The traditional approach to the surgical correction of lower extremity ischemia resulting from combined aortoiliac and femoropopliteal disease has consisted of aortofemoral bypass as the initial step. This operation is of considerable magnitude, mandates the use of prosthetic material, and may not adequately relieve distal ischemia. Extraperitoneal iliac endarterectomy is an operation of lesser magnitude and does not require the use of prosthetic material. When applied to selected patients with multilevel disease, it can be conveniently and expeditiously combined with distal bypass and deep femoral repair, femorofemoral bypass, or both for the simultaneous and complete correction of multilevel disease. In the past 10 years, 65 patients underwent simultaneous extraperitoneal iliac endarterectomy in combination with an outflow procedure for the correction of multilevel lower extremity arterial occlusive disease. Using a two-team approach, operative time averaged 3 hours. Operative mortality was 5 percent. The procedure was combined with femoral endarterectomy in 60 patients, with femoropopliteal-to-tibial bypass in 30 patients, and with femorofemoral bypass in 10 patients. The life table patency for iliac endarterectomy was 100 percent at 6 years, whereas patency for the associated outflow procedures was 87 percent at 6 years. These results indicate that extraperitoneal iliac endarterectomy is uniquely suited for combination with distal procedures to permit the simultaneous repair of combined aortoiliac and femoropopliteal disease in a single operation of reasonable magnitude.
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