TY - JOUR
AU - van Schilfgaarde, R
AB - Abstract Background The main aim of performing a vascular anastomosis is to achieve maximal patency rates. An important factor to achieve that goal is to minimize damage to the vessel walls. Sutures inevitably induce vascular wall damage, which influences the healing of the anastomosis. Over time, several alternatives to sutures have become available. Methods A Medline literature search was performed to locate English, German and French language articles pertinent to non-suture methods of vascular anastomosis. Manual cross-referencing was also performed and many historical articles were included. Results and conclusion The non-suture techniques can be categorized into five groups based on the materials used: rings, clips, adhesives, stents and laser welding. With all these techniques a faster and less traumatic anastomosis can be made compared with sutures. However, each device is associated with technique-related complications. As a consequence, suturing continues to be the standard approach. The disadvantages of the non-suture techniques include: rigidity and a non-compliant anastomosis with rings; toxicity, leakage and aneurysm formation with adhesives; early occlusion with stents; cost, reduced strength in larger-sized vessels and demand for surgical skills with laser welding. Further refinement is needed before widespread adoption of these techniques can occur. Clips, however, may be particularly promising but long-term evaluation is required. Introduction When performing a vascular anastomosis, the surgeon should comply with several basic rules in order to achieve the best possible anatomical restoration, which in turn should maximize patency. Vascular anastomoses became successful only after Alexis Carrel in 1902 had formulated four main guidelines for vascular repair1. Using sutures, he recommended avoiding luminal narrowing at the anastomotic site, avoiding the creation of folds and a rough inner surface of the vessel, and opposing the two intimal edges closely. As a fourth rule, he suggested eliminating contact of suture material with blood, although in his later experiments his sutures included the entire thickness of the vessel wall. Using these guidelines, vascular anastomoses were performed in all sorts of configurations with the aid of triangulated everting sutures inserted at equidistant points. Traction upon these stitches approximated the vessel edges; application of a continuous suture was relatively easy (Fig. 1). Fig. 1 Open in new tabDownload slide Vascular anastomosis using Carrel's method1, in which three traction sutures are used to facilitate the application of a continuous circumferential suture The needle and thread are still used for vascular anastomosis, more or less as described 100 years ago. Suturing, however, has several detrimental aspects. The penetrating needle induces vascular wall damage, which influences the healing response. Non-absorbable suture material is left as an intraluminal foreign body and may cause an inflammatory reaction, thrombocyte aggregation, impaired endothelial function, intimal hyperplasia, and hence stenosis2–6. The suture material Carrel used in his early experiments was fine silk on a curved needle. Attempts have been made to reduce damage to the vascular wall by using other non-absorbable suture materials (cotton, nylon, stainless steel), absorbable sutures (catgut, polyglycolic acid, polydioxanone, polyglactin), or the atraumatic needle. Vascular wall damage cannot, however, be eliminated entirely by such means. Several arguments favour a non-suture anastomosis. It is conceivable that long-term patency may improve with less trauma to the vascular wall. Additionally, the surgeon would welcome simpler, faster and less technically demanding techniques. Furthermore, the recent development of minimally invasive techniques in cardiac and vascular surgery requires alternative techniques of anastomosis that can be performed through small access sites. New devices developed for minimally invasive work may also be useful for vascular anastomosis at sites that are difficult to reach during open surgery. Over time a variety of alternative non-suture techniques has been developed. Some of them are only of historical interest, but others are still being evaluated clinically. The aim of this article is to categorize these techniques systematically and to discuss the advantages and disadvantages of each. Search strategy A Medline search from January 1966 to July 2002 using the terms ‘vascular anastomosis’, ‘suture’, ‘non-suture’, ‘ring’, ‘clip’, ‘staple’, ‘adhesive’, ‘glue’, ‘stent’ and ‘laser welding’ in various combinations with the Boolean operators AND, OR and NOT was carried out to identify publications reporting experience with non-suture methods of vascular anastomosis. Manual cross-referencing was also performed. Rings The history of vascular anastomosing rings goes back to 1900, when Payr introduced an extraluminal magnesium prosthesis7. With this technique, the proximal vessel end was passed through a ring and everted over it. The proximal vessel end and ring was then pulled into the dilated distal vessel end and secured with a circumferential ligature (Fig. 2). Absorption of the magnesium, however, resulted in a perivascular inflammatory mass that eventually occluded the vessel. To avoid this inflammation, other materials have been introduced, such as caramel1, silver8, polyethylene9 and tantalum10. None of these, however, gained wide application as a cuffed ring technique. The same applies to a method based on the use of the magnetic force between two matching magnet rings and a cogwheel-shaped hollow metal instrument with six spurs11. Fig. 2 Open in new tabDownload slide Vascular anastomosis with an extraluminal magnesium ring as introduced by Payr7 In 1960, Holt and Lewis first described the use of paired anastomotic rings12 (Fig. 3). Each teflon ring had six evenly spaced pinholes and interposed between the holes were six pins. The arteries were slipped through the rings and their edges everted and fixated to the pins in each, after which the rings were approximated. Two fixating sutures on the outside joined the two rings. Nakayama and colleagues presented a ring-pin device with instrumentation in 196213 (Fig. 4). Their device consisted of two metallic rings, each of which also had pinholes and pins. The rings were used in vessels ranging from 1·5 to 4 mm in outer diameter and remained in situ as a permanent implant. The apparatus was also used for end-to-side anastomoses, although it resulted in inclusion of a great part of the vessel wall, with subsequent stenosis at the anastomotic site. Based on the Nakayama apparatus, Östrup and Berggren introduced the Unilink system® (3M Company, St. Paul, Minnesota, USA) in 198614 (Fig. 