**3.1 Arterial repair: end-to-end**

For an end-to-end anastomosis, the vessel ends are usually aligned (and cut if they are prepared vessels) perpendicularly to the vascular axis. If one end is larger than the other, the smaller vessel may be cut at an angle to match the diameter size of the larger vessel (**Figure 12A**).

## *3.1.1 Triangulation method*

In summary, the technique requires the circumference of the vessel wall to be divided into thirds and a stay suture placed at each point (**Figure 12B**). Subsequently sutures are placed between the three stay sutures and depending on the size of the vessel one, two or even three may be squeezed in.

#### **Figure 10.**

*Trimming the adventitia. (A) The adventitia is pulled using a jeweler's forceps (left hand) and using the micro-scissors (right hand), it is nipped just at the vessel edge (media). (B) With the hole thus created, one blade of the scissors is used to enter, and then cut the adventitia all the way around the vessel, above and below. (C) End result.*

#### **Figure 11.**

*Prepared vessels. After the adventitia is cleared, the vessels are almost translucent. A dark background and bathing them in saline facilitates repair. Inset: clamps facing the surgeon make certain repair techniques easier.*

#### **Figure 12.**

*Triangulation method of repair. (A) If the diameter of the vessel walls are grossly mismatched, the smaller one may be cut obliquely to increase the diameter size. (B) Three stay sutures are placed 120° apart as a guide.*

The first stay suture is placed as in **Figure 13**. The needle tip is used to hook the adventitia and the left-hand forceps is placed gently just inside the lumen. The tip of the needle is then pushed into the lumen with the forceps acting as a counterforce [6].

The needle is then brought out and equidistant through the opposite lumen with the left-hand forceps again acting as a resistive force. The needle is pushed through in between the tips of the forceps and picked up in two or three steps gently ensuring the needle swage does not damage the vessel wall and that the thrombogenic cut ends are not inverted inside. Once tied, one thread is kept longer to wind around the clamp bar to stabilise the vessel ends. The first two stay sutures are difficult but especially important because they prevent the back wall of the vessel being caught up. The second suture should be performed in an easy position: on the upper surface of the vessel (**Figure 14**). Once these two are in, two or three intervening sutures are put in. Due to the tightness of the space sometimes it is difficult to place the last two sutures, so it can be modified by not tying the second last suture and continuing the stitching to the last one, leaving the needle in place (**Figure 15**). This allows good visualisation when inserting the needle for the last stitch, preventing catching the 'back wall'. The second last suture is tied followed by the final suture.

#### **Figure 13.**

*First stay suture. (A) The adventitial layer is lifted with the tip of the needle and the forceps is gently inserted into the lumen. (B) The needle is then placed on the media and pierced through perpendicularly into the jaws of the forceps tips. (C) A bite on the opposite lumen is similarly placed with the aid of the forceps, this time from outside. × is where the second stay suture should be placed.*

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*3.1.2 One-way-up*

**Figure 14.**

*one line.*

**Figure 15.**

*Tips and Tricks in Microvascular Anastomoses DOI: http://dx.doi.org/10.5772/intechopen.92903*

The double clamp may then be flipped 180° and the third suture placed with the back wall up, so it is not taken in with the suturing. The double clamps are moved slightly apart to apply tension on the vessel ends, separating them, allowing the sutured vessel wall to be seen through (**Figure 16**). One can check the repair done as well as safely proceed with the rest of the suturing. The third stay suture is placed equidistant from the other two main stay sutures. The suture is tied and again one end may be wound around the clamp bar to steady the vessel ends. The remaining two thirds of the vessel wall are sutured in a similar fashion. The vessel repair is now complete.

*Double suture. Once the first pass of the needle is done, the knot is not tied and the needle is passed again between the first pass and the last tied suture. The needle is left in situ and the first pass knot is tied by grabbing* 

*the free end of the suture. Once this is tied, the needle is pulled through and the second knot tied.*

*Second stay suture. (A) The 2nd stay suture is put in at approximately 1/3 of the circumference of the vessel from the first one. It is more difficult to place than the first and is crucial to get it right. Therefore, it is placed in the easier position on the front wall. (B) The two stay sutures are tightened until the front edges approximate in* 

An extremely useful technique to master in situations where there is hardly any manoeuvrability (short vessel length and space) or space to flip the clamp or perform a vascular repair. Suturing is started at the most difficult point in the back wall and done using the inside out technique, moving upwards to easier points. Place the double clamp with the tips facing you, this will reduce the amount of space they utilise and allow better visualisation (**Figure 11** – inset). Next, place the first suture at the far end of the back wall using the 'inside out' technique so that the knot is outside (**Figure 17A**). The needle is pushed from the outside of the left vessel

