VASCULAR AND ENDOVASCULAR TECHNIQUES Thomas L. Forbes, MD, Section Editor
ViPS technique as a novel concept for a sutureless vascular anastomosis Stefano Bonvini, MD, PhD,a Joseph J. Ricotta, MD,b Michele Piazza, MD,a Luca Ferretto, MD,a and Franco Grego, MD,a Padova, Italy; and Atlanta, Ga Objective: To describe a novel technique (Viabhan Padova Sutureless [ViPS]) that connects a vascular prosthetic graft to a target artery in a sutureless fashion. Methods: The patient was a 74-year-old male with complete superficial femoral artery (FA) occlusion and reconstitution of a circumferentially calcified above-knee popliteal artery (ANPA). The proximal end of a surgeon-modified 7-mm Viabahn endoprosthesis was sutured to a 7-mm polytetrafluoroethylene graft (PTFEg). After surgical exposure, the ANPA was transected, and the undeployed distal portion of the Viabahn was inserted, supported by a stiff guidewire. The distal portion of the Viabahn graft was then deployed and ballooned with optimal apposition. Finally, the proximal end of the PTFEg was sutured to the common FA. Results: Operative time was 60 minutes. Completion angiogram and the computed tomography angiogram at 6 months demonstrated a patent graft. Conclusion: The ViPS technique provides an alternative for bypass creation when challenging arterial anastomoses are required. ( J Vasc Surg 2011;54:889-92.)
Patients with peripheral arterial occlusive disease (PAOD) can present a significant challenge for lower extremity revascularization because of extensive and circumferential calcification of distal target arteries. In the past, the majority of these patients were treated with open surgical bypass. However, as endovascular technology has advanced, and vascular surgeons have acquired the skills and knowledge to perform these procedures, a variety of endovascular techniques have been introduced as an alternative to open surgical bypass. One such endovascular device that has been demonstrated to be an effective treatment for patients with PAOD is the Viabahn stent graft (W. L. Gore & Associates, Inc, Flagstaff, Ariz).1 The difficulty with these patients is that they often have long-segment occlusions in the femoral and popliteal arteries that could preclude endovascular treatment. Therefore, the only option is surgical bypass. This can be quite challenging when the distal target artery is extensively and circumferentially calcified, making suturing of that artery From the Clinic of Vascular and Endovascular Surgery, Padova University School of Medicine, Padovaa; and Vascular Surgery and Endovascular Therapy, Emory University School of Medicine, Atlanta.b Competition of interest: none. Reprint requests: Stefano Bonvini MD, PhD, Clinic of Vascular and Endovascular Surgery, Padova University, Via Giustiniani 2, 35128 Padova, Italy (e-mail:
[email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a competition of interest. 0741-5214/$36.00 Copyright © 2011 by the Society for Vascular Surgery. doi:10.1016/j.jvs.2011.04.005
Fig 1. Preoperative angiographic detail of the above-knee popliteal artery.
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Fig 2. Description of the on-bench surgeon-modified Viabahn stent graft steps procedure for Viabahn Padova Sutureless (ViPS) technique.
very difficult. In these situations, a more distal suitable target in the tibial vessels is sought, which is associated with lower patency rates than when the target vessel is the popliteal artery.2 We describe a novel technique (Viabahn Padova Sutureless [ViPS]) that connects a vascular prosthetic graft to a target artery in a sutureless fashion, using a surgeon-modified Viabahn stent graft. TECHNIQUE A 74-year-old male with known PAOD, on chronic dialysis therapy, presented with a nonhealing right leg ulcer. The preoperative computed tomography angiogram (CTA) and the subsequent intraoperative angiography demonstrated complete occlusion of the right superficial femoral artery with reconstitution of a patent but circumferentially calcified above-knee popliteal artery (AKPA; Fig 1) and single-vessel runoff to the foot via the peroneal artery. A duplex ultrasound revealed no adequate vein for autogenous bypass creation. Due to our concern over inability to safely cross-clamp or place sutures into the AKPA, we offered the patient a femoral-to-AKPA bypass using the ViPS technique. In the operating room, during induction of anesthesia, on a sterile back table, we modified a standard Viabahn endoprosthesis (W. L. Gore & Associates, Inc.) and manually sutured it to an expanded polytetrafluoroethylene graft (ePTFEg). First, the Viabahn stent with its releasing wire system is withdrawn from its delivery system. To accomplish this, the deployment knob is loosened and the constraining string is pulled, thereby unsheathing only the distal portion of the Viabahn stent. The string is cut with scissors (Fig 2, A-D). At this point, the constraining string is free to be removed from the proximal portion of the delivery system catheter shaft where the device remains
undeployed within its sheath. The distal tip of the delivery system catheter is then cut with scissors, and the device is removed from its delivery system (Fig 2, E). The constraining string is subsequently pulled, permitting further unsheathing of the distal portion of the endoprosthesis for a length of approximately 2 cm (Fig 2, F). Following this, the operator sutures the unsheathed most distal portion of the Viabahn stent to a similar diameter, standard ePTFEg in an end-to-end fashion with monofilament nonabsorbable polypropylene continuous sutures (Fig 2, G and H). In this way, the direction of deployment and orientation of the Viabahn is reversed. The ePTFEg is then punctured with a standard 16gauge access needle. A 0.035-inch stiff guidewire is placed through this needle into the ePTFEg and through the modified Viabahn stent in order to support the entire system (Fig 2, I). The modified graft is then ready to be implanted, and standard surgical exposure of the common femoral artery (CFA) and AKPA is performed. Proximal control was achieved at the CFA, and the calcified AKPA was transacted. Adequate suction of the minimal backbleeding guaranteed clear visualization of the inner wall of the artery (Fig 3, A). The undeployed portion of the Viabahn was manually inserted under direct vision into the target artery for a length of approximately 2.5 cm, supported by the stiff guidewire that does not protrude outside of the undeployed Viabahn. Deployment of the remainder of the stent was accomplished by pulling the constraining string and unsheathing the entire device from the ePTFE side toward the artery (Fig 3, B). The proximal end of the ePTFEg was tunneled to the groin and sutured to the CFA in standard end-to-side fashion.
