This study describes our experience using an improved technique for microsurgical sleeve anastomosis of arteries. Modifications of previously described techniques include utilization of a sidecut and placement of the two stitches within separate vertical planes. In 40 arteries, we attained a patency rate of 97.5%. Histology, in vivo observation, and flow study using high-frequency pulsed ultrasound Doppler at 2 hr to 8 weeks demonstrate that the sidecut sleeve anastomosisshows patency and flow characteristics similar to those of standard end-to-end anastomosis, but with a dramatic decrease in operative time. MICROSURGERY 12:321-325
1991
A NEW TECHNIQUE FOR MICROVASCULAR SLEEVE ANASTOMOSIS LING ZHANG, M.D., Ph.D., ROBERT E. TUCHLER, M.D., WILLIAM W. SHAW, M.D., and JOHN W. SIEBERT, M.D.
Reliable anastomosis of small blood vessels is fundamental to the advances seen in microsurgery over the last 2 decades. Further refinements in microvascular techniques, however, are still important in making the routine anastomosis quicker and the difficult anastomosis easier. The “sleeve” anastomotic technique was first described by Lauritzen in 1978.’ Its reliability has been confirmed by several investigations. Attempts at further modifications have included a “sutureless sleeve,”’ a three-stitch sleeve,6 and various sidecuts or supplementary stitches.* We have developed an improved “sleeve” anastomosis, which utilizes one sidecut and the placement of only two sutures in separate vertical planes. To assess the clinical relevance of this technique, the anastomotic time, patency, and hemodynamic flow characteristics were studied.
*-’ ’
MATERIALS AND METHODS
Our study utilized forty male Sprague-Dawley rats with an average body weight of 324 (236-500) gm. Anesthesia was accomplished with 4% chloral hydrate administered intraperitoneally at a dose of 0.75 m1/100 gm. A modified sleeve anastomosis was performed on one femoral artery with the contralateral femoral artery serving as a conventional sutured anastomotic control in most rats. The modified sleeve technique anastomosis begins with preparation of the divided femoral artery by removal of protruding adventitial tags. A sidecut is placed in the distal
From the Microsurgical Research Laboratoryof the Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY. Address reprint requests to Ling Zhang, M.D., Ph.D., c/o John Siebert, M.D., at 109 East 38th Street, New York, NY 10016. Received for publication February 7, 1990; revision accepted December 17, 1990. 0 1991 Wiley-Liss, Inc.
segment using microvascular scissors (Fig. 1A). The length of this sidecut should be approximately one-third to onehalf the arterial diameter. The first stitch is placed 180” opposite the sidecut. Its depth is partial thickness, taking adventitia and media only, approximately 1.5 diameters from the end of the uncut vessel. This is continued as a full-thickness bite from inside the distal vessel lumen. The second stitch is inserted in a similar partial-thickness fashion, one diameter from the end of the uncut vessel. The stitch is continued as a full-thickness bite at the apex of the side cut on the distal vessel (Fig. 1B). The first stitch may be tied prior to insertion of the proximal end into the distal lumen (Fig. 1C). Alternatively, both sutures can be left untied until the proximal end is inserted into the distal vessel (Fig. 1D-F). Standard end-to-end anastomoses of divided femoral arteries served as controls. Anastomotic patency at both shortterm and long-term intervals was assessed by 1) in vivo observation utilizing an operating microscope ( x 20), 2) hemodynamic comparison using high-frequency pulsed ultrasound Doppler, and 3) histologic preparations. The numbers of anastomoses studied for both short- and long-term patency are given in Table 1. Acute hemodynamic characteristics of modified sleeve technique and control anastomoses were studied in six rats (12 carotid arteries, diameter 1.O-1.4 mm). In each animal one artery was repaired using our modified sleeve technique, and the contralateral vessel was repaired using endto-end technique (with eight stitches) as control. Immediately after repair and then at 30 min intervals up to at least 240 min each anastomosis was examined by a 20 mHz pulsed ultrasonic Doppler utilizing a tandem Doppler probe developed in our laboratory.’* Phasic and mean velocity waveforms were recorded at identical pre- and postanastomotic sites simultaneously.
Zhang et al.
322
A
B
C
D P
R 1’UCHLER.me
Figure 1. Diagrammatic illustration of modified sleeve anastomosis. See text for detailed description.
Table 1.
Patency Short-term 2 Hours 1 Day 3 Days Long-term 1 Week 2 Weeks 4 Weeks 8 Weeks Total
Table 2. Patency and Related Data.
No. of Anastomoses.
Sleeve (n = 40)
Modified sleeve anastomosis
Control
3 3
4 3
5
5
8 6 7 8
4 5 4 3
40
28
RESULTS
Patency and related results for both the modified sleeve and control anastomotic groups are presented in Table 2. Histologic examination demonstrated complete reendothelialization of both sleeve and control groups at 2-4 weeks postoperatively. There was no evidence of protrusion of sutures into the lumen of the sleeve group. The fusion of distal and proximal telescoping vessels was clearly seen. The sleeve groups exhibited slight proliferation of intima and thickening of the overlapped vessel segment (2 weeks). No obvious medial necrosis was observed (Figs. 2, 3). We found no hemodynamically significant vasospasm or stenosis using the modified sleeve technique. Examina-
Ave. vessel diameter (mm) 0.67 % 0.12 Operating time (min) 5.97 _C 0.77 Anastornotic 22.5 leakage (>.5min) (YO) Patency rate (Yo) 97.5 Aneu wsms 0
Control (n = 28) 0.66
?
