HOW TO DO IT

End-to-Side Vascular Anastomosis

A Modified Technique
David G. Ellertson, M.D., Edwin C. McGough, M.D.,
and Richard K. Hughes, M.D.

ABSTRACT A modified end-to-side vascular anastomosis utilizing poly-

propylene sutures is presented. Of the currently available suture materials,
polypropylene has the lowest coefficient of friction. It is therefore possible to
place each anastomotic line without approximating graft to artery until all
sutures are in position. The advantage of combining the visualization afforded
by an interrupted anastomosis with the relative speed offered by a continuous
anastomosis is thus achieved.

T he recent introduction of polypropylene suture material (Prolene)*

permits adoption of a useful modification of Linton’s [l] end-to-side
vascular anastomosis. Polypropylene suture has a lower coefficient
of friction than other suture materials.? Therefore, each anastomotic suture
line can be run continuously without approximating the edges of graft to
artery until all sutures are in position. This technique combines the speed
and even tension of a continuous suture line with the visualization of an
interrupted type of anastomosis. The surgeon is able to view the intimal
surface of the artery at all times, thus decreasing the chances of intimal dis-
lodgement, flap formation, and subintimal dissection.
The technique is a modification of the technique Linton described
during his presidential address to the Society for Vascular Surgery in 1955.
The graft is prepared by beveling the end and making a longitudinal in-
cision proximally (Figure, A). The dimensions of these incisions are designed
From the Division of Thoracic and Cardiovascular Surgery, Department of Sumrgery,Univer-
sity of Utah College of Medicine, Salt Lake City, Utah.
Accepted for publication Oct. 17, 1973.
Address reprint requests to Dr. McGough, Department of Surgery, University of Utah
College of Medicine, Salt Lake City, Utah 84132.
*Ethicon, Inc.. Somerville. N.I.
+The coefficient of friction of monofilament Prolene sutu.re is 0.43; Ethiflex suture @raided
Teflon-coated Dacron), 0.55: black braided silk, 0.61 : and monofilament Ethilon nylon suture,
0.67. These values were obtained with the use of 2-0 sutures drawn through a $-inch thickness
of beef muscle. Data supplied by Ethicon, Inc., Somerville, N.J.

510 THE ANNALS OF THORACIC SURGERY

 HOW TO DO I T : End-@-Side Vascular Anastomosis

( A ) T h e end of the graft has been beveled and a longitudinal incision is being made.
Dimensions of the graft are designed so that the lateral corners (grasped here by forceps)
align with the midpoint of the arterial incision. ( B ) Left: Inferior horizontal mattress
suture has been placed. T h e left a r m of superior mattress sutures is shown passing through
t h e graft. Right: O n e side is completed. Separation of graft and arteiy allows optimal
exposure of intimal edges. (C) Sewing is completed and mild tension is applied t o sutures
t o approximate edges. T w o knots remain t o be tied. T h e graft end has a diamond shape.

so that the lateral corners of the resultant diamond-shaped orifice are placed
at the midpoint of the artery's longitudinal incision (Figure, C).
In the illustrations, 6-0 double-armed Prolene suture is used to anasto-
mose the saphenous vein to the aorta. Horizontal mattress sutures are placed

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ELLERTSON, MC GOUGH, AND HUGHES

at each end of the anastomosis (Figure, B). T h e direction of the needle is

always from the outside to the inside for the graft and inside to outside for
the artery. Proximal and distal sutures are not tied.The graft is held a short
distance from the artery during the entire anastomosis. Particular care is
taken to include small bites of graft and artery intima at each end of the
shunt. This anastomosis can be performed with relative speed and ease since
the graft is not approximated to the artery. Each suture arm is run in an
over-and-over fashion to the midlateral part of the suture line and brought
out on the host vessel side (Figure, C). When each of the four suture arms
have been placed, the surgeon and his assistant apply gentle traction to the
two sutures on each side until the graft and artery are approximated. Undue
tension on this slippery suture material may cause it to pull up like a purse
string and narrow the anastomosis.
This technique is useful in any end-to-side vascular anastomosis, includ-
ing use of prosthetic grafts as well as autogenous veins.

Reference
1. Linton, R. R. Some practical considerations in the surgery of blood vessel
grafts. Surgery 38:817, 1955.

512 THE ANNALS OF THORACIC SURGERY