Vascular Anastomosis Workshop Dr. Husain jabbad King Abdul-Aziz University Department of Surgery November 2007
Introduction Despite the fact that interventional radiology is more frequently being used for the management of vascular diseases, the skills of handling, surgical anastomosis and repair of blood vessels remain an important asset to all general surgeon. Vascular surgeons may not be available in an emergency situations and the general surgeon may be the only person available who can do the required repair of a vascular injury.
Principles of vascular anastomosis Adequate exposure Proximal & distal control Careful & gentle handling of the tissues Heparinization before clamping the vessels Appropriate diameter of the anastomosis in relation to the vessel size Endothelium to endothelium approximation Monofilament non absorbable sutures Full thickness sutures Small bites, evenly displaced along the anastomosis No tension at the anastomosis line or knots
Types of vascular Anastomosis Arterial- Arterial anastomosis End to end End to side Side to side Interposition prosthetic graft Arterial- Veinous anastomosis End vein to side artery End vein to end artery Veinous- veinous anastomosis
Techniques of vascular Anastomosis Interrupted sutures technique Continuous single suture techniques Open Closed Continuous double suture technique
Single Suture Technique Closed
Double suture technique closed
Single suture technique open
Continuous Single Suture Open Anastomosis Technique
End to side anastomosis
End to side anastomosis
Side to side anastomosis
Factors Affecting Graft Patency Technical factors Graft related factors Patient related factors Drug management
Factors Affecting Graft Patency The most significant factor in patency of vascular anastomosis is flawless surgical technique - Small pieces of adventia caught in the anastomosis can cause platelet thrombus formation - large bites may decrease the diameter of the lumen& invites thrombus formation
Graft Patency (Technical Factors) Gentle handling of the tissues Heparinization before clamping Full thickness bites Approximation of the endothelium Avoid tension on the anastomosis Appropriate anastomosis diameter compared to the vessel size Size, shape & type of needles & sutures
Graft Patency (Technical Factors) Mechanical factors related to the needle: Needle tip configuration Needle body configuration Needle curvature Suture diameter
Graft Patency (needle handling)
Graft Patency (Technical Factors) Surgical Skill: Approximation of intima to intima Angle of the needle Bite of suture Suture tension Number of stitches Knots tension ** Clip applicators (new trends) Improved results especially with artificial grafts Higher coast compared to sutures
Round Body Needle(Technical Factors) Needle type Description Typical application Intestinal The hole made by this needle is no larger than the diameter of the needle. The hole is then filled by the material, which reduces the risk of leakage. Gastrointestinal tract; biliary tract; dura; peritoneum; urogenital tract; vessels; nerve Heavy In some situations where particularly strong needles are required, a heavy wire diameter needle would be appropriate Muscle; subcutaneous fat; fascia; pedicles Blunt taperpoint Where needlestick injury is a major concern, the blunt taperpoint needle virtually eliminates accidental glove puncture Uterus; pedicles; muscle; fascia Blunt point This needle has been designed for suturing extremely friable vascular tissue. Liver; spleen; kidney; uterine cervix for incompetent cervix
Cutting Needlse (Technical Factors) Needle type Description Typical application Tapercut™ This needle combines the initial penetration of a cutting needle with the minimised trauma of a round-bodied needle. The cutting tip is limited to the point of the needle, which then tapers out to merge smoothly into a round cross-section. Fascia; ligament; uterus; scar tissue. Cutting This needle has a triangular cross- section with the apex on the inside of the needle curvature. The effective cutting edges are restricted to the front section of the needle. Skin; ligament; nasal cavity; tendon; oral. Reverse cutting The body of this needle is triangular in cross-section with the apex on the outside of the needle curvature Skin; fascia; ligament; nasal cavity; tendon; oral.
Needle Shape (Technical Factors)
Types of suture materials
Vessel Preparation (Technical Factors) Proper shape of the graft end (lazy S shape ) Proper size of the graft end Avoid mechanical dilatation Avoid intimal injury and manipulation Appropriate length of arteriotomy incision Use atraumatic clamps & instruments Reduce the duration of clamp application
Graft preparation ( lazy S shape)
Types of Grafts (Graft related Factors) Arterial conduits LIMA & RIMA Radial artery Gastro-epiploec artery Vein conduits Great saphenous vein Umbilical vein Prosthetic grafts PTFE (Gore Tex) Dacron (woven, netted, +/- velour)
Graft Patency (Patient related Factors) Vessel size (less than 1.5 mm) Vessel quality (thin or friable vessels) Disease proximal to the anastomosis (in flow) Disease at the site of the anastomosis Disease distal to the anastomosis (out flow)
Graft Patency (Drug Management) Heparin papaverine Aspirin Clopidogrel (plavix) Persantine (dipyridamole) Cardiazem Verapamil warfarin
Principles of vascular anastomosis Adequate exposure Proximal & distal control Careful & gentle handling of the tissues Heparinization before clamping the vessels Appropriate diameter of the anastomosis in relation to the vessel size Endothelium to endothelium approximation Monofilament non absorbable sutures Full thickness sutures Small bites, evenly displaced along the anastomosis No tension at the anastomosis line or knots
Thank You