Principles of vascular anastomosis

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.

1. Principles of Vascular
Anastomosis
By
Professor
Abdulsalam Y Taha
School of Medicine/ University of Sulaimaniyah/ Region of
Kurdistan/Iraq
https://sulaimaniu.academia.edu/AbdulsalamTaha

2. Introduction
The principles of vascular repair with sutures were established
in the first decade of the 20
th
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Silk was used for many years, but it has now been replaced by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.
15/10/14 2
Prof. A Y Taha: Principles of
vascular anastomosis

3. History
1899 – Dorfler advocated use of all layers of vessels
in repair
1907 – (Carrel) “The Surgery of Blood Vessels” (JH
Hospital Bull.)
1
st
replantation of canine limbs
1
st
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
15/10/14 3
Prof. A Y Taha: Principles of
vascular anastomosis

4. 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.
15/10/14 4
Prof. A Y Taha: Principles of
vascular anastomosis

5. 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).
15/10/14 5
Prof. A Y Taha: Principles of
vascular anastomosis

6. √ ᵡ
15/10/14 6
Prof. A Y Taha: Principles of
vascular anastomosis

7. 15/10/14 7
Prof. A Y Taha: Principles of
vascular anastomosis

8. 15/10/14 8Prof. A Y Taha: Principles of vascular anastomosis

9. 15/10/14 9
Prof. A Y Taha: Principles of
vascular anastomosis

10. 15/10/14 10
Prof. A Y Taha: Principles of
vascular anastomosis

11. 15/10/14 11
Prof. A Y Taha: Principles of
vascular anastomosis

12. Simple suture
15/10/14 12
Prof. A Y Taha: Principles of
vascular anastomosis

13. Kunlin suture
● If an endarterectomy has been performed,
there is a risk of intimal flap dissection at
the downstream edge. To eleminate this
risk, sutures are inserted to secure the
intima. The needle passes from outside to
inside through an endarterectomized part
of the wall and back from inside to outside
through the atheroma to be finally tied on
the outside.
15/10/14 13
Prof. A Y Taha: Principles of
vascular anastomosis

14. 15/10/14 14
Prof. A Y Taha: Principles of
vascular anastomosis

15. Patch angioplasty
15/10/14 15
Prof. A Y Taha: Principles of
vascular anastomosis

16. End to end anastomosis: stay
sutures
15/10/14 16
Prof. A Y Taha: Principles of
vascular anastomosis

17. End to end anastomosis:
interrupted suture
15/10/14 17
Prof. A Y Taha: Principles of
vascular anastomosis

18. End to end anastomosis:
continuous suture
15/10/14 18
Prof. A Y Taha: Principles of
vascular anastomosis

19. 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.
15/10/14 19
Prof. A Y Taha: Principles of
vascular anastomosis

20. 15/10/14 20
Prof. A Y Taha: Principles of
vascular anastomosis

21. End to end anastomosis:
single-stitch method
● Used when there is
a difficulty in rotating the
vessels, for example at
a large bifurcation.
● Commensing on the side
nearest the operater, the
sutures are inserted from
within the lumen to
complete the deep or
posterior aspect and then
continued across the anterior
aspect to the starting point.
● Alternatively, a double ended
suture may be commensed
at the midpoint posteriorly and
each side completed in turn.
15/10/14 21
Prof. A Y Taha: Principles of
vascular anastomosis

22. 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.
15/10/14 22
Prof. A Y Taha: Principles of
vascular anastomosis

23. Inlay parachute technique
● The double ended
suture is left untied
in order to allow
a number of stitches
to be placed on each
side before the graft
is pulled down onto
the artery.
15/10/14 23
Prof. A Y Taha: Principles of
vascular anastomosis

24. Buttressing sutures
● Sutures may be buttressed
with Dacron pieces when
the wall of the artery is
friable and may cut out
causing hemorrhage.
15/10/14 24
Prof. A Y Taha: Principles of
vascular anastomosis

