A typical end-to-end anastomosis of a large vessel is exemplied in the arterial reconstruction following open repair of abdominal aortic aneurysm (AAA). The end of the divided aorta below the renal arteries is anastomosed to a prosthetic graft (Dacron or PTFE). After proximal control is obtained, the anterior wall of the aortic neck is divided, and the posterior wall can be left intact. The posterior wall of the aorta can be used as a double layer to buttress the suture line. In patients with satis­factory thickness of the aortic neck, the continuous suture starting intraluminal at 4 o’clock position is started. A double-armed 3-0 cardiovascular polypropylene suture is started in a continuous fashion with the suture line kept on loops (strings of a parachute) and the needle comes out in about 8 o’clock position. The suture line is then tightened on each side to bring the graft to the aortic neck. To avoid accidental loosening of the suture line, a new suture is tied to the rst one on either side at 4 o’clock and at 8 o’clock and continued anteriorly. In patients with tenuous aortic neck or in patients with juxtarenal abdominal aortic aneurysm, a two-layer anasto­mosis is performed with two techniques. (1) In patients with juxtarenal abdominal aortic aneurysms, the initial suture line is started at 3 o’clock and at 9 o’clock as horizontal mattress suture and continued anteriorly in the same fashion. And a sec­ond layer of a continuous over and over suturing is done. (2) In patients with weak and tenuous aortic neck or in patients with juxtarenal AAA, a two-layer anastomosis is performed with two techniques. Technique one is telescoping technique in patients with juxtarenal AAA.Technique two consists of interrupted sutures and a second with continuous suture. In patients with thin-walled and friable aortic neck, the rst layer comprises of interrupted horizontal mattress.

A technique to end-to-side attachment to a prosthetic graft to the artery is shown in Figs.1.9, 1.10, 1.11, and 1.12. The length of the arteriotomy is about two and a half times the diameter of the graft. After arteriotomy is made, the prosthetic graft is cut in a lazy “S”-shaped manor to produce a wide anastomosis with diminished chance of turbulence and intimal hyperplasia. The anastomosis is started at the heel using a double-armed suture at 11:30’ and 12:30’clock position, and suture line continued on each side with suture line stopping around 8 o’clock and then the second suture is continued to complete the suture line (Figs.1.12, 1.13, and 1.14). Before com­pleting the anastomosis, appropriate ushing maneuvers are performed to prevent distal embolization. In patients with end-to-side saphenous vein anastomosis to the common femoral artery, the hood of the greater saphenous vein (in situ technique) is spatulated, and a parachute technique is used to ensure the accuracy of the place­ment of all the sutures. In patients undergoing subclavian transposition into the

The classical example of open endarterectomy is carotid endarterectomy. This pro­cedure is more suitable for short-segmented lesions. The arteries open longitudi­nally after primary and distal clamping following administration of systemic heparin. A cleavage plane is developed between the thickest part of the plaque and the adventitia with the help of arterial dissector (dural elevator) and continued dis­tally till the plaque ends in a feathery end (Figs.1.16, 1.17, and 1.18). Tacking sutures at the distal end of the endarterectomy are not necessary unless the intima does not appear to be well adherent to the arterial wall. In those circumstances, two tacking sutures of a 7-0 cardiovascular polypropylene suture at 4 o’clock and at 8 o’clock positions are applied (Fig.1.19). Proximally, the plaque is usually sharply divided by Potts scissors. In patients with thick atheromatous plaque proximally, the vascular clamp is tightened to intentionally fracture the plaque, and this enables the calcied core to be removed from the proximal end from the jaws of the clamp (Figs.1.17 and 1.18), thus resulting in approximation of the intima to the wall of the artery. All the debris are irrigated with heparinized saline and removed with a ne pointed pickup. Arteriotomy is generally closed with a bovine patch graft (Fig.1.20).