SECTION 12.00 LOWER ANASTOMOSIS

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12.01 STARTING THE LOWER ANASTOMOSIS

The upper anastomosis is now finished and is satisfactory.
Turn your attention to the lower anastomosis.

12.02 ADJUST THE TRAVERS SELF-RETAINING RETRACTOR

Move the retractor distally to display the lower end of the aneurysm.
Keep the handles distal, to prevent them interfering with the positioning of the graft in the next few steps.

12.03 SUCK OUT ANY BLOOD FROM THE ANEURYSM

12.04 CHECK THE ILIAC ARTERY HAEMOSTASIS

Retighten or reposition the iliac clamps to make sure there is no leakage.
Any bleeding from the iliac arteries will flood the anastomosis, making it very difficult.

12.05 CHECK THE LUMBAR ARTERY HAEMOSTASIS

Suture off any persistent or newly bleeding lumbar vessels. (Ethicon W9136)

12.06 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.
Ligate the vessel with 2/0 Vicryl (Ethicon W9125) if it bleeds now.

12.07 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 again.
   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 TO STEP 8.01 PAGE 45 for the steps to manage blocked iliac arteries.

12.08 CHECK THE AORTIC BIFURCATION

Make sure your decision to insert a straight graft was correct.
The bifurcation should be between 18 and 25mm in diameter for anastomosis with a straight graft.
If not, consider using a trouser graft. This will mean anastomosing the trouser graft end-to-end onto the uppermost 5cm of the straight graft.

12.09 TRIM THE LOWER END OF THE OPENING INTO THE ANEURYSM

Use Pott’s vascular right angled scissors.
Make a transverse cut across the end of the incision 10mm proximal to the bifurcation.
Extend the cut to include the anterior half of the circumference of the aorta.

12.10 REMOVE ANY ATHEROMATOUS PLAQUES FROM THE BIFURCATION

Any residual plaques may prevent a watertight joint between the graft and the aorta.

12.11 LAY THE GRAFT IN THE ANEURYSM SAC

This is in preparation for cutting the graft to a correct length.

12.12 PULL THE GRAFT DISTALLY

Use vascular dissecting forceps.
This stretching is to allow for lengthening of the graft when distended with arterial blood.
The unstretched graft should be 1-2cm shorter than the aneurysm sac for a non-stretch graft, and 3-4cm shorter for a stretchy knitted graft.

12.13 CUT THE GRAFT

Use stitch scissors.
Cut the graft straight across.

12.14 CHECK THE LENGTH OF THE GRAFT

Pull the graft distally to reach the posterior of the bifurcation.
Cut the graft shorter if it seems slack.
If the graft is on the tight side, have it held distally with a right angled De Bakey clamp until the lower anastomosis is complete. This will prevent the excess traction on the first sutures of the distal anastomosis.
If the graft is seriously to short:
   Suture in an extra section of graft.

12.15 INSERT THE FIRST STITCH OF THE LOWER ANASTOMOSIS

Use the two suture method as for the upper anastomosis.
Use the same 2/0 polypropylene suture on a 25mm 3/8 curved round bodied needle (Ethicon W8577).
Remove the second needle from the suture.
Insert the needle into the right hand side of the graft from outside in, 5mm from the graft edge.
Pull the needle and suture into the lumen of the graft. Leave 10cm of suture outside the graft.
Insert the needle into the inside of the right hand side of the aortic wall 10mm proximal to the bifurcation.
Bring the needle out of the interior of the left hand side of the bifurcation.
Pull the needle and suture through.
Tie a knot on the outside of the graft and aorta.
Use a 750gm to 1000gm pull to make a watertight joint between the graft and the aortic wall.
Use 6 throws.
Hold the end in an artery forcep.
Hold the needle on a bulldog clip.

12.16 INSERT THE SECOND STITCH OF THE LOWER ANASTOMOSIS

This is the same as the first stitch, but is on the left side.
Use the same 2/0 polypropylene suture on a 25mm 3/8 curved round bodied needle (Ethicon W8577).
Remove the second needle from the suture.
Insert the needle into the left hand side of the graft from outside in, 5mm from the graft edge.
Pull the needle and suture into the lumen of the graft. Leave 10cm of suture outside the graft.
Insert the needle into the inside of the left hand side of the aortic wall 10mm proximal to the bifurcation.
Bring the needle out of the interior of the left hand side of the bifurcation.
Pull the needle and suture through.
Tie a knot on the outside of the graft and aorta.
Use a 750gm to 1000gm pull to make a watertight joint between the graft and the aortic wall.
Use 6 throws.
Hold the end in an artery forcep.

