Indian Journal of Vascular and Endovascular Surgery

CASE REPORT
Year
: 2019  |  Volume : 6  |  Issue : 3  |  Page : 218--220

Ilioiliac crossover graft: Revival of an old technique – A report of two cases


Raja Lahiri 
 Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand, India

Correspondence Address:
Dr. Raja Lahiri
Department of Cardiothoracic and Vascular Surgery, AIIMS, Rishikesh, Uttarakhand
India

Abstract

Surgical management of unilateral iliac artery occlusion commonly involves a femorofemoral graft or an aortofemoral graft. We report two cases of atherosclerotic common iliac artery occlusion, one on the left and another on the right, wherein we did a crossover graft to the external iliac artery from the opposite common iliac artery through a single skin incision. The approach and graft placement in both the cases were completely retroperitoneal. Both these patients had an adequate recovery with complete relief of symptoms. This approach has the benefit of avoiding multiple incisions and incisions in the groin area, which tends to get infected easily and is associated with other complications such as lymphorrhea.



How to cite this article:
Lahiri R. Ilioiliac crossover graft: Revival of an old technique – A report of two cases.Indian J Vasc Endovasc Surg 2019;6:218-220


How to cite this URL:
Lahiri R. Ilioiliac crossover graft: Revival of an old technique – A report of two cases. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Oct 21 ];6:218-220
Available from: http://www.indjvascsurg.org/text.asp?2019/6/3/218/265772


Full Text



 Introduction



Atherosclerotic peripheral arterial disease with unilateral iliac arterial obstruction is not so uncommon to find in the clinical practice. The surgical techniques employed in its management commonly include either a femorofemoral crossover graft or a iliofemoral crossover graft through the space of Retzius.[1],[2] These, however, are associated with risk of infection due to groin incision,[3] increased graft length, and thus increased risk of thrombosis and multiple incisions. It also avoids the risk of impotence associated with dissection over the aorta and common iliac artery.[4] We present a series of two cases, wherein, we did an ilioiliac crossover graft through the retroperitoneal space, using a single paramedian incision.

 Case Reports



Case 1

A 48 years, thin built male, who was a heavy smoker, presented with severe claudication in the left lower limb. On evaluation using a computed tomography (CT) angiography, his left common iliac artery was completely occluded with distal reformation using collaterals. The abdominal aorta, although not stenosed, was heavily calcified. The procedure was done under regional anesthesia. A left-sided oblique paramedian incision was given. After splitting the muscles at the junction of the rectus and the obliques, the peritoneum was swept away toward the right. On exposing the iliac vessels of the left side, the left external iliac was looped. Dissection was carried further up to the bifurcation. Care was taken not to injure the ureter. Further dissection was done into the retroperitoneum to expose the right common iliac artery, which was palpated to ensure the absence of any calcification. An 8-mm double-velour Dacron graft was used to do a bypass from the right common iliac artery to the left external iliac artery [Figure 1]. The patient was maintained postsurgery on oral antiplatelets and had no wound-related complications. The patient was relieved of his symptoms.{Figure 1}

Case 2

A 38-year-old male, a heavy smoker and alcoholic, with central obesity, presented with severe calf claudication in the right lower limb with nonhealing ulcer right foot. On evaluation using a CT angiography, 80% stenosis of the right common iliac artery was seen. The surgery was carried out under general anesthesia. A left paramedian incision was given, and the muscle was split at the junction of rectus and obliques. The peritoneum was swept away toward the right, exposing the retroperitoneum. The left common iliac artery was looped, and dissection was carried over to the right side. With extended dissection, the right external iliac artery was identified and looped. A side-to-side bypass graft using ringed expanded PolyTetraFluoroEthylene (ePTFE), 8-mm vascular graft was done from the left common iliac artery to the right external iliac artery [Figure 2]. The patient had minor wound complications postoperatively and was relieved of his claudication symptom.{Figure 2}

