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Ribaudo JG, He K, Madira S, Young ER, Martin C, Lu T, Sacks JM, Li X. Sutureless vascular anastomotic approaches and their potential impacts. Bioact Mater 2024; 38:73-94. [PMID: 38699240 PMCID: PMC11061647 DOI: 10.1016/j.bioactmat.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/25/2024] [Accepted: 04/04/2024] [Indexed: 05/05/2024] Open
Abstract
Sutureless anastomotic devices present several advantages over traditional suture anastomosis, including expanded global access to microvascular surgery, shorter operation and ischemic times, and reduced costs. However, their adaptation for arterial use remains a challenge. This review aims to provide a comprehensive overview of sutureless anastomotic approaches that are either FDA-approved or under investigation. These approaches include extraluminal couplers, intraluminal devices, and methods assisted by lasers or vacuums, with a particular emphasis on tissue adhesives. We analyze these devices for artery compatibility, material composition, potential for intimal damage, risks of thrombosis and restenosis, and complications arising from their deployment and maintenance. Additionally, we discuss the challenges faced in the development and clinical application of sutureless anastomotic techniques. Ideally, a sutureless anastomotic device or technique should eliminate the need for vessel eversion, mitigate thrombosis through either biodegradation or the release of antithrombotic drugs, and be easily deployable for broad use. The transformative potential of sutureless anastomotic approaches in microvascular surgery highlights the necessity for ongoing innovation to expand their applications and maximize their benefits.
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Affiliation(s)
- Joseph G. Ribaudo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Kevin He
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Sarah Madira
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Emma R. Young
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Cameron Martin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Tingying Lu
- Department of Plastic Surgery, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Justin M. Sacks
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
| | - Xiaowei Li
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University in St. Louis, MO, 63110, USA
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Heitzer M, Kilic K, Merfort R, Emonts C, Winnand P, Kniha K, Hölzle F, Modabber A. Evaluation of fibrin, cyanoacrylate, and polyurethane-based tissue adhesives in sutureless vascular anastomosis: a comparative mechanical ex vivo study. Int J Oral Maxillofac Surg 2023; 52:1137-1144. [PMID: 37019734 DOI: 10.1016/j.ijom.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 04/05/2023]
Abstract
The stability of a microvascular anastomosis is an important prerequisite for successful tissue transfer. Advances in tissue adhesives are potentially opening new avenues for their use in sutureless microsurgical anastomosis, however they have not yet gained clinical acceptance. In this ex vivo study, a novel polyurethane-based adhesive (PA) was used in sutureless anastomoses and its stability compared with that of sutureless anastomoses performed with fibrin glue (FG) and a cyanoacrylate (CA). Stability was assessed using hydrostatic (15 per group) and mechanical tests (13 per group). A total of 84 chicken femoral arteries were used in this study. The time taken to create the PA and CA anastomoses was significantly faster when compared to the FG anastomoses (P < 0.001): 1.55 ± 0.14 min and 1.39 ± 0.06 min, respectively, compared to 2.03 ± 0.35 min. Both sustained significantly higher pressures (289.3 mmHg and 292.7 mmHg, respectively) than anastomoses using FG (137.3 mmHg) (P < 0.001). CA anastomoses (0.99 N; P < 0.001) and PA anastomoses (0.38 N; P = 0.009) could both withstand significantly higher longitudinal tensile forces compared to FG anastomoses (0.10 N). Considering the background of an in vitro study, the PA and CA anastomosis techniques were shown to be similar to each other and superior to FG, due to their stability and faster handling. These findings need to be validated and confirmed in further in vivo studies.
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Affiliation(s)
- M Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany.
| | - K Kilic
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - R Merfort
- Department of Orthopaedics, Trauma and Reconstructive Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - C Emonts
- Institut für Textiltechnik, RWTH Aachen University, Aachen, Germany
| | - P Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - K Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - F Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
| | - A Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of RWTH Aachen, Aachen, Germany
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Orădan AV, Dindelegan GC, Vinaşi RC, Muntean MV, Dindelegan MG, Chiriac L, Volovici V. Reduction of Anastomotic Time Through the Use of Cyanoacrylate in Microvascular Procedures. Plast Surg (Oakv) 2022; 30:335-342. [PMID: 36212098 PMCID: PMC9537713 DOI: 10.1177/22925503211019619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/16/2021] [Indexed: 11/03/2023] Open
Abstract
Background: Ever since the description of the first microvascular anastomosis, numerous alternative methods have been described to the classical approach. Tissue adhesive has shown promising result in previous studies and can be a fast and efficient alternative which still requires more studies to allow its clinical implementation. Methods: A randomized comparative experimental study was conducted on rats' femoral arteries and an end-to-end anastomosis was performed in order to compare 2 anastomosis techniques. In one group, a simple interrupted suture was utilized, whereas in the second group a combination between fewer sutures and tissue adhesive was used. The anastomotic time, total operative time, blood flow velocity before, immediately after and 48 hours after the procedure, as well as an independent grading of the anastomosis immediately after the procedure were performed. Magnetic resonance imaging (MRI) was performed in order to assess the degree of stenosis. After euthanasia, histology and scanning electron microscopy (SEM) were performed on the vessels in order to assess possible complications. Results: A total of 24 anastomoses were performed, of which 12 with a classic technique and 12 with an adhesive technique. All the anastomoses were patent with a significant reduction of anastomotic and total operative time. The grading of the anastomoses showed better results in the classic suture group. The blood flow velocities were not statistically significant between the 2 groups. On MRI there was one stenotic anastomosis, whereas histology and SEM showed more complications on the adhesive group. Conclusion: Anastomotic times were significantly lower with a non-significant trend toward more thrombotic complications in the adhesive group. Further improvement of the glue properties and refinement of the technique will likely make it a viable alternative to interrupted suturing in the future.
