Chapter 106 - Aortoiliac disease direct reconstruction Flashcards
John Hunter 1700 on AIOD
First to describe aortic bifurcation disease
Leriche on AIOD
first characterized AIOD symptoms
dos Santos 1947 on peripheral arterial disease
First FEA Portuguese surgeon
Wylie 1951 on AIOD
First Aortic endarterectomy in San Francisco
AIOD associated disease in anatomical branches
1) 1/3 in profunda 2) 40% SFA 3) rare visceral and not enough to repair concomitently
Collaterals around AIOD
1) lumbar and hypogastric to circumflex iliac, femoral, profunda 2) internal mammary to inferior epigastric (Winslow pathway) 3) SMA to IMA + hemorrhoidal (Arc of Riolan)
Small aortic syndrome risk factors
hypoplastic aortic syndrome 1) smoking 2) young females
I.C. from AIOD compared to I.C. from infrainguinal disease
10 years younger in AIOD disease
AIOD rate of ED
30% cannot achieve or maintain erection due to decreased internal pudendal flow
Leriche syndrome
terminal aortic occlusion 1) claudication to thigh/hip/butt 2) leg muscle atrophy 3) decrease femoral pulses 4) impotence
Non invasive diagnosis with duplex cut off to indicate disease
20 mmHg drop indicate disease at level above
Reasons to choose direct reconstruction over hybrid
1) failure of stent 2) renal failure 3) complication of stent
Heparin discovered by
Best in 1930
Arteriography developed in this yaer
1927
Gross 1948 on AIOD
arterial homograft
Vorhees 1952 on AIOD
first prosthetic graft
Gruntzig 1974 on AIOD
POBA
Puel/Sigwart 1986 on AIOD
stent
Aortic endarterectomy candidate
1) focal disease 2) distal aorta and proximal CIA 3) impotence as symptom
Harrison on AIOD
eversion endarterectomy
Inahara 1970 on AIOD
modified eversion endarterectomy
Heparon dose and ACT
70-100 Units/kg ACT 250-350s
Knitted vs Woven polyester
Knitted: higher durability Woven: less dilatation
End to end vs end to side
End to end perceived benefit: 1) more comprehensive thromboendarterectomy 2) less turbulent flow 3) decrease pseudoaneurysm 4) better patency 5) less risk of clamp induced emboli 6) easier position to close retroperitoneal 7) technically easier if calcified 8) concomitant aneurysmal disease End to side benefit 1) occluded EIA patent CIA and IIA 2) preserve large IMA or accessory low renal artery
Protamine dose
1 mg/100 Units of circulating heparin
Name of the vein in front of proximal profunda
Lateral femoral circumflex vein
Reasons to do aortoiliac bypass instead of ABF
1) hostile groin 2) redo groin 3) infected groin 4) obesity 5) diabetes
Perioperative mortality for aorta, renal or combined recon
Aortic recon: 0.7% Renal recon: 1.7% Combined recon: 5-6%
Improvement in HTN and renal function in combined recon
HTN improve in 60-70% renal function improve in 33%
Minilaparotomy or laparoscopic AIOD treatment chance of conversion to full open
20%
Patency of endarterectomy of aorta
5 year 95% 10 years 85-90%
ABF mortality in 30 days
4-4.4% more recently closer to 1%
Patency of ABF
5 year: 85-90% 10 year: 75-85%
Effect of age on patency of ABF at 5 year
Age > 60: 95% AGe < 50: 66% more aggressive atherosclerosis causes younger patients
Patency of ABF over last few years
Worse due to more complex disease and worse technicians due to less exposure in training
Renal protection best practice
1) avoid repetitive clamping 2) avoid perioperative hypotension
Spinal ischemia risk in ABF
0.3%
ABF entire graft and single limb thrombosis causes
Entire graft: proximal disease in remaining aorta Single limb: distal anastomosis intimal hyperplasia
False aneurysm after ABF rate
1-5%
Reasons to repair false aneurysm after ABF size
>2cm in femoral >50% diameter of graft in aorta
Most common Aortoenteric fistula location
Proximal aortic suture with 3rd/4th duodenum
Isolated profundoplasty results in CLI and IC
75% limb salvage at 3 year in CLI 88% 5 year patency in I.C.
Complications and rates in ABF