0.10
P N.S.”
11.87 rfi 1.25
1991
A NEW TECHNIQUE FOR MICROVASCULAR SLEEVE ANASTOMOSIS LING ZHANG, M.D., Ph.D., ROBERT E. TUCHLER, M.D., WILLIAM W. SHAW, M.D., and JOHN W. SIEBERT, M.D.
Reliable anastomosis of small blood vessels is fundamental to the advances seen in microsurgery over the last 2 decades. Further refinements in microvascular techniques, however, are still important in making the routine anastomosis quicker and the difficult anastomosis easier. The “sleeve” anastomotic technique was first described by Lauritzen in 1978.’ Its reliability has been confirmed by several investigations. Attempts at further modifications have included a “sutureless sleeve,”’ a three-stitch sleeve,6 and various sidecuts or supplementary stitches.* We have developed an improved “sleeve” anastomosis, which utilizes one sidecut and the placement of only two sutures in separate vertical planes. To assess the clinical relevance of this technique, the anastomotic time, patency, and hemodynamic flow characteristics were studied.
*-’ ’
MATERIALS AND METHODS
Our study utilized forty male Sprague-Dawley rats with an average body weight of 324 (236-500) gm. Anesthesia was accomplished with 4% chloral hydrate administered intraperitoneally at a dose of 0.75 m1/100 gm. A modified sleeve anastomosis was performed on one femoral artery with the contralateral femoral artery serving as a conventional sutured anastomotic control in most rats. The modified sleeve technique anastomosis begins with preparation of the divided femoral artery by removal of protruding adventitial tags. A sidecut is placed in the distal
From the Microsurgical Research Laboratoryof the Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, NY. Address reprint requests to Ling Zhang, M.D., Ph.D., c/o John Siebert, M.D., at 109 East 38th Street, New York, NY 10016. Received for publication February 7, 1990; revision accepted December 17, 1990. 0 1991 Wiley-Liss, Inc.
segment using microvascular scissors (Fig. 1A). The length of this sidecut should be approximately one-third to onehalf the arterial diameter. The first stitch is placed 180” opposite the sidecut. Its depth is partial thickness, taking adventitia and media only, approximately 1.5 diameters from the end of the uncut vessel. This is continued as a full-thickness bite from inside the distal vessel lumen. The second stitch is inserted in a similar partial-thickness fashion, one diameter from the end of the uncut vessel. The stitch is continued as a full-thickness bite at the apex of the side cut on the distal vessel (Fig. 1B). The first stitch may be tied prior to insertion of the proximal end into the distal lumen (Fig. 1C). Alternatively, both sutures can be left untied until the proximal end is inserted into the distal vessel (Fig. 1D-F). Standard end-to-end anastomoses of divided femoral arteries served as controls. Anastomotic patency at both shortterm and long-term intervals was assessed by 1) in vivo observation utilizing an operating microscope ( x 20), 2) hemodynamic comparison using high-frequency pulsed ultrasound Doppler, and 3) histologic preparations. The numbers of anastomoses studied for both short- and long-term patency are given in Table 1. Acute hemodynamic characteristics of modified sleeve technique and control anastomoses were studied in six rats (12 carotid arteries, diameter 1.O-1.4 mm). In each animal one artery was repaired using our modified sleeve technique, and the contralateral vessel was repaired using endto-end technique (with eight stitches) as control. Immediately after repair and then at 30 min intervals up to at least 240 min each anastomosis was examined by a 20 mHz pulsed ultrasonic Doppler utilizing a tandem Doppler probe developed in our laboratory.’* Phasic and mean velocity waveforms were recorded at identical pre- and postanastomotic sites simultaneously.
Zhang et al.
322
A
B
C
D P
R 1’UCHLER.me
Figure 1. Diagrammatic illustration of modified sleeve anastomosis. See text for detailed description.
Table 1.
Patency Short-term 2 Hours 1 Day 3 Days Long-term 1 Week 2 Weeks 4 Weeks 8 Weeks Total
Table 2. Patency and Related Data.
No. of Anastomoses.
Sleeve (n = 40)
Modified sleeve anastomosis
Control
3 3
4 3
5
5
8 6 7 8
4 5 4 3
40
28
RESULTS
Patency and related results for both the modified sleeve and control anastomotic groups are presented in Table 2. Histologic examination demonstrated complete reendothelialization of both sleeve and control groups at 2-4 weeks postoperatively. There was no evidence of protrusion of sutures into the lumen of the sleeve group. The fusion of distal and proximal telescoping vessels was clearly seen. The sleeve groups exhibited slight proliferation of intima and thickening of the overlapped vessel segment (2 weeks). No obvious medial necrosis was observed (Figs. 2, 3). We found no hemodynamically significant vasospasm or stenosis using the modified sleeve technique. Examina-
Ave. vessel diameter (mm) 0.67 % 0.12 Operating time (min) 5.97 _C 0.77 Anastornotic 22.5 leakage (>.5min) (YO) Patency rate (Yo) 97.5 Aneu wsms 0
Control (n = 28) 0.66
?
0.10
P N.S.”
11.87 rfi 1.25
