Thromboendarterectomy of the Pelvic Arterial Pathway
The aortoiliac vascular pathway represents approximately 30% of common locations for peripheral arteriosclerotic lesions. In many cases, there are additional peripheral occlusive processes in the femoropopliteal and crural vascular pathways, which must be considered when choosing the procedure for interventional and/or surgical revascularization 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 vascular findings constellation, and the existing general comorbidity.
TASC Criteria for Aortoiliac Vascular Occlusions
Types | Morphology | Treatment 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 in vascular surgery [1-7]. TEA was first performed in the area of the superficial femoral artery in 1946 by Dos Santos and aortoiliac in 1951 by Wylie [8,9]. In the 1960s and 1970s, aortoiliac TEA was the standard procedure in this vascular segment. Due to the development of suitable bypass materials, the importance of TEA was declining, but it experienced a renaissance through combination with endovascular procedures (so-called hybrid procedures). Independent of interventional procedures, there continue to be indications for performing TEA in the pelvic region.
A distinction is made between local open and semi-closed TEA, which is performed with a ring stripper.
Open TEA
Open local TEA of the aortoiliac vascular pathway is usually performed with a patch plasty using synthetic material, as vein patches tend to form aneurysms later [10]. In combination with a bypass procedure, open TEA is often performed for deobliteration of the central anastomosis segment. Local deobliteration is also frequently necessary in open aneurysm reconstruction using a prosthesis to achieve a sutureable 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]. Another indication is seen in male patients with claudication or critical ischemia and concomitant erectile dysfunction due to an origin stenosis of the internal iliac artery [12]. The recommended extraperitoneal approach can reduce the incidence of postoperative ejaculatory disorders [13].
The 5-year patency rate of aortoiliac TEA is 60-94% according to literature [14]. The 10-year patency rate is reported as 89% [12].
Semi-closed Ring Stripper Deobliteration
Open local TEA of the femoral bifurcation can be combined with an ipsilateral ortho- or retrograde iliofemoral ring stripper deobliteration. In particular, retrograde TEA of the external iliac artery has proven effective, which can usually be performed semi-closed via an infrainguinal incision without exposure of the pelvic vascular pathway. It can be performed in isolation or in combination, for example, with a femoral TEA or a peripheral bypass graft. This procedure is optimized by balloon occlusion of the proximal pelvic arteries and separation of the occlusive 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 necessary for safety reasons. In cases of accidental central dissections, the membrane can usually be securely fixed by a proximal stent. Retrograde semi-closed ring deobliteration represents an effective variant of endarterectomy [16, 17].
In an extensive comparative meta-analysis of the three most commonly used conventional procedures, the aorto- and iliofemoral bypass and endarterectomy were compared [18]. The results of conventional vascular surgical therapy for lesions in 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, proven methods over decades as a safe cornerstone in the therapeutic spectrum of vascular medicine, despite the increasing number of endovascular procedures.