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Hybrid procedure, a combination of endovascular and open surgical approach, has emerged as the first-line treatment for patients with severe aortoiliac diseases because of its effectiveness. We report a hybrid procedure in a 72 year old man with an Abdominal Aortic Aneurysm (AAA) and Trans-Atlantic Inter-Society Consensus (TASC) D aortoiliac occlusive disease. After two failed attempts using the intraluminal technique (retrograde and antegrade), we successfully performed an endovascular approach with subintimal and Subintimal Arterial Flossing Antegrade-retrograde Intervention (SAFARI) technique with the help of roadmap technology. The vascular surgeon completed the procedure by creating femorofemoral bypass using a Great Saphenous Vein (GSV) graft. The graft was patent and there were no complications at 1 week, 1 month and 6 months follow-up.

Objective: The aim of this multicentric registry was to assess the outcomes of “anteRior versus posteRior divisional bRanches Of the hYpogastric artery as distAl landing zone for iLiac branch devices (R3OYAL).” Methods: The main exposure of interest for the purpose of this study was the internal iliac artery (IIA) divisional branch (anterior vs posterior) that was used as distal landing zone. Early endpoints included technical success and adverse events. Late endpoints included survival, primary/secondary IIA patency, and IIA branch instability. Results: A total of 171 patients were included in the study, of which 50 received bilateral implantation of iliac branch devices (IBDs). This resulted in a total of 221 incorporated IIAs included in the final analysis, of which 40 were anterior divisional branches and 181 were posterior divisional branches. Technical success was high in both groups (anterior division: 98% vs posterior division: 100%, P = .18). Occurrence of any adverse event was noted in 14% of patients in both groups ( P = 1.0). The overall rate of freedom from the composite IBD branch instability did not show significant differences between patients receiving distal landing in the anterior or posterior division of the IIA at 3 years (79% vs 87%, log-rank test = .215). The 3-year estimates of IBD patency were significantly lower in patients who received distal landing in the anterior divisional branch than those who received distal landing in the posterior divisional branch (primary patency: 81% vs 96%, log-rank test = .009; secondary patency: 81% vs 97%, log-rank test < .001). Conclusions: The use of the anterior or posterior divisional branches of the IIA as distal landing zone for IBD implantation shows comparable profiles in terms of immediate technical success, perioperative safety, and side-branch instability up to 3 years. However, IBD patency at 3 years was higher when the distal landing zone was achieved within the posterior divisional branch of the IIA. Clinical Impact The results from this large multicentric registry confirm that use of the anterior or posterior divisional branches of the internal iliac artery (IIA) as distal landing zone for implantation of iliac branch devices (IBD) shows comparable profiles of safety and feasibility, thereby allowing to extend the indications for endovascular repair of aorto-iliac aneurysms to cases with unsuitable anatomy within the IIA main trunk. Although mid-term rates of device durability and branch instability seem to be similar, the rates of primary and secondary IBD patency at three years was favored when the distal landing zone was achieved in the posterior divisional branch of the IIA.

A variety of diseases are known to develop in the aortoiliac segment; these include abdominal aortic aneurysm (AAA) and aortoiliac occlusive disease. This review summarizes several differences of aortoiliac diseases between eastern and western populations. The prevalence of AAA was higher in western countries (4.57% to 19%) than in eastern countries (0.89% to 4.9%). Greater aortic bifurcation angles were observed in the eastern population, while longer common iliac arteries and aneurysm necks were found in the western population with AAA. However, the angle of the aneurysm was found to be more acute in patients from western countries. Several differences were found between patients from western countries and those from eastern countries regarding the diseases that occur in the aortoiliac segment and their anatomical characteristics. Therefore, different approaches to the treatment of aortoiliac diseases in these two groups should be considered.

1.1 Methods A computerized search was conducted in the medical databases Medline (from January 2000 to July 2007), Embase (from January 2000 to July 2007) and the Cochrane Database of Systematic Reviews. Operative times, ICU-stay, clamping time, blood loss, anastomosis time, time to resume to solids, hospital stay, mortality and conversion rates were described. Experimental studies reporting on the creation of an aortic anastomosis with the robotic system were included.

