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Vascular Anastomosis Workshop Dr. Husain jabbad

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

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Vascular Anastomosis Workshop Dr. Husain jabbad

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  1. Vascular Anastomosis WorkshopDr. 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 • Open • Closed

  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)

  20. Cutting Needlse(Technical Factors)

  21. Needle Shape (Technical Factors)

  22. Types of suture materials

  23. Vessel Preparation (Technical Factors) • 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

  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

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