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Fig 3. A, Intraoperative characteristics of the circumferentially calcified above-knee popliteal artery. B, Final result after Viabhan stent graft deployment.
distal embolization, endoleak, loss of device integrity, or popliteal artery dissection (Fig 4, B). DISCUSSION
Fig 4. A, Final angiographic imaging after Viabahn Padova Sutureless (ViPS) technique (.035 hydrophilic guidewire inserted). B, Follow-up computed tomography angiogram at 6 months.
To better ensure the complete apposition of the Viabahn to the wall of the AKPA, balloon angioplasty was performed through the preloaded stiff guidewire. Completion angiogram demonstrated a patent graft with no evidence of dissection in the landing zone of the Viabahn (Fig 4, A) and preserved single-vessel runoff to the right foot. The total operative time from skin incision to skin closure was 60 minutes, while the on-bench ViPS system preparation was 7 minutes. The patient’s ulcer resolved after 2 weeks with complete functional recovery. CTA performed after 6 months revealed a patent graft with no signs of kinking of the stent,
Sutureless anastomotic techniques have been previously described. The Viabahn Open Revascularization Technique (VORTEC) was first used to facilitate renal revascularization.3 With this technique, the Viabhan stent is introduced via a direct puncture in the anterior wall of the target artery through a guidewire using the Seldinger technique. The end of the stent graft outside of the target artery is then sutured intraoperatively in an end-to-side fashion to an ePTFEg limb that is to be used for extra-anatomic bypass during aortic debranching. The ViPS technique is different than the VORTEC procedure in that it allows the operator to prepare the entire system preoperatively in order to be ready for deployment without the need for additional anastomoses or cumbersome deployment of the device in the operative field. Furthermore, with the VORTEC procedure, arterial wall calcification could represent a challenging condition at the time of puncture in the anterior wall of the target vessel, and access site complications should be considered. Another advantage of the ViPS technique is that with transection of the artery, the operator is allowed direct vision of the inside of the artery and therefore can safely introduce the Viabahn device with minimal risk of damaging the vessel (Fig 5), making it particularly useful in calcified or heavily diseased arteries. In addition, the ViPS technique is a “true” end-to-end sutureless anastomosis with no site along the device at risk for constriction. In fact, the VORTEC technique requires balloon dilatation after deployment along its entire length, especially at the site where the Viabahn enters the puncture site in the side wall of the target artery. The customized ViPS system also has the potential to dramatically reduce operative time in both cases of challenging anastomosis and standard arterial bypasses that require two anastomoses. We calculated 7 minutes for the on-bench preparation of the ViPS system, 36 seconds for the AKPA transaction and
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CONCLUSION The ViPS technique is easily performed with common commercially available devices. It provides an alternative for bypass creation, and may significantly reduce operative time, particularly in cases where challenging arterial anastomoses are required. AUTHOR CONTRIBUTIONS
Fig 5. Visually guided insertion of the Viabahn Padova Sutureless (ViPS) system into the target artery.
complete Viabahn deployment, and 60 minutes for the entire procedure to be completed. In the worst case scenario of thrombosis of the system, the Viabahn stent graft could undergo thrombectomy in the same way as a standard ePTFEg bypass. Compared with the traditional end-to-side PTFE anastomosis, the end-to-end ViPS system has the disadvantage of potentially excluding some collateral blood flow to the AKPA, although this is a risk also present during normal vessel dissection for end-toside anastomosis creation with a standard PTFE bypass. Because the ViPS technique requires target vessel dissection, we always try, where feasible, to spare large collateral vessels and introduce the system distally to them.
Conception and design: SB, LF Analysis and interpretation: SB, JR, MP, FG Data collection: MP Writing the article: JR, MP Critical revision of the article: SB, JR, MP, LF, FG Final approval of the article: SB, JR, MP, LF, FG Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: SB REFERENCES 1. Lammer J, Dake MD, Bleyn J, Katzen BT, Cejna M, Piquet P, et al. Peripheral arterial obstruction: prospective study of treatment with a transluminally placed self-expanding stent-graft. International Trial Study Group. Radiology 2000;217:95-104. 2. Dalman RL. Expected outcome: Early results, life table patency, limb salvage, In Mills JL (ed). Management of chronic lower limb ischemia. London: Arnold; 2000, p. 106-12. 3. Lachat M, Mayer D, Criado FJ, Pfammatter T, Rancic Z, Genoni M, et al. New technique to facilitate renal revascularization with use of telescoping self-expanding stent grafts: VORTEC. Vascular 2008;16:69-72. Submitted Feb 8, 2011; accepted Apr 5, 2011.
