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Hand Surgery and Rehabilitation 35 (2016) 85–94

Original article

Tips and tricks for end-to-side anastomosis arteriotomies

Artifices d’artériotomies en anastomoses termino-latérales
Sébastien El Rifaï a,b,c,*, Julien Boudard a,b,c, Mathieu Haïun a,b,c, Laurent Obert a,b,c,
Julien Pauchot a,b,c
a
Service d’orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU de Besançon, 29, rue des Boucheries,
25033 Besançon, France
b
EA 4268 innovation, imagerie, ingénierie et intervention en santé « I4S », IFR 133 Inserm, 1, place Saint-Jacques, 25030 Besançon cedex, France
c
Faculté de médecine et de pharmacie, université de Franche-Comté, 19, rue Ambroise-Paré, 25000 Besançon, France
Received 13 August 2015; received in revised form 31 January 2016; accepted 2 February 2016
Available online 4 March 2016

Abstract
Arteriotomy is a critical step during end-to-side anastomosis procedures. However, it is challenging to carry out because of the concentric
lamellar structure of blood vessels and the need for clean margins. We performed a review of the literature to identify the advantages and
disadvantages of the available arteriotomy methods. The techniques were classified into (1) single-cut or slit arteriotomy (longitudinal and
transverse) or (2) excision arteriotomy. The latter techniques can be performed from either outside-in (excision with straight microscissors, curved
microscissors, Acland-Banis arteriotomy clamp, micro-arteriotomy scissors, or triangular cutting scissors, and vaporization with Excimer1 laser)
or inside-out (excision with punch/micropunch). Microsurgeons have multiple arteriotomy methods at their disposal. By being familiar with these
methods, they can select the most appropriate one for the situation at hand.
# 2016 Published by Elsevier Masson SAS on behalf of SFCM.

Keywords: Microsurgery; End-to-side anastomosis; Arteriotomy; Microscissors; Micropunch

Résumé
L’artériotomie est un temps essentiel lors de la réalisation des anastomoses termino-latérales. Elle est cependant difficile à réaliser car les
vaisseaux ont une structure concentrique lamellaire et les contours de l’artériotomie doivent être nets. Notre travail consistait en une revue de la
littérature des différentes méthodes d’artériotomie avec leurs avantages et inconvénients. Nous avons pu classer les techniques en : (1)
artériotomies par incision simple (longitudinale et transversale) et (2) artériotomies par excision : (a) de dehors en dedans (excision conventionnelle
aux microciseaux droits, excision aux microciseaux courbes, excision avec le clamp d’artériotomie d’Acland-Banis, excision aux ciseaux de
microartériotomie, ciseaux de coupe triangulaire d’artériotomie, évaporation au LASER Excimer1) et (b) de dedans en dehors (excision au punch/
micropunch). Le microchirurgien dispose donc de nombreuses méthodes d’artériotomie. Connaître ces différentes méthodes peut être intéressant
afin qu’il puisse choisir la méthode la plus adaptée à la situation à laquelle il peut être confronté.
# 2016 Publié par Elsevier Masson SAS pour la SFCM.

Mots clés : Microchirurgie ; Anastomose termino-latérale ; Artériotomie ; Microciseaux ; Micropunch

* Corresponding author at: Service d’orthopédie, de traumatologie, de chirurgie plastique, reconstructrice et assistance main, CIC IT 808, CHU de Besançon, 29,
rue des Boucheries, 25033 Besançon, France.
E-mail address: sebastienelrifai@gmail.com (S. El Rifaï).