5). This system, which is still in use, consists of two polyethylene rings with alternating stainless steel pins and holes. After insertion of the vessel ends, the rings are approximated with a special device. Currently, four sizes of ring are available, ranging from 1·0 to 2·5 mm in diameter. Reports continue to appear on the use of the Unilink system®, proving the device to be simple, efficacious and significantly faster than conventional suturing15. The system seems best suited for end-to-end anastomoses of soft, pliable, minimally size-discrepant vessels. Although most reports concern venous anastomoses, the device can also used for arteries16,17. Previous radiation therapy does not appear to be a contraindication to its application18, but severely atherosclerotic arteries are19. In addition, the rings are permanently placed with subsequent detrimental physiological effects at the anastomotic site, inducing atrophy of the media both at the level of the ring and proximal to it20. Fig. 3 Open in new tabDownload slide Vascular anastomosis with paired anastomotic rings as introduced by Holt and Lewis12 Fig. 4 Open in new tabDownload slide Ring-pin device of Nakayama et al.13 with two metallic rings, each containing six pinholes and six pins. Inlay shows vessel end everted and fixated by pins on to the face of the ring Fig. 5 Open in new tabDownload slide Clinical use of the Unilink system® at the anastomoses of donor and recipient artery (above) and vein (below). The rings are indicated by black arrows. Inlay shows the Unilink system®, consisting of two polyethylene rings with alternating pinholes and pins To solve the problems associated with permanent rigid rings, absorbable anastomotic couplers were introduced. In 1984, Daniel and Olding described the use of a polyglactin coupler in which the vessel ends were everted 180° 21,22. Consequently, a greater amount of vessel wall was needed with an increased risk of intimal damage. In 1999, a Japanese group of investigators published their experimental results with a pin-ring coupler with absorbable rings that consisted of l-lactid acid and glycolic acid23–25. Although the rings dissolved through hydrolysis, the stainless steel pins persisted. Furthermore, the chronic inflammatory reaction, especially in the adventitia, was more intense than that in sutured anastomoses23. A new device has recently been introduced to facilitate an end-to-side vein-to-aorta anastomosis for coronary surgery (Fig. 6)26. The key features are internal and external struts for positioning of the connector on the aorta, racetracks that radially expand to seal the anastomosis, and vein hooks to retain the vein. With this device (the St Jude Medical SymmetryTM aortic connector system, St. Jude Medical Inc., Minneapolis, Minnesota, USA), 65 such anastomoses have been performed with good results in 43 consecutive patients undergoing coronary artery bypass27. All the anastomoses were done without the use of any aortic clamp. The system has not yet been tested for other types of vascular anastomosis. Fig. 6 Open in new tabDownload slide The St Jude Medical SymmetryTM aortic connector system used for vein-to-aorta anastomoses in coronary bypass. The external struts are visible on the outside of the aorta once the device is deployed. Inlay shows an inside view of the connector demonstrating that the vein is flared out on the internal wall of the aorta allowing an intima-only blood path In summary, vascular anastomotic ring techniques predominantly include extraluminal cuffing rings and everting pinned-ring devices. Both techniques are faster than conventional suturing and have mainly been used to perform end-to-end anastomoses. The main disadvantages of these coupling techniques are the limited number of ring diameters, difficulties due to diameter mismatch, and detrimental effects in the perianastomotic area. Staples and clips In 1908, Hümér Hültl, a Hungarian surgeon, used a stapler, originally designed by Fischer, to perform gastric resections. It was a crushing staple-forceps with a cogwheel, gear rod, and a moving crankshaft constructed to deliver two double rows of U -shaped staples of steel wire that were bent into a B -shape, sealing both sides of the stomach. The device, which weighed 3·5 kg, was manufactured until 192128. Modifications of this stapler were described in 1924 by von Petz29 and in 1935 by von Brücke30. All these instruments were used for gastrointestinal procedures but formed the basis for the introduction of the same anastomotic principle in vascular surgery. Between 1945 and 1950, a group of Russian engineers and physicians developed a mechanical apparatus for vascular anastomosis (Fig. 7). Inverted U -shaped tantalum clips with pointed ends were used to perform end-to-end anastomoses in vessels ranging from 1·3 to 20 mm in diameter. The first report on its clinical application came in 1956 from Androsov31, who did not use the device for anastomosis but for the repair of various vessel injuries and traumatic aneurysms. Fig. 7 Open in new tabDownload slide Mechanical clipping apparatus for vascular anastomosis as developed by a group of Russian engineers between 1945 and 1950 The first publications on the use of metal clips for vascular anastomosis were reports of animal experiments. In 1953, Bikfalvi and Dubecz32 applied silver clips by means of a vessel encircling mechanism based on the principle of the von Petz clamp29. In 1955, Samuels used stainless steel clips that were inserted into adjustment forceps by a mechanical loader. This device was tested for the closure of arteriotomies and for end-to-end aortic anastomoses in dogs33,34. Shortly thereafter, two modifications of the Russian device were developed in Japan, one for end-to-end and the other for end-to-side vascular anastomoses35,36. Both staplers used U -shaped stainless steel clips. Inokuchi36 reported the use of the first end-to-side device in seven patients requiring splenorenal shunts in 1961. A common feature of these early devices, including the Canadian37 and American38 staplers of the 1960s, was their complexity; they were cumbersome to apply. These aspects hardly helped their wide acceptance and they were rightly abandoned. In the 1980s, Kirsch and associates39–41 developed a non-penetrating method of vascular anastomosis, in which small titanium clips were applied to everted vessel edges in an interrupted fashion. After 1995, this means of anastomosis became commercially available as a disposable device (the VCS clip applier system®, AutoSuture, United States Surgical Corporation, Norwalk, Connecticut, USA) (Fig. 8). It is still in use and has a distributing cartridge of 25–40 arcuate-legged clips. The top end of the cartridge allows 360° rotation for accurate placement of the clips, which are released by manual pressure