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

  1. Indication

    The TASC II criteria recommend therapeutic treatment options depending on the length of the local occlusion/stenosis. The length of the stenosis and its regional location determine the treatment: endovascular or open vascular surgery.

    TASC II classification of aortoiliac lesions





    Unilateral or bilateral CIA stenosis; unilateral or bilateral short single (<3 cm) EIA stenosis  



    Single or multiple stenosis totaling 3–10 cm involving the EIAnot extending into the CFA and/or unilateral CIA occlusion



    Bilateral CIA stenoses; bilateral EIA stenosis, 3–10 cm long, not extending into the CFA; unilateral EIA occlusion; bilaterasl CIA occlusions 

    Open revascularization


    Diffuse disease involving the aorta and both iliac arteries requiring treatment; bilateral EIA occlusions; unilateral occlusions of both CIA and EIA; infrarenal aortoiliac occlusion; diffuse multiple stenosis involving the unilateral CIA, EIA and CFA  

    Open revascularization

    Video example:

    High aortic occlusion with subtotal stenosis of the iliac bifurcation, occlusion of the right CIA and thrombosis at the left EIA (bilateral clinical Fontaine stage IIb).

    -> TASC II D, hence recommendation for open revascularization

    Preoperative intra-arterial DSA

    PM 303-1
    High aortic occlusion in bifurcation stenosis
    PM 303-2
    Bilateral CIA occlusion; embolism in left EIA


    Classification of PAD according to Fontaine stage and Rutherford category                                                                                                        

    Fontaine stage


    Rutherford category









    Mild claudication (> 200 m)



    Mild claudication


    Moderate to severe claudication (< 200 m)



    Moderate claudication




    Severe claudication


    Ischemic rest pain



    Ischemic rest pain


    Ulceration or gangrene



    Minor tissue loss



    Major tissue loss

  2. Contraindication

    • Serious cardiopulmonary risks (e.g. NYHA IV, COPD Gold stage IV)
    • Acute or chronic inflammatory abdominal processes (e.g., florid ulcerative colitis, recurrent sigmoid diverticulitis)
    • History of multiple extensive abdominal procedures (“hostile abdomen”)
    • Liver cirrhosis
    • Advanced malignancy
    • Transmural calcification of the aorta and pelvic axis*
    • Abdominal aortic aneurysm*

    in such cases: Y-graft

  3. Preoperative diagnostic work-up

    Medical history

    • Claudication
    • Walking distance
    • Risk factors -> nicotine abuse; arterial hypertension; coronary heart disease; cardiac failure; diabetes, manifest renal failure with/without dialysis; coagulopathy


    • Skin changes
    • Muscular abnormalities
    • Orthopedic malalignment
    • Skin color
    • Body hair
    • Trophic changes
    • Swelling, edema, mycosis, phlegmon, leg ulcers    

    Palpatory bilateral comparison

    • Pulse status
    • Skin temperature

    Auscultatory bilateral comparison of the limb arteries


    PM 303-3

    Ankle-Brachial Index (ABI)

    • ABI = systolic BP of posterior tibial artery / systolic BP of brachial artery

    ABI value

    PAD severity

    > 1.3

    Falsely high values (suspected Mönckeberg medial sclerosis, e.g. in diabetes)

    > 0.9

    Normal finding

    0.75 - 0.9

    Mild PAD

    0.5 - 0.75

    Moderate PAD

    < 0.5

    Severe PAD

    • ABI < 0.9 is considered evidence of significant PAD.
    • Determining the ankle-brachial index (ABI) through non-invasive Doppler occlusion pressure measurement is a suitable test for confirming PAD.
    • PAD diagnosis is determined by the ABI value with the lowest ankle artery pressure.
    • A pathologic ankle-brachial index is an independent risk indicator for increased cardiovascular morbidity and mortality.

    Color flow Doppler ultrasonography

    • Carotid arteries, abdominal aorta, limb arteries
    • Stenoses and occlusions in almost all vascular regions apart from chest
    • Allows quantifying the degree of stenosis and assessing plaque morphology
    • Sensitivity and specificity around 90%   
    • Well suited as screening modality

    CT angiography

    • Multislice computed tomography (MS-CT) with nonionic contrast agent
    • Broad range of indications: traumatic vascular lesion (esp. trunk); vascular dissection/rupture; aneurysm; arterial thrombosis/embolism; portal vein/mesenteric vein thrombosis; pulmonary artery embolism; PAD; vascular tumors
    • Benefits: rapid; detects relevant comorbidities; visualizes peripheral arteries; sensitivity and specificity each about 90%.
    • Drawbacks: Radiation and contrast agent exposure, allergies (about 3%), no functional assessment.

    Angiography (intra-arterial DSA)

    • Most often performed as digital subtraction angiography (DSA)
    • Contraindication: hyperthyroidism; manifest renal disease; creatinine elevation relative to indication; metformin-containing antidiabetics (risk of lactic acidosis); PT < 30%.
    • Benefits: visualization in highest detail; superselective imaging possible; immediate intervention possible; sensitivity 100%, specificity 100%. 
    • Drawbacks: Radiation exposure; contrast medium exposure; only patent vessels can be visualized while thrombosed regions and extravascular processes remain hidden; puncture and catheter complications. 
    • TSH and creatinine levels must be determined prior to DSA
    • Caution in patients with multiple myeloma -> renal failure

    Cardiac check

    • Resting ECG
    • Exercise ECG
    • Echocardiography

    Chest x-ray

    Possibly spirometry

    Laboratory panels

    • Blood count
    • Electrolytes
    • Coagulation
    • Kidney function parameters
    • Liver function parameters
    • Blood lipids
    • Blood group
  4. Special preparation

    • Enema the evening before
    • Hair cut in surgical field
    • Order packed RBCs
    • Foley catheter
    • Administer prophylactic perioperative antibiotics 30 min. before beginning surgery (see KRINKO recommendation, Robert Koch Institute)
    • Enema the evening before
    • Hair cut in surgical field
    • Order packed RBCs
    • Foley catheter
    • Administer prophylactic perioperative antibiotics 30 min. before beginning surgery (see KRINKO recommendation, Robert Koch Institute)
  5. Informed consent

    General surgical risks

    • Major bleeding, blood transfusions, transmission of hepatitis/HIV through allogeneic blood transfusions
    • Allergy/intolerance
    • Wound infection
    • Thrombosis/embolism
    • Skin/vascular/nerve damage, e.g. due to patient positioning
    • Keloid
    • Incisional hernia

    Specific procedural risks

    • Thrombosis, possibly leg ischemia, amputation
    • Infection with secondary suture bleeding; sepsis; leg ischemia; amputation
    • Damage to adjacent organs, e.g., ureter; bladder; spleen; liver; intestinal ischemia -> resection, ostomy
    • Paraplegia in the presence of deep origin of artery of Adamkiewicz
    • Nerve lesions -> dysesthesia; pain; paralysis of abdominal wall / thigh muscles
    • Peritoneal adhesions -> chronic pain, mechanical ileus
    • Lymph fistula
    • Secondary bleeding
    • Impotence    
    • Deterioration of renal function induced by intraoperative angiography

General anesthesia ... - Operations in general, visceral and transplant surgery, vascular surgery a

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