This article is part of the operation script for grafting an abdominal aortic aneurysm. The article can be used on its own, or to go to the next part of the operation, click on NEXT PART OF THE OPERATION at the bottom of this page.

AORTIC ANEURYSM 340 SECTION 22.00 - LOWER ANASTOMOSIS WITH BIFEMORAL GRAFTS

STEP 22.01 INTRODUCTION

The lower anastomoses may take an hour or more.

Ties may need to be placed around vessels associated with other more distal aneurysms.

See STEP 10.07 TECHNIQUE FOR ISOLATING DISTAL ANEURYSMS

STEP 22.02 CONTROLLING THE LOWER END OF THE ANEURYSM

The femoral arteries have been exposed and the vascular tunnels have been made.

A Y graft has been inserted successfully into the upper aorta.

The Y graft is lying in the aneurysm sac together with the upper parts of the two limbs of the graft.

The next steps are to feed the limbs of the grafts down the vascular tunnels.

This is in readiness for anastomosing the grafts to the femoral arteries.

These procedures are usually much less difficult than the operation so far.

STEP 22.03 CLEAR OUT THE AORTA AND THE ILIAC VESSELS

Remove thrombus and debris from inside the vessels as far as the iliac clamps.

Use swabs, heparinised saline and a sucker.

STEP 22.04 CHECK HAEMOSTASIS INSIDE THE ANEURYSMAL SAC

You must have control of all bleeding from inside the aneurysm before starting the anastomosis.

If left, any bleeding here is likely to get worse and obscure the anastomoses.

Readjust the clamps and oversew lumbar vessels as needed.

There is often some minor overspill from any retroperitoneal haematoma or minor vessels outside the aneurysm.

Control this overspill by tucking in gauze swabs and with the sucker as needed.

If necessary

Tie off or repair bleeding vessels.

STEP 22.05 CHECK THE INFERIOR MESENTERIC ARTERY HAEMOSTASIS

Sometimes this artery does not bleed until this point in the operation, when the blood volume has been restored.

If the artery bleeds now:

Ligate the vessel with 2/0 Vicryl (eg Ethicon W9125).

STEP 22.06 CHECK THE ILIAC ARTERIES AGAIN

Part open the iliac artery clamp on each side in turn to confirm that there is back bleeding.

If there is back bleeding from each iliac artery:

Anticoagulate the iliac arteries.

Use the 20ml. syringe with a bulb adapter (blob) containing heparin saline.

Temporarily open each iliac clamp in turn to flush 3 syringefuls of heparin saline down each iliac artery.

If there is no back bleeding from one or both iliac arteries:

Go back to SECTION 12.00 CHECKING THE ILIAC ARTERIES

STEP 22.07 PASS THE LEFT LIMB OF THE GRAFT THROUGH THE LEFT TUNNEL

Pass an O’Shaughnessy forcep up the left iliac tunnel.

As a guide, pass your right index finger down the tunnel to touch the tip of the forcep

Have the forcep emerge at the upper end of the tunnel.

Grasp the end of the left limb of the graft with the O’Shaughnessy forcep.

Avoid rotation of the graft by seeing that the anterior longitudinal markings on the limb of the graft stay in line.

Pull the limb through the tunnel and out into the groin wound.

Check again that there is no rotation of the graft.

Pull on the limb of the graft to tension the limb in the tunnel.

This will prevent the limb looping into the abdomen when full of blood under arterial pressure.

It will also relieve the distal anastomosis of tension while it is being stitched.

Use a 1000 gm. pull.

Hold the tension by clamping the limb as it emerges from under the inguinal ligament into the groin .

Use an O’Shaughnessy forcep with the handles lying on the abdominal wall.

STEP 22.08 REPEAT ON THE RIGHT HAND SIDE

STEP 22.09 CLAMP OFF THE RIGHT LIMB OF THE GRAFT

Place an O’Shaughnessy forcep across the origin of the right graft limb.

This will prevent blood passing down the right limb of the graft when the left limb is being flushed through later.

STEP 22.10 RETURN TO THE LEFT GROIN

STEP 22.11 CLAMP OFF THE LEFT COMMOM FEMORAL ARTERY

Use an angled De Bakey clamp.

Place the handles on the abdomen.

STEP 22.12 CLAMP OFF THE LEFT PROFUNDA FEMORIS ARTERY

Use a bulldog clamp.

STEP 22.13 CLAMP OFF THE LEFT SUPERFICIAL FEMORAL ARTERY

Use an angled De Bakey clamp with the handles lying down the thigh.

