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The Venous Coupler:Is Time Money?
Pouria Moradi, Victoria Rose
Imperial College LondonCharing Cross Hospital, UK
The Ideal Non-Suture Anastomotic Device
• Minimal blood- exposed non-intimal surface
• Minimal inflammatory response
• Minimal vessel trauma
• Easy, quick & safe deployment (recovery)
• Multiple vessel sizes
• Patency equal or better than hand sewn
• Cost
Theoretical Benefits of Coupler by avoidance of
• Foreign body suture contact with blood flow
• Subendothelial collagen exposure from poor intimal contact
• Lumin narrowing prevented by stenting effect of coupler
Holt & Lewis, S Forum 1960:11:243
Holt & Lewis
• 2 rings
• Teflon
• Pinned
• Interlocking
• No FB within lumen
• Neo-endothelium lining
Nakayama K, Tamiya T, Yamamoto K, et al.A simple new method for small vessel anastomoses (free autograft of the
sigmoid included).Surgery. 1962;52:918–931
• Refined
• Applicator
• Lumen measuring tool
• Stainless steel
• 1.5mm
• End-to-side
• Vein patch
Östrup LT, Berggren A. The UNILINK instrument system for fast and safe microvascularanastomoses. Ann Plast Surg. 1986;17:521–525.
• Sweden (Unilink/3M Synovis/MAC)
• 2 Polyethylene rings
• 6 Stainless steel pins
• Push fit seal
• 90° eversion
How does it work?
Select Coupler Size
Flap Vessel
Closing The Coupler
Final Result
Animal Studies
• Rabbit Carotid artery & Facial veins
• End-to-End & End-to-Side
• Average times quoted 2-5 minutes
• 98-100% patency rates
• 2 year follow up
• Media thinning of artery and 40% aneurysm rate
• Tensile strength greater
Ostrup Berggren, Gilbert & Ragnarsson
Animal Studies• Artery:
– Initially no difference is seen between
coupled anastomoses micro and
macroscopically
–2 years significant media thinning was
seen in the artery for 10mm distal to
the coupler with possible aneurysm
formation in 40%
• No problems were detected with the
vein
1000 Consecutive Venous Anastomoses using the microvascularanastomotic coupler in breast reconstruction
PRS 2010 Jandali et al
• 6 instances of venous thrombosis (0.6%)
– Nil flap loss
– 2 partial flap losses
• Same institution (Vega PRS 2008)
– 500 free TRAMS
– 2.8% Hand sewn venous anastomosis thrombosis
Venous thrombosis in coupled versus sutured microvascularanastomoses
Ann PlastSurg 2006 Yap et al
• 139 anastomosis in coupler group
– 2/139 thrombosis (1.4%)
• 584 anastomosis in hand sutured group
– 19/584 thrombosis (3.3%)
Relative Contraindications
• Not for thick walled vessels
• Not for Arteries
• Not for Short vessel lengths
• Size mismatch
• Registrar training???
Purpose of the Study Is The Coupler Cost Effective?
Cost
Coupler• Instrumentation
– Coupler kit £950• Consumable
– Coupler £112
• In Australia $610 per case on consignment– Covered by Private Insurance
Suture• Consumable
– 8’0 ethilon £20 $Aus 19.12– 9’0 ethilon£40 $Aus 21.68– 10’0 ethilon £60 $Aus 26.28
Methods
• DIE vessels to IM vessels only
• Vein Coupler compared to Arterial Suture
2 Surgeons
• Registrar
~ 6 years Plastic Surgery
• Consultant
~ 11 years Plastic Surgery
Technique
• Artery
– From first suture puncture
– To clamps off
– Minutes
• Vein
– Coupler placed in microscope field
– To clamps off
– Minutes
RESULTS
Mean Time
0
5
10
15
20
25
30
Registrar Consultant
Mean Artery
Mean Coupler
Tim
e in
min
ute
s
• Definite improvement in hand tie times is
seen with increasing experience
• This is not seen with coupler
• All surgeons averaged similar coupler
times
% of Ischaemia Time
0
5
10
15
20
25
30
35
Reg Con
% Ischaemia Artery
% Ishaemia Coupler
• Over 28% of all ischaemia time was spent
on the artery
• An average of 11% of the total ischaemiatime was spent on the coupler
Complications
• No Coupler Leaks
• No Failed Deployments
• 100% Patency all Anastomoses
• No Flap Failures
• Extra Arterial Time in 5 Cases
– ie extra sutures for leaks
Time Conclusions
• Coupled Vein is quicker than sutured artery
• Consistent time for coupled anastomosis across grades
• % Ischaemia time of Coupler is less than sutured artery
Time is Money
• OR p/hr £800/hr $Aus1200/hr• Time (C) 5.50 mins• Time (S) 17.50 mins• Time saved 12.00 mins
– 12/60 x £800=£160– 12/60 x $1200= $aus240
• Coupler cost £112• 9‘0 cost £40
– £112-£40=£72
• Net saved per Case – £160-£72=£88.00
Conclusions
• Microvascular coupler is a safe alternative to suture for venous anastomosis
• Microvascular coupler is faster than suture
• Microvascular coupler has a shorter learning curve than suture
• Microvascular coupler is cost effective
Thank You