Objective The long-term durability of the open bypass is better than that of endovascular treatment (EVT) for Trans-Atlantic Inter-Society Consensus (TASC) D aortoiliac lesions, but many recently developed devices and a variety of access options have increased the success rates of EVT, with less operative mortality and complication rates. In this study, we aimed to compare the technical success rates, primary patency rate, clinical outcomes, and complication for TASC D aortoiliac lesions treated by endovascular and surgical procedures. Patients and methods Data from 89 patients with chronic iliac artery stenosis and/or occlusion who were treated with endovascular or surgical treatment were retrospectively reviewed in the period between January 2003 and December 2017. Results The procedure time was longer for the surgical group than for the EVT group. The total complication rate was higher in the surgical group than in the EVT group. The mortality rate associated higher with the surgical group. There was no statistically significant difference between the groups regarding 2-year primary patency rates. Conclusion This study revealed that patients with severe aortoiliac occlusive disease (TASC D) can be treated with EVT or surgically with satisfactory results, with better technical success in the surgical group than in the EVT group. Furthermore, the 2-year patency rate for both groups was acceptable.

Background: In the present study, it was aimed to compare the stent grafts and bare-metal stents in terms of post-procedural patency, clinical recovery and complications in the subjects with symptomatic aorto-iliac arterial disease. Methods: A total of 79 subjects with symptomatic aorto-iliac arterial disease treated with endovascular methods were included in the present study. Forty three subjects received self-expendable bare metal stent (ev3 Protege stent system, Endovascular Inc., Plymouth, Minnesota, USA) and 36 subjects received PTFE-covered stent graft (Fluency Plus Stent Graft, Bard Peripheral Vascular, Tempe, Arizona). The subjects were compared after and at Months 1, 6, and 12 following the procedure in terms of Rutherford’s classification, ankle-arm index (AAI), patency rates, and complications. Results: The subjects receiving bare metal stent and stent graft for aorto-iliac arterial disease were followed for averagely 15 months. For the subjects receiving bare metal stent, primary patency rates at months 1, 6, and 12 were 98%, 81%, and 70%, respectively, while secondary patency rate at month 12 was found to be 84%. For the group of stent graft, primary patency rates were found as 97%, 97%, and 92%, respectively and secondary patency rate at month 12 was found to be 94%. Stent grafts were applied at the same time in 2 patients who had metal bare metal because the rupture occurred during the procedure. In the comparison between two groups, the group of stent graft was found to be statistically superior to the other in terms of patency, clinical and post-procedural complications. Conclusion: In conclusion, it was found that the stent grafts were superior to the bare metal stents in terms of patency and complication rates in the subjects with symptomatic aortoiliac disease.

Objectives Various configurations of kissing stent (KS) configurations exist and patency rates vary. In response the covered endovascular reconstruction of the aortic bifurcation configuration was designed to minimize mismatch and improve outcome. The aim of the current study is to compare geometrical mismatch of kissing stent with the covered endovascular reconstruction of the aortic bifurcation configuration in vivo. Methods Post-operative computed tomographic data and patient demographics from 11 covered endovascular reconstruction of the aortic bifurcation and 11 matched kissing stent patients were included. A free hand region of interest and ellipse fitting method were applied to determine mismatch areas and volumes. Conformation of the stents to the vessel wall was expressed using the D-ratio. Results Patients were mostly treated for Rutherford category 2 and 3 (64%) with a lesion classification of TASC C and D in 82%. Radial mismatch area and volume for the covered endovascular reconstruction of the aortic bifurcation group was significantly lower compared to the kissing stent configuration ( P Conclusions The present study shows that radial mismatch exists in vivo and that large differences in mismatch exist, in favour of the covered endovascular reconstruction of the aortic bifurcation configuration. Future research should determine if the decreased radial mismatch results in improved local flow profiles and subsequent clinical outcome.

Internal thoracic artery (ITA) is an excellent conduit for coronary artery bypass surgery (CABG). We present a patient with known preoperative aortoiliac disease with anterior collateral pathway who had an indication for elective coronary bypass. The use of ITA in these patients may cause lower limb ischemia. Detecting Winslow's anastomotic pathway before CABG is of utmost importance.