25. End to side anastomosis: four
quadrant technique
15/10/14 25
Prof. A Y Taha: Principles of
vascular anastomosis

26. End to side anastomosis:
parachute technique
15/10/14 26
Prof. A Y Taha: Principles of
vascular anastomosis

27. 15/10/14 27
Prof. A Y Taha: Principles of
vascular anastomosis

28. How to make a venous patch?
15/10/14 28
Prof. A Y Taha: Principles of
vascular anastomosis

29. 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.
15/10/14 29
Prof. A Y Taha: Principles of
vascular anastomosis

30. 15/10/14 30
Prof. A Y Taha: Principles of
vascular anastomosis

31. Non- sutured anastomosis
15/10/14 31
Prof. A Y Taha: Principles of
vascular anastomosis

32. 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
15/10/14 32
Prof. A Y Taha: Principles of
vascular anastomosis

33. 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
15/10/14 33
Prof. A Y Taha: Principles of
vascular anastomosis

34. 3 suture technique
15/10/14 34
Prof. A Y Taha: Principles of
vascular anastomosis

35. End-to-side Anastomosis
15/10/14 35
Prof. A Y Taha: Principles of
vascular anastomosis

36. 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)
15/10/14 36
Prof. A Y Taha: Principles of
vascular anastomosis

37. 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
15/10/14 37
Prof. A Y Taha: Principles of
vascular anastomosis

38. Mechanical flap monitoring
Doppler
External
Implanted

Buried flaps

80-100% salvage

(Disa J, et
al 1999)
Color flow
Other
15/10/14 38
Prof. A Y Taha: Principles of
vascular anastomosis

39. Complications of Vascular
Anastomosis
Badr Aljabri MD, FRCSC
Associate Professor and Consultant
Vascular Surgeon, KKUH

40. Anastomotic bleeding
Needle hole bleeding.
- more common with PTFE grafts.
- Rx: Local haemostatic agents.
Reverse systemic heparin
effect.
15/10/14 40
Prof. A Y Taha: Principles of
vascular anastomosis

41. Anastomotic bleeding
Suture line bleeding.
- Rx: Simple or U-shaped suture at
the defect.
tying should be with non-
Pulsetile flow.
15/10/14 41
Prof. A Y Taha: Principles of
vascular anastomosis

42. Anastomotic Psudoaneurysm
Disruption of the suture line at the
anastomosis result in walled off extra-
luminal circulation of the blood.
15/10/14 42
Prof. A Y Taha: Principles of
vascular anastomosis

43. Patient Factors
1.Native Artery Disease.
2.Infection.
3.Smoking
4.Hypertension.
5.Healing complications
( Seroma, Hematoma)
Material Factors
1.Graft Defect
2.Suture Degradation or
breakage.
3.Prosthetic graft- arterial wall
compliance mismatch
Technical Factors
1.Inadequate suture bites.
2.Excessive tension.
3.Joint Motion.
4.Redo Procedure.
5.Endarterectomy.
15/10/14 43
Prof. A Y Taha: Principles of
vascular anastomosis

44. 15/10/14 44
Prof. A Y Taha: Principles of
vascular anastomosis

45. 15/10/14 45
Prof. A Y Taha: Principles of
vascular anastomosis

46. 15/10/14 46
Prof. A Y Taha: Principles of
vascular anastomosis

47. 15/10/14 47
Prof. A Y Taha: Principles of
vascular anastomosis

48. Anastomotic stenosis
Early : Technical.
1-18 months: Intimal hyperplasia.
> 18 months: Progression of
atherosclerosis.
15/10/14 48
Prof. A Y Taha: Principles of
vascular anastomosis

49. 15/10/14 49
Prof. A Y Taha: Principles of
vascular anastomosis

50. 15/10/14 50
Prof. A Y Taha: Principles of
vascular anastomosis

51. 15/10/14 51
Prof. A Y Taha: Principles of
vascular anastomosis

52. Graft thrombosis
Early
1.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
infection
5.Low circulatory volume.
6.Hypercoagulable state.
Intermediate
Intimal Hyperplasia
(1 month -18 months)
Late
1.Progression of Atherosclerosis.
2.Degenerative lesions in the graft
15/10/14 52
Prof. A Y Taha: Principles of
vascular anastomosis

53. Thrombectomy
15/10/14 53
Prof. A Y Taha: Principles of
vascular anastomosis

54. Questions?
Thanks!!!