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Affiliation(s)
- Alex V. Orădan
- Department of Plastic Surgery, Clinical Rehabilitation
Hospital, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - George C. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- First Surgical Clinic, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ramona C. Vinaşi
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Neuroscience, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Maximilian V. Muntean
- Department of Plastic Surgery, “Prof. Dr. I. Chiricuta”
Institute of Oncology, “Iuliu Hatieganu” University of Medicine and
Pharmacy, Cluj-Napoca, Romania
| | - Maximilian G. Dindelegan
- Center for Surgical Simulation and Training, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
- Department of Otorhinolaryngology, “Iuliu Haţieganu” University of
Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Liviu Chiriac
- National Magnetic Resonance Center, Faculty of Physics,
Babeş-Bolyai University, Cluj Napoca, Romania
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
- Center for Medical Decision Making, Department of Public
Health, Erasmus MC University Medical Center, Rotterdam, The
Netherlands
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Heitzer M, Ooms M, Katz MS, Peters F, Kilic K, Tolba R, Jockenhoevel S, Hermanns-Sachweh B, Hölzle F, Modabber A. Evaluation of the long-term results of vascular anastomosis using polyurethane adhesive and shape-memory stent in the rat carotid artery model. Microsurgery 2022; 42:480-489. [PMID: 35670105 DOI: 10.1002/micr.30926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 04/04/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION In free flaps, 5%-10% of complications are related to failure of sutured vascular anastomoses. Adhesive-based microvascular anastomoses are potential alternatives but are associated with failure rates of 70% in research studies. VIVO is a new adhesive with slow biodegradation within 6 months that has shown a 100% patency rate in research studies over 2 h observation time but long-term patency has not been evaluated. The authors hypothesize that VIVO will enable a reliable microvascular procedure comparable to sutured anastomoses over a 28-day period. MATERIALS AND METHODS The right common carotid artery of 60 male Sprague Dawley rats, ~450 g, were used for microvascular end-to-end anastomosis. VIVO was applied with reduced sutures with a temporary catheter in one group and in the other with a custom-shaped memory stent. Anastomoses with eight interrupted sutures served as control. All groups were n = 20. Anastomosis time and bleeding were recorded for each procedure. Doppler flowmetry was performed 20 min, 1, 10, and 28 days postoperatively. Postmortem toluidine staining was used for semi-quantitative analysis of stenosis, thrombosis, necrosis, and aneurysm formation by histologic evaluation. RESULTS No occlusion was detected 20 min and 1 day postoperative, and after 28 days of observation in all anastomoses. The anastomosis time of the VIVO with catheter group was about 32% significantly faster than the VIVO with stent group. In the VIVO group with stent, the bleeding time was ~80% shorter than in the control group with 2.1 ± 0.3 and VIVO with catheter 2.0 ± 0.5 (p ≤ .001 each). Minor and nonsignificant stent-associated thrombus formation and stent-typical intraluminal stenosis were detected exclusively in the VIVO with stent group. CONCLUSION Within the limitations of a rat study, the use of VIVO in anastomosis showed promising results. VIVO with catheter was found to be advantageous.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Mark Ooms
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Marie Sophie Katz
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Florian Peters
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Konrad Kilic
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - René Tolba
- Institute of Laboratory Animal Science and Experimental Surgery of RWTH-Aachen, Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid and Medical Textiles (BioTex), AME-Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, Germany
| | | | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Aachen, Germany
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Modabber A, Winnand P, Goloborodko E, Möhlhenrich SC, Kniha K, Tolba R, Jockenhoevel S, Hermanns-Sachweh B, Hölzle F, Heitzer M. Biodegradation and Immunological Parameters of Polyurethane-based Tissue Adhesive in Arterial Microvascular Anastomoses - a Long-term in Vivo Study. Macromol Biosci 2022; 22:e2100451. [PMID: 35080346 DOI: 10.1002/mabi.202100451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/16/2022] [Indexed: 11/07/2022]
Abstract