that causes the jaws of the clips close. There are four different sizes of clip. Since its introduction, a number of experimental and clinical reports by different groups of investigators have appeared. Experimental studies showed that advantages of clips compared with sutures are a reduced anastomotic time42,43 and a higher patency rate, probably related to an improved anastomotic healing pattern5,6,43–45. Fig. 8 Open in new tabDownload slide Clinical use of the VCS clip applier system® during the creation of an arteriovenous Brescia–Cimino fistula. Inlay shows four different sizes of the clip applier, everting forceps and a clip remover To date, there have been approximately 30 000 clinical applications worldwide, the majority during vascular access procedures for haemodialysis46. Other clinical applications include microvascular reconstructive tissue transfer19, coronary artery bypass grafting47, transplantation surgery48, carotid artery surgery46 and peripheral arterial bypass surgery49. Two reports have appeared recently in the field of cardiovascular literature on the use of a new anastomotic device from the same distributor that applies 12 clips simultaneously along the suture line in one shot, aiming to facilitate and speed up the anastomotic procedure50,51 (Fig. 9). So far, only prototypes have been tested and this new device is not yet commercially available. Fig. 9 Open in new tabDownload slide One-shot stapler with a cartridge that is loaded circumferentially containing 12 equally spaced clips. Inlay shows the tip of the one-shot stapler With the use of staples and clips a fast interrupted end-to-end or end-to-side vascular anastomosis can be made. Disadvantages of clips include the limited number of sizes, difficulty in everting the walls of atherosclerotic vessels, difficulty in joining vessels with a diameter mismatch, and high cost. Tubes and stents The use of a tube or stent to perform a vascular anastomosis was first described in 1894 by Robert Abbe52. He reported animal experiments in which permanently placed hourglass-shaped intraluminal glass tubes were used as end-to-end anastomoses. When applied in the canine femoral artery and the cat aorta, immediate results were favourable, but the anastomoses occluded in the short term. In 1897, Nitze53used small ivory tubes for anastomosis. The vessel ends were slipped over a small ivory cylinder, after which a ligature was used to hold them in place. In 1902, Carrel described the use of dissolvable intraluminal stents composed of caramel candy cylinders for vascular anastomosis1, but this technique has never been applied clinically. During World War II, Blakemore and associates54 bridged arterial defects by joining two vessel ends over a tube of vitallium (Fig. 10). Although initially designed to bridge gaps, the method was also used to facilitate vascular end-to-end anastomoses without defects, such as in portacaval anastomosis55. In 1947, however, Johns56 reported lower patency rates using the same vitallium tubes for renal artery to splenic vein anastomoses in dogs compared with rates in a sutured control group (17 versus 72–90 per cent); after this vitallium tubes were abandoned. Fig. 10 Open in new tabDownload slide Different methods of using a single vitallium tube for vascular end-to-end anastomosis as described by Blakemore et al.54 Better results were achieved in the same year by Swenson and Gross57, who used absorbable fibrin tubes in 27 end-to-end jugular or caval vein anastomoses in dogs. After 6–7 weeks the fibrin tubes had dissolved, leaving patent anastomoses in 26 specimens. The tubes Weiss and Lam used for end-to-end femoral artery anastomoses in dogs were made of tantalum58. They achieved a patency rate of 86 per cent in vein grafts between two short tantalum cuffs, but attempts with longer tantalum tubes were less successful. In 1965, Ota and colleagues59 used a soluble gelatin stent to perform vascular anastomoses. Although the stent dissolved, it temporarily impeded blood flow by swelling. With the water-soluble spindle-shaped tube composed of a saccharide mixture introduced by Suzuki and Onuma60, patency rates in end-to-end dog artery anastomoses with an external diameter of between 2·5 and 4 mm were not more than 70 per cent. In 1994, Moskovitz et al.61 described a fibrin glue-based microvascular anastomosis applied over a soluble stent made of monoglycerides, diglycerides and triglycerides. The stents were used in vessels ranging from 0·3 to 0·8 mm in diameter. Although the technique was faster than suturing, late patency rates were reduced owing to aneurysm formation. In 2000, a new intravascular stent made of a metal alloy of nickel and titanium was designed for sutureless end-to-side anastomoses between coronary arteries and grafts62. The T -shaped device (the GraftConnector®, Jomed International AB, Helsingborg, Sweden), expands after its insertion into the receiving vessel (Fig. 11). As far as the authors are aware, there is a single clinical study in progress assessing this device for arteriovenous fistula; results have not yet been published. Fig. 11 Open in new tabDownload slide The GraftConnector, a new T -shaped intravascular stent made of a metal alloy of nickel and titanium, in use during coronary bypass. Inlay shows detail of the GraftConnector® stent In summary, stents may be applied in two ways, one as the sole means for vascular anastomosis, the other was as an aid to facilitate handsewn anastomosis. Many reports describe low patency rates. Adhesives The adhesives used clinically may be categorized into two groups, fibrin glues and cyanoacrylate glues. Fibrin glue consists of two components and imitates the final step of blood coagulation. The first component contains fibrinogen, factor XIII and plasma proteins; the second usually consists of thrombin, aprotinin and calcium chloride. Fibrin glue was introduced in 1977 by Matras et al.63 as a material for the creation of vascular anastomoses. They described their results with fibrin-sealed end-to-end carotid artery anastomoses in rats. This was a safe and effective method, provided that two 10/0 stay sutures remained permanently. Gestring et al.64,65 were the first to use fibrin glue for end-to-side vascular anastomoses in dogs and rabbits. They used a sutureless technique in which the angled end of the femoral artery was pulled into the femoral vein. Long-term results were not reported, but narrowing of the vessel lumen at the anastomotic site can be expected with this technique. In general, fibrin glue sticks and seals tissues well, is time saving and is easy to apply66. The disadvantages include allergic reactions and anaphylaxis67,68. The Food and Drug Administration (FDA) in the USA cancelled licences for manufacture of fibrinogen in 1978, as the heat treatment, at that