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Abstract
The infra-renal abdominal aorta and the iliac arteries are among the most common sites of chronic obliterative atherosclerosis in patients with symptomatic occlusive disease of the lower extremities. Treatment of patients with PAD has 2 goals. The first and foremost goal is to reduce the risk of vascular events (myocardial infarction, stroke, vascular death) that occur at a high rate in patients with PAD. About 30% of patients with PAD will die within 5 years, and death usually is due to an ischaemic coronary event. The second goal of treatment is to improve symptoms in those patients with claudication and limb salvage in patients with critical limb ischaemia. Critical limb is ischaemia usually mandates evaluation with aortography and endovascular and/or surgical revascularization to prevent limb loss. In terms of indications for surgical intervention, ischaemic pain at rest and actual tissue necrosis, including ischaemic ulcerations or frank digital gangrene, are well accepted as indicating advanced ischaemia and threatened limb loss. Without treatment, most limbs with these symptoms experience disease progression and require major amputation.
Currently, excellent early and late results of direct aortoilio-femoral reconstructions can be anticipated. It is reasonable to expect an 85% to 90% graft patency rate at 5 years and 70% to 75% at 10 years. Endovascular therapies may be a valuable treatment modality in some patients with aortoiliac occlusive disease. However, patient selection is paramount. When the determination has been made that the ischaemia is significant enough to warrant mechanical intervention, the role played by endovascular intervention depends on an understanding of its benefits and risks and how they compare with other treatment options.
Laparoscopic techniques have gained widespread acceptance in many surgical fields, largely because of their ability to offer the benefits of less invasive therapy including reduced postoperative pain, shortened hospital stays, and earlier return to normal activities when compared with conventional open surgery. The use of laparoscopic techniques in intra-abdominal vascular surgery may have the potential to provide similar benefits, and either laparoscopically assisted or totally laparoscopic aortobifemoral bypass grafts have been reported.
Although the availability of these numerous alternative therapies is beneficial, enabling the surgeon to select a procedure appropriate to the individual anatomy and risk status of each patient, decision making is often complex and difficult. Substantial differences in reported early and late results of alternative methods have contributed to the confusion. Indeed, the optimal method of management of aortoiliac disease represents one of the most controversial areas of contemporary vascular practice.