12.17 START THE POSTERIOR HALF OF THE ANASTOMOSIS

Use the right hand stitch.
Hold the anterior lip of the graft out of the way using the assistant’s vascular dissecting forceps.
Make the first bite deeply into the posterior aorta 3mm medial to the right hand stitch 10mm proximal to the bifurcation.
Bring the bite out at the bifurcation of the aorta.
Pull the needle and suture through the aorta.
Make the second bite through the edge of the graft from the inside to the outside the usual 5mm from the edge and 3mm from the lateral stitch.
Pull the needle and stitch through the graft.
Tighten the suture to 750 – 1000gm to make a watertight fit.
Have the suture held by the first assistant using vascular dissecting forceps.

12.18 CONTINUE THE POSTERIOR HALF OF THE ANASTOMOSIS

Use stitches as above.
Take care that the sutures bunch up any redundant aorta to make a watertight closure onto the graft.
If the aorta tears:
   Take deeper bites more proximally.
    Use patches of graft material to bolster the aorta.
    Continue until you reach the left hand suture.
    Make the last bite pass through the graft to the outside.

12.19 TIE THE POSTERIOR SUTURE

Tie the right hand suture to the free end of the left hand suture outside the vessels.
Use 6 throws.
Cut the loose ends 10mm long.

12.20 CLEAN OUT THE GRAFT

Use a sucker to remove any blood clot and debris that may have gathered in the graft, ilac arteries and the aortic stump during this half of the anastomosis.

12.21 FLUSH THE GRAFT WITH HEPARIN SALINE

Use 20 ml. of heparin saline to prevent clotting of any blood seeping into the graft during the second half of the anastomosis.
Suck out the heparin saline.

12.22 START THE ANTERIOR HALF OF THE LOWER ANASTOMOSIS

Use the right hand needle and suture.
Bite into the graft from the outside, 5mm from the graft edge and 7mm from the left side stitch.
Pull the needle and suture through the inside of the graft.
Bite into the inside of the anterior tissue of the aorta 10mm proximal to the bifurcation.
Bring the needle out of the outside of the bifurcation. (If the outside wall of the aorta is not accessible, use internal stitches until it is.)
Pull the needle and suture out of the aortic tissue with a 750 – 100gm pull.
Have the suture held by the assistant with vascular dissecting forceps, maintaining the same pull and direction.
Continue suturing until you are 10mm from the left hand stitch.

12.23 INSERT A LOCK STITCH

The aim is to lock the suture line here so that the suture line remains watertight.
You will be using looser stitches in the final 10mm of the anastomosis as a vent when releasing the iliac clamps.
Bring the needle and suture from the last aortic exit site.
Pass the needle and suture inside the loop between the last graft exit site and the previous aortic entrance site.
Snug the lock stitch with a 750gm pull.

12.24 INSERT TWO MORE STITCHES

Keep them loose.
Put one throw on the final knot. ie Between this end of the suture and the end of the right hand suture.
Keep the ends ready to tie the final suture when the graft has is flushed.

12.25 WARN THE ANAESTHETIST YOU WILL BE RELEASING THE ILIAC CLAMPS IN A MINUTE OR TWO

This will give the anaesthetist time to provide a reserve of blood volume as blood passes into the lower limbs and to compensate for any blood loss.
Keep the anaesthetist informed of your progress.
Stop if the anaesthetist needs more time to correct hypovolaemia or dysrhythmias.

12.26 PREPARE TO CLEAR THE GRAFT OF DEBRIS

The aim is to flush out any blood clot, platelet thrombus, atheromatous debris and air out of the graft and iliac arteries to prevent them causing emboli when the circulation if fully restored.
This is done by letting such matter flow out of the iliac arteries out of a partly sealed lower anastomosis.

12.27 REMOVE ANY SLOOPS FROM ABNORMAL ILIAC ARTERY BRANCHES

12.28 PART RELEASE THE LEFT ILIAC ARTERY CLAMP

Do this slowly in case there is bleeding from iliac arterial tears.
Watch blood flood up the left iliac artery to fill the graft and spill out of the loose part of the lower anastomosis.
If there is no flow up the left iliac artery:
   Check the artery has not remained squashed flat despite the clamp being opened.
    Massage the artery with your fingers to open it up.
    Squeeze the left thigh muscles to force blood from branches of the iliac artery up the main vessel.
If there is still no flow:
   The left iliac artery is probably thrombosed or blocked by an embolus.
   You need to pass a Fogarty catheter as you did before starting the upper anastomosis.
   SEE STEP 8.02 (PASSING A FOGARTY CATHETER).

