Principles of Vascular Anastomosis

ByProfessor

Abdulsalam Y Taha

School of Medicine/ University of Sulaimaniyah/ Region of Kurdistan/Iraq

https://sulaimaniu.academia.edu/AbdulsalamTaha

Introduction The principles of vascular repair with sutures were

established in the first decade of the 20th century by Alexis Carrel, who in 1912 was awarded the Nobel Prize for medicine for his work .

Since then, technical refinements of suture materials have made possible surgical reconstruction of most arteries from the root of the aorta to microvascular anastomosis or repair of the smallest vessels, e.g., digital arteries or those on the surface of the brain.

Fine sutures on atraumatic needles are best for arterial anastomosis.

Silk was used for many years, but it has now been replaced by synthetic fibers, which are less traumatic to the vessel walls.

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vascular anastomosis

History 1899 – Dorfler advocated use of all layers of

vessels in repair 1907 – (Carrel) “The Surgery of Blood Vessels”

(JH Hospital Bull.) 1st replantation of canine limbs 1st esophageal-intestinal interposition

1959 – (Seidenberg) human esophageal-intestinal interposition

1960 – (Jacobson/Suarez) operating microscope introduced (1 mm vessels)

1966 – (Antia/Buch) fasciocutaneous transfer 1972 – (McLean/Buncke) omental flap to scalp

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vascular anastomosis

a. Pass a right angle clamp gently through the soft tissue directly on the dorsal aspect of the artery and direct it away from the larger veins to avoid iatrogenic injuries. Caution! Avoid accidental penetration of the dorsal wall of the artery. b. Gently lift the artery with the vessel-loop to achieve tension in the tissues, thus facilitating the dissection.

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vascular anastomosis

Different methods for controlling bleeding are demonstrated.From left to right: doubly applied vessel loop, bulldog( small metallic vascular clamp), balloon catheter, loop of ligature, vascular clamp).

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vascular anastomosis

√ ᵡ

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vascular anastomosis

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vascular anastomosis

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anastomosis

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

Simple suture

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vascular anastomosis

Kunlin suture

● If an endarterectomy has been performed, there is a risk of intimal flap dissection atthe downstream edge. To eleminate this risk, sutures are inserted to secure theintima. The needle passes from outside toinside through an endarterectomized partof the wall and back from inside to outsidethrough the atheroma to be finally tied onthe outside.

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vascular anastomosis

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vascular anastomosis

Patch angioplasty

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vascular anastomosis

End to end anastomosis: stay sutures

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vascular anastomosis

End to end anastomosis: interrupted suture

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vascular anastomosis

End to end anastomosis: continuous suture

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vascular anastomosis

When two vessels with different diameters are being sutured

end to end, the smaller has to be slit open and the edges

trimmed to fit the larger one, which must be cut somewhat

obliquely to avoid kinking.

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vascular anastomosis

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vascular anastomosis

End to end anastomosis: single-stitch method

● Used when there isa difficulty in rotating the vessels, for example at a large bifurcation.● Commensing on the side nearest the operater, thesutures are inserted from within the lumen to complete the deep or posterior aspect and thencontinued across the anterioraspect to the starting point.● Alternatively, a double endedsuture may be commensed at the midpoint posteriorly and each side completed in turn.

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vascular anastomosis

End to end anastomosis: inlay technique

● Used for AAA repair.● Double ended horizontal mattress suture in the middle of the graft.● Needles should pass from graft to aorta● Take large bites incorporating all layers.

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vascular anastomosis

Inlay parachute technique

● The double endedsuture is left untiedin order to allow a number of stitchesto be placed on eachside before the graftis pulled down ontothe artery.

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vascular anastomosis

Buttressing sutures

● Sutures may be buttressed with Dacron pieces whenthe wall of the artery isfriable and may cut out causing hemorrhage.

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vascular anastomosis

End to side anastomosis: four quadrant technique

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vascular anastomosis

End to side anastomosis: parachute technique

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vascular anastomosis

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vascular anastomosis

How to make a venous patch?

