King Abdul-Aziz University Department of Surgery

November 2007

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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.

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1. Adequate exposure2. Proximal & distal control3. Careful & gentle handling of the tissues4. Heparinization before clamping the vessels5. Appropriate diameter of the anastomosis in

relation to the vessel size 6. Endothelium to endothelium approximation7. Monofilament non absorbable sutures8. Full thickness sutures9. Small bites, evenly displaced along the

anastomosis10. No tension at the anastomosis line or knots

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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

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I. Interrupted sutures techniqueII. Continuous single suture techniques

◦ Open◦ Closed

III. Continuous double suture technique ◦ Open◦ Closed

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Closed

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closed

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open

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I. Technical factorsII. Graft related factorsIII. Patient related factorsIV. Drug management

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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

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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

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Mechanical factors related to the needle:

◦ Needle tip configuration◦ Needle body configuration◦ Needle curvature◦ Suture diameter

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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

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Needle type Description Typical application

Intestinal The hole made by this needle isno 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

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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.

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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

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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)

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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)

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

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1. Adequate exposure2. Proximal & distal control3. Careful & gentle handling of the tissues4. Heparinization before clamping the vessels5. Appropriate diameter of the anastomosis in

relation to the vessel size 6. Endothelium to endothelium approximation7. Monofilament non absorbable sutures8. Full thickness sutures9. Small bites, evenly displaced along the

anastomosis10. No tension at the anastomosis line or knots

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