Patch plasty

1. Clamp artery, give heparin and perform a longitudinal arteriotomy
2. Arteriotomy: use scalpel with blade Nr 11, perform a stab incision holding blade upwards, extend arteriotomy with Potts scissors
3. Tailor vein patch (for ‘isometric’ reconstruction: diameter results from diameter multiplied with pi), place intima facing inwards; patch end should not be pointed
4. Adjust length of longitudinal incision to accommodate patch
5. Place stay sutures
6. Apply a corner stitch at your far end (consider U-stitch to enforce eversion), tie suture keeping the same length of both suture ends
7. Perform a running suture along both sides to the middle of the arteriotomy
8. Apply a corner stitch at your close end (consider U-stitch to enforce eversion), tie suture keeping the same length on both suture ends
9. Perform a running suture along both sides to the middle of the arteriotomy
10. Tie on one side
11. Flush from proximally and distally through opposite side, rinse lumen with heparin and saline
12. Tie on other side
13. Perform angiography

Alternative options:

1. Corner stitches using 4 interrupted sutures (to avoid stenosis), then running sutures between the outer of these single sutures (Heidelberg technique)
2. Vein patch with 1 running suture (i.e. one suture around the whole patch without interruptions)

Attention:

1. Handling of artery wall with forceps: don’t squeeze intima,use forceps as counterforce during the stitch, hold only adventitia
2. Hold the needle holder correctly
3. Position the needle correctly in the needle holder
4. Stitch all wall layers using perpendicular stitches (no tangential stitches)
5. Stitch the vessel from inside out vessel, and the patch from outside in
6. Interaction between needle, needle holder and forceps: pick up needle, plan next stitch

Control of learning targets

• Eversion
• Regularity of stiches
• Tightness of suture
• Caliber of reconstruction