J Neurosurg 48:1042-1045, 1978

Continuous suturing for microvascular anastomosis Technical note

JOHN R. LITTLE, M.D., AND TOMAS A. SALERNO, M.D.

Department of Neurosurgery, Montreal Neurological Institute and McGill University, Montreal, Quebec, and the Division of Cardiovascular Surgery, Department of Surgery, Queen's University, Kingston, Ontario, Canada v" A continuous suture technique for the microsurgical end-to-side anastomosis of extracranial to intracranial arteries is described. This method combines the speed and even tension of a continuous suture line with improved visualization of the arteries to be anastomosed. KEY WORDS cerebral ischemia 9 cerebral revascularization continuous suture technique vascular anastomosis 9

T

HE use of vein bypass grafts in the treatment of proximal coronary artery occlusive disease has gained considerable popularity since it was first performed by Garrett, et al., in 1964. 3 This procedure requires an end-to-side anastomosis of the vein graft to a coronary artery frequently as small as 1.5 to 2 m m in diameter. Initially, interrupted sutures were employed for these anastomoses 2 but most cardiovascular surgeons subsequently have found the continuous suture t e c h n i q u e m o r e advantageous.l,5, 8 Microsurgical end-to-side anastomosis of the superficial temporal artery to a cortical branch of the middle cerebral artery with interrupted sutures has been described in numerous reports. 4,7,9 Recently, we have been using a continuous suture method for this procedure and have been encouraged with the results. It appears to combine the speed and even tension of a continuous suture line with improved visualization of the arteries. In this 1042

9

report, the continuous suture technique is described and its efficacy briefly discussed. Technique

The procedure is carried out with the aid of an operating microscope with a 200-mm objective lens, a • 20 eyepiece, and a magnification setting of 16. The donor and receptor arteries are t e m p o r a r i l y occluded with miniature Mayfield clips. The distal end of the d o n o r artery is cut obliquely. A linear incision, corresponding to the length of the lumen of the donor vessel, is m a d e in the receptor artery with a piece of razor blade and m i c r o s c i s s o r s . M o n o f i l a m e n t nylon suture (9-0 or 10-0) is used for the anastomosis. T h e procedure is carried out with the two vessels 0.5 to 1.0 cm apart. Each anastomotic line is run continuously without approximating the edges of the donor to receptor arteries until all sutures are in position. The initial suture is passed from outside to inside through the donor artery at the basal

J. Neurosurg. / Volume 48 / June, 1978

Microvascular anastomosis by continuous suture

FIG. 1. Continuous suture technique for microvascular end-to-side anastomosis.

end (Fig. 1 A). The suture is then passed through the basal end of the arteriotomy in the receptor vessel, going from inside to outside. The needle end of the suture is then brought behind the first segment of suture running between the two arteries. Three to five passes are made through the donor and receptor arteries running along the back wall toward the apical end. Each stitch is passed from outside to inside through the donor artery and then from inside to outside through the receptor artery. Once this is completed, the ends of the initial suture are held off to the side with two aneurysm clips (Fig. 1 B). The second suture is begun at the apex and run along the anterior wall toward the base. Three to five passes are required. Gentle traction applied to the initial and secondary sutures brings the two arteries into apposition. Care must be taken that the sutures are snug and that no redundant loops are presJ. Neurosurg. / Volume 48 / June, 1978

ent. The sutures at the apical end are tied with five knots (Fig. 1 C). Slight tension is applied to the sutures at the basal end, following which they are tied with five knots. The miniature Mayfield clips are removed initially from the receptor artery and then from the donor artery.

Experimental and Clinical Results Experimental Results

Twenty Sprague-Dawley rats weighing 400 to 500 mg were anesthetized with intraperitoneal pentobarbital (40 mg/kg) and atropine sulfate (0.01 rag). The carotid arteries were exposed through a longitudinal midline incision e and their outside diameter measured. In 10 rats, the interrupted suture technique of Rosenbaum and Sundt 6 was used. In the remaining 10 rats, the continuous suture technique described above was used. Suture material was 10-0 monofilament 1043

J. R. Little and T. A. Salerno angiography and cerebral blood flow studies. A 10-day postoperative angiogram of one of the patients with an anastomosis using the continuous suture technique is shown in Fig. 2. Increase in the luminal diameter of the superficial t e m p o r a l artery was noted in all cases when preoperative and postoperative angiograms were compared; the mean increase was 1.5 + 0.5 m m . Comment