http://dx.doi.org/10.1016/j.hansur.2016.02.002
2468-1229/# 2016 Published by Elsevier Masson SAS on behalf of SFCM.
86 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94
1. Introduction
End-to-side anastomosis is a common technique in
microsurgery, of which arteriotomy is an essential component.
Some have said that arteriotomy is the key to success during
end-to-side anastomosis [1]. However, an arteriotomy is very
difficult to perform correctly because of the concentric
structure of blood vessels and the accompanying risk of
dissecting the various layers of their walls. This procedure is
even more challenging when the blood vessels are abnormal
due to trauma, atherosclerosis, etc. [2]. The edges of the
arteriotomy must be as clean as possible—without dissecting
the various layers of the wall—and ideally obtained with the
first cut. Creating a smooth, even, good-quality opening in the
arterial wall is difficult, time-consuming and requires practice.
If performed incorrectly, the patency of the vessel may be
unacceptable. For this reason, several techniques have been
described that make arteriotomy easier. This article uses a
review of the literature to provide an overview of all the
arteriotomy methods (Table 1).
2. Material and methods
We performed a Medline search with the keywords ‘‘end-to-
side anastomosis’’, ‘‘microsurgery’’, ‘‘arteriotomy’’ and
‘‘Microsurgery’’ [Mesh] AND ‘‘Arteriovenous Shunt, Sur-
gical’’ [Mesh]. We also looked through microsurgery textbooks
and catalogues put out by microsurgery tool manufacturers.
The various arteriotomy techniques were analyzed based on
the arteriotomy technique, the angle between the two vessels,
the suturing method and the patency of the anastomosis.
3. Results
The techniques were grouped into single-cut or slit
arteriotomies (longitudinal and transverse) and excision
arteriotomies (also be called arteriectomies). Excision arterio-
tomies may be performed from outside-in (conventional
excision with straight microscissors, or excision with curved
microscissors, Acland-Banis arteriotomy clamp, micro-arte-
riotomy scissors, or triangular cutting scissors, and vaporization
with Excimer laser) or inside-out (excision with punch/
micropunch).
3.1. Slit arteriotomy
This is a simple method in which a microknife is used to
perform a single longitudinal or transverse incision. The main
advantage of this method is that no defect is created, which is a
plus when working with small vessels. The main disadvantage
is the potential to damage the posterior wall or cut through the
vessel (Figs. 1 and 2).
3.2. Excision arteriotomy methods
These methods create a good arteriotomy opening, thereby
making it easier to place the sutures. But all the excision
techniques have the same drawback: they create a defect in the
vessel wall.
3.2.1. Conventional excision with straight microscissors
This is the standard method. It involves the following steps:
 excise adventitia;
 place traction suture in center of arteriectomy;
 apply traction to suture;
 make the first cut on one side at 308 from perpendicular;
 make a second symmetric cut on the other side [3,4].
However, the resulting cross-cutting increases the risk of
vascular thrombosis. The surgeon must shift the scissors to the
other hand to make the second cut. This second cut is also
harder to make because the angle is altered by the action of the
longitudinal fibers. Lastly, the size of the arteriotomy hole is
difficult to control (Fig. 3).
3.2.2. Excision with curved microscissors
With this method, the arteriectomy is performed with a
single cut, thereby avoiding cross-cutting. This simple,
effective technique results in a uniform opening width and
clean edges, and is reproducible. However, it is difficult to
control the size of the arteriotomy (Fig. 4).
3.2.3. Excision using Acland-Banis arteriotomy clamp
This technique requires an Acland-Banis clamp, developed
specifically for arteriotomy (S&T AG, Neuhausen, Switzer-
land), and the use of a microknife. The technique consists of:
 clamping the artery;
 excising the adventitia;
 carefully pinching a piece of the wall that is half the length
and slightly wider than the desired arteriotomy (this step
cannot be reversed because of the pressure applied by the
clamp tip);
 placing the microknife metal-on-metal against the tip of the
clamp and making a semicircular cut around the clamp with a
continuous sweeping motion (Fig. 5).
This technique results in fewer aneurysms [5]. Its drawbacks
are the cost of the clamp and the irregular nature of the cut,
which is not always performed in a single stroke.
3.2.4. Excision with microarteriotomy scissors
This technique makes use of specialized microarteriotomy
scissors available in 1.0, 1.5 and 2.0 mm sizes (Micrins
microsurgical instruments; Lake Forest, IL, USA). It has four
steps:
 place vessel in Acland double microclamp;
 bring the two microclamps together;
 pull the lateral vessel wall towards the top of the vessel’s
circular opening;
 use the scissors to cut the vessel.
Table 1
Summary of the various arteriotomy techniques reviewed here.
Technique Principle Required instruments/ Description Advantages Disadvantages Our assessment
availability
Longitudinal slit Arteriotomy without Microknife/basic Adventitia excision No defect, thus larger Risk of damaging Simple, results in good
defect microsurgery tool Single incision diameter and larger posterior wall patency; wider
circumference at anastomosis
anastomosis site Preferred method for very
No specific tools required small diameter vessels
Transverse slit Arteriotomy without Microknife/basic Adventitia excision No defect Risk of damaging Does not increase the
defect microsurgery tool Single incision No specific tools required posterior wall diameter of the
Risk of cutting through anastomosis site

