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Principles of vascular anastomosis

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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

  1. 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. 2. 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  Silk was used for many years, but it has now been replaced by synthetic fibers, which are less traumatic to the vessel walls. Prof. A Y Taha: Principles of 15/10/14 2 vascular anastomosis
  3. 3. 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 Prof. A Y Taha: Principles of 15/10/14 3 vascular anastomosis
  4. 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. Prof. A Y Taha: Principles of 15/10/14 4 vascular anastomosis
  5. 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). Prof. A Y Taha: Principles of 15/10/14 5 vascular anastomosis
  6. 6. √ ᵡ Prof. A Y Taha: Principles of 15/10/14 6 vascular anastomosis
  7. 7. Prof. A Y Taha: Principles of 15/10/14 7 vascular anastomosis
  8. 8. 15/10/14 Prof. A Y Taha: Principles of vascular anastomosis 8
  9. 9. Prof. A Y Taha: Principles of 15/10/14 9 vascular anastomosis
  10. 10. Prof. A Y Taha: Principles of 15/10/14 10 vascular anastomosis
  11. 11. Prof. A Y Taha: Principles of 15/10/14 11 vascular anastomosis
  12. 12. Simple suture Prof. A Y Taha: Principles of 15/10/14 12 vascular anastomosis
  13. 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. Prof. A Y Taha: Principles of 15/10/14 13 vascular anastomosis
  14. 14. Prof. A Y Taha: Principles of 15/10/14 14 vascular anastomosis
  15. 15. Patch angioplasty Prof. A Y Taha: Principles of 15/10/14 15 vascular anastomosis
  16. 16. End to end anastomosis: stay sutures Prof. A Y Taha: Principles of 15/10/14 16 vascular anastomosis
  17. 17. End to end anastomosis: interrupted suture Prof. A Y Taha: Principles of 15/10/14 17 vascular anastomosis
  18. 18. End to end anastomosis: continuous suture Prof. A Y Taha: Principles of 15/10/14 18 vascular anastomosis
  19. 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. Prof. A Y Taha: Principles of 15/10/14 19 vascular anastomosis
  20. 20. Prof. A Y Taha: Principles of 15/10/14 20 vascular anastomosis
  21. 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. Prof. A Y Taha: Principles of 15/10/14 21 vascular anastomosis
  22. 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. Prof. A Y Taha: Principles of 15/10/14 22 vascular anastomosis
  23. 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. Prof. A Y Taha: Principles of 15/10/14 23 vascular anastomosis
  24. 24. Buttressing sutures ● Sutures may be buttressed with Dacron pieces when the wall of the artery is friable and may cut out causing hemorrhage. Prof. A Y Taha: Principles of 15/10/14 24 vascular anastomosis
  25. 25. End to side anastomosis: four quadrant technique Prof. A Y Taha: Principles of 15/10/14 25 vascular anastomosis
  26. 26. End to side anastomosis: parachute technique Prof. A Y Taha: Principles of 15/10/14 26 vascular anastomosis
  27. 27. Prof. A Y Taha: Principles of 15/10/14 27 vascular anastomosis
  28. 28. How to make a venous patch? Prof. A Y Taha: Principles of 15/10/14 28 vascular anastomosis
  29. 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. Prof. A Y Taha: Principles of 15/10/14 29 vascular anastomosis
  30. 30. Prof. A Y Taha: Principles of 15/10/14 30 vascular anastomosis
  31. 31. Non- sutured anastomosis Prof. A Y Taha: Principles of 15/10/14 31 vascular anastomosis
  32. 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 Prof. A Y Taha: Principles of 15/10/14 32 vascular anastomosis
  33. 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 Prof. A Y Taha: Principles of 15/10/14 33 vascular anastomosis
  34. 34. 3 suture technique Prof. A Y Taha: Principles of 15/10/14 34 vascular anastomosis
  35. 35. End-to-side Anastomosis Prof. A Y Taha: Principles of 15/10/14 35 vascular anastomosis
  36. 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) Prof. A Y Taha: Principles of 15/10/14 36 vascular anastomosis
  37. 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 Prof. A Y Taha: Principles of 15/10/14 37 vascular anastomosis
  38. 38. Mechanical flap monitoring  Doppler  External  Implanted  Buried flaps  80-100% salvage (Disa J, et al 1999)  Color flow  Other Prof. A Y Taha: Principles of 15/10/14 38 vascular anastomosis
  39. 39. Complications of Vascular Anastomosis Badr Aljabri MD, FRCSC Associate Professor and Consultant Vascular Surgeon, KKUH
  40. 40. Anastomotic bleeding  Needle hole bleeding. - more common with PTFE grafts. - Rx: Local haemostatic agents. Reverse systemic heparin effect. Prof. A Y Taha: Principles of 15/10/14 40 vascular anastomosis
  41. 41. Anastomotic bleeding  Suture line bleeding. - Rx: Simple or U-shaped suture at the defect. tying should be with non- Pulsetile flow. Prof. A Y Taha: Principles of 15/10/14 41 vascular anastomosis
  42. 42. Anastomotic Psudoaneurysm  Disruption of the suture line at the anastomosis result in walled off extra-luminal circulation of the blood. Prof. A Y Taha: Principles of 15/10/14 42 vascular anastomosis
  43. 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 Technical Factors compliance mismatch 1. Inadequate suture bites. 2. Excessive tension. 3. Joint Motion. 4. Redo Procedure. 5. Endarterectomy. Prof. A Y Taha: Principles of 15/10/14 43 vascular anastomosis
  44. 44. Prof. A Y Taha: Principles of 15/10/14 44 vascular anastomosis
  45. 45. Prof. A Y Taha: Principles of 15/10/14 45 vascular anastomosis
  46. 46. Prof. A Y Taha: Principles of 15/10/14 46 vascular anastomosis
  47. 47. Prof. A Y Taha: Principles of 15/10/14 47 vascular anastomosis
  48. 48. Anastomotic stenosis  Early : Technical.  1-18 months: Intimal hyperplasia.  > 18 months: Progression of atherosclerosis. Prof. A Y Taha: Principles of 15/10/14 48 vascular anastomosis
  49. 49. Prof. A Y Taha: Principles of 15/10/14 49 vascular anastomosis
  50. 50. Prof. A Y Taha: Principles of 15/10/14 50 vascular anastomosis
  51. 51. Prof. A Y Taha: Principles of 15/10/14 51 vascular anastomosis
  52. 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 Prof. A Y Taha: Principles of 15/10/14 52 vascular anastomosis
  53. 53. Thrombectomy Prof. A Y Taha: Principles of 15/10/14 53 vascular anastomosis
  54. 54. Questions? Thanks!!!

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