastamosis.

                Use 3-0 prolene

Create distal anastomosis (end or side).

                Use 5-0 prolene

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