2. The Venous Coupler:
Is Time Money?
Pouria Moradi, Victoria Rose
Imperial College London
Charing Cross Hospital, UK

3. The Ideal Non-Suture Anastomotic
Device
• Minimal blood- exposed non-intimal surface
• Minimal inflammatory response
• Minimal vessel trauma
• Easy, quick & safe deployment (recovery)
• Multiple vessel sizes
• Patency equal or better than hand sewn
• Cost

4. Theoretical Benefits of Coupler by
avoidance of
• Foreign body suture contact with blood flow
• Subendothelial collagen exposure from poor
intimal contact
• Lumin narrowing prevented by stenting effect
of coupler

5. Holt & Lewis
• 2 rings
• Teflon
• Pinned
• Interlocking
• No FB within lumen
• Neo-endothelium
lining
Holt & Lewis, S Forum 1960:11:243

6. Nakayama K, Tamiya T, Yamamoto K, et al.
A simple new method for small vessel anastomoses (free autograft of the
sigmoid included).
Surgery. 1962;52:918–931
• Refined
• Applicator
• Lumen measuring tool
• Stainless steel
• 1.5mm
• End-to-side
• Vein patch

7. Östrup LT, Berggren A. The UNILINK instrument system for fast and safe
microvascularanastomoses. Ann Plast Surg. 1986;17:521–525.
• Sweden (Unilink/3M
Synovis/MAC)
• 2 Polyethylene rings
• 6 Stainless steel pins
• Push fit seal
• 90° eversion

8. How does it work?

9. Select Coupler Size

10. Flap Vessel

12. Closing The Coupler

15. Final Result

16. Animal Studies
• Rabbit Carotid artery & Facial veins
• End-to-End & End-to-Side
• Average times quoted 2-5 minutes
• 98-100% patency rates
• 2 year follow up
• Media thinning of artery and 40% aneurysm rate
• Tensile strength greater
Ostrup Berggren, Gilbert & Ragnarsson

17. Animal Studies
• Artery:
– Initially no difference is seen between
coupled anastomoses micro and
macroscopically
– 2 years significant media thinning was
seen in the artery for 10mm distal to
the coupler with possible aneurysm
formation in 40%
• No problems were detected with the
vein

18. 1000 Consecutive Venous Anastomoses using the
microvascularanastomotic coupler in breast reconstruction
PRS 2010 Jandali et al
• 6 instances of venous thrombosis (0.6%)
– Nil flap loss
– 2 partial flap losses
• Same institution (Vega PRS 2008)
– 500 free TRAMS
– 2.8% Hand sewn venous anastomosis thrombosis

19. Venous thrombosis in coupled versus sutured
microvascularanastomoses
Ann PlastSurg 2006 Yap et al
• 139 anastomosis in coupler group
– 2/139 thrombosis (1.4%)
• 584 anastomosis in hand sutured group
– 19/584 thrombosis (3.3%)

20. Relative Contraindications
• Not for thick walled vessels
• Not for Arteries
• Not for Short vessel lengths
• Size mismatch
• Registrar training???

21. Purpose of the Study
Is The Coupler Cost Effective?

22. Cost
Coupler
• Instrumentation
– Coupler kit £950
• Consumable
– Coupler £112
• In Australia $610 per case on consignment
– Covered by Private Insurance
Suture
• Consumable
– 8’0 ethilon £20 $Aus 19.12
– 9’0 ethilon£40 $Aus 21.68
– 10’0 ethilon £60 $Aus 26.28

23. Methods
• DIE vessels to IM vessels only
• Vein Coupler compared to Arterial Suture

24. 2 Surgeons
• Registrar
~ 6 years Plastic Surgery
• Consultant
~ 11 years Plastic Surgery

25. Technique
• Artery • Vein
– From first suture – Coupler placed in
puncture microscope field
– To clamps off – To clamps off
– Minutes – Minutes

26. RESULTS

27. Mean Time
30
25
Time in minutes
20
15 Mean Artery
Mean Coupler
10
5
0
Registrar Consultant

28. • Definite improvement in hand tie times is
seen with increasing experience
• This is not seen with coupler
• All surgeons averaged similar coupler
times

29. % of Ischaemia Time
35
30
25
20
% Ischaemia Artery
15 % Ishaemia Coupler
10
5
0
Reg Con

30. • Over 28% of all ischaemia time was spent
on the artery
• An average of 11% of the total ischaemia
time was spent on the coupler

31. Complications
• No Coupler Leaks
• No Failed Deployments
• 100% Patency all Anastomoses
• No Flap Failures
• Extra Arterial Time in 5 Cases
– ie extra sutures for leaks

32. Time Conclusions
• Coupled Vein is quicker than sutured artery
• Consistent time for coupled anastomosis
across grades
• % Ischaemia time of Coupler is less than
sutured artery

33. Time is Money
• OR p/hr £800/hr $Aus1200/hr
• Time (C) 5.50 mins
• Time (S) 17.50 mins
• Time saved 12.00 mins
– 12/60 x £800=£160
– 12/60 x $1200= $aus240
• Coupler cost £112
• 9‘0 cost £40
– £112-£40=£72
• Net saved per Case
– £160-£72=£88.00

34. Conclusions
• Microvascular coupler is a safe alternative to suture
for venous anastomosis
• Microvascular coupler is faster than suture
• Microvascular coupler has a shorter learning curve
than suture
• Microvascular coupler is cost effective

35. Thank You