time required to inactivate hepatitis B virus, would damage the fibrinogen product69. The second group of surgical glues comprises the synthetic cyanoacrylates (methyl-, ethyl- and butyl-cyanoacrylates). Gottlob and Blümel70 in 1968, used alkyl-cyanoacrylates to secure bushings that were used for experimental vascular anastomosis in vessels ranging from 1·0 to 5·0 mm in diameter. They reported satisfactory short-term patency rates, but already stated in the same paper that they had changed the type of cyanoacrylate because of histotoxicity. Further reports on the tissue toxicity of cyanoacrylates when implanted around blood vessels have appeared. Green et al.71 investigated the microscopic appearance of end-to-end femoral artery anastomoses in rats performed with three 10/0 nylon stay sutures, followed by direct application of butyl-cyanoacrylate (Histoacryl®, B Braun Surgical GmbH, Melsungen, Germany). An early marked foreign body granulomatous response with giant cell formation was noted, with later extreme thinning of the vessel wall, splitting of the elastic lamina and calcification of the media. These authors therefore confirmed previous reports of damage to the outer layers of vessel walls after the experimental application of cyanoacrylates72,73. The development of false aneurysms at the anastomotic join has also been reported74. Factors that have been postulated to explain the above problems include the high heat of polymerization and the difficulty in determining the exact amount of glue to apply with respect to the thickness of the vessel walls. These disadvantages have prevented further use of cyanoacrylates for vascular anastomosis in the clinical setting. Recent reports suggest that 2-octyl-cyanoacrylate may be less toxic, but the FDA has so far approved it for topical use only in wound closure75,76. With any type of adhesive, proper adjustment of the vessel ends before application of the adhesive is essential to avoid the danger of glue entering the vessel lumen. To achieve this, the placement of conventional sutures or the use of some other anastomosing device is essential. Because of this, many studies have simply examined the glue as a means of reducing the number of interrupted sutures required for an adequate seal77,78. In summary, fibrin adhesives or cyanoacrylates for vascular anastomosis have little advantage and several drawbacks, especially allergic and toxic reactions. A further problem is that a few sutures continue to be required to prevent leakage or aneurysm formation in the longer term. Welding The process of welding with either thermal or laser energy is yet another approach for joining two vessel ends. Thermal welding can be performed by electrocautery using bipolar coagulation forceps, as reported by Sigel and Acevedo in 196279, or using the technique described by Wintermantel80, which employs a geared approximator and hand-made wire loops. As far as the authors are aware, there are no clinical reports of thermally welded vascular anastomoses. In the past two decades, lasers have also been used to weld blood vessel edges. Laser-assisted vascular anastomosis was introduced in 1979 by Jain and Gorisch, who used a neodymium yttrium–aluminum–garnet laser to seal incisions without additional sutures in rat vessels with a diameter ranging from 0·3 to 1·0 mm81. Laser energy was passed back and forth over the opposed vessel walls until fusion was achieved by heat-induced changes of the media into collagen, which occurs at temperatures of 70–80° C. Five years later, Jain82 reported a small clinical series of extracranial–intracranial end-to-side anastomoses using the same technique. Each anastomosis was performed in less than 5 min. All five patients were alive after 6–9 months and had angiographically proven patent anastomoses without anastomotic aneurysms. Vascular anastomoses have also been accomplished by other types of laser. Gomes et al.83 in 1981 published the results of a series of anastomoses performed using an argon laser. Larger arteries with a diameter of 4–5 mm were welded with an initial patency rate of 100 per cent. White et al.84,85 performed a clinical series of arteriovenous anastomoses using the argon laser. Patients were followed by physical examination and duplex scanning. After 4·5 years of follow-up, seven of ten patients still had a functioning fistula. Three patients required fistula revision for inadequate maturation of the fistula or for proximal vein thrombosis not related to the laser welding process. Serure et al.86 in 1983 and Quigley et al.87–89 in 1985 reported the use of laser energy from a carbon dioxide source for microvascular anastomosis. Three equidistant 10/0 nylon stay sutures were used to support the join. Sadly these early attempts at carbon dioxide laser welding resulted in an unacceptable rate of anastomotic aneurysm formation and dehiscence, probably as a result of a decreased bursting strength compared with sutured anastomosis89–91. Other groups have achieved better experimental results. Guo and Chao92 in 1988 achieved patency rates of up to 100 per cent with superficial femoral artery end-to-end anastomoses in rabbits, even without the use of stay sutures. They emphasized the importance of accurate adjustment of the transected vessels, of precise control of laser energy, and of minimizing the area exposed to the laser beam. Okada et al.93,94 used carbon dioxide laser welding with the aid of four stay sutures for the creation of arteriovenous Brescia–Cimino fistulas and femoropopliteal bypasses with saphenous vein grafts in humans. There were no laser-related complications. The laser power (measured in watts) and the amount of energy and time required (energy fluence or power density) vary for the type of laser and for the size of the vessels95; variation in outcome may be explained by this. Kopchok et al. reported the optimal range for the argon laser to be 43–48° C, which is lower than the range of 80–120° C for the carbon dioxide laser as reported by Badeau et al.96,97 Consequently, there is less heat damage to collagen with the argon laser. Further improvements in the field of laser-assisted vascular anastomosis came with the introduction of smaller diode probes98, with the excimer laser that vaporizes tissue layer by layer without thermal effects in the deeper layers99,100, and with the introduction of real-time thermal control systems101. Despite these advances, it is important to realize that optimal wavelengths and laser parameters for the different types of seal have not yet been established. In short, laser welding both for end-to-end and for end-to-side vascular anastomosis has mainly been used experimentally. Apart from cerebral microvascular anastomosis, no clinical application has yet been established. Disadvantages include poor anastomotic