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Table of Contents    
ORIGINAL ARTICLE
Year : 2017  |  Volume : 65  |  Issue : 1  |  Page : 69-72

The “11 O'clock Heel First” technique for microvascular end-to-side anastomosis


1 Department of Neurosurgery, Kasr Al-Ainy Medical College, Cairo University, Cairo, Egypt
2 Department of Interventional Neurology, Ain Shams Medical College, Ain Shams University, Cairo, Egypt
3 Department of Neurosurgery, Nasser Institute for Research and Treatment, Cairo, Egypt
4 Department of Otorhinolaryngiology and Head and Neck Surgery, Kasr Al-Ainy Medical College, Fayoum University, Egypt
5 Department of Neurosurgery, Albert Einstein Medical College, New York, USA

Date of Web Publication12-Jan-2017

Correspondence Address:
Arundhati Biswas
Department of Neurosurgery, Albert Einstein Medical College, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.198207

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 » Abstract 

Background: The heel of a microvascular end-to-side anastomosis is a common site for technical imperfections. We describe a simple technique to overcome this challenge. The aim of the technique is to insert all the sutures in an inside-to-outside manner at the heel area on the donor side of the anastomosis. This technique has first been tested in a laboratory setting and then was further elaborated in a clinical setting.
Materials and Methods: One hundred and twenty adult albino Wistar rats of both genders were randomized into the following two groups: (A) Control, 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique; (B) Study group, 72 rats, representing approximately 60% of the total sample, underwent the technique described. Patency was confirmed both clinically and by the use of fluorescein angiography. Rat weight, diameter of both the donor and recipient vessels, type of anastomosis (arterio–arterial or arterio–venous) and angiographic findings were used as variables. A P value of less than 0.05 was considered significant.
Results: The proposed technique had increased patency rates as compared to the standard technique, which was statistically significant (P = 0.021). However, there was no difference between the patency rates of arterio-arterial and arterio-venous atastomoses.
Conclusion: The proposed technique is useful for perfecting the heel area of a microvascular end-to-side anastomosis in both laboratory and clinical settings.


Keywords: Cerebral revascularization, end-to-side microvascular anastomosis, heel
Key Messages:
In this study conducted on adult albino Wistar rats, a new technique of microvascular anastomosis, by first securing the heel suture at 11 O′ clock position in the recipient vessel, facilitated the placement of all other sutures in an inside-to-outside fashion while visualizing the vessel lumen from inside.The technique showed better patency rates when compared to the standard two anchoring stitch technique of microvascular anastomosis.


How to cite this article:
Hegazy A, Adel MF, Abd-Allah F, Al-Shamy H, Elbassiouny A, Amin SM, El. Samadoni A, Sandler A, Biswas A. The “11 O'clock Heel First” technique for microvascular end-to-side anastomosis. Neurol India 2017;65:69-72

How to cite this URL:
Hegazy A, Adel MF, Abd-Allah F, Al-Shamy H, Elbassiouny A, Amin SM, El. Samadoni A, Sandler A, Biswas A. The “11 O'clock Heel First” technique for microvascular end-to-side anastomosis. Neurol India [serial online] 2017 [cited 2017 Feb 21];65:69-72. Available from: http://www.neurologyindia.com/text.asp?2017/65/1/69/198207


The heel of the anastomosis is the most vulnerable part of an end-to-side microvascular anastomosis. Several microvascular techniques have been described, with variable patency rates.[1],[2],[3],[4],[5] However, the stitch at the 11 o'clock location is the most common site for a through stitch owing to the surgeon's inability to see inside the lumen while putting this one stitch in particular and because of the proximity of both walls of the donor vessel to each other in this area. We describe a simple technique to obviate this problem. This technique aims at starting the anastomosis with the stitch at the 11 o'clock position first, and in the meantime, allowing an opportunity to place all the other stitches in an inside-to-outside fashion on the donor vessel. This aims at perfecting the heel area and removing the possibility of a through stitch in this area.


 » Materials and Methods Top


Sample and variables in the study

  1. Sample:120 adult albino Wistar rats of both genders (mean weight 345.7 ± 34.5 gm, 95% CI 339.4-351.9), were randomly divided into two groups, using random numbers technique
    • Groups: (a) Controls: 48 rats, representing approximately 40% of the total sample, underwent the usual two anchoring stitch technique
    • (b) Study group: 72 rats, representing approximately 60% of the total sample, underwent the new technique
  2. Variables in the study:
    • Weight of the rats
    • Diameter of the donor vessel
    • Diameter of the recipient vessel
    • Type of anastomosis: 120 end-to-side microvascular anastomoses were created either as arterio–arterial (between both common carotid arteries in the neck) or arterio–venous (between the femoral artery's end and the femoral vein's side in the right hind limb)
    • Flow across the anastomosis, as assessed by fluorescein angiography after the creation of anastomosis. This was classified as good flow, poor flow, and occluded anastomosis
    • Statistical technique: For testing of sample homogeneity, descriptive statistics were obtained by cross-tabulating study groups against type of anastomosis, and by calculating the mean, standard deviation, and 95% confidence interval for means. The t-test for two independent groups was used to test the differences between means of the two groups, whereas chi-square test was used to test for independency. For testing of hypothesis, chi-square test and Kolmogorov–Smirnov (KS) test were used
    • The statistical techniques were performed using an ∝ = 0.05 and β ≤ 0.20, with two independent samples (control versus study groups) as the experimental design
    • The statistical studies were performed using the Statistical Package for the Social Sciences IBM SPSS Statistics version 20.0.