S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94

vessel
Excision with Arteriectomy from Suture Adventitia excision No specific tools required Defect created Used mainly for training
straight outside-in Straight microscissors/ Traction using suture Cross-cutting purposes
microscissors basic microsurgery tool 308 cut on one side Second cut not truly
308 symmetric cut on symmetric
other side Scissors used with non-
dominant hand
Size difficult to control
Excision with Arteriectomy from Suture Adventitia excision No specific tools required Defect created Used mainly for training
curved outside-in Curved microscissors/ Traction using suture Clean margins Size difficult to control purposes
microscissors basic microsurgery tool Single cut Uniform width
Excision using Arteriectomy from Acland-Banis clamp/S&T Adventitia excision Good control over size Defect created Of little interest; other
Acland-Banis outside-in AG, Neuhausen, Pinch vascular wall with Expensive clamp, methods exist to control
clamp Switzerland clamp available in several sizes the size of the arteriotomy
Microknife Cut around clamp Irregular margins because that have more regular
Available in several sizes more than one cut often margins (e.g.,
directly from company in needed micropunch)
2015
Excision with microarteriotomy Arteriectomy from Microarteriotomy scissors Place vessel in Acland Clean margins, circular Defect created
scissors outside-in (Micrins microsurgical double microclamp opening, no irregularities Size difficult to control if
instruments; Northbrook, Bring the two Only 4 steps surgeon is inexperienced
IL, US) microclamps together Expensive, specialized
Available in several sizes Pull up on lateral wall of instrument; additional
directly from company in vessel cost due to multiple sizes
2015 Close scissors to cut
vessel

Excision with Arteriectomy from Triangular cutting scissors
triangular outside-in (Stille Company, Sweden)
cutting scissors Not mass produced due to
high cost, but can be
special ordered directly
from company
Place vessel in Acland Several sizes using a Defect created Difficult to procure; our
double microclamp single instrument Expensive, specialized team has not used them
Bring the two Oval, symmetric opening instrument
microclamps together Clean margins
Pull up on vascular wall
Close scissors to cut
vessel

87
 88
Table 1 (Continued )
Technique Principle Required instruments/ Description Advantages Disadvantages Our assessment
availability
Diamond Arteriectomy from Straight microscissors/ Two cuts of different sizes No specific tools required Defect created Theoretically attractive
technique outside-in basic microsurgery tool made Larger cross-sectional Cross-cutting method, but difficult to
area at anastomosis site Second cut not truly carry out in practice
(useful when anastomosis symmetrical Variation on standard
angle < 608) Scissors used with non- excision method with
Useful when the two dominant hand straight scissors
vessels have very different Size difficult to control