strength, especially in larger-sized vessels, requiring the insertion of multiple sutures. Furthermore, the surgeon must have knowledge of laser physics and the equipment is expensive. Discussion A century after Carrel's pioneering work on sutured anastomosis, one may conclude that the non-absorbable suture with attached needle is the standard means of vascular anastomosis. Sutures are relatively inexpensive, reliable, readily available, and they can be adapted to almost any tissue condition that may be encountered. Nevertheless, sutures do not fully meet the criteria of an ‘ideal’ anastomosis. In theory, at least, the non-suture techniques developed over the past century appear superior in this regard. Unfortunately, when applied practically, all non-suture methods, including those employing the newest devices, have their own inherent disadvantages. Although anastomoses can be made more rapidly and with less trauma than using sutures, the problems include rigidity and a non-compliant anastomosis with rings; toxicity, leakage and aneurysm formation with adhesives; early occlusion with stents; and high cost, reduced strength in larger-sized vessels and demands on surgical skill with welders. Various non-suture anastomotic techniques are currently available. At present, the benefits of stents and glues hardly outweigh their disadvantages. Lasers need further development before routine clinical use. Worldwide, the two systems that have been used most frequently as alternatives to sutures in the past decade are the Unilink system® and the VCS clip applier system®. Both are available and both secure an easy and rapid anastomosis. Furthermore, they can be used for arteries and for veins in either an end-to-end or an end-to-side configuration. With respect to Carrel's four principles of anastomosis, a join without luminal narrowing can be made with the Unilink system®. Among the components of this device are gauges for measuring the vessel diameter for appropriate matching of the size of the ring in order to avoid stenosis. Scanning electron microscopy of ringed anastomoses has shown smooth and complete endothelial healing in both arterial and venous anastomoses after 2 weeks20 and, while marked atrophy of the media at the site of the anastomotic rings was observed, this did not seem to affect the patency rate, which compared favourably with that of sutured controls17,19,22,102,103. The Unilink system® fits with Carrel's third and fourth principles, alignment of both intimal layers and absence of intraluminal foreign material. Clipped vascular anastomoses, too, meet the important prerequisites. There is no intraluminal foreign body, there is minimal platelet aggregation, and there is less endothelial injury with clips than with sutures2,3,104. Furthermore, in clipped constructions there is close intima-to-intima contact, demonstrated by scanning electron microscope studies in which a continuous and homogenous endothelial layer was found intraluminally at the anastomotic site2,3,44. This may explain the finding of most studies that patency rates with clips are superior to those of sutured controls. With non-suture approaches there are limitations to the size of the vessels being anastomosed. Rings can only be used in vessels up to 3·3 mm in diameter105 and clips are limited largely in terms of thickness of the vessel wall. Furthermore, it must be recognized that there are as yet no large randomized clinical trials to show any long-term advantage of any of the non-suture techniques over conventional suture methods. Acknowledgements The following people are acknowledged for providing the figures: Roald Bos, Medisch Spectrum Twente, Enschede, The Netherlands (Figs 1, 2, 3 and 10); Anders Berggren, University Hospital, Linköping, Sweden (Fig. 4 and inlay photo of Fig. 5); Rafael Acosta, University Hospital, Uppsala, Sweden (Fig. 5); Friedrich Eckstein, University Hospital, Bern, Switzerland (Fig. 6); M. A. Verschuyl, Reinier de Graaf Group, Delft, The Netherlands (Fig. 7); and Jan Solem, University Hospital, Lund, Sweden (Fig. 11). The authors also thank Ralph Houston, University Hospital, Utrecht, The Netherlands and Robert Geelkerken, Medisch Spectrum Twente, Enschede, The Netherlands for reading the manuscript. References 1 Carrel A . La technique opératoire des anastomoses vasculaires et la transplantation des viscères . Lyon Med 1902 ; 98 : 859 – 864 . Google Scholar OpenURL Placeholder Text WorldCat 2 Pagnanelli DM , Pait TG, Rizzoli HV, Kobrine AI. Scanning electron micrographic study of vascular lesions caused by microvascular needles and suture . J Neurosurg 1980 ; 53 : 32 – 36 . Google Scholar Crossref Search ADS PubMed WorldCat 3 Lidman D , Daniel RK. The normal healing process of microvascular anastomoses . Scand J Plast Surg 1981 ; 15 : 103 – 110 . Google Scholar OpenURL Placeholder Text WorldCat 4 Macchiarelli G , Familiari G, Caggiati A, Magliocca FM, Riccardelli F, Miani A et al. Arterial repair after microvascular anastomosis. Scanning and transmission electron microscopy study . Acta Anat 1991 ; 140 : 8 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 5 Zeebregts CJAM , van den Dungen JJAM, Kalicharan D, Cromheecke M, van der Want JJL, van Schilfgaarde R. Nonpenetrating vascular clips for small-caliber anastomosis . Microsurgery 2000 ; 20 : 131 – 138 . Google Scholar Crossref Search ADS PubMed WorldCat 6 Zeebregts C , van den Dungen J, Buikema H, Tiebosch A, van der Want J, van Schilfgaarde R. Preservation of endothelial integrity and function in experimental vascular anastomosis with non-penetrating clips . Br J Surg 2001 ; 88 : 1201 – 1208 . Google Scholar Crossref Search ADS PubMed WorldCat 7 Payr E . Beiträge zur Technik der Blutgefäss- und Nervennaht nebst Mittheilungen über die Verwendung eines resorbirbaren Metalles in der Chirurgie . Arch Klin Chir 1900 ; 62 : 67 – 93 . Google Scholar OpenURL Placeholder Text WorldCat 8 Tuffier M . De l'intubation dans les plaies des grosses artères . Bull Acad Mèd (Paris) 1915 ; 74 : 455 – 460 . Google Scholar OpenURL Placeholder Text WorldCat 9 Carter EL , Roth EJ. Direct nonsuture coronary artery anastomosis in the dog . Ann Surg 1958 ; 148 : 212 – 218 . Google Scholar Crossref Search ADS PubMed WorldCat 10 Goetz RH , Rohman M, Haller JD, Dee R, Rosenak SS. Internal mammary-coronary artery anastomosis: a nonsuture method employing tantalum rings . J Thorac Cardiovasc Surg 1961 ; 41 : 378 – 386 . Google Scholar Crossref Search ADS PubMed WorldCat 11 Obora Y , Tamaki N, Matsumoto S. Nonsuture microvascular anastomosis using magnet rings: preliminary report . Surg Neurol 1978 ; 9 : 117 – 120 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 12 Holt GP , Lewis FJ. A new technique for end-to-end anastomosis of small arteries . Surg Forum 1960 ; 11 : 242 – 243 