Vascular Closure Staple Research Articles

Sutureless Microvascular Anastomosis: Literature Review

Traditionally, suturing techniques have been the mainstay for microvascular anastomoses, but owing to its technical difficulty and labour intensity, considerable work has gone into the development of sutureless microvascular anastomoses. In this review, the authors take a brief look at the developments of this technology through the years, with a focus on the more recent developments of laser-assisted vascular anastomoses, the unilink system, vascular closure staples, tissue adhesives, and magnets. Their working principles, with what has been found concerning their advantages and disadvantages are discussed.

総胆管直接閉鎖術における血管吻合用クリップ(Vascular Closure Staple:VCS)の有用性に関する検討

総胆管直接閉鎖術における血管吻合用クリップ(Vascular Closure Staple:VCS)の有用性に関する検討

Heterotopic renal transplantation in piglets using vascular closure stapler metallic clips or conventional suturing techniques: comparison of vessel growth and macroscopical study

Background/purposeOur aim was to perform a macroscopic and imaging (ultrasonographic and angiographic) evaluation of vascular closure stapler (VCS) metallic clips for renal transplantation in growing piglets to assess their role for transplantation surgery in young children. If these techniques are to be useful, it is necessary to prove that their use avoids one of the main pitfalls of conventional sutures in this setting, namely lack of growth in the suture line. MethodsTwenty-four piglets were used for this study. Animals were subjected to a heterotopic renal autotransplantation when they were 45 days old. The right kidney was moved from its normal location to the cranial area of the iliac fossa. The end-to-side anastomoses between the renal artery and vein and the aorta and vena cava, respectively, were performed using VCS metallic clips in 6 animals. Continuous polypropylene suturing was used in another 6 piglets, and continuous polyglycolic acid suture was used in 6 additional piglets. A control group of 6 animals without renal autotransplantation was also included in the study. All animals were allowed to grow for 6 months, during which time serial angiographic and ultrasonographic studies were carried out to assess the existence of vascular flow disturbances or stenosis. Similarly, angiographic measurements were obtained to document growth at the anastomotic site. Longitudinal growth was evaluated postmortem after the 6-month growing period. ResultsAngiography showed significant (P < .001) transverse growth in both arteries and veins belonging to the VCS clips, running absorbable suture, or control groups. No significant difference was observed among the 3 groups. Vascular growth in the running nonabsorbable suture (polypropylene) group, however, was significantly less than in the other 3 groups and did not significantly differ from baseline. Baseline luminal diameters at the anastomotic site as measured by angiography in the VCS group were 3.64 ± 0.40 mm in the artery and 5.30 ± 1.43 mm in the vein. After growth, these values increased to 6.87 ± 0.90 mm and 11.27 ± 2.53 mm, respectively. Significant longitudinal growth was evidenced macroscopically after 6 months in both aorta and vena cava in all groups. On the other hand, significant longitudinal growth in the renal artery and vein were only observed in the control, VCS, and absorbable suture groups. ConclusionsIn this experimental setting, satisfactory macroscopic and angiographic vascular growth results were obtained using the VCS clips, suggesting that this suture could be the technique of choice in pediatric transplantation surgery.

Microvascular anastomosis using the vascular closure device in free flap reconstructive surgery: A 13-year experience

The achievement of patency of the microvascular anastomosis in free flap surgery is dependent on a number of factors, central to which is atraumatic handling of the vessel lumen, and intimal apposition. Initial laboratory studies demonstrating the superiority of the non-penetrating vascular closure staple (VCS - Anastoclip ®) were followed by our report in 1999 on a series of free flaps. There is still a paucity of data in the literature on the use of non-penetrating devices for microvascular anastomosis, and our review gives evidence to support the routine use of the VCS in microsurgical free flap surgery. We now report on its successful use over a thirteen year period in 819 free flap reconstructions. Our data indicates the VCS device to be as effective as sutured anastomoses in free tissue transfer surgery. There is also statistically significant data (Barnard's Exact Test) to demonstrate a higher vascular patency rate of the VCS device over sutured anastomoses when sub group analysis is performed. 'Take-back' revision rates were lower amongst flaps that employed VCS use. For arterial anastomoses, this equated to 3/654(0.05%) vs 4/170(2.4%) with hand-sewn anastomoses (p=0.02). Similarly, for venous anastomoses the 'take-back' revision rate was 7/661(1.1%) vs 8/165(4.8%) with hand-sewn anastomoses (p=0.003). Furthermore, the major advantage of the VCS is reduction in anastomosis time, from approximately 25min per anastomosis for sutures to between five and 10min for staples.

