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Microvascular Anastomotic Techniques

last modified on: Wed, 08/30/2017 - 11:39

Microsurgical technique

 return to:Microvascular Surgery Protocols

Arterial anastomosis (end-to-end)

  Fibula free flap: peroneal artery to facial artery, 9-0 nylon, N. Pagedar & J. Hill, 2009.

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Arterial anastomosis

  1. 8-0 or 9-0 Nylon depending on the size and thickness of the vessels
  2. Back wall first, then front wall
    1. Vessel approximating clamps are not needed with this technique
    2. Allows improved view of the back wall during the procedure
  3. First suture is placed right-to-left
    1. Assistant holds the vessels end-to-end during knot-tying
  4. Remainder of the back wall sutures are placed left-to-right
    1. Second suture should be close to the first
    2. Subsequent sutures can be spaced apart
    3. Liberal use of Weck-Cel spears to visualize the vessel intima
    4. "Too few sutures" is easier to fix than "too many sutures"
  5. Front wall sutures are placed right-to-left
    1. Start adjacent to the first suture
  6. Apply papaverine prior to release of vessel clamps
  7. Arterial anastomosis has been described with the coupler device - this is not part of UIHC routine

Venous anastomosis (end-to-end)

  Radial forearm free flap: cephalic vein to external jugular vein, Synovis 3.5mm coupler, D. Shonka & N. Pagedar, 2010.

VIDEO PENDING RETRIEVAL
 

Venous anastomosis 

  1. Principles
    1. Anastomotic coupler provides greater reliability in less time
      1. Can be used for end-to-side anastomosis
      2. Use whenever possible, especially for smaller veins
    2. Measure the caliber of the smaller of the two veins
      1. Err on the side of small coupler
    3. Attention to the orientation of the vessel prevents kinking
      1. Orient the coupler device accordingly
    4. Synovis Coupler tray, including anastomotic device, measuring gauge, and Coupler forceps should be available for all cases
      1. 1.5 - 4.0mm couplers should be available
  2. Start with the longer or more mobile vein
  3. Pull the end of first vein through the coupler lumen
    1. Only far enough to avoid tension
    2. Keep the vessel lumen in view
  4. Place the first three pins in a triangular pattern
    1. The surgeon everts the vessel edge over the pin, and the assistant seats the vessel over the pin
    2. Use of angled micro forceps may be advantageous to the surgeon
  5. Evert the vessel over the three remaining pins
  6. Gentle traction on the vein is used to better visualize the lumen and inspect patency
    1. If the vein is large, the excess can be used to create "pleats," proceeding either clockwise or counterclockwise
  7. Repeat the procedure with the second vein
  8. Close the coupler, with an extra squeeze with a fine hemostat especially for larger veins
  9. Vessel adventitia or clips placed on side branches may become caught in the coupler device as it closes
    1. It is important to open the device before pulling it away from the completed anastomosis 
References
  1. Harris GD, Finseth F, Buncke H. Posterior-wall-first microvascular technique. Br J Plast Surg. 1981 Jan;34(1):47-9.
  2. Ross DA, Chow JY, Shin J, et al. Arterial coupling for microvascular free tissue transfer in head and neck reconstruction. Arch Otolaryngol Head Neck Surg. 2005 Oct;131(10):891-5.