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vascular anastomosis

Spiral graft technique

Spiral graft technique to create a graft of large diameter for replacing vein segments. A saphenous vein is cut longituidinally and sutured in a spiral fashion over plastic tubing used as a stent.

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vascular anastomosis

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vascular anastomosis

Non- sutured anastomosis

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vascular anastomosis

Microvascular surgical technique Trim adventitia

2-3mm Gentle handling (no full-

thickness) Trim free edge, if needed Dissect vessels from

surrounding tissues Irrigate and dilate

Heparinized saline Mechanical dilation (1 ½

times normal –paralyses smooth muscle)

Chemical dilation, if necessary

Suturing

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vascular anastomosis

Microvascular suture technique 3 guide sutures (120

degrees apart) Perpendicular piercing Entry point 2x thickness

of vessel from cut end Equal bites on either side Microforceps in lumen vs.

retracting adventitia Pull needle through in

circular motion Surgeon’s knot with

guide sutures, simple for others

Avoid backwalling—2 bites/irrigation

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vascular anastomosis

3 suture technique

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vascular anastomosis

End-to-side Anastomosis

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vascular anastomosis

Mechanical anastomosis Devices

Clips Coupler Laser

Results Increased efficiency and

speed, use in difficult areas Patency rates at least equal

to hand-sewn (Shindo, et al 1996, De Lorenzi, et al 2002)

Can be used for end-to-end or end-to-side (DeLacure, et al 1999)

Poorer outcome with arterial anastomosis—20-25% failure (Shindo, et al 1996, Ahn, et al 1994)

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vascular anastomosis

Microvascular Hints & Helps Use background to help

visualize suture Demagnetize

instruments, if needed May reclamp vessels for

repair after 15 minutes of flow

Reclamp both arterial and venous vessels when revising venous anastomosis

Support your hands and hold instruments like a pencil

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vascular anastomosis

Mechanical flap monitoring Doppler

External Implanted

Buried flaps 80-100% salvage

(Disa J, et al 1999)

Color flow Other

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vascular anastomosis

Complications of Vascular Anastomosis

Badr Aljabri MD, FRCSC

Associate Professor and Consultant Vascular Surgeon, KKUH

Anastomotic bleeding

Needle hole bleeding. - more common with PTFE

grafts. - Rx: Local haemostatic

agents. Reverse systemic

heparin effect.

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vascular anastomosis

Anastomotic bleeding

Suture line bleeding.

- Rx: Simple or U-shaped suture at the defect.

tying should be with non-Pulsetile flow.

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vascular anastomosis

Anastomotic Psudoaneurysm

Disruption of the suture line at the anastomosis result in walled off extra- luminal circulation of the blood.

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vascular anastomosis

Patient Factors1. Native Artery Disease.2. Infection.3. Smoking4. Hypertension.5. Healing complications ( Seroma, Hematoma)

Material Factors1. Graft Defect2. Suture Degradation or

breakage.3. Prosthetic graft- arterial wall

compliance mismatchTechnical Factors1. Inadequate suture bites.2. Excessive tension.3. Joint Motion.4. Redo Procedure.5. Endarterectomy.

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

Anastomotic stenosis

Early : Technical.

1-18 months: Intimal hyperplasia.

> 18 months: Progression of atherosclerosis.

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

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vascular anastomosis

Graft thrombosisEarly1. Technical (kink, missed valve, AV fistula,

intimal flap)2. Poor choice of inflow or outflow sites.3. Insufficient runoff.4. Ongoing or progression of soft tissue

infection5. Low circulatory volume.6. Hypercoagulable state.

IntermediateIntimal Hyperplasia (1 month -18 months)

Late 1. Progression of Atherosclerosis.2. Degenerative lesions in the graft

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vascular anastomosis

Thrombectomy

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vascular anastomosis

Questions?

Thanks!!!