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.
Call Girls Visakhapatnam Just Call 9907093804 Top Class Call Girl Service Ava...
Principles of vascular anastomosis
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 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Silk was used for many years, but it has now been replaced by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. 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. 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. 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. √ ᵡ
Prof. A Y Taha: Principles of
15/10/14 6
vascular anastomosis
7. Prof. A Y Taha: Principles of
15/10/14 7
vascular anastomosis
9. Prof. A Y Taha: Principles of
15/10/14 9
vascular anastomosis
10. Prof. A Y Taha: Principles of
15/10/14 10
vascular anastomosis
11. Prof. A Y Taha: Principles of
15/10/14 11
vascular anastomosis
12. Simple suture
Prof. A Y Taha: Principles of
15/10/14 12
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.
Prof. A Y Taha: Principles of
15/10/14 13
vascular anastomosis
14. Prof. A Y Taha: Principles of
15/10/14 14
vascular anastomosis
16. End to end anastomosis: stay
sutures
Prof. A Y Taha: Principles of
15/10/14 16
vascular anastomosis
17. End to end anastomosis:
interrupted suture
Prof. A Y Taha: Principles of
15/10/14 17
vascular anastomosis
18. End to end anastomosis:
continuous suture
Prof. A Y Taha: Principles of
15/10/14 18
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.
Prof. A Y Taha: Principles of
15/10/14 19
vascular anastomosis
20. Prof. A Y Taha: Principles of
15/10/14 20
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.
Prof. A Y Taha: Principles of
15/10/14 21
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.
Prof. A Y Taha: Principles of
15/10/14 22
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.
Prof. A Y Taha: Principles of
15/10/14 23
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.
Prof. A Y Taha: Principles of
15/10/14 24
vascular anastomosis
25. End to side anastomosis: four
quadrant technique
Prof. A Y Taha: Principles of
15/10/14 25
vascular anastomosis
26. End to side anastomosis:
parachute technique
Prof. A Y Taha: Principles of
15/10/14 26
vascular anastomosis
27. Prof. A Y Taha: Principles of
15/10/14 27
vascular anastomosis
28. How to make a venous patch?
Prof. A Y Taha: Principles of
15/10/14 28
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.
Prof. A Y Taha: Principles of
15/10/14 29
vascular anastomosis
30. Prof. A Y Taha: Principles of
15/10/14 30
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
Prof. A Y Taha: Principles of
15/10/14 32
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
Prof. A Y Taha: Principles of
15/10/14 33
vascular anastomosis
34. 3 suture technique
Prof. A Y Taha: Principles of
15/10/14 34
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)
Prof. A Y Taha: Principles of
15/10/14 36
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
Prof. A Y Taha: Principles of
15/10/14 37
vascular anastomosis
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. 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.
Prof. A Y Taha: Principles of
15/10/14 40
vascular anastomosis
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. 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
44. Prof. A Y Taha: Principles of
15/10/14 44
vascular anastomosis
45. Prof. A Y Taha: Principles of
15/10/14 45
vascular anastomosis
46. Prof. A Y Taha: Principles of
15/10/14 46
vascular anastomosis
47. Prof. A Y Taha: Principles of
15/10/14 47
vascular anastomosis
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. Prof. A Y Taha: Principles of
15/10/14 49
vascular anastomosis
50. Prof. A Y Taha: Principles of
15/10/14 50
vascular anastomosis
51. Prof. A Y Taha: Principles of
15/10/14 51
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
Prof. A Y Taha: Principles of
15/10/14 52
vascular anastomosis