SECTION 8.00 CHECKING THE ILIAC ARTERIES

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8.01 CHECK THE ILIAC ARTERIES ARE PATENT

Part open the iliac artery clamp on each side in turn to confirm that there is back bleeding.
The peripheral vessels are usually patent, and even larger than normal, since the aneurysmal condition often affects all arteries to some degree
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.
GO TO STEP 9.01 CONSIDER A STRAIGHT OR ROUSER GRAFT
If there is no back bleeding from one or both iliac arteries:
   Squeeze the quadriceps to force blood from branches of the external iliac back up the common iliac artery into the aorta.
If there is no back flow from quadriceps compression:
   Pass a Fogarty catheters down the blocked iliac artery from inside the aneurysm.

8.02 PASSING A FOGARTY CATHETER

8.03 CHECK THE FOGARTY CATHETER

Check it is a No 4 French Gauge catheter. ie 4mm in circumference.
Check you have a spare No 4 catheter available.
Have the catheter brought to the operating table.
Make sure it does not flip onto unsterile areas.
Remove the central wire.
Test the balloon at the tip of the catheter.
Have 0.75ml of heparin saline inserted into a 2ml syringe.
Check that there is no air in the syringe, which will upset the feel of the procedure.
Push the syringe onto the catheter until any creaking on the joint stops.
Inflate the balloon with the 0.75ml of liquid.
Check that the balloon does not burst and the balloon is a regular sphere shape.
Replace the catheter if substandard.
Open the left iliac artery clamp fully, but leave it in place.
Pass the Fogarty catheter down the artery.
The catheter usually passes easily down to about 40cm ie down the superficial femoral artery and its extension, the popliteal artery to the popliteal trifurcation.
The catheter will pass through thrombus and embolus material.
If it meets an obstruction at less than 20cm ie above the origin of the profunda femoris artery from the superficial femoral artery :
   This may be due to a kink in a tortuous vessel, Bend the distal 2cm of the catheter.
    Repass the catheter and rotate it to negotiate any kink.
    Try to pass a narrower catheter.
If the catheter will still not pass:
   The iliac arteries are probably blocked with atheroma.
   Consider a trouser graft.
If the catheter passes to 40cm or more:
    Push the heparin saline into the balloon until resistance is felt.
    The resistance is the wall of the artery.
If you push too hard, you can rupture the arterial wall, especially when it is healthy. This will most likely be in the vessels below the inguinal ligament.
The balloon will suddenly inflate easily.
This sudden inflation can happen also if the balloon bursts.
Withdraw the balloon.
If it has burst:
   Replace it. Be more gentle with the new balloon.
If you think you have ruptured the vessel:
    Plan to examine the limb at the end of the operation.
    Explore and repair the vessel as needed.
    Pull the catheter steadily out of the artery with your left hand.
    At the same time, with your right hand, increase or decrease the amount of liquid in the balloon to match the diameter of     the vessel being swept clear of the thrombus or embolus.
You will probably feel the narrowing of the superficial femoral artery at the adductor hiatus (about 35cm from the aortic bifurcation).
You will feel the roughness of atheromatous plaques on the arterial wall.
As the balloon of the catheter approaches the mouth of the common iliac artery, get the first assistant ready with a vascular sucker to remove thrombus or emboli.
If you bring up thrombus or emboli:
   Repeat passing the catheter until no more material is obtained.
    You should have a steady stream of back bleeding if the blockage is relieved.
    Flush 60ml of heparin saline down the left iliac artery.
    Reclamp the left iliac artery.
If there is no back bleeding and the catheter pass to 40cm or more, the limb may not be viable below the knee.
    Flush 60ml of heparin saline down the left iliac artery as above.
    Reclamp the left iliac artery.
    Continue the operation with a straight graft in anticipation of improvement in the distal limb when the aortic flow is     reestablished.
However, the patient may eventually lose part of the left limb from ischaemia.