Narrowing and occlusion of the aorta and pelvic arteries

common iliac artery
The lower limbs are the most common site of arterial occlusions;
incidence - 6% of the population over 50, 10% over 60, 4 times more often women;
causes - atherosclerosis is the main , closures in young men can cause Bürger disease ;
- atherosclerotic changes are typically in 3 levels - aortic, femoropopliteal, crural;
clinical picture ;
- isolated involvement of the aortoiliac region - claudication in the gluteal muscles;
  - complete closure of the caudal aorta - in addition impotence, lack of pulsations in the groin ( Leriche's syndrome );
- femoropopliteal closure - calf claudication;
- trophic changes are usually only in the case of multiple closure or crural closure (individual closures usually have collateral circulation centrally and this is sufficient to maintain viability);
choice of therapy - what to consider;
- severity of the condition and degree of threat to the limb;
- the degree of vascular involvement and the possibility of effective surgery;
- overall condition of the patient - about 50% of patients have coronary heart disease, another 20% have damaged coronary heart disease;
  - Acute myocardial infarction is the most common cause of death after aortoiliac reconstruction;
- we consider surgery for resting pain and trophic changes;
- claudication - we consider the length of the claudication interval, the overall activity of the patient, his way of life…

Reconstruction of the aortoiliac region[edit | edit source]

Method of choice, only vascular prostheses are used;
most often in the form of a bifurcated aortobifemoral graft (the Y-shaped graft is found above the stenosis into the aorta and below the stenosis into the iliac);
- the most common place of separation is from the anterior wall between the distance between the renals and the lower mesenteric (least altered part);
at complete closure - proximal anastomosis end to end with suturing of the caudal part of the severed aorta (simply connect the bypass directly to the aorta);
retroperitoneal tissues and the back of the peritoneum should always be interposed between the prosthesis and the duodenum (prevention of aortoenteral fistula);
aortofemoral bypass is typically performed from a long moderate laparotomy (extraperitoenal approach is also possible);
at one-sided pelvic artery occlusion - extraperitoneal aortofemoral or iliacofemoral bypass;
results - very good, operative mortality 1-2%, immediate bypass function is 95-100%.

In patients with endangered limbs, when anatomical bypass cannot be established (general condition, previous surgery, infection site);
femorofemoral cross-over bypass ;
- with a one-sided riverbed closure, the performance is only minimally burdensome;
- can be performed in LA or in an epidural ;
axillofemoral bypass - in bilateral pelvic flow ;
- if it is necessary to revascularize both legs - the connection between the femorals is still stretched under the subcutaneous tissue (see picture);
- long-term function is worse, about 25% of joints require secondary thrombectomy;
PTA - (Percutaneous transluminal angioplasty) suitable for short stenoses of the common or external iliac, it is possible to insert a stent.

Sufficient inflow and outflow should always be verified (if there is no inflow - then proximal bypass before or simultaneously with the femoro-popliteal, or PTA, if there is no outflow - prolongation of reconstruction, lumbar sympathectomy);
PTA, endarterectomy, patch patch - short stenoses;
bypasses - femoropopliteal from the femoral artery to the upper or lower part of the popliteal artery, femoro-crural;

vascular prostheses (PTFE) - distal to the upper part of the poplitea (if there is sufficient drainage);
venous grafts - v. saphena magna, or v. cephalica, if the saphenous vein is not long enough - it is sutured distally to the lower part of the popliteal artery (there are no atherosclerotic changes - distal femoro-popliteal bypass is indicated for severe changes to the popliteal artery):
1. eversion- sewing the saphenous vein inversely (due to the flaps);
2. in situ - maintaining the normal course, but it is necessary to remove the valves with a valvulotomy;
3. composite graft - a combination of vein and vascular prosthesis;
special types of popliteal artery disease;
- entrapment syndrome - anomalous course of the popliteal artery, which is pulled over the beginning of the medial gastrocnemius, stenosis and poststenotic dilatation, clinical claudication, microembolization to critical ischemia, surgical treatment ( cut the gastrocnemius medialis head or venous bypass);
- cystic adventitial degeneration - deposition of jelly-like matter between the media and adventitia, narrows the artery and manifests itself in typical claudications, bypass treatment (venous, popliteo-popliteal)

it is necessary to distinguish between claudication pain (ischemic) pain and pain when the veins are affected:
1. phlebothrombosis - positive Homan's and plantar symptom, edema;
2. chronic venous insufficiency - feeling of heaviness without claudication, swelling, night cramps in the calves;
the most common cause (especially in men under 40, heavy smokers) is Bürger disease - it manifests itself in the development of trophic defects without a previous claudication stage and migratory phlebitis, diffuse shin artery disease is seen on angiography, treatment includes smoking cessation and prostaglandin infusions;
reconstructions are performed as an attempt to save the limb, preoperative angiography is necessary, according to which a place for suturing the distal end of the anastomosis is chosen, as the graft is the best v. saphena magna in situ.