21.29 FLUSH HEPARIN SALINE DOWN THE LEFT ILIAC ARTERY

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

21.30 CLAMP OFF THE LEFT ILIAC ARTERY

21.31 CLEAN OUT THE GRAFT

Use a sucker.

21.32 FLUSH OUT THE GRAFT WITH HEPARIN SALINE

Use 60ml

21.33 PARTLY OPEN THE RIGHT ILIAC CLAMP

Manage the right vessels as you have done for the left vessels above.

21.34 TIE OFF THE 2 SUTURES ON THE ANASTOMOTIC VENT

Use 750gm pull.
Use 6 throws.
Cut the ends 10mm long.

12.35 CHECK THE LOWER ANASTOMOSIS FOR BLEEDING

The pressure in the graft is low, and it is unlikely that there will be more than minor oozing.
Use sutures of 2/0 polypropylene (Ethicon W8577) if there is serious bleeding.
Expect more serious bleeding when the aortic clamp is opened.

12.36 PART OPEN THE AORTIC CLAMP

Keep a hand in the handles of the clamp ready to close it off if there is serious bleeding from either anastomosis.
The graft will become tense and may bow forwards a little.
If the graft bows forwards right out of the sac:
   Shorten it by cutting out a section and reanastomosing it.
   Continue with haemostasis of the anastomotic lines before shortening the graft.

12.37 ASSESS THE AMOUNT AND SITE(S) OF BLEEDING

The most likely is that there will be some bleeding from both anastomoses, particularly from the lower site.
Use the same techniques and patience as for the upper anastomosis earlier in the operation.
It may take ten minutes or an hour or more to obtain satisfactory haemostasis.
Even rather vigorous bleeding will stop using swabs and gauzes, a little pressure and waiting for blood clotting to close defects in the anastomotic lines.
Deficiencies in clotting factors are likely to be a major problem at this stage if more than 6 units of blood have been used.
Check that the blood has been tested for clotting factors and the anaesthetist has given appropriate fresh frozen plasma and, if necessary, platelets.
For minor bleeding from either anastomosis:
   Place a gauze swab around accessible parts of each anastomosis.
   Cover the swabs with large gauze packs.
   Press on the packs for 3 minutes.
   Remove the packs and swabs slowly, and inspect the anastomoses.
If there is continued minor bleeding, or less bleeding:
   Place a cellulose gauze on the bleeding area.
    Recover the area with a swab and a pack.
    Press on the area for a further 3 minutes.
    Repeat until the anastomoses are dry.
    GO TO STEP 12.39 (OPEN THE AORTIC CLAMP FULLY)
If there is moderate bleeding. ie More than 50ml per minute:
   Place a cellulose gauze on the bleeding area.
   Cover the two anastomoses with a swab and a pack.
    Press on the anastomoses for 3 minutes.
    Examine the anastomoses.
If the bleeding is less:
   Continue with this use of swabs and packs until the anastomoses are dry.
   GO TO STEP 12.39 (OPEN THE AORTIC CLAMP FULLY)
If the bleeding continues or is worse:
   Continue as below.
If there is serious bleeding. ie Blood that is spurting or fills the aneurysm sac within 5-10 seconds:
   Identify where the bleeding is coming from.
   Clamp the aorta.