Objectives : To determine technical and clinical success of kissing stents for aortoiliac occlusive disease. Design : Retrospective study. Venue : Different private centers in Dhaka City. Subjects : Patients presenting with intermittent claudication (IC) or critical limb ischaemia (CLI) due to aortoiliac disease. Methods: Balloon or self expanding kissing stents with or without predilatation depending upon the nature of the disease, was inserted via bilateral retrograde femoral approach. Patients were followed up clinically and by ankle brachial index (ABI) and Duplex study. Results : Technical and clinical success was achieved in all of 34 cases. All patients with CLI improved and ulcerated limbs showed complete healing. During follow-up 3 patients died and 1 patient required major amputation at 3 months. Conclusion: Kissing stents implantation is a safe and alternative treatment for aortoiliac disease. It is cosmetic, requires short hospital stay. No incision, regional or general anesthesia is needed. Bangladesh Heart Journal 2015; 30(2) : 74-77

There is increasing use of Impella for high risk percutaneous interventions with or without left ventricular dysfunction. Patients with complex coronary anatomy often have aortoiliac disease. Inability to place Impella device through difficult aortoiliac anatomy may preclude the high risk procedure

Renal transplantation in a patient with aortoiliac prosthetic graft is a unique challenge. It requires that the renal artery is anastomosed directly to the vascular prosthetic graft. Nearly 0.2%-1.7% of the patients with aortoiliac prosthesis require renal transplantation in their life time. Outcomes following such procedure are controversial and anecdotal. In this report we present a unique case in which the renal artery was anastomosed to vascular prosthetic graft with a pertinent review of the literature.

Peripheral artery disease (PAD) has been associated with reduced survival in addition to increased morbidity including amputation, decreased quality of life, and immobility [(1)][1]. Endovascular revascularization has emerged as an attractive alternative to surgical revascularization for the

The purpose of this study is to assess the image quality and diagnostic accuracy of non-contrast quadruple inversion-recovery balanced-SSFP MRA (QIR MRA) for detection of aortoiliac disease in a clinical population. QIR MRA was performed in 26 patients referred for routine clinical gadolinium-enhanced MRA (Gd-MRA) for known or suspected aortoiliac disease. Non-contrast images were independently evaluated for image quality and degree of stenosis by two radiologists, using consensus Gd-MRA as the reference standard. Hemodynamically significant stenosis (≥50%) was found in 10% (22/226) of all evaluable segments on Gd-MRA. The sensitivity and specificity for stenosis evaluation by QIR MRA for the two readers were 86%/86% and 95%/93% respectively. Negative predictive value and positive predictive value were 98%/98% and 63%/53% respectively. For stenosis evaluation of the aortoiliac region QIR MRA showed good agreement with the reference standard with high negative predictive value and a tendency to overestimate mild disease presumably due to the flow-dependence of the technique. QIR MRA could be a reasonable alternative to Gd-MRA for ruling out stenosis when contrast is contraindicated due to impaired kidney function or in patients who undergo abdominal MRA for screening purposes. Further work is necessary to improve performance and justify routine clinical use.

The traditional approach to revascularization in aortoiliac disease is surgical. Endovascular treatment techniques for revascularization have emerged in recent years and have resulted in less invasive options for management of vascular disease. In this article, we describe a novel approach to endovascular stent graft reconstruction of a heavily calcified infrarenal aortic occlusion. The interventional management of aortic occlusions is subsequently discussed.

Objective To present our modification of the transperitoneal direct approach (TDA) for totally laparoscopic aortoiliac surgery. Methods and results From September 2003 to August 2005 a total of 52 patients underwent laparoscopic operations for aortoiliac disease (50 aortoiliac occlusive disease; two abdominal aortic aneurysm). The modified TDA was used in 20 patients. Conclusion The main advantage of TDA is reduced dissection of the aorta and pelvic arteries resulting in lowered blood loss and lymphatic injury.

We present the cases of two middle aged women who were referred to our physiatric spine center with chronic and proximal lower extremity pain complaints of suspected upper lumbar and stenotic origin. Their histories, physical examinations, and imaging studies were not convincing for a primary radicular pain generator. Non-invasive arterial Doppler studies demonstrated a significant brachial to high thigh pressure discrepancy without a focal segmental drop affecting the more distal lower extremity vasculature. Computed tomography (CT) angiograms confirmed advanced aorto-iliac atherosclerotic disease in each case. Spine practitioners are often consulted by the medical community to direct care in patients with suspected lumbar stenosis. These atypical cases of patients with isolated proximal lower extremity pain remind us of the symptomatic overlap between neurogenic and vascular claudication and emphasize the importance of a detailed history, physical examination, and appropriate imaging studies in identifying patients with primary arterial insufficiency.