In microsurgical anastomosis, non-synthetic fibrin-based adhesives have predominantly shown superior properties to synthetic cyanoacrylates, but they have hardly any clinical application. This study aimed to investigate the local and systemic effects of synthetically produced biodegradable adhesive VIVO when used in microsurgical anastomosis. VIVO was used in two different anastomosis procedures in the common carotid artery in a rat model: VIVO in addition to a temporary catheter (VIVO TC) and VIVO with a custom-shaped memory nitinol stent (VIVO SM). Conventionally sutured anastomoses served as controls (C). Tissue response was assessed by in vivo fluorescence imaging and histological examination. The systemic effects of biodegradation were measured using hematologic parameters and serum levels of transaminase activity and lactate dehydrogenase. Finally, the degree of local adhesion of the different anastomotic procedures was evaluated. Fluorescence imaging showed reduced inflammatory blood flow in the VIVO TC group. Histological analysis of the anastomosed vessels also revealed significantly more inflammation in C than in the two adhesive groups. The severity of VIVO adhesions proved acceptable, and no histotoxic effects of VIVO were detected. The data demonstrated that the synthetic tissue adhesive VIVO is a reliable and- compared to sutures-tissue-friendly adhesive for microsurgical anastomoses. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
| | - Philipp Winnand
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
| | - Evgeny Goloborodko
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
| | - Stephan Christian Möhlhenrich
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle.,Department of Orthodontics, University of Witten/Herdecke, Alfred-Herrhausen Str. 45, Witten, 58455, Germany.,Head & Chairman Univ.-Prof. Dr. med. dent. Golamreza Danesh
| | - Kristian Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
| | - René Tolba
- Institute of Laboratory Animal Science and Experimental Surgery of RWTH-Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ.-Prof. Dr. med. René H. Tolba
| | - Stefan Jockenhoevel
- Department of Biohybrid and Medical Textiles (BioTex), AME-Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, Aachen, 52074, Germany
| | - Benita Hermanns-Sachweh
- Implant Pathology ZBMT, Campus Melaten, Pauwelsstraße 17, Aachen, 52074.,Prof. Dr. med. Benita Hermanns-Sachweh
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
| | - Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, Aachen, 52074, Germany.,Head & Chairman Univ. Prof. Dr. med. Dr. med. dent. Frank Hölzle
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Heitzer M, Möhlhenrich SC, Kniha K, Tolba R, Jockenhoevel S, Hölzle F, Modabber A. Microvascular anastomosis techniques using the medical adhesive VIVO and expandable micro-stents in a rat carotid artery model. Ann Anat 2021; 238:151782. [PMID: 34144156 DOI: 10.1016/j.aanat.2021.151782] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sutured anastomosis remains the gold standard in microvascular surgery. The procedure is not free of complications and is a time-consuming operation requiring a high level of experience. The aim of this study was to develop new methods for a stable, faster, and safer anastomosis using a novel biodegradable adhesive, VIVO, and a custom-made microvascular stent. METHODS The VIVO medical adhesive was used for a total of 30 anastomoses in rats in the right carotid artery: 15 anastomoses were performed with a temporary intraluminal catheter, VIVO, and reduced sutures (VIVO + TC). A further 15 anastomoses were performed with nitinol stents, VIVO, and reduced sutures (VIVO + SM). Sutured anastomoses served as controls (C) and were performed on the left carotid arteries of the 30 rats. Operation and bleeding times were assessed, and patency was evaluated by Doppler flowmetry and indocyanine green (ICG) angiography. Subsequently, the anastomoses were evaluated histopathological. RESULTS The overall patency was recorded as 100% in all groups. No thrombosis or circulatory disturbance was found. Compared to C and VIVO + SM, VIVO + TC proved to be significantly less traumatic, less demanding, and time-saving. The sealing properties of VIVO lead to shorter bleeding times and less oozing. In contrast, VIVO + SM proved to be the most technically demanding and time-consuming procedure. CONCLUSION The success of a microvascular sutured anastomosis is determined by a short ischemic interval. Compared to sutured anastomosis, VIVO + TC showed ease of use as well as shorter time taken for anastomosis, less trauma, and lower blood loss. More long-term studies on the functions, biological interactions, and survival rates of glue-based anastomoses need to be initiated.
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Affiliation(s)
- Marius Heitzer
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Stephan Christian Möhlhenrich
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; Department of Orthodontics, University of Witten/Herdecke, Alfred-Herrhausen Str. 45, 58455 Witten, Germany
| | - Kristian Kniha
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - René Tolba
- Institute of Laboratory Animal Science and Experimental Surgery of RWTH-Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Stefan Jockenhoevel
- Department of Biohybrid and Medical Textiles (BioTex), AME-Helmholtz Institute for Biomedical Engineering, RWTH Aachen University, 52074 Aachen, Germany
| | - Frank Hölzle
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Ali Modabber
- Department of Oral and Maxillofacial Surgery, University Hospital of Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
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