STEP 22.14 TIGHTEN ANY SLOOPS AROUND MINOR ARTERIES

STEP 22.15 CHOOSE A GRAFTING SITE ON THE COMMON FEMORAL ARTERY

Find a 15mm. long site on the anterior surface which is free from atheroma ie soft and thin.

If one is not present:

Find one on the superficial femoral or on the lowest part of the external iliac artery under the inguinal ligament.

STEP 22.16 OPEN THE COMMON FEMORAL ARTERY

Use a No 15 blade on a Swann Morton handle.

Make a longitudinal incision 12mm.long.

This will fit the obliquely - cut S shaped end of a 6mm. graft limb.

STEP 22.17. INSPECT THE INSIDE OF THE ARTERY

Suck out any clot.

If there is bleeding:

Check the clamps and sloops are tight.

Check for any minor arteries that may have been overlooked.

STEP 22.18 CHECK THE HOLDING CLAMP ON THE GRAFT AT THE INGUINAL LIGAMENT

Check that it is tensioning the limb of graft to 1000 gm.

STEP 22.19 PLACE THE DISTAL GRAFT OVER THE CHOSEN ANASTOMOSIS SITE

STEP 22.20 CUT THE LIMB OF THE GRAFT

Use stitch scissors.

Flatten the graft in the anterior- posterior plane.

Make an oblique cut across the flattened graft, so that the anterior wall wall is longer than the posterior anterior wall by 10mm.

This cut should lie over the arteriotomy site.

This will produce an oblique end to side anastomosis on the anterior wall of the artery.

Do not make a straight cut, which will produce an ellipse opening in the graft with pointed ends.

This is difficult to anastomose.

Instead, curve the cut in an S shape, starting and finishing perpendicular to the graft wall.

This will make an ellipse opening in the end of the graft with a broad heel and a broad toe for easier anastomosis.

If the S shape is cut tangentially to the graft wall, the ellipse will have very pointed ends.

This make the anastomosis even more difficult than a straight cut.

Practise on a piece of graft that will not be used in the patient to get it right.

STEP 22.21 INSERT THE FIRST STITCH

Get your assistant to pull the distal end of the graft distally with a vascular forcep.

Use 4/0 Polypropylene with 2 tapercut needles (eg Ethicon W8557).

Start at the heel of the graft.

Stitch from inside to out on the graft and on the artery.

Use both needles.

Make a mattress suture with equal free ends of suture.

Ie in the middle of the suture.

Tie with 4 throws on the outside of the graft and the artery.

This is not an end knot, so fewer throws are needed.

STEP 22.22 STITCH ALONG THE RIGHT HAND SIDE OF THE ANASTOMOSIS

Place stitches 1mm. apart with 1mm. bites.

Use a forehand stitch.

Pass the needle from inside the artery to outside.

Pass the needle perpendicularly through the artery .

Do not pass it obliquely.

This may lead to the suture tearing through the artery when the stitch is tightened.

STEP 22.23 STITCH AROUND THE TOE OF THE ANASTOMOSIS

You will appreciate the benefit of a wide toe to the graft.

Continue stitching from inside the artery to the outside.

STEP 22.24 COME BACK 5MM. ALONG THE LEFT HAND SIDE OF THE GRAFT

Lie the suture distally, held in a bulldog clip.

STEP 22.25 RETURN TO THE HEEL OF THE ANASTOMOSIS

Use the other length of suture with its needle.

Run stitches down the left hand side of the anastomosis towards the toe of the anastomosis.

As before, 1mm. apart, 1mm. bites, forehand, running inside to outside on the artery.

End up 1mm. from the first suture line.

Keep the last 3 throws slack.

This will give a 3mm. defect for flushing the graft limb and the artery.

STEP 22.26 WARN THE ANAESTHETIST

There may be some blood loss at this point.

The anaesthetist will want to increase the patient’s blood volume in anticipation.

STEP 22.27 OPEN THE CLAMPS ON THE DEEP FEMORAL ARTERY

This will confirm backflow.

Squeeze the thigh to confirm backflow.

If there is no back flow:

Pass Fogarty catheters.

See STEP 26.26 PASSING THE FOGARTY CATHETER

STEP 22.28 OPEN THE CLAMP ON THE SUPERFICIAL FEMORAL ARTERY

This will confirm back flow.

Squeeze the thigh to confirm backflow.

If there is no backflow:

Pass Fogarty catheters.