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 13 Nakayama K , Tamiya T, Yamamoto K, Akimoto S. A simple new apparatus for small vessel anastomosis (free autograft of the sigmoid included) . Surgery 1962 ; 52 : 918 – 931 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 14 Östrup LT , Berggren A. The UNILINK instrument system for fast and safe microvascular anastomosis . Ann Plast Surg 1986 ; 17 : 521 – 525 . Google Scholar Crossref Search ADS PubMed WorldCat 15 Nylander G , Ragnarsson R, Berggren A, Östrup LT. The UNILINK system for mechanical microvascular anastomosis in hand surgery . J Hand Surg A 1989 ; 14 : 44 – 48 . Google Scholar Crossref Search ADS WorldCat 16 Ragnarsson R , Berggren A, Östrup LT, Gilbert RW. Arterial end-to-side anastomosis with the UNILINK system . Ann Plast Surg 1989 ; 22 : 405 – 415 . Google Scholar Crossref Search ADS PubMed WorldCat 17 DeLacure MD , Wong RS, Markowitz BL, Kobayashi MR, Ahn CY, Shedd DP et al. Clinical experience with a microvascular anastomotic device in head and neck reconstruction . Am J Surg 1995 ; 170 : 521 – 523 . Google Scholar Crossref Search ADS PubMed WorldCat 18 Ragnarsson R , Berggren A, Klintenberg C, Östrup L. Microvascular anastomoses in irradiated vessels: a comparison between the Unilink system and sutures . Plastic Reconstr Surg 1990 ; 85 : 412 – 418 . Google Scholar Crossref Search ADS WorldCat 19 Zeebregts C , Acosta R, Bölander L, van Schilfgaarde R, Jakobsson O. Clinical experience with non-penetrating vascular clips in free-flap reconstructions . Br J Plast Surg 2002 ; 55 : 105 – 110 . Google Scholar Crossref Search ADS PubMed WorldCat 20 Berggren A , Östrup LT, Lidman D. Mechanical anastomosis of small arteries and veins with the Unilink apparatus: a histologic and scanning electron microscopic study . Plast Reconstr Surg 1987 ; 80 : 274 – 283 . Google Scholar Crossref Search ADS PubMed WorldCat 21 Daniel RK , Olding M. An absorbable anastomotic device for microvascular surgery: experimental studies . Plast Reconstr Surg 1984 ; 74 : 329 – 336 . Google Scholar Crossref Search ADS PubMed WorldCat 22 Daniel RK , Olding M. An absorbable anastomotic device for microvascular surgery: clinical applications . Plast Reconstr Surg 1984 ; 74 : 337 – 342 . Google Scholar Crossref Search ADS PubMed WorldCat 23 Qu W , Muneshige H, Ikuta Y. An absorbable pinned-ring device for microvascular anastomosis of vein grafts: experimental studies . Microsurgery 1999 ; 19 : 128 – 134 . Google Scholar Crossref Search ADS PubMed WorldCat 24 Joji S , Muneshige H, Ikuta Y. Experimental study of mechanical microvascular anastomosis with new biodegradable ring device . Br J Plast Surg 1999 ; 52 : 559 – 564 . Google Scholar Crossref Search ADS PubMed WorldCat 25 Kimura H , Muneshige H, Ikuta Y. Evaluation of an absorbable ring for vascular anastomosis . J Reconstr Microsurg 1999 ; 15 : 331 – 336 . Google Scholar Crossref Search ADS PubMed WorldCat 26 Eckstein FS , Bonilla LF, Englberger L, Stauffer E, Berg TA, Schmidli J et al. Minimizing aortic manipulation during OPCAB using the symmetry aortic connector system for proximal vein graft anastomoses . Ann Thorac Surg 2001 ; 72 : S995 – S998 . Google Scholar Crossref Search ADS PubMed WorldCat 27 Eckstein FS , Bonilla LF, Englberger L, Immer FF, Berg TA, Schmidli J et al. The St Jude Medical symmetry aortic connector system for proximal vein graft anastomoses in coronary artery bypass grafting . J Thorac Cardiovasc Surg 2002 ; 123 : 777 – 782 . Google Scholar Crossref Search ADS PubMed WorldCat 28 Hültl H . II Kongress der Ungarischen Gesellschaft für Chirurgie, Budapest, May 1908 . Pester Med Chir Presse 1909 ; 45 : 108 – 110 , 121–122. Google Scholar OpenURL Placeholder Text WorldCat 29 von Petz A . Zur Technik der Magenresektion: Ein neuer Magen–Darmnähapparat . Zentralbl Chir 1924 ; 5 : 179 – 188 . Google Scholar OpenURL Placeholder Text WorldCat 30 von Brücke H . Über ein neuartiges chirurgisches Nähinstrument . Zentralbl Chir 1935 ; 29 : 1684 – 1689 . Google Scholar OpenURL Placeholder Text WorldCat 31 Androsov PI . New method of surgical treatment of blood vessel lesions . Arch Surg 1956 ; 73 : 902 – 910 . Google Scholar Crossref Search ADS WorldCat 32 Bikfalvi A , Dubecz S. Observations in animal experiments with mechanised vessel suture . J Int Chir 1953 ; 5 : 481 – 496 . Google Scholar OpenURL Placeholder Text WorldCat 33 Samuels PB . Method of blood vessel anastomosis by means of metal clips: an experimental study . Arch Surg 1955 ; 70 : 29 – 38 . Google Scholar Crossref Search ADS WorldCat 34 Samuels PB . The use of metal clips in the surgery of blood vessels . Bull Soc Int Chir 1962 ; 21 : 21 – 33 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 35 Inokuchi K . A new type of vessel-suturing apparatus . Arch Surg 1958 ; 77 : 954 – 957 . Google Scholar Crossref Search ADS WorldCat 36 Inokuchi K . Stapling device for end-to-side anastomosis of blood vessels . Arch Surg 1961 ; 82 : 337 – 341 . Google Scholar Crossref Search ADS PubMed WorldCat 37 Vogelfanger IJ , Beattie WG. A concept of automation in vascular surgery: a preliminary report on a mechanical instrument for arterial anastomosis . Can J Surg 1958 ; 1 : 262 – 265 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 38 Mallina RF , Miller TR, Cooper P, Christie SG. Surgical stapling . Sci Am 1962 ; 207 ( 4 ): 48 – 56 . Google Scholar Crossref Search ADS PubMed WorldCat 39 Zhu YH , Kirsch WM, Cushman R, Becker K, McCabe W, Kornfeld M et al. Comparison of suture and clip for microvascular anastomoses . Surg Forum 1985 ; 36 : 492 – 495 . Google Scholar OpenURL Placeholder Text WorldCat 40 Kirsch WM , Zhu YH, Hardesty RA, Chapolini R. A new method for microvascular anastomosis: report of experimental and clinical research . Am Surg 1992 ; 58 : 722 – 727 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 41 Kirsch WM , Zhu YH, Hardesty RA, Webster MHC, Boukouvalas Z, Furnas D. The non-penetrating arcuate-legged clip: clinical applications. In Color Atlas of Microsurgery , Lee S (ed.). EA Publishers : St Louis , 1993 ; 89 – 101 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 42 Leppäniemi A , Wherry D, Pikoulis E, Hufnagel H, Waasdorp C, Fishback N et al. Arterial and venous repair with vascular clips: comparison with suture closure . J Vasc Surg 1997 ; 26 : 24 – 28 . Google Scholar Crossref Search ADS PubMed WorldCat 43 Baguneid MS , Goldner S, Fulford PE, Hamilton G, Walker MG, Seifalian AM. A comparison of para-anastomotic compliance profiles after vascular anastomosis: nonpenetrating clips versus standard sutures . J Vasc Surg 2001 ; 33 : 812 – 820 . Google Scholar Crossref Search ADS PubMed WorldCat 44 Boeckx WD , Darius O, van den Hof B, van Holder C. Scanning electron microscopic analysis of the stapled microvascular anastomosis in the rabbit . Ann Thorac Surg 1997 ; 