S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94

diameters
Vaporization with Arteriectomy from Excimer laser Two end-to-side No transient ischemia in Defect created Our team has no
Excimer laser outside-in using Available in 2015; sold by anastomoses without recipient vessel Difficult, time-consuming experience with this
vaporization various companies; arteriotomy Clean margins method method, but prolonged
routinely used in Excimer laser introduced Costly instrument cerebral ischemia is
ophthalmic surgery into artificial branch of avoided in neurosurgery
donor vessel and cases
advanced into recipient
vessel
Shrinkage of vessel wall
Ligation of artificial
branch of donor vessel
Excision with Arteriectomy from inside- 2.7 or 1.7 mm vascular Clamp recipient vessel Round, clean opening of Defect created Our preferred method at
vascular punch out, punch biopsy punch Make slit incision the same size as anvil of Risk of complete Besançon Hospital Easy
Available in 2015 from Insert anvil through punch laceration of posterior to procure, routine
Teleflex Medical incision into vessel lumen Three steps wall instrument for cardiac
Press down on handle No detachment of plaque Non-ergonomic handle, surgery (2.7 or even
not suitable for 1.7 mm)
microsurgery (two hands Avoids intimal dissection
needed to use it) and detachment of plaque
Expensive, specialized
instrument; additional
cost due to multiple sizes
Technically difficult
Excision with Arteriectomy from inside- Harris micropunch (1.5, Clamp recipient vessel Round, clean opening of Defect Small available sizes are
vascular out, punch biopsy 1.0, 0.5 mm) Make slit incision the same size as anvil of Risk of complete very useful when
micropunch Available from multiple Insert anvil through punch in three steps laceration of posterior performing end-to-side
companies in 2015 incision into vessel lumen No detachment of plaque wall anastomosis of small-
(TedPella Inc., GE Press down on handle Ergonomic handle; can be Expensive, specialized diameter vessels
Healthcare Life Sciences) used with one hand instrument; additional
Very small diameters cost due to multiple sizes
available
 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94 89

3.2.5. Excision with triangular cutting arteriotomy scissors

Fig. 1. Longitudinal arteriotomy.
The cut is made by placing the scissors at a 908 angle to the
blood vessel. The action of the longitudinal fibers results in an
oval arteriotomy. The size of the arteriotomy can be easily
adjusted by changing the depth of the cut. These scissors are
manufactured by Stille AB (Torshälla, Sweden) [6]. However,
this specialized instrument is very expensive; for this reason, it
is now only available by special order (Fig. 7).

3.2.6. Excision using the diamond technique [7,8]

Fig. 2. Transverse arteriotomy.
This technique has the advantage of creating a smooth,
circular arteriotomy opening with regular margins in just four
steps. The drawbacks are the cost of the scissors and the size of
the defect, which can be larger than the scissors despite the
various sizes available (Fig. 6).
This technique creates a lateral diamond-shaped arterio-
tomy by making two cuts of different sizes in the artery, and a
vertical arteriotomy in the connecting vessel of the same size as
the opening in the recipient vessel. Although relatively simple
to carry out, it has the same drawbacks as the conventional
excision technique. A larger cross-sectional area at the
anastomosis site and a gradual change in the diameter help
to reduce the risk of thrombosis by reducing turbulence
(Fig. 8).

Fig. 3. a: excision arteriotomy using straight microscissors–lateral view–1st cut; b: excision arteriotomy using straight microscissors–lateral view–2nd cut;
c: excision arteriotomy using straight microscissors–anteroposterior view.

Fig. 4. a: excision arteriotomy using curved microscissors–lateral view–traction using sutures; b: excision arteriotomy using curved microscissors–lateral view–after
cut has been made; c: excision arteriotomy using curved microscissors–anteroposterior view.
90 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94

Fig. 5. a: excision arteriotomy using Acland-Banis clamp–lateral view–traction using clamp; b: excision arteriotomy using Acland-Banis clamp–lateral view–after
cut has been made; c: excision arteriotomy using Acland-Banis clamp–anteroposterior view.

Fig. 6. a: excision arteriotomy using microarteriotomy scissors–lateral view–traction using suture; b: excision arteriotomy using microarteriotomy scissors–lateral
view–after cut has been made; c: excision arteriotomy using microarteriotomy scissors–anteroposterior view.

Fig. 7. a: excision arteriotomy using triangular cutting scissors–lateral view–before cut is made; b: excision arteriotomy using triangular cutting scissors–lateral
view–after cut has been made; c: excision arteriotomy using triangular cutting scissors–anteroposterior view.
 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94 91

Fig. 8. a: excision arteriotomy using diamond hole technique–lateral view; b: excision arteriotomy using diamond hole technique–anteroposterior view.