 Discussion



Unilateral iliac artery disease has been a therapeutic dilemma throughout. Right from the angioplasty and stenting to surgeries such as femorofemoral crossover, iliofemoral crossover, or a classical aortofemoral bypass, all have their respective sets of merits and demerits. The reaction study[5] done in Japan showed good long-term patency rates with crossover grafts. The commonly performed femorofemoral crossover graft, although seems lucrative with smaller incisions, has many demerits. First, the incisions are in a “not-so-sterile” zone, thereby increasing the chance of infection and further complications. Groin incision has been shown in many studies to be a significant risk factor for vascular graft injections.[6],[7] The groin area is particularly susceptible to infections because of its rich microbial flora, the proximity of this area to the perineum, and the superficial location of vascular grafts in the groin. Moreover, the graft crosses natural creases twice, and hence risk of graft compression and thrombosis, especially in the Indian population, who largely still squat for defecation.[8] Studies have also shown reduced long-term patency in femorofemoral grafts. Lymphorrhea and lymphocele are common complications of groin incision. Similarly, aortofemoral or iliofemoral bypass does cross the groin once, needs a separate groin incision and a longer length of the graft as it is tunneled through the space of the Retzius. Moreover, aortofemoral carries the risk of developing postoperative impotence in male patients.[4] Our technique has the advantage of a single incision in a sterile field, a shorter length of the graft and does not cross any creases. As illustrated in both the cases, it is feasible for both right-sided and left-sided lesions and can be easily performed irrespective of the type of graft conduit used. As illustrated in the second case, it can also be performed in an obese individual. The dissection is completely retroperitoneal, and the graft is placed in the retroperitoneum. Studies comparing aortoiliac bypass to aortofemoral bypass have shown better results in the former, with respect to wound complications of groin incision.[9] This kind of procedure is beneficial in professional athletes, especially cyclists, whose sport involves repeated flexion at the hip joint.[10]

In patients with unilateral inflow obstruction, wherein the disease is limited to the common iliac artery, an ilioiliac crossover graft, through retroperitoneal approach is a safe and better option in comparison to more popular femorofemoral or aortofemoral bypass surgery. However, studies with long-term follow-up are required to comment on the patency rate and outcome in patients as compared to time-proven techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Perler BA, Burdick JF, Williams GM. Femoro-femoral or ilio-femoral bypass for unilateral inflow reconstruction? Am J Surg 1991;161:426-30.
2Muresan M, Jimborean O, Jimborean G, Neagoe R, Bancu S, Muresan S, et al. Crossover iliofemoral bypass graft through tension-free abdominal wall-repair mesh. Ann Ital Chir 2017;6:433-7.
3Bonardelli S, Nodari F, De Lucia M, Cervi E, Giulini SM. Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treatment for the infection of crossover bypass in aorto-uni-iliac endovascular aneurysm repair. Vascular 2012;20:306-10.
4Weinstein MH, Machleder HI. Sexual function after aorto-lliac surgery. Ann Surg 1975;181:787-90.
5Miyama N, Komai H, Nakamura T, Iwahashi M, Mukobara N, Yoshida M, et al. Long-term results of crossover bypass for iliac atherosclerotic lesions in the era of endovascular treatment: The re-ACTION study (Retrospective Assessment of Crossover bypass as a Treatment for Iliac lesiONs). Ann Vasc Dis 2018;11:217-22.
6Gharamti A, Kanafani ZA. Vascular graft infections: An update. Infect Dis Clin North Am 2018;32:789-809.
7Inui T, Bandyk DF. Vascular surgical site infection: Risk factors and preventive measures. Semin Vasc Surg 2015;28:201-7.
8Cormier JM, Laurian C, Noel Y, Gigou F, Ricco JB, Fichelle JM, et al. Aorto-femoral bypass with polytetrafluoroethylene prostheses: Preliminary results in 363 cases. Ann Vasc Surg 1986;1:43-9.
9York JW, Johnson BL, Cicchillo M, Taylor SM, Cull DL, Kalbaugh C. Aortobiiliac bypass to the distal external iliac artery versus aortobifemoral bypass: A matched cohort study. Am Surg 2013;79:61-6.
10Peach G, Schep G, Palfreeman R, Beard JD, Thompson MM, Hinchliffe RJ. Endofibrosis and kinking of the iliac arteries in athletes: A systematic review. Eur J Vasc Endovasc Surg 2012;43:208-17.