#### **Figure 14.**

*The Current Perspectives on Coronary Artery Bypass Grafting*

**152**

**Figure 13.**

**Figure 12.**

*First stay suture. (A) The adventitial layer is lifted with the tip of the needle and the forceps is gently inserted into the lumen. (B) The needle is then placed on the media and pierced through perpendicularly into the jaws of the forceps tips. (C) A bite on the opposite lumen is similarly placed with the aid of the forceps, this time* 

The first stay suture is placed as in **Figure 13**. The needle tip is used to hook the adventitia and the left-hand forceps is placed gently just inside the lumen. The tip of the needle is then pushed into the lumen with the forceps acting as a counterforce [6]. The needle is then brought out and equidistant through the opposite lumen with the left-hand forceps again acting as a resistive force. The needle is pushed through in between the tips of the forceps and picked up in two or three steps gently ensuring the needle swage does not damage the vessel wall and that the thrombogenic cut ends are not inverted inside. Once tied, one thread is kept longer to wind around the clamp bar to stabilise the vessel ends. The first two stay sutures are difficult but especially important because they prevent the back wall of the vessel being caught up. The second suture should be performed in an easy position: on the upper surface of the vessel (**Figure 14**). Once these two are in, two or three intervening sutures are put in. Due to the tightness of the space sometimes it is difficult to place the last two sutures, so it can be modified by not tying the second last suture and continuing the stitching to the last one, leaving the needle in place (**Figure 15**). This allows good visualisation when inserting the needle for the last stitch, preventing catching the 'back wall'. The second last suture is tied followed by the final suture.

*Triangulation method of repair. (A) If the diameter of the vessel walls are grossly mismatched, the smaller one may be cut obliquely to increase the diameter size. (B) Three stay sutures are placed 120° apart as a guide.*

*from outside. × is where the second stay suture should be placed.*

*Second stay suture. (A) The 2nd stay suture is put in at approximately 1/3 of the circumference of the vessel from the first one. It is more difficult to place than the first and is crucial to get it right. Therefore, it is placed in the easier position on the front wall. (B) The two stay sutures are tightened until the front edges approximate in one line.*

#### **Figure 15.**

*Double suture. Once the first pass of the needle is done, the knot is not tied and the needle is passed again between the first pass and the last tied suture. The needle is left in situ and the first pass knot is tied by grabbing the free end of the suture. Once this is tied, the needle is pulled through and the second knot tied.*

The double clamp may then be flipped 180° and the third suture placed with the back wall up, so it is not taken in with the suturing. The double clamps are moved slightly apart to apply tension on the vessel ends, separating them, allowing the sutured vessel wall to be seen through (**Figure 16**). One can check the repair done as well as safely proceed with the rest of the suturing. The third stay suture is placed equidistant from the other two main stay sutures. The suture is tied and again one end may be wound around the clamp bar to steady the vessel ends. The remaining two thirds of the vessel wall are sutured in a similar fashion. The vessel repair is now complete.

#### *3.1.2 One-way-up*

An extremely useful technique to master in situations where there is hardly any manoeuvrability (short vessel length and space) or space to flip the clamp or perform a vascular repair. Suturing is started at the most difficult point in the back wall and done using the inside out technique, moving upwards to easier points.

Place the double clamp with the tips facing you, this will reduce the amount of space they utilise and allow better visualisation (**Figure 11** – inset). Next, place the first suture at the far end of the back wall using the 'inside out' technique so that the knot is outside (**Figure 17A**). The needle is pushed from the outside of the left vessel *The Current Perspectives on Coronary Artery Bypass Grafting*

#### **Figure 16.**

*Doing the back wall. Once the clamps are flipped and tensioned, the view of the sutured first segment can be seen and repair checked before proceeding.*

#### **Figure 17.**

*One-way-up suture technique. (A) Take the first bite the furthest away from you. (B) The second bite is placed next to the first starting with the left vessel wall edge from outside-in. (C) The needle is then pulled out and inserted inside-out of the right vessel wall edge. (D) This is continued to the end till complete.*

wall edge to inside the lumen and then it goes from the right vessel wall edge lumen to outside, where the knot is tied. Again, one end is kept long to assist in stabilising the vessel ends. The next suture is placed next to the first one, nearer to you in a similar outside in fashion (**Figure 17B** and **C**), until one moves upwards, then the suturing becomes easier and may be done in the usual way at the top side until complete (**Figure 17D**).

