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Year : 2021  |  Volume : 8  |  Issue : 4  |  Page : 363-365

Advancement on the alexis carrel technique: A practical alternative for continuous end-to-end vascular anastomosis


Department of Vascular Surgery, Royal North Shore Hospital, Sydney, Australia

Date of Submission06-Jul-2021
Date of Acceptance26-Jul-2021
Date of Web Publication9-Dec-2021

Correspondence Address:
Animesh Singla
Department of Vascular Surgery, Royal North Shore Hospital, Sydney
Australia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_76_21

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  Abstract 


Since description of the first vascular anastomosis techniques pioneered by Alexis Carrel, vascular reconstructive techniques have undergone several advancements. The traditional three-point “Alexis” technique for and end-to-end anastomosis remains a textbook description of an ideal anastomosis, especially in microsurgery. In clinical practice, dissection extent, vessel mobility, and timing can limit the applicability for daily use. We describe a more intuitive procedure, using common vascular techniques of parachuting and growth factor inclusion to achieve a technically perfect end-to-end anastomosis. In particular, the usual limitations of the “Alexis” technique do not limit this procedure making it easily learnable and reproducible.

Keywords: Anastomosis, surgical technique, transplant


How to cite this article:
Singla A, Kotecha K. Advancement on the alexis carrel technique: A practical alternative for continuous end-to-end vascular anastomosis. Indian J Vasc Endovasc Surg 2021;8:363-5

How to cite this URL:
Singla A, Kotecha K. Advancement on the alexis carrel technique: A practical alternative for continuous end-to-end vascular anastomosis. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Aug 16];8:363-5. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/363/332055




  Introduction Top


Vascular surgery is a relatively young specialty, which has undergone rapid evolution in open and endovascular techniques. Alexis Carrel, a French born surgeon and biologist, is considered the pioneer of vascular reconstructions. At the time, he was in medical school, no clear techniques existed for repairing injured vessels. After the assassination of French President by a fatal knife injury to the portal vein, in a time when no clear vascular repair techniques existed, Alexis was left deeply “troubled.” He then spent the next decade pioneering several techniques of vascular reconstruction, which would earn him a Noble Prize in Medicine.[1] Among these, one the most recognizable is the three-point fixation for a well-spaced end-to-end anastomosis to avoid anastomotic stenosis. Although successful and still used in practice, its day-to-day use is often limited. It does involve considerable dissection to allow vessel mobility and adequate space for proximal and distal control away from the anastomosis. It can also be time consuming and more technically challenging.[2],[3] Spatulation of the ends is much more commonly used alternative when sufficient length is available, in addition to mismatched sizing.[4] This report introduces through comparison a more practical end-to-end anastomosis, which is intuitive and easily reproducible.


  Technique Top


Indication

The typical indication for an end-to-end anastomosis includes peripheral bypass surgery, portal-venous anastomosis, and portacaval reconstructions. In addition, the principles of this technique can be applied to the typical end-to-side anastomosis such as an arteriovenous fistula or living kidney transplantation.

Steps

  1. Adequate dissection of the blood vessel proximally and distally to allow for control of the vessel/s for anastomosis. An advantage over the “Alexis” technique is that only enough vessel to allow for anastomosis is required, with minimal vessel mobility required
  2. With the ends of the vessel lined up for anastomosis, an anterior and posterior wall can be appreciated. This part is similar to the “Alexis” technique [Figure 1]
  3. Using a double-armed monofilament suture (typically 5-0 or 6-0 in vascular surgery), each end is passed inside to out at the middle of the posterior wall. In the “Alexis” technique, three-point suture fixation is performed [Figure 2]
  4. In a continuous fashion, on the one end, an inside-out and outside-in throw is completed with parachute technique to mid-point of the anterior wall. This allows for close apposition but not constriction of the anastomosis. Similarly, the other arm of the suture is completed using parachute technique. The “Alexis” technique completes each side of the triangle of the created section, which are sutured and tied [Figure 3]. We believe that our technique is a much simpler and familiar to perform due to routine use of parachute technique in clinical surgery. In addition, it allows continuous visualization of the suture to prevent inadvertently picking up the back wall.
  5. Following parachuting, a fine nerve hook is used to systemically ensure the suture which is pulled to approximate the end of each vessel such that it is adequately snug but not pulled tightly [Figure 4].
  6. Before tying the suture, release of the side with low-pressure flow allows distension at the anastomosis. This incorporation of “growth factor” in the vessel during flow prevents anastomotic stenosis.[5] The anastomosis is then tied firmly but avoiding over tightening. Temporary hemostasis is required as the suture tension redistributes [Figure 5]. This is a common technique used in fistula creation and most venous anastomoses. The growth factor is not accounted for in the “Alexis” technique, which instead relies on tension to each end during suturing to prevent anastomotic stenosis.
Figure 1: Placement of vessel ends

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Figure 2: Placement of initial sutures using different technique

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Figure 3: Carrell Anastamosis (classical)

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Figure 4: Running continuous anastamosis

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Figure 5: Incorporation of growth factor

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Clinical experience

With utilization of this technique, the most common end-to-end anastomoses in vascular surgery can be performed with good technical reproducibility and speed. This technique works best for end-to-end <8 mm caliber arterial, venous, and microvascular arteriovenous reconstructions. This would incorporate most bypass surgeries, interposition grafting, and transplantation surgical anastomosis. For larger anastomosis, the authors have not performed this technique in large numbers, but we feel that it would hold similar advantages.


  Conclusion Top


This report highlights an advancement of the classical “Alexis” technique in performing an end-to-end anastomosis. With incorporation of the standard parachute technique in vascular surgery, combined with the “growth factor” previously described, an easily reproducible and technically acceptable anastomosis can be performed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Savlania, A. Alexis Carrel: Father of vascular anastomosis and organ transplantation. Historical Vignette. Indian J Vasc Endovasc Surg 2017;4:115-7.  Back to cited text no. 1
    
2.
Dutkowski P, de Rougemont O, Clavien PA. Alexis carrel: Genius, innovator and ideologist. Am J Transplant 2008;8:1998-2003.  Back to cited text no. 2
    
3.
Rath T. Current issues and future direction in kidney transplantation techniques. Ch. 7. IntechOpen; 2012.  Back to cited text no. 3
    
4.
Hoballah J. Vascular reconstructions: Anatomy, Exposure and Techniques. NY: Springer; 2000.  Back to cited text no. 4
    
5.
Starzl TE, Iwatsuki S, Shaw BW Jr. A growth factor in fine vascular anastomoses. Surg Gynecol Obstet 1984;159:164-5.  Back to cited text no. 5
    


    Figures

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



 

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