Thromboendarterectomy of the Iliac Arterial Pathway
At approximately 30%, the aortoiliac arterial pathway represents a common localisation of peripheral atherosclerotic lesions. In many cases, additional peripheral occlusive processes of the femoropopliteal and crural arterial pathways are present, which must be taken into account when selecting the procedure for interventional and/or surgical revascularisation or reconstruction. The choice of procedure should take into account the specific risks, the short- and long-term results of a method given the existing constellation of vascular findings, and the existing general comorbidity.
TASC Criteria for Aortoiliac Vascular Occlusions
Types | Morphology | Therapeutic Principle |
|---|---|---|
A | Focal stenoses of the A. iliaca communis or A. iliaca externa <3 cm, uni- or bilateral | endovascular |
B | Focal stenoses 3–10 cm long and/or unilateral occlusion of the A. iliaca communis | endovascular |
C | Bilateral stenoses of the A. iliaca communis, 5–10 cm, or unilateral complete occlusion of the A. iliaca externa or bilateral occlusions of the A. iliaca communis | open reconstruction |
D | Diffuse stenotic changes of the entire iliac axis, or unilateral occlusion of the A. iliaca communis and externa, or bilateral occlusions of the A. iliaca externa | open reconstruction |
Thromboendarterectomy
The principle of thromboendarterectomy (TEA) as a reconstructive element in the aortoiliac segment is considered a classic of vascular surgery [1-7]. TEA was first performed in the region of the A. femoralis superficialis in 1946 by Dos Santos, and in the aortoiliac segment in 1951 by Wylie [8,9]. In the 1960s and 1970s, aortoiliac TEA was the standard procedure in this vascular segment. With the development of suitable bypass materials, the importance of TEA declined; however, it experienced a renaissance through combination with endovascular procedures (so-called hybrid procedures). Independently of interventional procedures, indications for performing TEA in the iliac region still remain.
A distinction is made between local open TEA and semi-closed TEA, the latter being performed with a ring stripper.
Open TEA
Open local TEA of the aortoiliac arterial tract is usually performed with a patch plasty using synthetic material; vein patches tend to develop aneurysms later on [10]. In combination with a bypass procedure, open TEA is frequently performed for desobliteration of the central anastomotic segment. Local desobliteration is also often required in open aneurysm reconstruction using a prosthesis, in order to achieve a suturable vessel wall.
Aortoiliac TEA as an isolated procedure is recommended exclusively in younger patients with soft atheromatous lesions of the distal aorta and proximal iliac vessels [11]. A further indication is seen in male patients with claudication or critical ischaemia and concomitant erectile dysfunction due to an origin stenosis of the A. iliaca interna [12]. The recommended extraperitoneal approach can reduce the incidence of postoperative ejaculatory disorders [13].
According to the literature, the 5-year patency rate of aortoiliac TEA is 60-94% [14]. The 10-year patency rate is reported as 89% [12].
Semi-closed ring stripper desobliteration
Open local TEA of the femoral bifurcation can be combined with an ipsilateral ortho- or retrograde iliofemoral ring stripper desobliteration. In particular, retrograde TEA of the arteria iliaca externa has proven effective, which can usually be performed semi-closed via an infrainguinal incision without exposure of the pelvic arterial pathway. It can be performed in isolation or in combination, for example, with a femoral TEA or a peripheral bypass graft. This procedure is optimised by balloon blockade of the proximal pelvic arteries and separation of the occlusion cylinder with the ring against the balloon [15]. Self-cutting ring strippers should be used with caution, as they carry a high potential for injury. If in doubt, TEA can also be performed between two incisions (central and peripheral) if this is necessary for safety reasons. In cases of accidental central dissections, the membrane can usually be safely fixed by a proximal stent. Retrograde semi-closed ring desobliteration represents an effective variant of endarterectomy [16, 17].
In an extensive comparative meta-analysis of the three most commonly used conventional procedures, aorto- and iliofemoral bypass and endarterectomy were compared [18]. The results of conventional vascular surgical therapy for lesions of the pelvic region are excellent, both in the early postoperative period and in the long term, with low morbidity and mortality.
TEA procedures of the aortoiliac and iliofemoral segments thus represent, with appropriate patient selection and correct indication, and despite the increasing number of endovascular procedures, as methods proven over decades, a safe cornerstone in the therapeutic spectrum of vascular medicine.