Made available in DSpace on 2016-04-01T18:42:43Z (GMT). No. of bitstreams: 0 Previous issue date: 2014. Added 1 bitstream(s) on 2016-04-01T18:48:57Z : No. of bitstreams: 1 S1677-54492014000300235-en.pdf: 3535584 bytes, checksum: fe5b5f29841df8e1c94b1203dc69a36c (MD5). Added 1 bitstream(s) on 2016-04-01T18:48:57Z : No. of bitstreams: 2 S1677-54492014000300235-en.pdf: 3535584 bytes, checksum: fe5b5f29841df8e1c94b1203dc69a36c (MD5) S1677-54492014000300235-pt.pdf: 3588122 bytes, checksum: 608308201df80b1059962c0017d83267 (MD5) O tratamento endovascular de aneurismas de aorta abdominal (AAA), envolvendo a saída das artérias renais e viscerais, constitui ainda um importante desafio. Diversas técnicas foram desenvolvidas ao longo do tempo para contornar as dificuldades oferecidas por esta situação, destacando-se as endopróteses fenestradas ou ramificadas, as técnicas envolvendo próteses paralelas, como Chaminé, Periscópio e Sanduíche, e, mais recentemente, a utilização da modulação de fluxo por stent multicamadas Multilayer. Apresentamos um caso de AAA sacular complexo justarrenal e com alto risco cirúrgico pela avaliação cardiológica e por apresentar via aérea difícil, em decorrência de laringectomia total por antecedente de neoplasia de laringe. Devido à facilidade técnica do uso do Multilayer, à presença de doença obstrutiva crônica aorto-ilíaca, à estenose ostial renal e ao diâmetro limitado da aorta suprarrenal, descartaram-se as opções envolvendo endopróteses fenestradas/ramificadas ou técnicas envolvendo próteses paralelas, pela necessidade de diversos acessos para a execução. Diante do dilema imposto, apresentamos este caso como desafio terapêutico e com uma opção de tratamento bem sucedida, em curto prazo. Endovascular aortic aneurysm repair (EVAR) involving renal and visceral arteries remains a great challenge. Several techniques have been developed over the time to treat juxtarenal, pararenal and thoracoabdominal aneurysms, highlighting the fenestrated and branched endografts, parallel prostheses as Chimney, Periscope and Sandwich Techniques and the use of flow modulation by multilayer stent. We report a case of saccular juxtarenal aortic aneurysm with high surgical risk for complex airway access due to a history of radical laryngectomy for laryngeal neoplasm. Due to chronic aorto-iliac obstructive disease, ostial stenosis of renal artery and limited diameter of the suprarenal aorta, we discarded options involving fenestrated/branched endografts and involving parallel prostheses techniques. We present this case as a therapeutic challenge and a successful treatment option in the short-term evaluation. Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil Universidade Estadual Paulista Júlio de Mesquita Filho (UNESP), Faculdade de Medicina de Botucatu (FMB), Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil

Objective. Bilateral internal iliac artery aneurysms constitute the utmost configuration of infrarenal aortoiliac disease. We detail characteristic aortoiliac disease patterns and reconstructive techniques we have used, along with a visualized decision-making chart and a short review of the literature.Material and Methods. A retrospective, observational study of twelve clinical cases of patients with aortoiliac disease are described. Two patients had a common iliac artery aneurysm and were managed by the application of inversed stent-grafts; another case was repaired by the insertion of a standard bifurcated stent-graft flared in the right common iliac artery and with an iliac branched device in the left iliac arterial axis. Open approach was used in 5 cases and in 4 cases a combination of aortouniliac stent-grafting with femoral-femoral bypass was applied.Results. Technical success was 100%. One endoleak type Ib in a flared iliac limb was observed and corrected by internal iliac embolism and use of an iliac limb stent-graft extension. We report 100% patency rate during 26.3 months of followup.Conclusion. Individualized techniques for the management of isolated iliac or aortoiliac aneurismal desease with special concern in maintaining internal iliac artery perfusion lead to elimination of perioperative complications and long-term durability and patency rates.

Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options.

