Arteriotomy, Basic suture techniques

• To always apply intravenous heparin  before arterial clamping (except patient has a history of heparin induced  thrombopenia (HIT)
• To understand the important differences between ‘clamping’ devices (e.g. DeBakey vascular clamp vs Overholt clamp)
• To apply arterial clamps correctly (pay attention to orientation of calcified plaques)
• To perform arteriotomy correctly  (Nr. 11 scalpel (upwards!) and Potts scissors)
• To handle forceps correctly to avoid  damage to arterial walls (don’t squeeze)
• To position needle correctly in the needle holder (usually 1/3 to 2/3; 30°  forward)
• To adopt  an ergonomic hold of instruments and position of body and arms
• To stitch correctly through arterial walls  (perpendicular direction)
• To direct stitches correctly: from inside out  in arteries and towards  outflow (to avoid dissection); from outside in in prostheses (and, if necessary, in  arteries towards inflow
• To never grasp sutures with instruments (it can be damaged or break)
• To always evert the arterial wall (to avoid contact of blood stream with adventitial  connective tissues)
• To understand pros and cons of interrupted sutures vs running sutures
• To understand optimal placement of the suture in  running sutures to ensure a tight suture (forward direction of every stitch,  shortest distance between stitch in and stitch out)
• As assistant: where to hold a suture to  secure suture line, avoid loops of the remaining suture but give enough leeway for the next stitch (45% to 55% principle)
• As assistant: to pull the suture in direction of the stitch,  and not backwards (to avoid pursestring effect
• As assistant: to let the surgeon adapt the  tissues first before pulling the suture (to avoid suture hole  bleeding)
• To always flush before closure, knotting and declamping

1. 2x transverse / 2x longitudinal arteriotomies. Close both arteriotomies with both techniques: interrupted and running sutures, respectively
2. Handling of arterial wall: grasp only adventitia with your forceps
3. Proper clamping of the artery: pay attention to plaque, use a vascular clamp, adjust the force of the clamp, don’t forget to give heparin before clamping!
4. Arteriotomy: use a s scalpel blade Nr 11, stab incision holding blade upward
5. Extend arteriotomy using Potts scissors
6. Handling of artery with forceps: don’t squeeze intima, use forceps as counterforce during the stitch, hold only adventitia
7. Hold the needle holder correctly
8. Position of needle correctly
9. Stitch all wall layers with a perpendicular stitch (no tangential stitches)
10. Direction of stitch inside-out (in arterial walls to avoid dissection)
11. Interaction between needle, needle holder and forceps: pick up needle, plan next stitch

Control of learning targets

• Eversion
• Regularity of stiches
• Tightness of suture