Before clamping, anesthesia team is informed and IV heparin is administered (60-70 U/kg), and mannitol (12.5 mg) is given to force diuresis. First, the iliac clamps are placed and this is followed by the placement of aortic clamp. This technique reduces the risk of distal embolization.
The aortic clamp is placed at a position where the chance of loose thrombus leading to renal embolization is less. If the infrarenal aorta appears “shaggy” on the CT scan or proximal aortic neck is short, suprarenal clamping is also required. Kidney perfusion with iced heparin is done if suprarenal aortic clamping is done and renal perfusion is interrupted for more than 30 minutes. If the aorta is friable, anastamosis can be supported by Teflo-felt pledges.
The aneurysmal sac is opened longitudinally after clamping using electrocautery and laminated mural thrombus is removed. Bleeding from the lumbar arteries is controlled with polypropylene suture ligature and bleeding from the inferior mesenteric artery is controlled with a vessel loop or clamp. If the iliac arteries are not aneurysmal, a straight collagen or gelatin-coated zero porosity polyester (Dacron) graft is used for repair.
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