Objectives: to determine medium term technical and clinical success of kissing stents for aortoiliac occlusive disease. Design: retrospective study. Subjects: twenty-five patients presenting with intermittent claudication (IC) or critical limb ischaemia (CLI) due to aortoiliac disease (41 complex stenoses, 8 occlusions). Methods: balloon- or self-expanding kissing stents, with or without predilatation depending upon the nature of the disease, were inserted via bilateral retrograde femoral artery punctures. Clinical examination, ABPI, exercise testing and duplex ultrasound were performed at 1, 3, 6, and 12 months, and then annually. Results: technical success was achieved in 86% segments. All patients with CLI improved and 6 of 7 ulcerated limbs showed complete healing. During follow-up, 7 patients died and two patients required major amputation at 7 and 8 months. The primary assisted patency rate was 94, 91 and 65% at 6, 12, and 24 months, respectively. Conclusions: despite acceptable short-term technical and clinical success, as the medium term patency rates are clearly inferior to those of bypass surgery, the kissing stent technique should be reserved for high risk patients with a limited life expectancy. Eur J Vasc Endovasc Surg 26 , 161-165 (2003)

Objectives: to evaluate the feasibility and long-term results of angioplasty and stenting in the treatment of restenosis following aortoiliac endarterectomy. Materials and Methods: between 1991 and 1999 19 patients underwent angioplasty with selective stenting for recurrent stenosis after previous aortoiliac endarterectomy. Aortic lesions were treated five times in four patients. At the iliac level 28 lesions (25 stenosis and three occlusions) were treated in 16 patients (one patient had a stenosis at the aortic as well as iliac level). All patients were followed clinically and by ultrasound. In the second half of 1999, an angiogram or spiral CT-angiography was performed in all patients to determine long-term outcome. Results: technical success was obtained in all patients and clinical succes was achieved in 18 of the 19 patients. Angiographic cumulative primary patency for aortoiliac lesions was 96% at 1 year and 76% at 3 years. Conclusions: angioplasty with selective stenting of recurrent aortoiliac disease after previous aortoiliac endarterectomy is feasable and safe. Long-term clinical and angiographic patency rates are in accordance with results of aortoiliac angioplasty in general.

Objective: To study the ability of a qualitative assessment of the common femoral Doppler waveform to screen for significant aortoiliac disease. Design: Prospective, semi-blind study. Setting: Vascular laboratory, University Hospital. Methods: A total of 118 aortoiliac segments were studied in 73 patients. Each aortoiliac segment was graded as normal or abnormal from visual intepretation of the common femoral Doppler waveform obtained by colour duplex ultrasound. Full ultrasound assessment of the aortoiliac vessels acted as the “gold standard”. Abnormal aortoiliac segments were defined by the presence of at least one ≥50% diameter reducing lesion, whereas vessels considered “normal” included those with disease between 0–49% diameter reduction. An increase in peak systolic velocity of two-fold or greater was used to define a ≥50% diameter reducing stenosis. Agreement between common femoral waveform analysis and the duplex scans was measured by the Kappa statistic. Results: The Kappa value for the agreement between common femoral waveform analysis and duplex scans was 0.74 (95% CI; 0.62–0.86). This represents substantial agreement. Doppler waveform analysis had a sensitivity of 95%, specificity of 80% and accuracy of 87% for the prediction of a significant aortoiliac stenosis seen by ultrasound. Conclusion: Visual interpretation of the common femoral Doppler waveform is a sensitive and accurate technique for the prediction of significant aortoiliac stenosis. It is of particular value when full ultrasound aortoiliac assessments are not feasible due to time constraints, obesity or the presence of bowel gas.

Transaortic balloon catheter insertion is an effective method to provide aortic counterpulsation when the conventional retrograde femoral route cannot be used, usually due to severe aortoiliac disease. A simple technique is described to achieve correct transthoracic intraaortic balloon pump catheter insertion and positioning without the need for special equipment.

Iliac arteries were occluded in adult mongrel dogs to investigate pelvic hemodynamics. When the unilateral common iliac artery was occluded, the blood flow making a "stopover" within the pelvis was found to be significantly less than that of anatomical hemodynamics even under a resting condition. The blood flow decreased more significantly under exercise loading than under a resting condition, which demonstrates the presence of the "steal" phenomenon. This only occurs in the collateral circulation in the pelvis formed by two arterial systems which are related in a series. In deciding the appropriacy of reconstruction for the internal iliac artery in patients with aorto-iliac occlusive disease, this "steal" phenomenon should be kept in mind. In most cases, ischemic symptoms in pelvic organs may be due to a simple decrease of the blood flow supplied to the pelvis, or due to the "steal" phenomenon. If the pelvic region is in the state of ischemia owing to the "steal" phenomenon, reconstruction of the blood vessels flowing into the pelvis is not required.