Four-year surveillance study of metal clip anastomoses in peripheral arterial reconstruction

In our preliminary study four years ago, using vascular closure staple (VCS) clips in making arterial anastomoses in peripheral vascular reconstructions, we showed that clip closure is easy and safe in early long-term (an average of 11 months) follow-up. In the present study we re-examined all the patients who had been bypassed using VCS clips in our earlier study. All together, ten of 17 patients were clinically examined, the ankle brachial index was measured, and a duplex Doppler examination was performed. The mean ankle brachial index in the operated leg of seven patients was 1.01 (range, 0.78–1.52). The anastomoses of nine patients were patent and neither turbulent blood flow nor aneurysms were seen. Only a PTFE prosthesis was occluded. The long-term experience of using metal clips in the peripheral vascular reconstructions seems to be encouraging, because the patency of grafts is good and no adverse reactions, such as aneurysms, were seen during the four-year surveillance period.

Vascular Clips in Anastomoses of Femoropopliteal Arterial Reconstruction.

The vascular anastomoses are usually made with sutures. Some mainly experimental studies have been published about a new method of doing the vascular anastomoses with metal clips. We studied the suitability of vascular closure staple (VCS) clip applier system for making the anastomoses in femoropopliteal and femorotibial arterial reconstruction. During an 11-month period, VCS clips were used in 17 out of 27 patients who were operated due to severe claudication or incipient gangrena of the foot. Altogether 26 anastomoses were made with VCS clips using either great saphenous vein or PTFE graft. The making of anastomosis was easy and reliable. No postoperative bleeding was noticed. All anastomoses were patent 4-6 weeks postoperatively studied by palpation and measured by ankle brachial pressure index (mean 0.96). In Duplex Doppler examination all studied patients had well patent anastomoses on an average 11 months after the operation. With VCS clip applier system, it is possible to do anastomoses in arteriosclerotic arteries like in femoropopliteal reconstructions. This method helps making reliable anastomoses more easily.

Performing two DIEP flaps in a working day: an achievable and reproducible practice

While the deep inferior epigastric artery perforator (DIEP) flap is a reliable technique for autologous breast reconstruction, the meticulous dissection of perforators may require lengthy operative times. In our unit, we have performed 600 free flaps for breast reconstruction over 8 years and have reduced operative times with a combination of preoperative computed tomographic angiography (CTA), various anastomotic techniques and the Cook-Swartz implantable Doppler probe for perfusion monitoring. We sought to assess the feasibility of performing two DIEP flaps within the working hours of a single day. A review of 101 consecutive patients undergoing DIEP flap breast reconstruction in a 12-month period was performed, comparing one DIEP flap per day (n=43) to two DIEP flaps per day (n=58). Complications, outcomes and techniques used were critically analysed. For cases of two DIEP flaps per day, a comparison was made between the use of two separate operating theatres (n=44) and a single consecutive theatre (n=14). Complications did not increase when two DIEP flaps were performed in a single working day. The use of vascular closure staple (VCS) sutures and ring couplers resulted in statistically significant reductions in anastomotic times. The use of two separate theatres for performing two DIEP flaps resulted in a reduction of 59min in operative time per case (p=0.004). Two DIEP flaps can be safely and routinely performed within the hours of a single working day. By minimising operative times, these techniques can improve productivity and substantially decrease surgeon fatigue.

