Starting from the top end of the arteriotomy and using a 4/0 Polypropylene suture on a 26 mm curved needle, the proximal part of the arteriotomy was closed primarily, just distally to the IMA orifice. At this stage, an arterial clamp was set below the IMA, reducing the blood loss from the lumbar arteries. Then, the arteriotomy was extended on the right iliac axis just before the right iliac bifurcation, and its plaque was removed. The distal part of the plaque was tacked down with a continuous 5/0 polypropylene tacking suture. After the plaque was removed, this part of the arteriotomy was closed, starting from its lowest with a new 4/0 suture. The top and the bottom sutures were tied together, and the arteriotomy was closed (Figure 5).

Figure 5: The arteriotomy from the aorta to the right CIA has been closed

The next step was to remove the plaque from the left iliac axis. A new small arteriotomy was done located on the left common iliac (Figure 6).

Figure 6: Arteriotomy on the left CIA

Again the plaque was removed easily from the top end as it was already endarterectomized, while the distal end was tacked down with a running 5/0 polypropylene suture, the same way it was done on the right side. Finally, this arteriotomy on the left common iliac artery was again closed with two separate 4/0 sutures starting from its top and the bottom end (Figure 7).

Figure 7: Final view of the aortoiliac bifurcation
Figure 8: Aortoiliac plaque