3.2.7. Excision by vaporization with Excimer laser [9]
This technique consists of making two end-to-side
anastomoses without arteriotomy between the recipient vessel
and the donor vessel on one hand, and the recipient vessel and
an artificial arterial branch on the other hand. An Excimer laser
is then introduced through the artificial arterial branch of the
donor vessel and advanced up to the vascular wall of the
recipient vessel. The arteriotomy is performed by shrinking the
vascular wall with the laser. Lastly, the artificial branch of the
donor vessel is ligated. The main advantage of this technique is
that there is no transient ischemia of the vascularized tissues in
the recipient vessel. Scanning electron microscopy showed the
arteriotomy to have clean edges. However, a second end-to-side
anastomosis needs to be made and then ligated, which
complicates the technique and makes it less reproducible.
3.2.8. Excision with vascular punch/micropunch
This is a punch biopsy method [1,10,11] that uses 2.7-mm or
even 1.7-mm vascular punches (Teleflex Medical, Athlone,
Ireland). The recipient vessel is clamped and a longitudinal slit
made; the anvil is inserted through the slit into the vessel’s
lumen and then the handle pressed down. This creates a round
opening the same size as the punch, which is excised from the
inside to the outside of the vascular wall.
The resulting arteriotomy is completely symmetrical [10].
The drawbacks are the risk of complete laceration of the intima
of the opposing wall and of the incision being larger than the
punch’s anvil. The initial incision has the same risks as those
described previously for slit arteriotomy. When the anvil is
passed through the slit into the vessel, the surgeon must be
careful not to tear the vessel wall. When the handle is pushed
down, the instrument’s action tends to push the anvil towards
the posterior wall, which can damage its intima layer (Fig. 9).
According to Pederson and Barwick, use of a vascular punch
helps to prevent detachment of atheromatous plaques, a
complication reported when using outside-in techniques that
leads to turbulence [1]. The punch makes a clean, clear-cut hole
that does not damage the intima. The instrument’s large size is the
main drawback; it is non-ergonomic for microsurgery, although
the 1.7-mm punch has a shorter handle than the 2.7-mm punch.
Hallock highlights the benefits of using a 1.0 or 1.5-mm
Harris micropunch (Ted Pella Inc., Redding, CA, USA) to
create a sharp, clean, elliptical, uniform arteriotomy, especially
in atherosclerosis cases where the atherosclerotic plaque or the
risk of intimal dissection can alter the patency of the
anastomosis when using incision methods or conventional
excision methods [11].
These micropunches are shorter, making them more
ergonomic than vascular punches, and are available in small
diameters (down to 0.5 mm). However, they are relatively
expensive, specialized instruments. Various sizes available
depending on the desired diameter.
4. Discussion
Our preferred technique is the punch biopsy arteriotomy with
a vascular punch. We have performed approximately thirty free
flap procedures using this technique. A longitudinal incision is
preferred when working with very small diameter vessels.

