Abdominal Aorto-iliac Occlusive Disease: Bifurcated Graft Bypass

Occlusive disease of distal infrarenal aorta and/or common iliac arteries. Collateral network providing blood flow to lower limbs (lumbar arteries or inferior epigastric arteries). As treatment a aorto-bi-iliac (external iliac artery) or aorto-bi-femoral bifurcation graft bypass needs to be done to restore blood flow to the lower limbs.

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Educational objectives

Implantation of a para-/infrarenal aortic bifurcated graft (Dacron 16x8mm or 18x9mm)
End-to-End (optional End-to-Side) anastomosis with clamping of one renal artery
To always apply intravenous heparin before arterial clamping (except patient has a history of heparin induced thrombopenia (HIT)
To apply tangential(partial) aortic clamp at the infrarenal aorta correctly (pay attention to orientation of calcified plaques)
to decide if suture line needs to be reinforced
To stitch correctly through arterial wall inside out (perpendicular direction)
To move the graft towards the correct position before pulling the thread after every stitch
To decide if distal anastomosis should be end-to-end or end-to-side on common iliac artery or external iliac artery
To rinse graft limbs and target vessels before restoring blood flow

All Steps in Detail

Step 1: Exposition

Abdominal wall retractor and transperitoneal exposition of the infrarenal aorta, including definition of anatomical landmarks
Placement of silicone tube around the proximal aortic neck distally to the renal arteries
Preparation of distal bypass zones. Placement of vessel loops around both external iliac arteries or common femoral arteries
Supra- /infrarenal crossclamping using Glover clamp (rear branch of the clamp is conducted behind the aortic wall by means of a silicone tube)
Left lateral longitudinal incision (more than 3 cm long), beginning below the left renal artery
Limited thrombendarterectomy of the infrarenal aorta

Step 2: Proximal anastomosis

Standing on the right side of the body the suture starts at 5 o‘clock on the contralateral side (suture material: 3-0 double needle polypropylene suture)
First stitch inside-out on the aorta, put a suture clamp on the second needle
Second stitch with the same needle outside-in on the graft and inside-out on the aorta clockwise to first stitch
Continue with a running suture around the heel up to 8 o‘clock, put a suture clamp on that needle when needle is outside the graft and pull on both clamps (suture ends) approximating graft and aorta (moving the graft up and down)
After positioning the graft at the anastomotic level, continue the suture with the second needle completing the cranial wall suture of the aorta
Flushing and control of the proximal anastomosis under pulsatile pressure, additional stitches if necessary (U stich, Borst stitch, suture reinforcement)

Step 3: Distal anastomosis

Clamping of target vessel
Longitudinal incision of 1 cm. Rounding ofincision ends with a 3.5 or 4 mm punch (allows better view into the artery)
Anastomosis with bypass graft starting at 5o’clock outside-in graft and inside-out artery using 5-0 double needlepolypropylene suture.
Continue suturing around the heel in parachutetechnique until 8 o’clock. Approximate the graft to the artery (mowing down thegraft)
Continue suturing around the toe with otherneedle, flush and knot under pressure
Perform same procedure on other side

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Control of educational objectives

Proximal Anastomosis

Leak tightness
Sequence of stitches
Transmural stitching ("big bites")
Correct match of aortic incision and length of anastomosis
Appropriate length of graft
Appropriate clamping
Number of extra stitches needed

Pictures and Drawings

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Courses Teaching this Procedure

European Vascular Master Class

Jan 21, 2026

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Jan 23, 2026

More Information

Simulators Used for this Procedure

Abdominal Aorta Simulator