Eur J Vasc Surg 4, 643-644(1990)
SURGICAL PRACTICE
End-to-end Anastomosis Between Two Vessels of Different Size Marco P. Merlini Department of Surgery, H6pital Communal, La Chaux-de-Fonds, Switzerland, and Department of Surgery A, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland A technique enabling end-to-end anastomosis between two vessels of different size is described. This method reduces the larger vessel to a truncated cone by excision of a triangle the base of which corresponds to a part of its circumference. By this method, the diameters are easily adapted to one another and the end-to-end anastomosis remains centred. Key Words: Vascular surgery; End-to-end anastomosis; Diameter discr~ancy.
Introduction An e n d - t o - e n d anastorhosis b e t w e e n two vessels of different size is sometimes difficult. A simple m e t h o d is described which allows a centred anastomosis, keeping the vascular axis straight by r e d u c i n g the cross-section of the larger vessel.
Method In order to carry out an e n d - t o - e n d anastomosis without requiring a millimetric rule fhe only distances we
n e e d to k n o w are the half circumference of the larger vessel (a) and the smaller vessel (b) (Fig. 1A). These distances are easily obtained b y flattening the walls of the two vessels. The diameter of the larger vessel is n a r r o w e d into a truncated cone by the excision of a triangle, the base of which c o r r e s p o n d s to a part of its circumference (Fig. 1B). The area of its cross-section is thus r e d u c e d and allows suitable suturing (Fig. 1C). At operation the large vessel is flattened and the half circumference of this vessel (a) determines the height of the triangle to excise (Fig. 2). This excision reduces the cross-section of this vessel. H o w e v e r the residual half circumference is slightly longer than that of the small vessel (b), (Fig. 3). The small vessel is cut
"
Fig. 1. Principle of the end-to-end anastomosis. Please address all correspondence to: Dr M. P. Merlini, Department or Surgery, H6pital Communal, 2300 La Chaux-de-Fonds, Switzerland. 0950~821X/90/060643+02$03.00/0© 1990Grune& Stratton Ltd.
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M.P. Merlini
slightly obliquely to match the larger vessel. A vascular suture is then used to stitch together the two sides of the triangle (of the large vessel) and the two vessels are finally stitched together (Fig. 4).
a
Discussion Fig. 2. Preparation of the large vessel. In order to obtain a smooth tapering of the anastomotic zone, the height of the triangle to excise equals the half-circumference of the vessel (distance a).
f-b Fig. 3. The triangle is excised. The residual circumference is left slightly larger than the circumference of the small vessel.
In peripheral vascular surgery an end-to-end anastomosis between two vessels of different size is difficult, particularly when a prosthesis and a small diameter vein have to be sutured together as a composite femoro-popliteal bypass graft. Due to the inflexibility of the prosthesis, the anastomosis is usually performed by stretching the vein, which creates a kinking and causes turbulence with a risk of thrombosis and graft failure. 1 For composite bypasses other methods allowing better matching of the diameters have been described. 2 Another technique 3 perfecting the fish mouth anastomosis described by Harashina 4 for microvessels can be used when joining vessels of different sizes. By reducing the large vessel (prosthesis) to a truncated cone as described here the end-to-end anastomosis is performed without stretching the venous wall and has the advantage of maintaining a straight vascular axis thereby reducing the risk of turbulence.
References
Fig. 4. The vascular suture is carried out.
1 TAYLOR RS, MCFARLAND RJ, Cox MI. An investigation into the causes of failure of PTFE grafts. Eur J Vasc Surg 1987; 1: 335-343. 2 HOLDSWORTHPJ, RIDDELLPS, LEVESONSH. Distal femoro-popliteal bypass using a composite graft of PTFE and non-reversed saphenous vein. Ann R Coll Surg Engl 1989; 71: 4-6. 3 MERLINI MP. End-to-end anastomosis by enclosure between a prosthesis and a vessel presenting a significant difference in diameter. Am J Surg 1990:159: 417-419. 4 HARASHINAT, IRIGARAYA. Expansion of smaller vessel diameter by fish-mouth incision on microvascular anastomosis with marked size discrepancy. PlastReconstr Surg 1980; 65: 502-502.
