Juxtarenal AAA Suprarenal Clamping, Reimplantation of Left Renal Artery, Reimplantation of Inferior Mesenteric Artery

Step 1: Exposition

1. The first steps are the same as in the tube graft procedure
2. The aortic neck is prepared and a silicone tube is positioned around the suprarenal aorta
3. The left renal vein is mobilized and kept above the clamping site

Step 2: First renal anastomosis

1. The left renal artery is divided and the stump secured
2. Cold perfusion of the left kidney (ie. 500cc Custadiol or Ringer’s lactate with 100 cc manitol)
3. Short incision of the renal artery
4. End-to-end anastomosis with a 6 mm ePTFE or dacron graft with 5/0 polypropylene suture, parachute suture technique

Step 3: Proximal aortic anastomosis

1. Suprarenal aortic clamping
2. Incision of the aorta, preserving the right renal artery and excluding the stump of the left renal artery.
3. Oblique anastomosis with 20mm dacron tube graft
4. Suture material: 4/0 or 3/0 double needle polypropylene suture starting again at three o‘clock inside-out on the aorta. Needle on rubber shoed clamp
5. Second needle inside-out on the graft and outside-in on the aorta. 5 stiches in parachute technique, then move the graft down towards the suture line. Keep suture tight before tying the knot

Step 4: Renal artery anastomosis

1. Side bite clamp on tube graft. Create hole for renal artery bypass
2. Use 6 mm dacron or ePTFE graft, Anastomosis with 5/0 suture
3. Anastomosis with renal artery bypass with 5/0 polypropylene suture

Step 5: Inferior mesenteric artery (IMA) anastomosis

1. Mobilize the IMA,either with the aortic wall or by completely separation from aortic wall
2. Side bite clamp ontube graft. Create hole for IMA bypass
3. Anastomosis with IMA with 5/0 polypropylene suture

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