It is sutured with 2-0 or 3-0 polypropylene sutures to the neck of aneurysm and aortic bifurcation. When the common iliac arteries are involved, a 16- or 18-mm bifurcated graft is used and sutured to the distal common iliac arteries in an end-to-end fashion, using 4-0 polypropylene running sutures. If internal iliac aneurysm is present, one of the limbs of the graft is connected to external iliac artery and internal iliac artery is reconstructed with an 8-mm interposition graft from the iliac limb to the distal internal iliac artery. Associated external iliac artery occlusive disease is treated with aortofemoral bypass. In all these situations, control of iliac arteries is maintained by mobilization of internal and external arteries and clamping them individually.
Before declamping, both the proximal and distal anastomoses are flushed to remove any loose plaque or thrombus and suture lines are completed. This also confirms the patency. Then the graft is filled with dilute heparinized saline solution and anesthesia team is informed that the aorta will be declamped soon. This allows time for stopping vasodilator infusion and adequate volume replacement. The aortic clamp is removed with caution to minimize hypotension and allow anesthesia for adequate volume replacement.
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