Vein Patch Angioplasty with Non-Penetrating Titanium Clips. Comparison to Standard Suture Technique

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angio-graphically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 ± 1.8 min. for clips vs. 8.5 ± 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 ± 1.5 min. vs. 10.1 ± 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histologi-cal differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

Reconstruction of the middle hepatic vein tributaries draining segments V and VIII of a right liver graft by using the recipient’s own middle hepatic vein and vascular closure staples

A right liver graft lacking the middle hepatic vein can result in congestion of the anterior segment. We describe a method of reconstructing the middle hepatic vein tributaries by using the recipient's own middle hepatic vein with vascular closure staples. During a living donor right liver transplantation, the middle hepatic vein tributaries draining segments V (V5) and VIII (V8) of the right lobe graft were reconstructed using the recipient's own middle hepatic vein and secured with vascular closure staples. Computed tomography showed good venous outflow from the middle hepatic vein and no congestion or atrophy of the anterior segment of the right liver grafts. Thus, using the recipient's own middle hepatic vein is a suitable option for reconstructing the middle hepatic vein tributaries (V8 and V5) in right-liver living donor transplantation and the application of vascular closure staples helps to accomplish this.

Use of nonpenetrating vascular closure staples in feline renal transplantation

Renal transplantation is a potential treatment for irreversible renal failure in pet cats. Our aim is to reduce warm ischemic time by using nonpenetrating vascular closure staples (VCS), thereby improving graft survival. Experimental cats were divided into the VCS group (n = 4; autotransplantation) or suture group (n = 6; allotransplantation). The renal artery was anastomosed with the external iliac artery in an end-to-end fashion, and the renal vein was attached to the external iliac vein in an end-to-side fashion. Warm ischemic time as well as arterial and venous anastomotic times were measured. Cats in the suture group were administrated cyclosporine and prednisolone orally after transplantation. Ischemic and anastomotic times in the VCS group were significantly reduced compared with the suture group. Two of 6 allografts had a ureteral anastomotic stricture, and 4 allografts were rejected. Histological findings of autografts showed normal structure. In conclusion, VCS staples were useful in feline renal transplantation.

Vascular Closure Stapler Clip Anastomosis Decreases Aortic Cross-Clamping Time Compared to Interrupted Nonabsorbable and Running Absorbable Sutures in Growing Pigs

The latest generation in titanium clip application systems, the vascular closure staples (VCS) system avoids intimal lesions and therefore minimizes the subsequent hyperplastic reaction, while at the same time enhancing distensibility and vascular growth. Moreover, VCS clips allow the surgeon to perform vascular anastomosis easily and faster than conventional suture. This system may become the option of choice for vascular reconstruction in pediatric surgery where, as in the case of aortic and transplant surgery, decreasing vascular occlusion times may influence the outcomes. The aim of this study was to determine whether VCS metallic clips would allow shorter anastomosis times than conventional interrupted polypropylene or running Dexon suturing in end-to-end anastomosis performed in the abdominal aorta of young pigs. Twenty-four domestic swine, 45 days old, were used for this study. All animals were subjected to an end-to-end anastomosis in the abdominal aorta using VCS clips, interrupted polypropylene, or running Dexon suture. Aortic cross-clamping time was significantly shorter in the VCS clips group (4.02 +/- 0.72 min), compared to interrupted polypropylene (21.89 +/- 1.93 min) or running Dexon (9.82 +/- 3.97 min) suture. VCS clips are easy to use, and therefore may aid surgeons to significantly decrease the time needed for performing an end-to-end anastomosis in the abdominal aorta, thus decreasing cross-clamping time when compared to interrupted polypropylene or running Dexon sutures.

Portal Vein and Hepatic Vein Reconstruction in Living Donor Liver Transplantation and the Usefulness of Vascular Closure Staples for Portal Vein Reconstruction

Portal Vein and Hepatic Vein Reconstruction in Living Donor Liver Transplantation and the Usefulness of Vascular Closure Staples for Portal Vein Reconstruction

Vein and artery growth after anastomosis with vascular closure staple clips vs interrupted polypropylene suture: application in pediatric vascular surgery

Background/Purpose Alternatives are still being sought in vascular surgery to address the problem of arrested growth after anastomosis in growing vessels, and opinions differ widely regarding the most suitable technique. This study compared vascular growth and permeability after anastomosis using the latest-generation vascular closure staple (VCS) system and the conventional suture technique to ascertain which approach yielded better results. Methods Thirty 55-day-old lambs underwent end-to-end anastomosis of the carotid artery and jugular vein. Serial ultrasonography and angiography were carried out over the ensuing 6-month growth period, after which lambs were euthanized. Results Both VCS clips and polypropylene suture allowed longitudinal and transverse vessel growth; however, longitudinal growth was significantly greater in clip-closed vessels than in either sutured or untreated vessels. Conclusions The results obtained for vascular growth and permeability suggest that VCS clips may provide a suitable alternative to conventional suture in pediatric vascular surgery.