FIG. 2. Angiogram in a 50-year-old man, with right internal carotid artery occlusion, performed 10 days following anastomosis of the right superficial temporal artery to a cortical branch of the right middle cerebral artery. Branches of the right middle cerebral artery are filling via the anastomosis (arrow). The diameter of the superficial temporal artery has already increased from 1 mm before surgery to 2 mm postoperatively.

nylon in b o t h groups. P a t e n c y of the a n a s t o m o s e s was checked 30 minutes later by carefully sectioning the two carotid arteries 4 to 5 m m rostral to the anastomotic site. The results are listed in Table 1. Clinical R e s u l t s

The continuous suture technique has been used in the end-to-side anastomosis of the superficial temporal artery to a branch of the middle cerebral artery in seven patients. The diameters of the donor arteries ranged from 1.0 to 1.6 m m and the diameters of the receptor arteries ranged from 1.0 to 1.5 m m . P a t e n c y in all cases was c o n f i r m e d by

Advantages of the continuous suture technique include: 1) reduction in the length of time required for anastomosis; 2) easier suture placement with the vessels separated; 3) fewer passes of the needle through the arterial wall; 4) reduction in the number of sutures tied, from 10 or m o r e required with interrupted suturing to two needed in continuous suturing; and 5) fewer leaks along the suture line. Cardiovascular surgeons have observed similar advantages with continuous suturing in cardiac revascularization? '~ P o t e n t i a l d i s a d v a n t a g e s , not yet encountered, include: 1) tangling of the sutures; 2) breakage of a suture when traction is applied to appose the arteries; and 3) a "purse-string" effect due to excessive tension on the sutures. These problems can be avoided by careful surgical technique. If suture placement is considered imperfect in the mid-suture " r u n " it is simply sectioned, removed, and replaced by another suture. References

1. Ellertson DG, McGough EC, Hughes RK: Endto-side vascular anastomosis. A modified technique. Ann Thorac Surg 17:510-512, 1974 2. Favaloro RG, Effler DB, Groves LK, et al: Direct myocardial revascularization by saphenous vein graft. Present operative tech-

TABLE 1 Emt-to-side anastomosis of carotid arteries in rats

Technique interrupted suture (10 to 16 sutures) continuous suture 1044

No. of Rats

Size of Carotid Artery (ram)

Patent Anastomoses

10 10

1-1.3 1-1.4

9/10 10/10

Anastomotic Site Focal Focal Narrowing Dilatation 3 0

0 6

Time Required (min)

55 :~ 10 20 :~ 5

J. Neurosurg. / Volume 48 / June, 1978

Microvascular anastomosis by continuous suture

3.

4.

5.

6.

nique and indications. Ann Thorae Surg 10:97-111, 1970 Garrett HE, Dennis EW, DeBakey ME: Aortocoronary bypass with saphenous vein graft. Seven-year follow-up. JAMA 223:792-794, 1973 Gratzl O, Schmiedek P, Spetzler R, et al: Clinical experience with extra-intracranial anastomosis in 65 cases. J Neurosurg 44:313-324, 1976 Miller DW Jr, Hessel EA II, Winterscheid LC, et al: Current practice of coronary artery bypass surgery. Results of a national survey. J Thorae Cardiovasc Surg 73:75-82, 1977 Rosenbaum T J, Sundt TM Jr: Neurovascular microsurgery. A model for laboratory investigation and the development of technical skills. Mayo Clin Proe 51:301-306, 1976

J. Neurosurg. / Volume 48 / June, 1978

7. Sundt TM Jr, Seikert RG, Piepgras DG, et al: Bypass surgery for vascular disease of the carotid system. Mayo Clin Proe 51:677-692, 1976 8. Urschel HC, Razzuk MA, Wood RE, et al: Factors influencing patency of aortocoronary artery saphenous vein grafts. Surgery 72:1048-1063, 1972 9. Yasargil MG, KrayenbUhl HA, Jacobson JH 2nd: Microneurosurgical arterial reconstruction. Surgery 67:221-233, 1970

Address reprint requests to: John R. Little, M.D., Department of Neurosurgery, Montreal Neurological Institute, Montreal, Quebec H3A 2B4, Canada.

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Continuous suturing for microvascular anastomosis. Technical note.

J Neurosurg 48:1042-1045, 1978 Continuous suturing for microvascular anastomosis Technical note JOHN R. LITTLE, M.D., AND TOMAS A. SALERNO, M.D. De...
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