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Rarely, tacking sutures will be required to prevent subintimal dissection (Figure 14). These horizontal mattress sutures of 7/0 polypropylene are placed at intervals circumferentially, using double-ended sutures passed from inside out and tied externally (Figure 14).

Occasionally a very large artery with a short length of arteriotomy can be closed, starting from both ends with 6/0 polypropylene sutures in a running manner using double ended vascular sutures. Care must be taken not to narrow the vessels during closure, especially the internal carotid artery distally. When approximately 1 cm of arteriotomy remains to be closed, the inlying shunt is doubly cross-clamped with straight mosquito hemostats and divided. The two ends of the shunt are then removed, first distally, then proximally, and bulldog clamps are reapplied (Figure 15). The remainder of the arteriotomy then is closed rapidly, great care being taken to flush the system of particulate debris and air (Figure 16). Following completion of closure, the clamps are removed in a specific order: external carotid artery, common carotid artery, and finally internal carotid artery. This order minimizes the possibility of cerebral embolization, permitting potential emboli to be flushed into the external carotid system preferentially. The completed endarterectomy must have thorough hemostasis and no residual stenosis.

Patch angioplasty with prosthetic material or autologous vein is preferred especially when dealing with small vessels (in women) or following technical misadventure where there is fragmentation or damage to the arterial wall. Mattress sutures of double ended 6/0 polypropylene are placed at either end Both needles of each end suture pass through the patch from outside to in and then pass from lumen to the outside of the carotid artery where the knots are tied (Figure 17). This provides a broad based loop that anchors the graft. The inferior or proximal suture B' is run superiorly in a continuous manner on the medial side of the graft and tied to A' (Figure 18). Sutures A and B are the run towards the midpoint on the lateral side of the arteriotomy. When approximately 1 cm of arteriotomy remains to be closed in the mid portion of the incision, the balloons are deflated and the shunt is cross-clamped with a straight mosquito hemostat. A brisk inflow and backflow are allowed so as to flush the area as the two ends of the shunt are removed, first distally, ...

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