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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.
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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Silk was used for many years, but it has now been replaced by synthetic fibers, which are less traumatic to the vessel walls.
13/04/23 2Prof. A Y Taha: Principles of
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
13/04/23 3Prof. A Y Taha: Principles of
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.
13/04/23 4Prof. A Y Taha: Principles of
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).
13/04/23 5Prof. A Y Taha: Principles of
vascular anastomosis
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13/04/23 6Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 7Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 8Prof. A Y Taha: Principles of vascular
anastomosis
13/04/23 9Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 10Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 11Prof. A Y Taha: Principles of
vascular anastomosis
Simple suture
13/04/23 12Prof. A Y Taha: Principles of
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.
13/04/23 13Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 14Prof. A Y Taha: Principles of
vascular anastomosis
Patch angioplasty
13/04/23 15Prof. A Y Taha: Principles of
vascular anastomosis
End to end anastomosis: stay sutures
13/04/23 16Prof. A Y Taha: Principles of
vascular anastomosis
End to end anastomosis: interrupted suture
13/04/23 17Prof. A Y Taha: Principles of
vascular anastomosis
End to end anastomosis: continuous suture
13/04/23 18Prof. A Y Taha: Principles of
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.
13/04/23 19Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 20Prof. A Y Taha: Principles of
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.
13/04/23 21Prof. A Y Taha: Principles of
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.
13/04/23 22Prof. A Y Taha: Principles of
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.
13/04/23 23Prof. A Y Taha: Principles of
vascular anastomosis
Buttressing sutures
● Sutures may be buttressed with Dacron pieces whenthe wall of the artery isfriable and may cut out causing hemorrhage.
13/04/23 24Prof. A Y Taha: Principles of
vascular anastomosis
End to side anastomosis: four quadrant technique
13/04/23 25Prof. A Y Taha: Principles of
vascular anastomosis
End to side anastomosis: parachute technique
13/04/23 26Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 27Prof. A Y Taha: Principles of
vascular anastomosis
How to make a venous patch?
13/04/23 28Prof. A Y Taha: Principles of
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.
13/04/23 29Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 30Prof. A Y Taha: Principles of
vascular anastomosis
Non- sutured anastomosis
13/04/23 31Prof. A Y Taha: Principles of
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
13/04/23 32Prof. A Y Taha: Principles of
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
13/04/23 33Prof. A Y Taha: Principles of
vascular anastomosis
3 suture technique
13/04/23 34Prof. A Y Taha: Principles of
vascular anastomosis
End-to-side Anastomosis
13/04/23 35Prof. A Y Taha: Principles of
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)
13/04/23 36Prof. A Y Taha: Principles of
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
13/04/23 37Prof. A Y Taha: Principles of
vascular anastomosis
Mechanical flap monitoring Doppler
External Implanted
Buried flaps 80-100% salvage
(Disa J, et al 1999)
Color flow Other
13/04/23 38Prof. A Y Taha: Principles of
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.
13/04/23 40Prof. A Y Taha: Principles of
vascular anastomosis
Anastomotic bleeding
Suture line bleeding.
- Rx: Simple or U-shaped suture at the defect.
tying should be with non-Pulsetile flow.
13/04/23 41Prof. A Y Taha: Principles of
vascular anastomosis
Anastomotic Psudoaneurysm
Disruption of the suture line at the anastomosis result in walled off extra- luminal circulation of the blood.
13/04/23 42Prof. A Y Taha: Principles of
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.
13/04/23 43Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 44Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 45Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 46Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 47Prof. A Y Taha: Principles of
vascular anastomosis
Anastomotic stenosis
Early : Technical.
1-18 months: Intimal hyperplasia.
> 18 months: Progression of atherosclerosis.
13/04/23 48Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 49Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 50Prof. A Y Taha: Principles of
vascular anastomosis
13/04/23 51Prof. A Y Taha: Principles of
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
13/04/23 52Prof. A Y Taha: Principles of
vascular anastomosis
Thrombectomy
13/04/23 53Prof. A Y Taha: Principles of
vascular anastomosis
Questions?
Thanks!!!