title: Enabling sutureless vascular bypass grafting with the exovascular sleeve anastomosis.
abstract: OBJECTIVE
  We describe a technique for end-to-end sleeve anastomosis that may enable minimally invasive bypass grafting and characterize the tensile strength, stenosis rate, durability, and healing of the anastomosis.
  
  
  METHODS
  An anastomotic device assembly consisting of a cable tie-type band with mobile teeth elements is mounted on the outer surface of a polytetrafluoroethylene graft. The graft is drawn over the artery resulting in a sleeve of vessel within the graft. As the band is tightened over an intraluminal obturator, the independently mobile anchoring teeth are driven through the graft into the artery. The tensile strength of the anastomosis was compared with sutured anastomosis during in vitro studies using cadaveric human femoral arteries. For in vivo studies on pigs and goats, we used a proximal exovascular sleeve anastomosis along with a distal sutured aortic anastomosis. Survival animals were studied by angiogram postoperatively and at the time of explantation.
  
  
  RESULTS
  In vitro studies showed no difference in maximal tensile strength between sutured and exovascular anastomoses (10.5 +/- 2.7 lb vs 10.2 +/- 3.0 lb, P =.83). However, loss of continuous graft to artery interface occurred at lower loads in the sutured anastomoses (6.5 +/- 0.6 lb, P <.05). In total, all 24 pigs tested in nonsurvival or survival settings sustained a successful and leakproof anastomosis. Of the 13 nonsurvival cases, maximal epinephrine-induced hypertension sustained over 15 minutes (peak systolic blood pressure > 210-250 mm Hg) was tolerated without leakage in a subgroup of five animals (100%). All 11 survival pigs had no pseudoaneurysms or stenosis relative to sutured control anastomoses at 6 week explantation (8.2 +/- 1.25 mm vs 8.5 +/- 1.6 mm, P =.21). The three long-term survival goats had no pseudoaneurysm or stenosis after 40 weeks. Histologic examination confirmed healing of the aorta to graft with minimal neointimal hyperplasia.
  
  
  CONCLUSIONS
  Exovascular sutureless anastomosis appears comparable to sutured anastomosis in stenosis rate, healing, and durability, with some advantages in tensile strength and rapidity of application.
authors.affiliation: Harvard Center for Minimally Invasive Surgery, Harvard Medical School, and the Division of Vascular Surgery, Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: D W
authors.initials: DW
authors.lastname: Chang
authors.forename: A
authors.initials: A
authors.lastname: Chan
authors.forename: R A
authors.initials: RA
authors.lastname: Forse
authors.forename: W M
authors.initials: WM
authors.lastname: Abbott
mesh_terms: D000714:Anastomosis, Surgical / Q000295:instrumentation*; D000818:Animals; D001012:Aorta, Abdominal / Q000473:pathology / Q000601:surgery; D019917:Blood Vessel Prosthesis Implantation / Q000295:instrumentation*; D005263:Femoral Artery / Q000473:pathology / Q000601:surgery; D006041:Goats; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation*; D011138:Polytetrafluoroethylene; D013537:Sutures; D013552:Swine; D013718:Tensile Strength; D014945:Wound Healing / Q000502:physiology
chemical_list: D011138:Polytetrafluoroethylene