Successful Graft Function and Longevity

• Good in-flow (above the disease).
  
• Good back-flow (i.e. run-off below the disease).
  
• Intermittently flush debris from vessels with heparinised saline.
  
• Systemic anticoagulation prior to clamping.
  
• Use of BMT (±anticoagulation).

Vessel Dissection

• Proximal dissection and control first.
  
• Then distal dissection and control.
  
• Followed by dissection and control of the diseased segment.

Handling the Vessel

• Minimally handling to reduce the risk of injury and thrombosis.
  
• Once vessel is opened, the intima should not be picked up with any instrument to prevent injury and thrombosis.
  
• For manipulation of the vessel, the adventitial layer can be gently picked up with forceps and manoeuvred.

Controlling the Vessel

• A vascular ‘loop’ should be slung around the vessel (preferably looped twice) both above and below the diseased segment (i.e. ‘looping’ or ‘Pottsing’ the vessel).
  
• This allows both easy vessel manipulation and control of bleeding by lifting the vascular loops upwards, which in turn will ‘snug-down’ on the vessel.
  
• Large branches may be controlled in the same way, while smaller branches may also be looped but with a surgical tie (without actually tying a knot so as to preserve collateral supply).
  
• Appropriate-sized and angled vascular clamps may then be applied. Although these are atraumatic, clamp damage may still occur from fracturing the wall (especially calcified vessels) and intimal tearing.

Basic Vascular Surgical Techniques

Anastomosis