Abdominal Aorto-iliac Occlusive Disease: Bifurcated Graft Bypass

Step 1: Exposition

1. Abdominal wall retractor and transperitoneal exposition of the infrarenal aorta, including definition of anatomical landmarks
2. Placement of silicone tube around the proximal aortic neck distally to the renal arteries
3. Preparation of distal bypass zones. Placement of vessel loops around both external iliac arteries or common femoral arteries
4. Supra- /infrarenal crossclamping using Glover clamp (rear branch of the clamp is conducted behind the aortic wall by means of a silicone tube)
5. Left lateral longitudinal incision (more than 3 cm long), beginning below the left renal artery
6. Limited thrombendarterectomy of the infrarenal aorta

Step 2: Proximal anastomosis

1. Standing on the right side of the body the suture starts at 5 o‘clock on the contralateral side (suture material: 3-0 double needle polypropylene suture)
2. First stitch inside-out on the aorta, put a suture clamp on the second needle
3. Second stitch with the same needle outside-in on the graft and inside-out on the aorta clockwise to first stitch
4. Continue with a running suture around the heel up to 8 o‘clock, put a suture clamp on that needle when needle is outside the graft and pull on both clamps (suture ends) approximating graft and aorta (moving the graft up and down)
5. After positioning the graft at the anastomotic level, continue the suture with the second needle completing the cranial wall suture of the aorta
6. Flushing and control of the proximal anastomosis under pulsatile pressure, additional stitches if necessary (U stich, Borst stitch, suture reinforcement)

Step 3: Distal anastomosis

1. Clamping of target vessel
2. Longitudinal incision of 1 cm. Rounding ofincision ends with a 3.5 or 4 mm punch (allows better view into the artery)
3. Anastomosis with bypass graft starting at 5o’clock outside-in graft and inside-out artery using 5-0 double needlepolypropylene suture.
4. Continue suturing around the heel in parachutetechnique until 8 o’clock. Approximate the graft to the artery (mowing down thegraft)
5. Continue suturing around the toe with otherneedle, flush and knot under pressure
6. Perform same procedure on other side

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Control of educational objectives (tutor and trainee)

Proximal Anastomosis

• Leak tightness
• Sequence of stitches
• Transmural stitching ("big bites")
• Correct match of aortic incision and length of anastomosis
• Appropriate length of graft
• Appropriate clamping