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  • Significant chronic lower extremity ischemia.
    • Lifestyle-limiting claudication, tissue loss, and rest pain.
    • Risk factor modification partially helpful.
  • Acute lower extremity ischemia.
    • Thrombosed aortoiliac system.
  • Infected aortic graft (prior abdominal aortic graft for aneurysmal or occlusive disease).
  • Abdominal aortic aneurysm with iliac disease (occlusive or aneurysmal).


  • Chronic ischemia: none.
  • Acute ischemia: nonsurvivable acidosis.


  • Cardiopulmonary comorbidities.
  • Prior abdominal surgery.
  • If significant comorbidities exist, extra-anatomic bypass (axillary-femoral bypass) is preferred.

  • The patient should be supine and prepared from mid chest to the feet.
    • The abdomen is entered through a midline incision.
    • Groin incisions can be transverse but more often are longitudinal.

  • Arterial line, central line, and pulmonary artery catheter for hemodynamic monitoring.
  • Nothing by mouth.
  • A nasogastric tube is needed for decompression for 12–24 hours in cases of abdominal entry.

  • Respiratory failure.
  • Renal failure.
  • Myocardial infarction.

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