So you have dived into a lake full of blood from a ruptured AAA. And you have proximal control. Great! What you need now is just distal (ilacs) control. How can you do this? 

On the commonest scenario, the common iliac arteries are of normal size (no aneurysmal dilatation) and can be clamped. There are three ways to do it:

  1. The official way. If you have time (the patient is not exsanguinating) you can dissect through the posterior peritoneum, find the common iliac arteries and clamp them. I can admit that although it is the most proper way it is very rarely been performed as the time is limited.
  2. The alternative way. You are already into the aneurysmal sac, the hematoma covers everything and you do not want to risk dissecting into it trying to find the common iliacs. Get two Folley catheters 12 or 14 size. Put a heavy clip on the end of the first catheter (where the urine sac is attached). Try to see the orifice of the common iliac artery from within the opened sac and put the tip of the catheter well into it. Do not push it too much if you feel any resistance. Inflate the balloon of the catheter with 5ml max of normal saline. The back-bleeding from the common iliac artery should have stopped by now. Throw the clip which is attached on the other side of the catheter outside the abdominal wound and let it hanging out. Do the same for the other common iliac artery. What is the problem here? You have to deal with the distal anastomosis with two pieces of rubber (catheters) in between the graft, the aorta and the Prolene stitch. Just be patient and take your time.
  3. The commando way. Do you remember how you put the infrarenal aortic clamp? Just do the same for the common iliacs.  Stick your index finger (or the small finger if you like) gently into the orifice and put a clamp across it. That’s it! The artery is clamped. Beware not to push the clamp too deep. You may end up with black blood coming up from deep inside, filling quickly the area. Do not worry! An iliac vein, or the IVC is torn!!! You have to fix and a vein now!!! Learn how here.

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