*4.1.4 One way up*

*Vascular Biology - Selection of Mechanisms and Clinical Applications*

By far, the most frequently employed technique is the end-to-end anastomosis. Because of its simplicity in less experienced hands, it has one of the lowest failure

This technique was described by Alexis Carrel in the 1902. His intention was to separate the posterior wall from the anterior, as he realised about the danger of transmural stitches. The technique employed three initial sutures, with 120° separation between each [25]. It was modified with the use of only two initial sutures at 120° or 150° distance, as the posterior side was then longer and also fell away (**Figure 3**). Finally, it was modified again to propose only two initial sutures at 180°. The rest of the anastomosis will be closed with simple sutures between the initial

The continuous suture saves time and corrects discrepancies of 2–3 mm in size between vessels, but it has as an inconvenient: the tobacco bag effect. Some authors propose to distribute at first the two vascular lumens with some simple stitches. This technique is not very popular in venous microvascular anastomosis due to its

The continuous interrupted technique (also known as open-loop technique) is our technique of choice. It combines the safety of simple sutures with the comfort and speed of the continuous ones. It allows to constantly maintain a perfect visualisation of the vascular lumen and at the same time minimises the necessary manoeuvres. In this technique, a continuous suture with a spiral of very wide loops is made,

*Triangulation technique, after placing tension between the first two stitches, the longer posterior wall of the* 

**4.1 End-to-end anastomosis**

rates.

*4.1.1 Triangulation*

points [24, 26].

*4.1.2 Continuous*

stenosing tendency [24, 26].

*4.1.3 Continuous interrupted*

**210**

**Figure 3.**

*anastomosis falls down, precluding transmural stitches.*

This technique is of first choice when we cannot properly manipulate both the vessels of the microvascular anastomosis, we cannot manage to rotate it in order to carry out the suture of the posterior wall. When performing the one-way-up technique, we begin suturing the posterior side. The needle is introduced from the deep side of the vessel to the intima of the posterior wall and returns through the intima in the lumen of the posterior wall of the opposite vessel. The knots are the same as in simple stitches. After placing three or four stitches in the posterior wall in an inverted fashion, it is easy to perform the remaining stitches in a conventional way. It is important to place the posterior wall stitches close enough to prevent any leakages, as revising the posterior wall is bothering. Lastly, the anterior face is sutured. This technique is one of our preferences as it minimises the incidence of transfixing sutures [24] (**Figure 5**).