Vascular closure staples for portal vein reconstruction in living-donor liver transplantation

Background Portal vein reconstruction is still a crucial problem in living-donor liver transplantation. Vascular closure staples (VCS) have been applied for small peripheral and large vessels because of the technical ease with which they can be employed. We describe here our experience with portal vein reconstruction in living donor-liver transplantation and compare VCS with conventional sutures in portal vein reconstruction. Methods The anastomosis between the donor portal vein and recipient portal vein or the right external iliac vein graft was created using either VCS or conventional sutures. Results The stenotic ratios were .51 ± .15 and .79 ± .25 for the conventional sutures and VCS, respectively. The stenotic ratio was significantly lower in VCS compared with conventional sutures. Conclusions VCS compared with conventional sutures has the advantage of low risk of anastomotic stenosis.

Vascular Closure Stapler Clips Versus Polypropylene Sutures in End-to-End Anastomoses of Growing Arteries and Veins

Alternatives are still being sought in vascular surgery to avoid the complications caused in growing vessels by the various suture techniques and materials currently in use. A major complication is arrested growth following anastomosis. Opinions differ widely regarding the best approach to this problem, and research is currently underway at our center on the latest generation of clip appliers (vascular closure stapler, or VCS) and their potential application as an alternative to the conventional suture technique in pediatric vascular surgery. This study compared vascular growth and reendothelialization following anastomosis of growing arteries and veins using VCS clips versus the conventional interrupted polypropylene suture technique. Thirty 55-day-old lambs underwent end-to-end anastomosis of the carotid artery and jugular vein. Serial ultrasonography and angiography were carried out over the ensuing 6-month growth period, after which the lambs were euthanized. Gross examination of the anastomosis site was followed by histologic examination involving light microscopy, immunohistochemical techniques, and transmission electron microscopy. Although both VCS clips and polypropylene sutures allowed transverse vessel growth, the clips did not penetrate the intima and thus provided enhanced reendothelialization. The satisfactory results obtained here, as in earlier studies, increasingly point to VCS clips as the method of choice in pediatric vascular surgery.

Clips metálicos VCS: una técnica de sutura más rápida y fácil de utilizar que la sutura convencional en reconstrucciones de vasos en crecimiento

Summary Introduction The latest generation of titanium clip appliers, called VCS (vascular closure staples) instruments, not only avoid damage being done to the tunica intima and hyperplasia while at the same time favouring the distensibility and growth of the vessel, but also provide the surgeon with a fast, easy-to-use method, which contrasts with the conventional discontinuous suture technique using polypropylene. This can be the method chosen for use in the reconstruction of vascular elements that are growing (paediatric aorta surgery and transplants), and where lowering the clamping time is important. Aims The purpose of this study was to check whether suturing with metallic VCS clips could be a faster method for the surgeon than conventional discontinuous suturing with polypropylene in end-to-end anastomosis of arteries and veins. Materials and methods At the age of 55 days, 30 lambs were submitted to end-to-end anastomosis in the carotid artery and the jugular vein. Results. It was confirmed that VCS clip appliers are easier for the surgeon to use and significantly lower the time needed to perform end-to-end anastomosis of arteries (clips, 4.02 ± 0.72 min; suture, 21.89 ± 1.93 min) and of veins (clips, 9.82 ± 3.97 min; suture, 29.31 ± 1.90 min). Conclusions VCS clips significantly reduce the time employed to perform end-to-end anastomosis of arteries and veins as compared to the conventional discontinuous technique using polypropylene.

The effect of Vascular Closure Staple in primary closure of common bile duct in experimental models

The effect of Vascular Closure Staple in primary closure of common bile duct in experimental models

Vascular closure staples reduce intimal hyperplasia in prosthesis implantation.

