An aortic clamp is then used to clamp the aorta proximally just below the renal arteries (Figure 4). A second aortic clamp is placed horizontally to occlude the iliac vessels and the lumbar arteries, as depicted in Figures 4 and 5. A small vascular clamp should be applied to the inferior mesenteric artery. It is important to have the distal aorta freed sufficiently that this clamp can be placed far posteriorly to avoid interference with the arteriotomy and the anastomosis. A linear arteriotomy is made in the aorta to a point just above the inferior mesentery artery takeoff (Figure 5). An attempt is made to preserve that vessel if at all possible. The graft is beveled (Figure 6A), and an end-to-side anastomosis is then created (Figures 6B, 7, 8, and 9) with a running 000 vascular suture, beginning at the inferior margin of the arteriotomy with a mattress suture, much as described in Plate 153. The running suture then is carried up each side of the arteriotomy, and finally the anastomosis is completed in the middle of the arteriotomy on the operator's side.