Surgical technique

Study group

After dissection and preparation of both donor and recipient vessels, a linear arteriotomy was performed in the recipient vessel, and a stent was placed inside to help keep the vessel patent and maintain good visualization inside the lumen while performing the anastomosis. The first suture was then passed from outside to inside on the 11 o'clock position on the recipient vessel side, and then the suture was passed from inside to outside on the donor vessel at the 1 o'clock position of the flipped vessel and tied [Figure 1]. The same process was repeated from proximal to distal, from 11o'clock to 6 o'clock, on the far side of the vessel, either in an interrupted or in a continuous fashion, until the far side is completed [Figure 2] and [Figure 3]. This was performed while visualizing the lumen of both donor and recipient vessels with every suture.
Figure 1: The donor artery is kept twisted and facing the surgeon and a small stent is placed inside the recipient vessel to keep it open and facilitate visualization. The first stitch is passed from outside to inside on the recipient vessel at the 11 o'clock position, and , then from inside to outsie on the donor vessel at the 1 o'clock position

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Figure 2: The same process is repeated from proximal to distal, from 11 o'clock to 6 o'clock on the recipient vessel and from 1o'clock to 6 o'clock on the donor vessel

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Figure 3: The suturing of the far side of the vessel is nearly complete

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Attention was now shifted towards the angle, and the suture at 12 o'clock was now placed; the same process was continued along the near side of the vessel [Figure 4] until the anastomosis was completed. Before placing the last few sutures, the stent was removed, and the last few sutures were tied. After clinical testing for patency, fluorescein angiography was done to test for patency and flow characteristics.
Figure 4: Attention is now shifted to the 12 o'clock suture, which is done in the same manner, and it becomes much easier with the far side of the vessel nearly complete, as it holds the vessel edges apart. Now, after completion of the 12 o'clock suture, the near side can be completed from proximal to distal and the tube removed

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Control group

Once both vessels were cleaned of their loose adventitial attachments, one vessel was selected as the donor and the other as the recipient. The donor vessel was temporarily occluded and divided. The distal end of the donor vessel was spatulated by trimming it at an oblique angle and then incising the vessel along one edge to create a funnel-shaped anastomosis. The heel stitch was applied first, followed by the toe stitch. Interrupted stitches were placed at equal intervals along the edge of the donor and recipient vessels over a stent.


 » Results Top


Grading

Grading of the anastomosis, according to fluorescein angiography, was done as follows: (a) Occluded anastomosis if the dye failed to appear in the recipient vessel; (b) poorly functioning anastomosis if the dye appeared in the recipient vessel but filled in only one direction, or if there was a filling defect; (c) well-functioning anastomosis if the dye appeared in the recipient vessel and filled in both directions with no filling defect.

Sample homogeneity

[Table 1], [Table 2], [Table 3] show no significant difference between the study and control groups regarding the weight, donor and recipient vessel diameters, and the type of anastomosis (P > 0.05).
Table 1: The differences between both groups through weight

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Table 2: The differences between both groups through donor and recipient vessel diameters

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Table 3: Studies the distribution between both groups through type of anastomosis

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Testing of hypothesis

There was no difference between the patency of the arterio-arterial and arterio-venous anastomosis (P > 0.05) [Table 4]. There was significant difference between the patency of anastomosis between the new proposed technique and the standard technique (P = 0.021) [Table 5].
Table 4: Studies the relationship between the type of anastomosis and patency

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Table 5: Studies the relationship between the technique of anastomosis and patency

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 » Discussion Top


As the heel of an end-to-side microvascular anastomosis is its most vulnerable part, the success of any microvascular anastomosis is highly dependent on the technical perfection in this heel area.[6] A number of techniques have been described for the creation of microvascular end-to-side anastomosis.[7] These include, but are not limited to, the one way up technique, the classic two anchoring stitch technique, and the triangulation technique.[6],[7],[8]

The classic two anchoring stitch technique,[1],[4] which is the most widely used, prevents rotation of the donor on the recipient vessel. However, it prevents visualization inside the lumen, which makes it highly likely to bite the back wall resulting in a through stitch.[9],[10] The one way up suture technique allows visualization inside the lumen during all stages of the anastomosis. However, it must be done with a continuous stitch on the back wall, which is against graft maturation, and the way the suture has to be started and ended is technically demanding.[11],[12]

Our results indicate a statistically significant difference between the anastomosis patency rates of the study and control groups with a P value of 0.021. There was no difference between the patency rates of arterial–arterial and arterial–venous anastomoses.

