King Abdul-Aziz University Department of Surgery November

 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. 2

1. Adequate exposure 2. Proximal & distal control 3. Careful & gentle handling of the tissues 4. Heparinization before clamping the vessels 5. Appropriate diameter of the anastomosis in relation to the vessel size 6. Endothelium to endothelium approximation 7. Monofilament non absorbable sutures 8. Full thickness sutures 9. Small bites, evenly displaced along the anastomosis 10. No tension at the anastomosis line or knots 3

 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 4

I. Interrupted sutures technique II. Continuous single suture techniques ◦ Open ◦ Closed III. Continuous double suture technique ◦ Open ◦ Closed 5

Closed 6

closed 7

open 8

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I. Technical factors II. Graft related factors III. Patient related factors IV. Drug management 13

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 14

 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 15

Mechanical factors related to the needle: ◦ Needle tip configuration ◦ Needle body configuration ◦ Needle curvature ◦ Suture diameter 16

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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 18

19 Needle typeDescriptionTypical application IntestinalThe 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 HeavyIn some situations where particularly strong needles are required, a heavy wire diameter needle would be appropriate Muscle; subcutaneous fat; fascia; pedicles Blunt taperpointWhere needlestick injury is a major concern, the blunt taperpoint needle virtually eliminates accidental glove puncture Uterus; pedicles; muscle; fascia Blunt pointThis needle has been designed for suturing extremely friable vascular tissue. Liver; spleen; kidney; uterine cervix for incompetent cervix

20 Needle typeDescriptionTypical 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. CuttingThis 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 cuttingThe 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.

21 Needle Shape (Technical Factors)

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iii. Vessel Preparation: – 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 23

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 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) 25

 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) 26

 Heparin  papaverine  Aspirin  Clopidogrel (plavix)  Persantine (dipyridamole)  Cardiazem  Verapamil  warfarin 27

1. Adequate exposure 2. Proximal & distal control 3. Careful & gentle handling of the tissues 4. Heparinization before clamping the vessels 5. Appropriate diameter of the anastomosis in relation to the vessel size 6. Endothelium to endothelium approximation 7. Monofilament non absorbable sutures 8. Full thickness sutures 9. Small bites, evenly displaced along the anastomosis 10. No tension at the anastomosis line or knots 28

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