Aortoiliac TEA (thromboendarterectomy) in bilateral stage IIb peripheral arterial (occlusive) disease (PAD) - Vascular surgery

Close the aortotomy directly with a running suture (monofilament, 4/0 or 5/0 depending on the thickness of the aortic wall). Flush the aorta before finishing the suture and check for central run-in and peripheral run-off. After completing the suture, gradually release the blood flow under manual control of the compression. Counteract the heparin and remove all bulldog clamps still in place.

Tips:

1. Direct suturing of the aortotomy is biologically superior compared to synthetic patches, as in the long run patch plasty is prone to aneurysm formation, necessitating repeat procedures. However, direct suture of the aorta requires a diameter of at least 16 mm. Diameters of 14 mm and less, however, require patch plasty. This is also necessary once the arteriotomy is extended into the common iliac artery.

2. Check the bowel perfusion once the blood flow has been restored.

3. The color of the sigmoid at this stage of the procedure does not reveal anything about blood flow quality. If there is any doubt about the sigmoid blood flow, check the marginal arteries by Doppler ultrasonography.

First, close the retroperitoneal lymphatic and adipose tissue pad anterior to the aorta with a running suture. Follow this with a second layer of a running suture closing the retroperitoneal cover. This does not anchor the duodenojejunal flexure, but rather repositions it anteriorly and allows it to move freely in response to peristaltic waves.

Close the abdominl wall in layers and check peripheral perfusion (leg pulses, capillary refill); these two steps are not shown here.

Tips:

1. Retroperitoneal closure is particularly critical for long-term outcome. Insidious paraaortic infection resulting in aortoduodenal fistula is most common when the duodenojejunal flexure has been firmly anchored to the graft bed in patch plasty. This is prevented by staggering the double-layered closure of the retroperitoneum.

2. A retroperitoneal Redon drain for 24 hours may be useful as it may signal acute bleeding (however, an empty drain does not reliably rule out bleeding). A larger retroperitoneal hematoma may also inhibit the onset of peristalsis and healing in the patch plasty graft bed.

3. Never forego retroperitoneal tissue coverage of the graft under any circumstances! If the wall to be sutured is fragile, it may be better to preplace interrupted sutures and then tie them successively. If that does not work either, this may require left- or right-pedicled omentoplasty.

Perform median laparotomy from xiphoid down to symphysis, carrying the incision to the left of the umbilicus.

Tips:

1. Maintain adequate distance from the umbilicus and do not incise the skin tangentially as this runs the risk of wound edge necrosis.

2. If the incisdion damages the cartilage of the xiphoid, it may trigger heterotopic ossification in the scar. Therefore start the incision somewhat lateral to the xiphoid.

Open the retroperitoneum, while sparing the inferior mesenteric artery (IMA), somewhat to the right of the palpable aorta and the right iliac axis. After sweeping the small bowel loops to the right, coagulate step by step and in advance any exposed small vessels to reduce unnecessary bleeding. After freeing the duodenojejunal flexure, locate and identify the crossing left renal vein as the upper boundary.

Exenterate the small bowel to the right. For this purpose, tilt the operating table about 30° to the right. Place the bowel in a plastic bag. This helps avoid damage to the serosa, keeps the bowel moist, and results in fewer or no postoperative adhesions. Sweep the transverse colon to the upper abdomen.

Do not transect the preaortic fat pad and lymphatic tissue body in midline, but keep to the right! Free the tissue layer from right to left by blunt and sharp dissection. Expose the aorta to the crossing left renal vein.

Tips:

1. This dissection technique provokes less bleeding and avoids injury to the inferior mesenteric artery (IMA). Moreover, sparing the preaortic nerve tissue in men (hypograstric plexus) may reduce the risk of postoperative sexual dysfunction.

2. In case of iatrogenic IMA injury, carefully review the preoperative angiogram to ensure intestinal perfusion via the superior mesenteric artery (AMS) and the Riolan anastomosis / marginal artery of Drummond.

3. Caution! In very rare cases, there is a large-caliber vessel in a retroperitoneal fold anterior to the aorta and posterior to the duodenojejunal flexure, just inferior to the left renal vein. This is the atypical "Williams-Klop" anastomosis, a direct communication between SMA and IMA. This vessel must not be transected under any circumstances, because often it is accompanied by other variants with very weak SMA or IMA, and adequate intestinal perfusion is no longer ensured once this communication is severed.

4. The more marked the stenosis of the aorta and iliac axis, the more pronounced the retroperitoneal collaterals, giving rise to bleeding during tissue transection. This bleeding should be controlled immediately.

5. Expose the aorta to the crossing left renal vein because usually there is only segment of the aorta amenable to cross-clamping. This is especially true in high aortic occlusion.

6. In most cases, it becomes necessary to transect the inferior mesenteric vein for a better view of the renal segment of the aorta. This can be done without risk.