1. Vascular Anastomosis Workshop Dr. Husain jabbad
King Abdul-Aziz University
Department of Surgery
November 2007

2. 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.

3. 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

4. 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

5. Techniques of vascular Anastomosis
Interrupted sutures technique
Continuous single suture techniques
Open
Closed
Continuous double suture technique

6. Single Suture Technique
Closed

7. Double suture technique
closed

8. Single suture technique
open

9. Continuous Single Suture Open Anastomosis Technique

10. End to side anastomosis

11. End to side anastomosis

12. Side to side anastomosis

13. Factors Affecting Graft Patency
Technical factors
Graft related factors
Patient related factors
Drug management

14. 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

15. 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

16. Graft Patency (Technical Factors)
Mechanical factors related to the needle:
Needle tip configuration
Needle body configuration
Needle curvature
Suture diameter

17. Graft Patency (needle handling)

18. 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

19. 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

20. 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.

21. Needle Shape (Technical Factors)

22. Types of suture materials

23. 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

24. Graft preparation ( lazy S shape)

25. 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)

26. 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)

27. Graft Patency (Drug Management)
Heparin
papaverine
Aspirin
Clopidogrel (plavix)
Persantine (dipyridamole)
Cardiazem
Verapamil
warfarin

28. 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

29. Thank You