May 14, 2007

Sutureless vascular grafting

How can end-to-end anastomosis be done in a minimally invasive way? What

are the requirements in tensile strength, and durability, of the
anastomosis for bypass grafting? Can laparoscopic-assisted anastomosis
bridge the road to a new innovative mechanical anastomosis?

Since the first reports of minimally invasive endoluminal repair of

abdominal aortas there has been a steadily escalating interest in
endoluminal vascular grafting for the exclusion of aneurysms inspite of the
longitudinal displacement and migration issues with the current generation
of stent-grafts. In contrast to stent-grafts, the gold standard of sutured
graft fixation prevents the loss of fixation, the development of type I and
type II endoleaks, and the lack of healing of the aorta to the graft with
minimal neointimal hyperplasia. Nevertheless, in order to avoid the main
disadvantage of invasive operative exposure with traditional vascular
grafting, a permanent minimally invasive anastomosis method is needed that
mimics sutured vascular anastomosis in a small confined space. One such
attempt is an anastomotic device assembly consisting of a band similar to a
cable tie with a one directional locking mechanism. Sharp hook elements are
mounted on the surface of a PTFE graft which is drawn over the artery
resulting in a sleeve of vessel within the graft. The band is then
tightened over an intraluminal delivery device and the anchoring hooks
penetrate through the graft into the wall of the artery. However, in many
cases the circular penetration of the hooks at precise intervals cannot be
accomplished due to calcified deposits in the aortic wall. Besides a rather
complicated method of delivery and fastening of the band, complications
such as the loss of continuous interface of graft to artery may prevent a
leakproof anastomosis and the absence of pseudo-aneurysms or stenosis can
no longer be expected. A major challenge in replicating a sutureless method
of graft fixation is the difference in tensile strength of the anastomosis
was compared with sutured anastomosis. Small retroperitoneal incisions and
new laparoscopic port devices have been used to dissect the abdominal aorta
laparoscopically. Sewing the graft through these mini incisions with the
help of self retaining retractors have resulted in a shorter period of
ileus, diminished pulmonary complications, and decreased postoperative
length of stay. The anastomosis through these devices appears to be a
feasible alternative to endovascular or conventional sutured anastomosis
and the laparoscopic-assisted repair method allows the expeditious
minimally invasive vascular graft anastomosis.

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