### *3.1.3 Continuous suturing*

In the hands of a practiced surgeon, this suturing technique is rapid and gives good results; however a single mistake may prove costly, requiring the suturing to be redone and perhaps the vessel shortened! Also, a less experienced surgeon may

**155**

**Figure 18.**

*started from the distal side proximally.*

*Tips and Tricks in Microvascular Anastomoses DOI: http://dx.doi.org/10.5772/intechopen.92903*

the long thread. The anastomosis is complete.

**3.2 Arterial repair: end to side**

*3.2.1 Preparing the vessel*

once it is anastomosed!

end up entangling the suture or pulling it too tight to cause purse-stringing. Thus, one should only attempt this when one's technique is smooth and well-orchestrated. In the first few attempts at this technique, the surgeon should aim to divide the vessel end walls into two by putting in one stay suture each on opposing ends. The first stay suture is tied and the long end of the thread is fastened to the clamp bar (**Figure 18**). The opposite is similarly knotted and anchored, but the needled thread is not cut, being used to start the front side of the suturing. Three or maximum four passes with the needle are most likely required in a 1.0–1.5 mm diameter vessel starting with the first one as close as possible to the stay suture to prevent leakage. At the end, any slack in the continuous run is picked up and the suture is tied to the free end of one of the threads. The clamp is then flipped 180° and the needle used to continue suturing the opposing side. Care must be taken not to accidentally take the back-wall for the two are close. Once the other end is reached, the suture is tied to

This technique is an important one to have in the armamentarium. It allows a "way out" for example when there is a paucity of recipient vessels or if the flap donor vessel is too short. It does however carry a risk of size mismatch in terms of diameter and wall thickness. While the former may be somewhat addressed by an oblique cut or narrowing the larger vessel, difference in thickness is more difficult

Ensure the donor vessel is of adequate length to reach the arteriotomy site without undue tension. It must be freed of adventitia at least up to 3 mm away and dilated to ease anastomosis. It is essential to ensure there are no kinks or twists in the donor vessel (artery or especially if it is a vein) because this may be disastrous

*Continuous suture technique. The vessel is locked by two stay sutures 180° apart. A continuous running suture is* 

to deal with. The risk of turbulent flow must be born in mind [7].

#### *Tips and Tricks in Microvascular Anastomoses DOI: http://dx.doi.org/10.5772/intechopen.92903*

*The Current Perspectives on Coronary Artery Bypass Grafting*

**154**

**Figure 17.**

**Figure 16.**

*seen and repair checked before proceeding.*

complete (**Figure 17D**).

*3.1.3 Continuous suturing*

*One-way-up suture technique. (A) Take the first bite the furthest away from you. (B) The second bite is placed next to the first starting with the left vessel wall edge from outside-in. (C) The needle is then pulled out and* 

*Doing the back wall. Once the clamps are flipped and tensioned, the view of the sutured first segment can be* 

wall edge to inside the lumen and then it goes from the right vessel wall edge lumen to outside, where the knot is tied. Again, one end is kept long to assist in stabilising the vessel ends. The next suture is placed next to the first one, nearer to you in a similar outside in fashion (**Figure 17B** and **C**), until one moves upwards, then the suturing becomes easier and may be done in the usual way at the top side until

In the hands of a practiced surgeon, this suturing technique is rapid and gives good results; however a single mistake may prove costly, requiring the suturing to be redone and perhaps the vessel shortened! Also, a less experienced surgeon may

*inserted inside-out of the right vessel wall edge. (D) This is continued to the end till complete.*

end up entangling the suture or pulling it too tight to cause purse-stringing. Thus, one should only attempt this when one's technique is smooth and well-orchestrated.

In the first few attempts at this technique, the surgeon should aim to divide the vessel end walls into two by putting in one stay suture each on opposing ends. The first stay suture is tied and the long end of the thread is fastened to the clamp bar (**Figure 18**). The opposite is similarly knotted and anchored, but the needled thread is not cut, being used to start the front side of the suturing. Three or maximum four passes with the needle are most likely required in a 1.0–1.5 mm diameter vessel starting with the first one as close as possible to the stay suture to prevent leakage. At the end, any slack in the continuous run is picked up and the suture is tied to the free end of one of the threads. The clamp is then flipped 180° and the needle used to continue suturing the opposing side. Care must be taken not to accidentally take the back-wall for the two are close. Once the other end is reached, the suture is tied to the long thread. The anastomosis is complete.
