Some tips for the operation?
- Complete dissection of the abdominal aorta and the common iliac arteries, from the renal level on the top to the iliac bifurcations on the bottom
- Control with elastic slings / heavy silk sutures/bulldog clamps etc., of as many aortoiliac branches (IMA and lumbar arteries) as possible. This way, the blood loss during the endarterectomy will be minimized. It is amazing how much blood you can lose if you do not consider this fact. In our case, the patient needed to receive five units of RBC. A cell saver device will be more than helpful, something we had not considered.
- Sequential arteriotomy and closure of the arteriotomy. It is unnecessary to make a complete arteriotomy from the beginning as this will result in severe back bleeding from the lumbar arteries unless you have controlled each one. The sequential arteriotomy will be followed by the sequential closure of the arteriotomy. This will still reduce the amount of blood lost.
- Two separate arteriotomies, one from the aorta to the right iliac and the other on the left common iliac artery.
- Tack suturing on the distal (iliac) plaques remnants
- Use of more than one suture for the closure of the arteriotomies. This is the best way to minimize the risk of anastomosis tearing, which may be disastrous if it happens after the patient leaves the operating theater.
- No need for patching. It seems that patching is not necessary as these are quite large vessels. Of course, if it is considered necessary, it can be done.
Our patient had a rewarding outcome with good pulsating dorsalis pedis arteries on both limbs. She had an uneventful recovery and was discharged home on POD 5.
Special thanks to all participating surgeons (NK, GP), anesthetists (DM, E?), our scrub nurses, and of course, AG, who was with us mentoring, giving advice, taking pictures, and emotionally supporting. Most of the above-mentioned tricks belong to him.