63 ( Suppl ): S128 – S134 . Google Scholar Crossref Search ADS PubMed WorldCat 45 Izzat MB , Yim APC, Ho KCH, Chan CSY, Yew D, Chow LTC. Favorable scanning electron microscopic findings of stapled saphenous vein–carotid artery anastomoses . Ann Thorac Surg 1999 ; 67 : 85 – 88 . Google Scholar Crossref Search ADS PubMed WorldCat 46 Kirsch WM , Cavallo C, Anton T, Zhu YH, Rouse G, Martin R et al. An alternative system for cerebrovascular reconstructions: non-penetrating arcuate-legged clips . Cardiovasc Surg 2001 ; 9 : 531 – 539 . Google Scholar Crossref Search ADS PubMed WorldCat 47 Nataf P , Kirsch W, Hill AC, Anton T, Zhu YH, Ramadan R et al. Nonpenetrating clips for coronary anastomosis . Ann Thorac Surg 1997 ; 63 ( Suppl ): S135 – S137 . Google Scholar Crossref Search ADS PubMed WorldCat 48 Papalois VE , Romagnoli J, Hakim NS. Use of vascular closure staples in vascular access for dialysis, kidney and pancreas transplantation . Int Surg 1998 ; 83 : 177 – 180 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 49 Shibata T , Suehiro S, Sasaki Y, Hattori K, Fujioka M, Kumano H et al. Use of a vascular closure system for bypass grafting of peripheral arteries . Vasc Surg 1998 ; 32 : 315 – 322 . Google Scholar Crossref Search ADS WorldCat 50 Nataf P , Hinchliffe P, Manzo S, Simpson J, Kirsch WM, Zhu YH et al. Facilitated vascular anastomoses: the one-shot device . Ann Thorac Surg 1998 ; 66 : 1041 – 1044 . Google Scholar Crossref Search ADS PubMed WorldCat 51 Heijmen RH , Hinchliffe P, Borst C, Verlaan CWJ, Mouës CM, van der Helm YJM et al. A novel one-shot anastomotic stapler prototype for coronary bypass grafting on the beating heart: feasibility in the pig . J Thorac Cardiovasc Surg 1999 ; 117 : 117 – 125 . Google Scholar Crossref Search ADS PubMed WorldCat 52 Abbe R . The surgery of the hand . N Y Med J 1894 ; 59 : 33 – 40 . Google Scholar OpenURL Placeholder Text WorldCat 53 Nitze F . Elfenbeinstütze für die Gefäβnaht. Kleinere Mitteillungen. Discussion am Internationale Medicin Kongreβ in Moskau . Zentralbl Chir 1897 ; 24 : 1042 –. Google Scholar OpenURL Placeholder Text WorldCat 54 Blakemore AH , Lord JW Jr, Stefko PL. The severed primary artery in the war wounded: a nonsuture method of bridging arterial defects . Surgery 1942 ; 12 : 488 – 508 . Google Scholar OpenURL Placeholder Text WorldCat 55 Blakemore AH , Lord JW Jr. A nonsuture method of blood vessel anastomosis: experimental and clinical study . JAMA 1945 ; 127 : 685 – 691 . Google Scholar Crossref Search ADS WorldCat 56 Johns TNP . A comparison of suture and nonsuture methods for the anastomosis of veins . Surg Gynecol Obstet 1947 ; 84 : 939 – 942 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 57 Swenson O , Gross RE. Absorbable fibrin tubes for vein anastomoses . Surgery 1947 ; 22 : 137 – 143 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 58 Weiss EW , Lam CR. Tantalum tubes in the non-suture method of blood vessel anastomosis . Am J Surg 1950 ; 80 : 452 – 454 . Google Scholar Crossref Search ADS PubMed WorldCat 59 Ota K , Mori S, Koike T, Inou T. Blood vessel repair utilizing a new plastic adhesive: experimental and clinical studies . J Surg Res 1965 ; 5 : 453 – 462 . Google Scholar Crossref Search ADS PubMed WorldCat 60 Suzuki J , Onuma T. A soluble internal splint for experimental vascular anastomosis: technical note . J Neurosurg 1971 ; 35 : 355 – 359 . Google Scholar Crossref Search ADS PubMed WorldCat 61 Moskovitz MJ , Bass L, Zhang L, Siebert JW. Microvascular anastomoses utilizing new intravascular stents . Ann Plast Surg 1994 ; 32 : 612 – 618 . Google Scholar Crossref Search ADS PubMed WorldCat 62 Solem JO , Boumzebra D, Al-Buraiki J, Nakeeb S, Rafeh W, Al-Halees Z. Evaluation of a new device for quick sutureless coronary artery anastomosis in surviving sheep . Eur J Cardiothorac Surg 2000 ; 17 : 312 – 318 . Google Scholar Crossref Search ADS PubMed WorldCat 63 Matras H , Chiari FM, Kletter G, Dinges HP. Zur Klebung von Mikrogefäßanastomosen (Eine Experimentelle Studie). In Wiederherstellung von Form und Funktion Organischer Einheiten der Verschiedenen Körperregionen , Schmid E, Widmaier W, Reichert H (eds). George Thieme : Stuttgart , 1977 ; 357 – 360 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 64 Gestring GF , Lerner R. Autologous fibrinogen for tissue-adhesion, hemostasis and embolization . Vasc Surg 1983 ; 17 : 294 – 304 . Google Scholar Crossref Search ADS WorldCat 65 Gestring GF , Lerner R, Requena R. The sutureless microanastomosis . Vasc Surg 1983 ; 17 : 364 – 367 . Google Scholar Crossref Search ADS WorldCat 66 Burnouf-Radosevich M , Bournouf T, Huart JJ. Biochemical and physical properties of a solvent-detergent-treated fibrin glue . Vox Sang 1990 ; 58 : 77 – 84 . Google Scholar Crossref Search ADS PubMed WorldCat 67 Berguer R , Staerkel RL, Moore EE, Moore FA, Galloway WB, Mockus MB. Warning: fatal reaction to the use of fibrin glue in deep hepatic wounds. Case reports . J Trauma 1991 ; 31 : 408 – 411 . Google Scholar Crossref Search ADS PubMed WorldCat 68 Mitsuhata H , Horiguchi Y, Saitoh J, Saitoh K, Fukuda H, Hirabayasi Y et al. An anaphylactic reaction to topical fibrin glue . Anesthesiology 1994 ; 81 : 1074 – 1077 . Google Scholar Crossref Search ADS PubMed WorldCat 69 Kennedy D , Whitehorn WV, Martin EW. Revocation of fibrinogen licenses . FDA Drug Bull 1978 ; 8 : 15 –. Google Scholar OpenURL Placeholder Text WorldCat 70 Gottlob R , Blümel G. Anastomoses of small arteries and veins by means of bushings and adhesive . J Cardiovasc Surg 1968 ; 9 : 337 – 341 . Google Scholar OpenURL Placeholder Text WorldCat 71 Green AR , Milling MA, Green AR. Butylcyanoacrylate adhesives in microvascular surgery: an experimental pilot study . J Reconstr Microsurg 1986 ; 2 : 103 – 105 . Google Scholar Crossref Search ADS PubMed WorldCat 72 Hoppenstein R , Weissberg D, Goetz RH. Fusiform dilatation and thrombosis of arteries following the application of methyl 2-cyanoacrylate (Eastman 910 monomer) . J Neurosurg 1965 ; 23 : 556 – 564 . Google Scholar Crossref Search ADS PubMed WorldCat 73 Goetz RH , Weissberg D, Hoppenstein R. Vascular necrosis caused by application of methyl 2-cyanoacrylate (Eastman 910 monomer): 7-month follow up in dogs . Ann Surg 1966 ; 163 : 242 – 248 . Google Scholar Crossref Search ADS PubMed WorldCat 74 Carton CA . Use of cyanoacrylates . J Neurosurg 1978 ; 49 : 473 – 474 (Letter). Google Scholar PubMed OpenURL Placeholder Text WorldCat 75 Hall WW , Wrye SW, Banducci DR, Ehrlich P. Microvascular anastomosis using 2–octyl cyanoacrylate in the rat femoral artery . Ann Plast Surg 2000 ; 44 : 508 – 511 . Google Scholar Crossref Search ADS PubMed WorldCat 76 Ang ESW , Tan KC, Tan LHC, Ng RTH, Song IC. 2-Octylcyanoacrylate-assisted microvascular anastomosis: comparison with a conventional suture technique in rat femoral arteries . J Reconstr Microsurg 2001 ; 17 : 193 – 201 . Google Scholar Crossref Search ADS PubMed WorldCat 77 Kletter G , Matras H, Dinges HP. Zur partiellen Klebung von Mikrogefäßanastomosen im intrakraniellen Bereich . Wien Klin Wochenschr 1978 ; 90 : 415 – 419 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 78 Aksik IA , Kikut RP, Apshkalne DL. Extraintracranial anastomosis performed by means of biological gluing materials: experimental and clinical study . Microsurgery 1986 ; 7 : 2 – 8 . Google Scholar Crossref Search ADS PubMed WorldCat 79 Sigel B , Acevedo FJ. Vein anastomosis by electrocoaptive union . Surg Forum 1962 ; 13 : 233 – 235 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 80 Wintermantel E . The thermic vascular anastomosis (TVA). A new nonsuture method. 