Accepted 29 March 1990
Eur J Vasc Surg Vol 4, December 1990
SURGICAL PRACTICE
End-to-end Anastomosis Between Two Vessels of Different Size Marco P. Merlini Department of Surgery, H6pital Communal, La Chaux-de-Fonds, Switzerland, and Department of Surgery A, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland A technique enabling end-to-end anastomosis between two vessels of different size is described. This method reduces the larger vessel to a truncated cone by excision of a triangle the base of which corresponds to a part of its circumference. By this method, the diameters are easily adapted to one another and the end-to-end anastomosis remains centred. Key Words: Vascular surgery; End-to-end anastomosis; Diameter discr~ancy.
Introduction An e n d - t o - e n d anastorhosis b e t w e e n two vessels of different size is sometimes difficult. A simple m e t h o d is described which allows a centred anastomosis, keeping the vascular axis straight by r e d u c i n g the cross-section of the larger vessel.
Method In order to carry out an e n d - t o - e n d anastomosis without requiring a millimetric rule fhe only distances we
n e e d to k n o w are the half circumference of the larger vessel (a) and the smaller vessel (b) (Fig. 1A). These distances are easily obtained b y flattening the walls of the two vessels. The diameter of the larger vessel is n a r r o w e d into a truncated cone by the excision of a triangle, the base of which c o r r e s p o n d s to a part of its circumference (Fig. 1B). The area of its cross-section is thus r e d u c e d and allows suitable suturing (Fig. 1C). At operation the large vessel is flattened and the half circumference of this vessel (a) determines the height of the triangle to excise (Fig. 2). This excision reduces the cross-section of this vessel. H o w e v e r the residual half circumference is slightly longer than that of the small vessel (b), (Fig. 3). The small vessel is cut
"
Fig. 1. Principle of the end-to-end anastomosis. Please address all correspondence to: Dr M. P. Merlini, Department or Surgery, H6pital Communal, 2300 La Chaux-de-Fonds, Switzerland. 0950~821X/90/060643+02$03.00/0© 1990Grune& Stratton Ltd.
C
644
M.P. Merlini
slightly obliquely to match the larger vessel. A vascular suture is then used to stitch together the two sides of the triangle (of the large vessel) and the two vessels are finally stitched together (Fig. 4).
a
Discussion Fig. 2. Preparation of the large vessel. In order to obtain a smooth tapering of the anastomotic zone, the height of the triangle to excise equals the half-circumference of the vessel (distance a).
f-b Fig. 3. The triangle is excised. The residual circumference is left slightly larger than the circumference of the small vessel.
In peripheral vascular surgery an end-to-end anastomosis between two vessels of different size is difficult, particularly when a prosthesis and a small diameter vein have to be sutured together as a composite femoro-popliteal bypass graft. Due to the inflexibility of the prosthesis, the anastomosis is usually performed by stretching the vein, which creates a kinking and causes turbulence with a risk of thrombosis and graft failure. 1 For composite bypasses other methods allowing better matching of the diameters have been described. 2 Another technique 3 perfecting the fish mouth anastomosis described by Harashina 4 for microvessels can be used when joining vessels of different sizes. By reducing the large vessel (prosthesis) to a truncated cone as described here the end-to-end anastomosis is performed without stretching the venous wall and has the advantage of maintaining a straight vascular axis thereby reducing the risk of turbulence.
References
Fig. 4. The vascular suture is carried out.
1 TAYLOR RS, MCFARLAND RJ, Cox MI. An investigation into the causes of failure of PTFE grafts. Eur J Vasc Surg 1987; 1: 335-343. 2 HOLDSWORTHPJ, RIDDELLPS, LEVESONSH. Distal femoro-popliteal bypass using a composite graft of PTFE and non-reversed saphenous vein. Ann R Coll Surg Engl 1989; 71: 4-6. 3 MERLINI MP. End-to-end anastomosis by enclosure between a prosthesis and a vessel presenting a significant difference in diameter. Am J Surg 1990:159: 417-419. 4 HARASHINAT, IRIGARAYA. Expansion of smaller vessel diameter by fish-mouth incision on microvascular anastomosis with marked size discrepancy. PlastReconstr Surg 1980; 65: 502-502.
Accepted 29 March 1990
Eur J Vasc Surg Vol 4, December 1990