12.38 DEAL WITH ANY SERIOUS BLEEDING FROM THE UPPER ANASTOMOSIS

This is a very serious complication.
It is particularly dangerous if the bleeding is coming from the posterior half of the upper anastomosis.
Access is very difficult with the graft lying in the aneurysmal sac.
The clamp on the aorta will reduce the tenseness in the graft. This will allow some access to the back of the anastomosis for vascular stitches.
After stitching, persevere with cellulose sponges and pressure with swabs and gauzes again.
Buttress stitches with patches of graft material if the aortic tissue tears.
Part release the aortic clamp.
If there is continued minor bleeding, or less bleeding:
   Place a cellulose gauze on the bleeding area.
   Recover the area with a swab and a pack.
   Press on the area for a further 3 minutes.
   Repeat until the anastomoses are dry.
   GO TO STEP 12.39 (OPEN THE AORTIC CLAMP FULLY)
If there is moderate bleeding. ie More than 50ml per minute:
   Place a cellulose gauze on the bleeding area.
   Cover the two anastomoses with a swab and a pack.
   Press on the anastomoses for 3 minutes.
   Examine the anastomoses.
If the bleeding is less:
   Continue with this use of swabs and packs until the anastomoses are dry.
   GO TO STEP 12.39(OPEN THE AORTIC CLAMP FULLY)
If there is still major bleeding from the upper anastomosis:
   You will need to perform the same manoeuvres as for the upper anastomosis earlier in the operation plus some extra.
    Reapply the aortic clamp.
    ***Apply also the spare large vascular clamp to the graft in case of leakage from the lower anastomosis.
   Apply a higher aortic clamp and remove the lower one to obtain a longer length of acceptable aorta.
   Restitch the leaking site(s).
   Consider taking down the anastomosis and starting anew.
   Insert a Foley balloon into the lumen to obtain higher and healthier aorta for a reanastomosis.
Consider stitching the aorta off and performing an axillo- bifemoral graft.
Your stitching ability will be tested to the limits.
Consider packing the bleeding area with a 6 metre pack, led out of the abdomen via a separate stab incision. If the patient survives, removal of the pack at a second look operation at 24-48 hours is feasible.
In 15-20% of leaking aneurysms, the extent of the disease, the effects of blood loss, clotting failure and general frailty of the patient may prove too much for any surgical technique.
The same applies for 1-2% of elective aneurysms.
You can only do your best.
The patient may develop a severe bradycardia or other dysrhymia at any stage in the operation and die on the table.
In the presence of continued severe bleeding at this point, a joint decision with the anaesthetist may be needed at this stage about stopping the operation.

12.39 OPEN THE AORTIC CLAMP FULLY

Go through the same process for obtaining haemostasis at the upper anastomosis as when the aortic clamp was partly open.
Continue until the upper anastomosis is has only minor bleeding which seems to be lessening.

12.40 PART RELEASE THE GRAFT CLAMP

If one was placed on the graft in the presence of serious bleeding from the lower anastomosis as well as the upper one.

12.41 CONTROL LEAKAGE FROM THE LOWER ANASTOMOSIS

Using the same techniques as for the upper anastomosis.

12.42 CHECK THE ILIAC ARTERY PULSES

If the arteries are pulsating and there is zero or minimal bleeding from the anastomoses:
   You are well on the way to a successful operation.
   Continue any packing of the anastomoses for ten minutes.
   Leave one member of the surgical team guarding the operation site.
   Have a cup of coffee.
If there is no pulsation in either artery:
   Check that the blood in the graft has not clotted.
   Palpate the graft to detect whether the contents feel semisolid. ie containing clotted blood.
   Aspirate the graft with a needle to check that the blood in the graft has not clotted.
If the graft seems to be clotted:
   Clamp the graft with a C-shaped Satinsky arterial clamp.
   Open the clamped piece of graft with a 10mm longitudinal incision using a No15 blade on a long handle.
    Part release the clamp.
If there is only liquid blood:
   GO TO STEP 12.43 (CHECK THE FEMORAL PULSES AGAIN)
If there is blood clot:
   Clamp the aorta above the upper anastomosis where there has to be liquid blood running into the renal arteries.
    Inject 20ml of heparin saline into the aorta above the clamp to ensure no thrombosis in the aorta.
    Release the Satinsky clamp
    Check a No 4 Fogarty catheter as before (STEP 8.03).
    Pass the Fogarty catheter to clear the vessels distally to the popliteal trifurcation.
    Use a vascular sucker to clear the upper graft.
    Flush out the contents of the lower aorta by part releasing the aortic clamp.
    Suck out the contents of the graft.
    Flush the graft with 20ml of heparin saline with a syringe and a bulb adaptor.
    Replace the Satinsky shaped clamp
    Close the incision in the graft with continuous 2/0 polypropylene (Ethicon W8577).
    Open the Satinsky clamp.
If there is minor bleeding:
   Place a swab on the closure site for 3 minutes until there is no more bleeding.
If there is spurting of blood:
   Insert another suture to close the defect.
   Place a swab on the closure site for 3 minutes until there no more bleeding.
   Release the aortic clamp.

12.43 CHECK THE FEMORAL PULSES AGAIN

If they are present:
   Continue below.
If they are not present:
   This suggests iliac artery thrombosis or embolism.
Continue below, but be prepared to perform femoral embolectomies later in the operation.