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A graft of appropriate size is then stretched and tailored to fit the aortic defect (Figure 11). Suturing of the graft begins in the midline posteriorly with a double-arm swedged 00 or 000 nonabsorbable suture usually made of monofilament nylon or polypropylene. The initial stitch begins by passing both needles from outside inward on the graft and from inside outward on the aorta. This suture is then tied (Figure 12). Over-and-over suturing is then carried from the midline position, proceeding from outside the graft to inside the aorta. At the midline anteriorly, this suture is again tied (Figure 13).

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Vascular clamps are temporarily applied to the iliac limbs of the graft, and the aortic clamp is momentarily released to check the proximal suture line for hemostasis and the preclotting of the graft. Should leaks be noted in the anastomosis, they can be controlled by individual mattress sutures.

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The iliac anastomoses are done in the same manner as that of the aorta (Figure 14). Just before completion of the anastomosis, the aortic clamp is opened momentarily to flush any clots that may have accumulated in the aorta or graft (Figure 15). This flushing out greatly lessens the incidence of subsequent thrombosis in either extremity and justifies a considerable loss of blood.

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