1. History, instruments, and microsurgical technique . Acta Neurochir 1981 ; 56 : 5 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat 81 Jain KK , Gorisch W. Repair of small blood vessels with neodymium-YAG laser: a preliminary report . Surgery 1979 ; 85 : 684 – 688 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 82 Jain KK . Sutureless extra-intracranial anastomosis by laser . Lancet 1984 ; ii : 816 – 817 (Letter). Google Scholar OpenURL Placeholder Text WorldCat 83 Gomes OM , Macruz R, Armelin E, Ribeiro MP, Brum JMG, Bittencourt D et al. Vascular anastomosis by argon laser beam . Tex Heart Inst J 1981 ; 10 : 145 – 149 . Google Scholar OpenURL Placeholder Text WorldCat 84 White RA , White GH, Fujitani RM, Vlasak JW, Donayre CE, Kopchok GE et al. Initial human evaluation of argon laser-assisted vascular anastomoses . J Vasc Surg 1989 ; 9 : 542 – 547 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 85 White RA , Kopchok GE. Laser vascular fusion: development, current status, and future perspectives . J Clin Laser Med Surg 1990 ; 8 : 47 – 54 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 86 Serure A , Withers EH, Thomsen S, Morris J. Comparison of carbon dioxide laser-assisted microvascular anastomosis and conventional microvascular sutured anastomosis . Surg Forum 1983 ; 34 : 634 – 636 . Google Scholar OpenURL Placeholder Text WorldCat 87 Quigley MR , Bailes JE, Kwaan HC, Cerullo LJ. Laser-assisted vascular anastomosis . Lancet 1985 ; i : 334 –. Google Scholar OpenURL Placeholder Text WorldCat 88 Quigley MR , Bailes JE, Kwaan HC, Cerullo LJ, Brown JT, Lastre C et al. Microvascular anastomosis using the milliwatt CO2 laser . Lasers Surg Med 1985 ; 5 : 357 – 365 . Google Scholar Crossref Search ADS PubMed WorldCat 89 Quigley MR , Bailes JE, Kwaan HC, Cerullo LJ, Brown JT, Fitzsimmons J. Comparison of bursting strength between suture and laser anastomosed vessels . Microsurgery 1985 ; 6 : 229 – 332 . Google Scholar Crossref Search ADS PubMed WorldCat 90 Quigley MR , Bailes JE, Kwaan HC, Cerullo LJ, Brown JT. Aneurysm formation after low power carbon dioxide laser-assisted vascular anastomosis . Neurosurgery 1986 ; 18 : 292 – 299 . Google Scholar Crossref Search ADS PubMed WorldCat 91 Ruiz-Razura A , Lan M, Hita CE, Khan Z, Hwang NHC, Cohen BE. Bursting strength in CO2 laser-assisted microvascular anastomoses . J Reconstr Microsurg 1988 ; 4 : 291 – 296 . Google Scholar Crossref Search ADS PubMed WorldCat 92 Guo J , Chao YD. Low power CO2 laser-assisted microvascular anastomosis: an experimental study . Neurosurgery 1988 ; 22 : 540 – 543 . Google Scholar Crossref Search ADS PubMed WorldCat 93 Okada M , Simizu K, Ikuta H, Horii H, Nakamura K. An alternative method of vascular anastomosis by laser: experimental and clinical study . Lasers Surg Med 1987 ; 7 : 240 – 248 . Google Scholar Crossref Search ADS PubMed WorldCat 94 Okada M , Ikuta H, Shimizu K, Horii H, Tsuji Y, Yoshida M et al. Experimental and clinical studies on the laser application in the cardiovascular surgery: analysis of clinical experience of 112 patients . Nippon Geka Gakkai Zasshi 1989 ; 90 : 1589 – 1593 . Google Scholar PubMed OpenURL Placeholder Text WorldCat 95 White RA , Kopchok G, Donayre C, White G, Lyons R, Fujitani R et al. Argon laser-welded arteriovenous anastomoses . J Vasc Surg 1987 ; 6 : 447 – 453 . Google Scholar Crossref Search ADS PubMed WorldCat 96 Badeau AF , Lee CE, Morris JR, Thompson S, Malk EG, Welch AJ. Temperature response during microvascular anastomosis using milliwatt CO2 . Lasers Surg Med 1986 ; 6 : 179 –. Google Scholar OpenURL Placeholder Text WorldCat 97 Kopchok GE , White RA, White GH, Fujitani R, Vlasak J, Dykhovsky L et al. CO2 and argon laser vascular welding: acute histologic and thermodynamic comparison . Laser Surg Med 1988 ; 8 : 584 – 588 . Google Scholar Crossref Search ADS WorldCat 98 Reali UM , Gelli R, Giannotti V, Gori F, Pratesi R, Pini R. Experimental diode laser-assisted microvascular anastomosis . J Reconstr Microsurg 1993 ; 9 : 203 – 210 . Google Scholar Crossref Search ADS PubMed WorldCat 99 Tulleken CAF , Verdaasdonk RM, Berendsen W, Mali WPTM. Use of the excimer laser in high-flow bypass surgery of the brain . J Neurosurg 1993 ; 78 : 477 – 480 . Google Scholar Crossref Search ADS PubMed WorldCat 100 Tulleken CAF , Verdaasdonk RM, Mansvelt Beck HJ. Nonocclusive excimer laser-assisted end-to-side anastomosis . Ann Thorac Surg 1997 ; 63 : S138 – S142 . Google Scholar Crossref Search ADS PubMed WorldCat 101 Stewart RB , Benbrahim A, LaMuraglia GM, Rosenberg M, L'Italien GJ, Abbott WM et al. Laser assisted vascular welding with real time temperature control . Lasers Surg Med 1996 ; 19 : 9 – 16 . Google Scholar Crossref Search ADS PubMed WorldCat 102 Gilbert RW , Ragnarsson R, Berggren A, Östrup L. Strength of microvascular anastomoses: comparison between the Unilink anastomotic system and sutures . Microsurgery 1988 ; 10 : 40 – 46 . Google Scholar Crossref Search ADS WorldCat 103 Falconer DP , Lewis TW, Lamprecht EG, Mendenhall HV. Evaluation of the Unilink microvascular anastomotic device in the dog . J Reconstr Microsurg 1990 ; 6 : 215 – 222 . Google Scholar Crossref Search ADS PubMed WorldCat 104 Berman SS , Kirsch WM, Zhu YH, Anton L, Chai Y. Impact of nonpenetrating clips on intimal hyperplasia of vascular anastomoses . Cardiovasc Surg 2001 ; 9 : 540 – 547 . Google Scholar Crossref Search ADS PubMed WorldCat 105 Sasson HN , Stofman GM, Berman P. Clinical use of the 3M 2·5 mm mechanical microcoupling device in free tissue transfer . Microsurgery 1994 ; 15 : 421 – 423 . Google Scholar Crossref Search ADS PubMed WorldCat Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) Copyright © 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.
TI - Non-suture methods of vascular anastomosis
JF - British Journal of Surgery
DO - 10.1002/bjs.4063
DA - 2003-02-19
UR - https://www.deepdyve.com/lp/oxford-university-press/non-suture-methods-of-vascular-anastomosis-XzysVNH75r
SP - 261
EP - 271
VL - 90
IS - 3
DP - DeepDyve
ER -