This article is part of the operation script for grafting an abdominal aortic aneurysm. The article can be used on its own, or to go to the next part of the operation, click on NEXT PART OF THE OPERATION at the bottom of this page.
AORTIC ANEURYSM 110 - OPERATION CHOICES
Five main factors affecting choice of operation.
1 Good distal run off.
- The graft must be sutured distally to vessels that are healthy enough for healing and that can take the blood flow distally to the lower limb(s).
2 Distal aneurysmal disease.
- If there is aneurysmal disease of more distal vessels, these secondary aneurysms should be bypassed and isolated.
3 Distal occlusive disease.
- If there is occlusive disease of more distal vessels, these obstructions should be bypassed as for secondary aneurysms, but do not need to be isolated.
4 Beware pelvic ischaemia.
- If both internal iliac arteries are tied off, the patient is likely to die of massive ischaemia to the sacral area.
5 Minimise patient's heat loss.
- In an elective operation where a Y graft is to be inserted, the patient’s heat loss can be reduced by dissecting out the femoral arteries before opening the abdomen.
The most common scenario
- Elective operation for a solitary aneurysm of the subrenal aorta with satisfactory iliac and femoral arteries.
- Procedure.
- Aorto-aortic graft. No groin exposure.
All leaking aneurysms
- The key is to stop the bleeding as soon as possible.
- Ie from the aneurysm itself plus retrograde bleeding from iliac and lumbar vessels.
- Procedure.
- Open the abdomen first, even if a groin exposure may be needed.
- Aorto-aortic graft:
- As long as the aortic bifurcation and iliac arteries are satisfactory.
- Aorto – bifemoral Y graft.
- In all other cases.
- Plus additional procedures for distal and iliac artery disease as described below.
Abdominal aneurysm + All iliac artery aneurysms or occlusions/stenoses
- Procedure.
- Aorto – bifemoral graft.
- An aorto – iliac Y graft is more difficult and more hazardous and no more effective than an aorto – bifemoral graft.
- We do not recommend it.
Abdominal aneurysm + Aneurysm of one common iliac artery
- Procedure.
- Aorto - bifemoral graft.
- Plus tie off the affected common iliac artery above and below the aneurysm.
- Blood supply to the pelvic organs will come via the limb of the graft on the same side, retrogradely up the external and internal iliac arteries.
Abdominal aneurysm + Aneurysms of both common iliac arteries
- Procedure.
- Aorto - bifemoral graft.
- Plus tie off two common iliac arteries above and below the iliac aneurysms.
- Blood supply to the pelvic organs will come via the limbs of the graft on the each side, retrogradely up the external and internal iliac arteries.
Abdominal aneurysm + Aneurysm of one external iliac artery
- Procedure.
- Aorto - bifemoral graft.
- Plus tie off the external iliac artery above and below the aneurysm.
- Blood supply to the pelvic organs will come via the limbs of the graft on the opposite side, retrogradely up the external iliac arteries.
Abdominal aneurysm + Aneurysms of both external iliac arteries
- Procedure.
- Aorto - bifemoral graft.
- Tie off the external iliac artery above and below the larger of the two aneurysms.
- Blood supply to the pelvic organs will come via the limb of the graft on the opposite side, retrogradely up the smaller aneurysm and the internal iliac artery.
- The smaller aneurysm should expand more slowly in the future.
Abdominal aneurysm + Aneurysm of one internal iliac artery
- Procedure.
- Aorto - bifemoral graft.
- Plus tie off the internal iliac artery proximal to the aneurysm.
- Blood supply to the pelvic organs will come via the limb of the graft on the opposite side, retrogradely up the opposite external iliac artery and through the internal iliac artery on that side.
Abdominal aneurysm +Aneurysms of both internal iliac arteries
- Procedure.
- Aorto - bifemoral graft.
- Tie off the internal iliac artery proximal to the larger aneurysm.
- Blood supply to the pelvic organs will come via the limb of the graft on the opposite side, retrogradely up the opposite external iliac artery and through the internal iliac aneurysm.
- The smaller aneurysm should expand more slowly in the future.
Abdominal aneurysm + Aneurysm of one femoral artery
- Procedure.
- Aorto - bifemoral graft.
- Plus anastomose the limb of the Y graft to a non – aneurysmal section of the superficial femoral artery distal to the aneurysm.
- Plus tie off the femoral artery above and below the aneurysm.
- Blood supply to the thigh muscles should be adequate via anastomotic channels from the superficial femoral artery.
- Blood supply to the pelvic organs will come via the limb of the graft on the opposite side, retrogradely up the opposite external and internal iliac arteries.
Abdominal aneurysm + Aneurysms of both femoral arteries
- Procedure.
- Aorto - bifemoral graft.
- Plus anastomose the limbs of the Y graft to non – aneurysmal section of the superficial femoral arteries distal to the aneurysm(s).
- Plus tie off the femoral artery above and below the larger of the aneurysms.
- Excision is often possible.
- Blood supply to the thigh muscles should be adequate via anastomotic channels from the superficial femoral arteries.
- Blood supply to the pelvic organs will come via the limb of the graft on the opposite side, retrogradely up the femoral aneurysm and the external and internal iliac arteries.
- The smaller aneurysm should expand more slowly in the future.
- Consider an extra graft from one limb of the Y graft to an iliac artery.
- Abdominal aneurysm + Aneurysm(s) of popliteal arteries
- Surgery on popliteal artery aneurysms can be postponed to a later date.
- Combinations of aneurysms
- Follow the above principles to create procedures that will ensure satisfactory blood flow to the pelvis and the lower limbs.