Thirty-eight patients presenting with severe limb ischaemia and considered unfit for major aortic reconstruction underwent axillofemoral bypass as a limb salvage procedure. Four patients (11 per cent) died, including two who had presented with bilateral ischaemia secondary to acute aortic occlusion. The operative mortality rate for patients presenting with rest pain or ulceration/gangrene was 6 per cent. Cumulative 5-year survival and limb salvage were 44 per cent and 86 per cent respectively. Graft occlusion was the principal cause of worsening symptoms during follow-up (5-year primary patency of 68 per cent) and accounted for all major amputations of the operated limb. Axillounifemoral grafts had a significantly worse 5-year patency (50 per cent) than axillobifemoral grafts (80 per cent, P < 0·05) and three of five patients who developed worsening symptoms in the non-operated limb died or required a major limb amputation as a consequence. Axillofemoral bypass is a valuable alternative to major aortic reconstruction in elderly patients and allows a greater proportion to be offered reconstruction than would otherwise be possible.

The numerous options currently available for treatment of aortoiliac occlusive disease have led to considerable controversy in regard to the optimal method of revascularization in such patients. Differences of opinion exist not only with respect to certain technical aspects of direct anatomic aortic reconstruction, which has traditionally been regarded as the “gold standard” treatment, but even more importantly as to whether alternative methods including a variety of catheter-based endoluminal therapies and extraanatomic grafts may offer nearly equivalent results with less risk and possible cost advantages. Although little truly definitive data is available, a review of published information can help clarify many of these management dilemmas. In the final analysis, the various methods may not be as competitive with one another as first seems apparent. Each has its own specific advantages and disadvantages and when used, in appropriate circumstances can provide excellent results. Indeed, it is this broad spectrum of options that can be matched to each patient's own unique anatomic and risk characteristics that make treatment of aortoiliac disease one of the most successful areas of contemporary vascular surgery practice. (J Vasc Surg 1997;25:365-79.)

The angioplasty of chronic total aortoiliac occlusion using transfemoral is controversial. From March 2014 to December 2015, four consecutive patients (4 males; mean age 58.2±6.8 years; age of range 51–65 years) underwent angioplasty and stenting of TASC-D occlusion. In all the cases, we failed to cross from femoral approach. On switching over to left brachial access, angioplasty was done successfully in all. There was no procedural site complication or clinical evidence cerebral thromboembolism. Self-expandable stents were implanted in all with adequate pre and post dilation. Complete revascularisation was achieved in two cases and in other two cases, the angioplasty to the left aortoiliac carina was staged. Therefore, it is better to avoid femoral approach as initial step to cross chronic TASC 2007 type D (chronic total aortoiliac occlusion or called extensive aortoiliac disease) because of failure to cross retrogradely due to subintimal course of guide wire leading to retrograde aortic dissection.

Purpose: This article describes an original laparoscopic technique that allows performance of aortobifemoral bypass grafting. Methods: The technique described is the result of 6 years of in vitro and animal experimentation. It also represents the end result of prior clinical research with laparoscopy-assisted aortoiliac surgery and totally laparoscopic retroperitoneal aortobifemoral bypass grafting. The technique consists of the creation of a flap of retroperitoneum that is used to separate the intraperitoneal organs from the content of the retroperitoneal cavity. Surgery can then be conducted with no intrusion of any intraabdominal organ into the operative field. Another advantage is that the pneumoperitoneum is equally distributed among the two cavities. A conventional aortobifemoral bypass procedure is then performed with laparoscopic instrumentation. Results: The described technique has been performed in three patients to date. The patients' intraoperative blood loss did not exceed 500 ml, and no complication arose. The intraoperative need for crystalloids was of the order of 3 L (almost half the quantity usually administered). The patients' analgesia requirement was low in these patients, and return to walking was rapid. They were sent home between the fourth and sixth postoperative days. Conclusions: The innovative technique described here is safe and appears to ease the patient's postoperative course. Data recovered from the multicenter study, which is now in its preliminary phase, should help answer numerous questions. We expect the procedure to be reproducible in other university centers that are participating in the trial. (J Vasc Surg 1997;26:685-92.)

Since our original description in 1997 of a totally laparoscopic technique for treatment of aortoiliac disease, this type of minimally invasive procedure has been used both in the United States and abroad. We describe improvements that should make this technique more easily reproducible. This modified procedure was offered to six patients, one of whom received a tube graft for treatment of aneurysm disease.