Today, aortoiliac endarterectomy may be considered an unnecessary procedure. How will you ever need to do it with all these endovascular options? But never say never. We treated a female patient with severe claudication. The CT angiogram demonstrated severe stenosis of the lower aorta extending to both common iliac arteries (Figure 1). Endovascular was considered the best option. The case was discussed with our IR colleagues, and to our surprise, they politely refused. “This will be very dangerous; it may lead to aortic rupture”, they said. “You’d better do something surgical”.

Figure 1: CT scan showing calcified plaque on the aorta bifurcation

What a lovely gift! The case seemed to be ideal for an aortoiliac endarterectomy.

After a full cardiopulmonary workup, the patient was taken to the OR. Generous midline incision and the usual exposure of the aorta from the level of the left renal vein to both iliac bifurcations. As usually happens in all occlusive AA cases, the dissection of the retroperitoneum was a bit more troublesome than in abdominal aortic cases. The retroperitoneum was thick, and the exposure of the aorta was harder to do. However, we made it! The abdominal aorta was fully exposed from the renal arteries (no need to divide the left renal vein) down to common iliac bifurcations bilaterally, with the inferior mesenteric artery controlled with an elastic sling. Heparin was given, clamps were applied proximally and distally, and ready to rock’n’roll! (Figure 2).

Figure 2: Full exposure of the abdominal aorta from the level of renal arteries to iliac bifurcations

The aorta was opened with an 11-blade and completed with scissors. No! At this stage, there is no need to carry the arteriotomy to the iliac arteries. Why? Because the back bleeding from the patent lumbar arteries may be significant. And this is something you may not expect if you have not thought about it in advance. After opening the aorta, we used an endarterectomy spatula to remove the plaque (Figure 3).

Figure 3: An arteriotomy is made in the aorta. The plaque inside the aorta can be seen

As plaque came out nicely, brisk back bleeding started to come from the (uncontrolled) lumbar arteries (Figure 4).

Figure 4: The proximal plaque has been removed and brisk back bleeding from the lumbar arteries has started