Vascular surgery, like the various other surgical specialities, has seen an increasing demand toward faster and more minimally invasive procedures. One such need is to create a reliable vascular anastomosis that is faster, easier and less damaging to the tissue. The vascular closure staples (VCS*) device provides such characteristics but, to date, no studies have investigated its effectiveness in reducing intimal hyperplasia when used for vascular prosthesis implantation. The present study evaluated its effectiveness compared with suturing of a graft in vascular prosthesis implantation. Twelve female Merino sheep underwent gelatin sealed Dacron patch graft implantation into the left and right common carotid artery. Grafts were randomly allocated so that one carotid artery and graft was anastomosed using sutures and the other with VCS*. The two techniques were compared for operation time, clip/suture numbers and blood loss during the implantation procedure. After a 4-week period, the sheep were killed and the grafts were harvested for intimal hyperplasia (IH) assessment. There was a significant reduction in the amount of IH seen in the VCS* group (mean +/- SD: 0.278 +/- 0.079 mm2/mm) when compared with the sutured group (0.575 +/- 0.331 mm2/mm) (P < 0.05). There was also significant reduction in anastomosis time (mean +/- SD: 14 +/- 4.4 min) and fewer points of contact (23 +/- 1.4) using the VCS* compared with suturing (22 +/- 3.2 min, P < 0.01; 27 +/- 3.3, P < 0.05, respectively). In this model, the VCS* shows several distinct advantages over suturing with significant time saving at operation and, most importantly, the reduction of IH seen at 1 month.

Can nonpenetrating vascular closure staples and hepatocyte growth factor prevent intimal hyperplasia following ePTFE grafting of the carotid artery in rabbits?

To evaluate whether nonpenetrating vascular closure staples (VCS) and hepatocyte growth factor (HGF) can effectively prevent anastomotic intimal hyperplasia. An expanded polytetrafluoroethylene graft, 2 mm in diameter, was implanted in the common carotid artery of rabbits divided into three experimental groups. In the control group, distal anastomosis was performed with interrupted suturing; in the VCS group, clips were applied along the lateral suture line after the placement of stay sutures; and in the VCS + HGF group, the same anastomotic technique was performed as in the VCS group, followed by the administration of the HGF for 4 days. The time taken to complete the anastomosis was significantly less in both the VCS groups than in the control group ( P < 0.0001). On postoperative day (POD) 28, the patency rate was significantly lower ( P < 0.05) in the VCS group (42.9%) than in the control group (100%), but the rate in the VCS + HGF group (100%) was the same as that in the control group. Intimal thickness was significantly less in the control group than in either the VCS or VCS + HGF groups ( P< 0.05). The percentage of area stenosis was significantly less ( P< 0.01) in the control group than in the VCS group. The VCS clip failed to suppress intimal thickness or reduce the percentage of stenosis at the anastomotic site.

Primary sciatic nerve repair using titanium staples

The primary epineural repair of human peripheral nerves is most often achieved using non-absorbable microsutures, which can elicit a foreign-body reaction. We describe a new system for neural-tissue approximation, consisting of non-penetrating vascular closure staples (VCS) applied to the epineurium. These clips were initially developed for use in microvascular anastomosis, with no knowledge of their effectiveness in neural-tissue approximation. We compare the efficacies of VCS clips and monofilament nylon microsutures in the repair of transected sciatic nerves in 36 adult Sprague Dawley rats (18 treated with 9/0 sutures and 18 treated with VCS clips). In the rat, regeneration starts by day 5, and is well advanced by 4 weeks. To assess the overall repair success, the site of injury, after perfusion fixation, was harvested at 5, 7 and 30 days. The two methods were compared in terms of operative time, the degree of self-mutilation (autotomy), the macroscopic specimens in vivo and the microanatomical continuity through the repair site. Continuity was studied by using PGP-9.5-labelled cryosections and fluorescent secondary antibodies to visualise axonal regeneration. Clip repair was significantly faster in the VCS group (mean +/- s.e.m. = 7.09 +/- 0.36 min versus mean +/- s.e.m. 11.56 +/- 0.51 min in the sutured group) and an equal and minimal degree of autotomy was observed. Macroscopically, all 36 nerves were in continuity and free from neuroma. The use of VCS clips resulted in equivalent visualised regeneration across the repair site at each time point. We believe the use of VCS clips to be a faster and comparable alternative to non-absorbable sutures in primary nerve repair in this experimental model.