See STEP 26.26 PASSING THE FOGARTY CATHETER

STEP 22.29 RELEASE SLOOPS ON MINOR GROIN ARTERIES

STEP 22.30 FLUSH THE COMMON FEMORAL ARTERY

Use 60ml. heparin saline on a 20ml. syringe plus a bulb ended adaptor.

STEP 22.31 RELEASE THE O'SHAUNESSY FORCEP TENSIONING THE LEFT LIMB OF THE GRAFT

STEP 22.32 PART OPEN THE AORTIC SATINSKY CLAMP FOR 2 SECONDS

Blood will run from the aorta down the left limb of the graft.

Any recent thrombus, platelet thrombus and atheromatous debris will flush into the groin wound.

Let the debris gather in a swab in the wound to minimise trauma to the artery.

STEP 22.33 SUCK OUT THE FEMORAL ARTERY

STEP 22.34 TIE OFF THE ANASTOMOSIS SUTURES

Use 7 throws.

Cut the ends 10mm. long.

STEP 22.35 CHECK FOR BLEEDING FROM THE FEMORAL ANASTOMOSES

If there is bleeding:

It is likely to be minor.

Go back to STEP 19.22 CONTROL ANY BLEEDING

STEP 22.36 PART OPEN THE SATINSKY CLAMP ON THE AORTA AGAIN

Close the clamp at the anaesthetist’s request if the increased circulation is too much for the patient’s heart.

Release the clamp later in stages according to the cardiac state

Check that there is no bleeding from the upper anastomosis.

If there is bleeding:

Go back to STEP 19.22 CONTROL ANY BLEEDING

When there is no bleeding from the upper anastomosis:

READ ON

STEP 22.37 FULLY OPEN THE AORTIC CLAMP

Close the clamp at the anaesthetist’s request if the increased circulation is too much for the patient’s heart.

Release the clamp later in stages according to the cardiac state.

If there is bleeding:

Go back to STEP 19.22 CONTROL ANY BLEEDING

When there is no bleeding:

READ ON.

STEP 22.38 CHECK THERE IS BLOOD FLOW INTO THE LEFT LIMB

Usually the blood flow is satisfactory, as shown by the presence of a pulsating graft and distal arteries and warm pink feet.

If the flow is not satisfactory, the causes will be:

Poor cardiac output.

Check the blood pressure and cardiac output with the anaesthetist.

Thrombosis.

Embolism into distal vesssels.

Compressed graft in the vascular tunnel.

Kinked or twisted graft.

Obstruction at anastomoses.

Occlusive disease in distal vessels.

Check the femoral artery is pulsating.

If the femoral artery is not pulsting.

Check the trunk of the graft is pulsating.

If the trunk is not pulsating:

The sides of the graft may have stuck together.

Release the sides of the graft squeezing.

The trunk may have clotted.

Consider a thrombectomy through the trunk of the graft.

If the trunk is pulsating, but not the limb of the graft:

Check the limb of the graft is not compressed in the vascular tunnel.

Enlarge the tunnel with the finger.

Release any tight bands.

Check the limb of the graft is not kinked or twisted.

Correct by cutting and reanastomosing the limb of the graft.

There will be thrombus in the limb of the graft.

Perform a thrombectomy through the limb of the graft using a Fogarty catheter.

See STEP 26.26 PASSING THE FOGARTY CATHETER

If the limb of the graft is pulsating but not the femoral arteries:

There is clot or embolus in the femoral arteries.

Perform a thrombectomy/ embolectomy through limb of the graft.

See STEP 26.26 PASSING THE FOGARTY CATHETER

Or, there is obstruction at the anastomosis.

Consider exploring and redoing the anastomosis.

If the femoral artery is pulsating, but the foot is white and cold with guttering of the veins:

There is embolism, clotting or occlusive disease below the femoral arteries in the groin.

Go to SECTION 12.00 CHECKING THE ILIAC ARTERIES

Check the foot is pink and warm.

STEP 22.39 MAKE THE ANASTOMOSIS ON THE RIGHT HAND SIDE

Do the same as for the left side

See Step 22.12 CLAMP OFF THE LEFT COMMON FEMORAL ARTERY.

With the exception of the following move:

Release the O’Shaughnessy clamp on the right limb of the graft instead of the aortic Satinsky clamp (which has already been opened).

You should now have a functioning aorto-bifemoral graft.

STEP 22.40 TIE OFF RELEVANT VESSELS FOR OTHER ANEURYSMS

See STEP 10.07 TECHNIQUE FOR ISOLATING DISTAL ANEURYSMS

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SECTION 19.00 UPPER ANASTOMOSIS WITH INLAY TECHNIQUE

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