Overview
Definition:
Endarterectomy of the external iliac artery is a surgical procedure to remove atherosclerotic plaque from the inner lining (intima) of the external iliac artery
This aims to restore normal blood flow to the lower limb in patients with significant stenosis or occlusion.
Epidemiology:
Atherosclerosis commonly affects the iliofemoral segment, contributing to 30-40% of all peripheral arterial disease (PAD) cases
External iliac artery involvement is frequent in patients with critical limb ischemia and intermittent claudication, particularly in older males with risk factors like smoking and diabetes.
Clinical Significance:
Significant stenosis or occlusion of the external iliac artery can lead to severe symptoms of limb ischemia, including rest pain, non-healing ulcers, and gangrene, necessitating timely intervention to prevent limb loss
Endarterectomy offers a durable solution for select cases, preserving the native artery.
Indications
Symptomatic Iliofemoral Occlusive Disease:
Patients with disabling intermittent claudication extending above the inguinal ligament, or critical limb ischemia (rest pain, ulcers, gangrene) due to external iliac artery disease.
Angiographic Findings:
Significant stenosis (>70%) or occlusion of the common or external iliac artery segment on angiography, amenable to direct surgical reconstruction.
Anatomical Considerations:
Favorable anatomy for endarterectomy, such as a localized, non-calcified, and non-tortuous segment of disease, often without extensive involvement of the common iliac artery or distal vessels.
Patient Factors:
Patients who are poor candidates for endovascular intervention or have failed endovascular treatment, and have adequate operative risk tolerance.
Preoperative Preparation
Detailed History And Physical Exam:
Assessing symptoms, risk factors (smoking, diabetes, hypertension, hyperlipidemia), and performing a thorough vascular exam of the lower extremities, including pulses, skin integrity, and temperature.
Imaging Studies:
Duplex ultrasonography for non-invasive assessment of stenosis and flow
Angiography (CTA or MRA) is crucial for detailed anatomical evaluation, identifying the extent of disease, and planning surgical approach.
Risk Assessment And Optimization:
Cardiac evaluation (ECG, stress test if indicated), pulmonary function tests, and optimization of comorbidities such as diabetes control, hypertension management, and smoking cessation counseling.
Informed Consent:
Discussing the procedure, risks (bleeding, infection, stroke, MI, limb ischemia, graft occlusion, nerve injury), benefits, alternatives (angioplasty, bypass), and expected outcomes.
Procedure Steps
Surgical Approach:
A curvilinear incision above the inguinal ligament provides access to the common and external iliac arteries
The peritoneum may be gently retracted to access the proximal iliac vessels.
Arterial Exposure And Control:
Careful dissection and isolation of the common iliac artery, external iliac artery, and common femoral artery
Proximal and distal control is achieved using vascular tapes or bulldog clamps.
Arteriotomy And Endarterectomy:
An longitudinal arteriotomy is made in the external iliac artery, typically at the most stenotic segment
The plane of dissection between the intima and media is meticulously developed
Atherosclerotic plaque is carefully dissected free from the vessel wall, often extending proximally into the common iliac artery and distally into the common femoral artery if indicated.
Patch Angioplasty Or Closure:
After plaque removal, the arteriotomy is typically closed with a prosthetic or autologous venous patch (e.g., saphenous vein or PTFE patch) to widen the lumen and prevent re-stenosis or thrombosis
Simple direct closure may be used for small arteriotomies.
Completion Angiography:
Intraoperative angiography is performed to confirm adequate restoration of blood flow, assess the distal runoff, and evaluate the integrity of the repair and presence of any intraluminal thrombus or dissection.
Postoperative Care
Hemodynamic Monitoring:
Close monitoring of blood pressure, heart rate, and fluid balance
Maintaining adequate perfusion pressure is crucial.
Pain Management:
Adequate analgesia to manage incisional pain and potential ischemic discomfort.
Wound Care:
Regular dressing changes, monitoring for signs of infection or hematoma formation
Prophylactic antibiotics are typically continued.
Anticoagulation And Antiplatelet Therapy:
Intravenous heparin may be used perioperatively, followed by long-term dual antiplatelet therapy (aspirin and clopidogrel) or anticoagulation, depending on the type of closure (patch vs
direct) and individual patient factors.
Ambulation And Rehabilitation:
Early ambulation as tolerated, followed by a structured physical therapy program to improve walking distance and functional capacity.
Complications
Early Complications:
Hemorrhage or hematoma at the surgical site
Infection
Arteriovenous fistula formation
Early graft occlusion or patch dehiscence
Distal embolization causing acute limb ischemia
Myocardial infarction or stroke.
Late Complications:
Late graft or patch occlusion
Neointimal hyperplasia leading to restenosis
Pseudoaneurysm formation
Chronic wound complications
Progressive atherosclerosis in untreated segments.
Prevention Strategies:
Meticulous surgical technique, complete plaque removal, adequate patch angioplasty, meticulous hemostasis, and aggressive postoperative medical management including antiplatelet therapy and risk factor modification.
Prognosis
Factors Affecting Prognosis:
The extent and severity of distal occlusive disease, quality of runoff vessels, patient's comorbidities, adherence to medical therapy, and successful surgical reconstruction are key prognostic factors.
Outcomes:
Successful external iliac endarterectomy with patch angioplasty offers durable limb salvage rates, with primary patency rates typically exceeding 80-90% at 5 years for well-selected patients
Relief of claudication and improvement in critical limb ischemia symptoms are common.
Follow Up:
Regular clinical assessment with physical examination and non-invasive vascular studies (duplex ultrasound) at 1, 6, and 12 months postoperatively, and annually thereafter, to monitor for graft patency and development of new disease.
Key Points
Exam Focus:
Indications for endarterectomy versus bypass for iliofemoral disease
Importance of patch angioplasty
Management of early and late complications
Role of antiplatelet therapy post-procedure.
Clinical Pearls:
Achieving a clean plane of dissection during endarterectomy is crucial to minimize intimal injury
Always ensure adequate distal perfusion and meticulous closure of the arteriotomy with a patch if needed
Careful intraoperative angiography is vital.
Common Mistakes:
Incomplete plaque removal leading to residual stenosis
Inadequate patch size or material causing turbulence
Over-aggressive dissection causing vessel perforation
Failure to adequately assess distal runoff
Neglecting postoperative medical management.