Yesterday, we treated a particularly demanding case of extensive aortoiliac occlusive disease. The patient was a man in his early seventies, still active, but severely limited by disabling claudication that had recently progressed to rest pain. He was seeking a definitive solution.
Preoperative CT angiography demonstrated diffuse, heavily calcified atherosclerotic disease involving almost the entire arterial tree below the diaphragm. Dense calcified plaques were present in the paravisceral and infrarenal aorta, including the origins of the visceral and renal arteries. At the level of the renal arteries, the aortic lumen was almost completely occluded. The disease extended distally to the aortic bifurcation and both common iliac arteries. The external iliac arteries were relatively spared, but both common femoral arteries were again severely calcified.
In other words, this was not a simple iliac occlusion or a standard aorto-femoral bypass case. This was extensive coral-reef aortic disease, involving the paravisceral aorta, the aortoiliac segment, and both femoral bifurcations.
The main question was: what is the best way to treat such a patient?
An extra-anatomic axillofemoral bypass was discussed but was not acceptable to the patient. Given the extent and distribution of the disease, we decided to proceed with an extensive open endarterectomy strategy, aiming to restore inline flow through the native arterial tree.
The planned procedure included:
- Transaortic endarterectomy of the paravisceral and infrarenal aorta
- Aortoiliac endarterectomy
- Bilateral common femoral artery endarterectomy
Operative approach
The patient was positioned in a right oblique position. The upper body was rotated approximately 60 degrees, while the pelvis and lower body were kept in a more horizontal position, approximately 30 degrees. This positioning allowed access to both the paravisceral abdominal aorta and to the iliac vessels.
A bilateral subcostal, or “rooftop,” incision was used, with a longer extension to the left side. The incision followed the costal margin, approximately 2 cm below it, and extended laterally to the level of the anterior axillary line. The abdominal wall muscles were divided accordingly to provide wide exposure.
A left visceral rotation was then performed. Initially, the left kidney was mobilized along with the viscera; however, after exposure was achieved, it was returned to its anatomical position. A complete mobilization of the left colon and spleen, including division of the renocolic and splenorenal ligaments, allowed excellent access to the abdominal aorta while leaving the kidney in place.
The left renal vein was identified and mobilized. The aorta was exposed from just below the diaphragm down to the iliac bifurcations. The celiac artery, superior mesenteric artery, both renal arteries, inferior mesenteric artery, and iliac arteries were isolated and controlled with vessel loops.
The entire operative field was challenging. Almost every arterial segment was densely calcified, except for a small proximal supraceliac segment and some distal iliac areas that were relatively softer.
One tool that proved extremely useful during the dissection was the LigaSure™ vessel-sealing device. In such extensive retroperitoneal exposure, diffuse venous and lymphatic bleeding can become troublesome. The device helped maintain a remarkably dry field and made the dissection safer and more efficient.
Aortic endarterectomy
After systemic heparinization, the aorta and all major branches were clamped: proximally, the aorta below the diaphragm, and distally at the visceral, renal, and iliac branches.
The aorta was opened near its bifurcation, which was the only relatively soft segment where an 11-blade could safely enter. From there, the arteriotomy was extended longitudinally using strong Metzenbaum scissors, all the way up to the level of the celiac artery. The arteriotomy was also extended into the right common iliac artery until a softer distal segment was reached. A separate arteriotomy was performed on the left common iliac artery.
The endarterectomy was difficult but feasible. The coral-reef plaque was carefully dissected from the aortic wall and removed. Particular attention was paid to the origins of the visceral and renal arteries. The plaques at the superior mesenteric artery and left renal artery orifices were removed using careful eversion endarterectomy, until satisfactory backflow was obtained.
The pararenal portion of the procedure required repeated mobilization of the left renal vein, moving it cranially and caudally with a vessel loop to improve visualization. This maneuver was essential to safely complete the endarterectomy beneath the renal arteries.
The aortic arteriotomy was closed primarily with 4/0 polypropylene sutures, using three consecutive running sutures. The common iliac arteriotomies were closed with bovine pericardial patches.
Femoral endarterectomies
Through separate groin incisions, both femoral bifurcations were exposed. As expected, both common femoral arteries were severely calcified.
Bilateral femoral endarterectomy was performed, extending to the femoral bifurcations, and both arteries were closed with bovine pericardial patches.
The abdominal incision was closed in two layers, and the groin wounds were closed in the standard fashion.
Lessons learned
This case highlighted several important technical points.
- First, the rooftop approach, combined with left visceral rotation and preservation of the left kidney in its anatomical position, provides excellent exposure of the abdominal aorta from the diaphragm to the iliac bifurcations. The main limitation is the left renal vein, which inevitably crosses the operative field. However, if adequately mobilized, the vein can be moved cranially or caudally as needed, allowing safe access to the pararenal aorta.
- Second, even very dense coral-reef plaque can be removed if the correct plane is found and the dissection is performed patiently. The orifices of the visceral and renal arteries require special attention. Eversion endarterectomy may restore good backflow, but one should always be prepared for adjunctive maneuvers if the result is not satisfactory. For this reason, it is useful to have short bare-metal stents available on the table, typically 6- or 8-mm stents. If residual plaque or stenosis remains at the origin of a visceral or renal artery, a stent may be advanced over a standard J-tip wire under direct vision.
- Third, meticulous exposure and bloodless dissection matter. In this case, the LigaSure™ device was extremely helpful, not as a substitute for surgical precision, but as a tool that made a long and complex exposure more controlled.
- Finally, this operation is a reminder that open vascular surgery still has an important role in selected patients with extensive calcified aortoiliac disease. Endovascular options are invaluable in many cases, but there are still patients for whom the most durable and anatomically sound solution is achieved through open reconstruction of the native arterial tree.