The technique described in the paper allows visualization inside the lumen of both donor and recipient vessels during all stages of the anastomosis, and allows the placement of all the sutures in an inside-to-outside fashion on the donor vessel. This prevents transfixing the back wall, and can be done in a continuous or interrupted manner, thus allowing for graft maturation.

The technique is elegant, as it minimizes the risk of biting the back wall even in vessels of very small diameter. This is because the needle constantly faces away from the other wall while each stitch is being placed. The main disadvantage of this technique is that when the recipient vessel is heavily atherosclerotic, passing the suture from outside to inside may result in the creation of an intimal flap. However, this was not encountered in the present series. It is also easier to perform this technique when the tip of the donor vessel is placed towards the surgeon, as is the case with most low flow microvascular anastomosis. When the vessel tip faces away from the operating surgeon, as is the case in high-flow anastomoses, this is more difficult, because the suture needs to be passed in a backhand fashion on the recipient vessel.

At present, this technique has been used in a number of microvascular anastomotic procedures, particularly superficial temporal artery to middle cerebral artery bypass for internal carotid artery occlusion as well as moya-moya disease and it has demonstrated excellent patency rates as demonstrated by computed tomography angiography and transcranial color coded duplex studies.[13]


 » Conclusion Top


This technique has proven to be useful in a laboratory and clinical setting, particularly for vessels of small diameter. It has helped to a great extent in removing the possibility of a through stitch at the heel area, which is the reason for most anastomotic failures in end-to-side microvascular anastomoses. The technique described with placement of a stent in the recipient vessel and putting all sutures in an inside-to-outside direction on the graft or donor vessel produced statistically significant increased patency rates than the conventional technique with two anchoring stitches. In addition, the technique succeeded in facilitating the perfection of the heel area of the anastomosis, while all sutures could be placed while visualizing the lumen inside. Our preliminary results from the animal experiments shows that this is a simpler technique with shorter learning curve among less experienced vascular surgeons and shorter operative time.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 » References Top

1.
Bisson EF, Visioni AJ, Tranmer B, Horgan MA. External carotid artery to middle cerebral artery bypass with the saphenous vein graft. Neurosurgery 2008;62(3 Suppl 1):134-8.  Back to cited text no. 1
    
2.
Charbel FT, Meglio G, Amin-Hanjani S. Superficial temporal artery-to-middle cerebral artery bypass. Neurosurgery 2005;56(1 Suppl):186-90.  Back to cited text no. 2
    
3.
Newell DW, Vilela MD. Superficial temporal artery to middle cerebral artery bypass. Neurosurgery 2004;54:1441-8.  Back to cited text no. 3
    
4.
Ramanathan D, Temkin N, Kim LJ, Ghodke B, Sekhar LN. Cerebral bypasses for complex aneurysms and tumors: Long-term results and graft management strategies. Neurosurgery 2012;70:1442-57.  Back to cited text no. 4
    
5.
Wanebo JE, Zabramski JM, Spetzler RF. Superficial temporal artery-to-middle cerebral artery bypass grafting for cerebral revascularization. Neurosurgery 2004;55:395-9.  Back to cited text no. 5
    
6.
Guity A, Young PH, Fischer VW. In search of the “perfect” anastomosis. Microsurgery 1990;11:5-11.  Back to cited text no. 6
    
7.
Chen L, Chiu DT. Spiral interrupted suturing technique for microvascular anastomosis: A comparative study. Microsurgery 1986;7:72-8.  Back to cited text no. 7
    
8.
Yazici I, Cavusoglu T, Comert A, Vural AC. Use of triangulation method in end-to-side arterial microvascular anastomosis. J Craniofac Surg 2009;20:222-5.  Back to cited text no. 8
    
9.
Alghoul MS, Gordon CR, Yetman R, Buncke GM, Siemionow M, Afifi AM, et al. From simple interrupted to complex spiral: A systematic review of various suture techniques for microvascular anastomoses. Microsurgery 2011;31:72-80.  Back to cited text no. 9
    
10.
Ozkan O, Ozgentaş HE. Open guide suture technique for safe microvascular anastomosis. Ann Plast Surg 2005;55:289-91.  Back to cited text no. 10
    
11.
Gumerlock MK, Coull BM, Howieson J, Buchan C, Neuwelt EA. Late stenosis of a superficial temporal-middle cerebral artery bypass: Angiographic and histological findings. Neurosurgery 1985;16:650-7.  Back to cited text no. 11
    
12.
Ochi M, Tanaka S. Arterial graft anastomosis in coronary surgery: Side by side stitch with parachute technique. Kyobu Geka 1994;47:360-3.  Back to cited text no. 12
    
13.
Biswas A, Samadoni A El, Elbassiouny A, Sobh K, Hegazy A. Extracranial to intracranial by-pass anastomosis: Review of our preliminary experience from a low volume center in Egypt. Asian J Neurosurg 2015;10:303-9.  Back to cited text no. 13
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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