Fig. 9. a: excision arteriotomy using micropunch–lateral view–incision; b: excision arteriotomy using micropunch–lateral view–micropunch insertion; c: excision
arteriotomy using micropunch–lateral view–after punch has been used; d: excision arteriotomy using micropunch–anteroposterior view.
92 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94
The vascular wall consists of three distinct layers
(adventitia, media and intima) that vary in thickness depending
on the type (artery or vein) and size of the vessel. The inner
intima layer is in contact with the bloodstream. Ensuring that it
stays intact prevents red blood cells from aggregating against
the media. Unlike outside-in arteriotomy techniques that use
scissors, inside-out techniques that use punches have the
advantage of reducing the risk of dissection between the vessel
layers, which would expose the media and adventitia and their
pro-aggregating collagens [12] in the vessel lumen. This is
consistent with the approach taken by vascular surgeons, who
typically cross a vessel from inside to outside when it is
predisposed to dissection (arteritis).
End-to-side anastomosis has several benefits for micro-
surgeons: they have fewer vascular occlusions than end-to-end
anastomoses, they allow two vessels of different diameters to be
joined and they are a good alternative to ligating the recipient
vessel (anastomosis on single major artery). Godina believes
that end-to-side anastomosis is better than end-to-end
anastomosis in terms of blood flow and patency, hence it is
the preferred method when transferring free flaps [4].
However, end-to-side anastomosis is more technically
difficult to carry out than end-to-end anastomosis because of
challenges associated with accessing the posterior wall of the
sutured vessel. As an alternative, Auquit-Auckbur et al.
proposed performing two end-to-end anastomoses when the
distal end of the vessel being sutured has a nearby collateral
branch of similar diameter; the two ends are passed through
each other in a Y- or T-configuration after transverse section (or
resection) of the recipient artery [13].
The available arteriotomy techniques have been evaluated in
many studies, but none of these studies compared more than
two techniques at a time [8,14]. The various techniques can be
divided into true arteriotomies (by incision) and arterectomies
(by excision), with or without specific instruments, from inside-
out or outside-in.
While a study on rats showed no differences in terms of
patency between the excision and incision methods, Adams
et al. state that most microsurgeons prefer the longitudinal slit
method because it is easier to carry out [15].
According to Gu et al. [16], the slit arteriotomy has several
advantages: it is a simple technique with clear-cut edges that
can easily be extended if too short and repaired if too long; the
lumen of the recipient vessel is widened, because the vascular
wall is not excised, which results in a larger circumference at
the anastomosis site. A computer modeling study concluded
that a longitudinal slit arteriotomy was superior to conventional
excision arteriotomy for several reasons: strength of donor
vessels that keep the lumen open, blood pressure, etc. [16].
According to Zoubos et al., one of the drawbacks of slit
arteriotomy is that the sutures are hard to place because of the
closed margins [5].
Dash et al. believe that arteriotomy with curved scissors is
superior to other methods because of its simplicity, effective-
ness, uniform width, clear-cut edges (requires no recutting) and
good reproducibility (requires little training) [17]. Excision
with straight scissors provides poor control over the size of the
arteriotomy, the single transverse slit has the potential to
damage the posterior wall, the margin of the arterial wall can
separate when doing a single longitudinal slit [14], and the
specialized arteriotomy scissors required are very expensive
[18]. However, the Dash group only directly evaluated excision
with curved scissors and did not compare it to other methods.
According to Zoubos et al. [5], and Lazzarini-Robertson [19],
the type of arteriotomy (elliptical or longitudinal slit) affects the
dynamics of blood flow because of surface irregularities and the
Bernoulli theorem [20]. However, Zoubos et al. suggest that these
factors are not relevant in high-pressure arteries. They note
however that an elliptical arteriotomy is technically more
difficult and may require specialized instruments [5].
Tan et al. evaluated the results of longitudinal slit
arteriotomy. They point out that since no part of the recipient
vessel wall is excised, the diameter of the anastomosis site is
increased (dilation), contributing to the flow of blood in the area
of the anastomosis (Poiseuille law). Bringing the clamps closer
together opens the arteriotomy and makes suturing easier; the
arteriotomy stays open because of recoil in the fibers (circular
or longitudinal, depending on whether the slit is transverse or
longitudinal) and because the donor vessel deforms the slit. He
concluded that longitudinal slit arteriotomy is most appropriate
for a single major artery and in situations where the recipient
vessels are small and relatively inflexible [21].
Many authors prefer using a longitudinal slit when
performing an arteriotomy [22]. However, Storrie’s group
prefers a transverse slit arteriotomy for end-to-side anastomosis
of small vessels as they feel that suturing is easier to carry out
because of the spontaneous spreading of the arteriotomy
margins [14].
Some studies have compared incision and excision
techniques. Yoleri and Songür found no differences between
venous end-to-side anastomosis (908) performed by elliptical or
slit venotomy based on patency tests performed 30 minutes and
7 days after the procedure [23]. Zoubos et al. found no
significant differences between elliptical excision and incision
procedures, or in the anastomosis angle of the vessel, based on
patency testing [5]. On the other hand, O’Brien’s team found
elliptical excision of a portion of the vascular wall to be
preferable to slit incision [24].
When using microarteriotomy scissors, recutting may be
needed when making the incision, which can result in intimal
irregularities. As a consequence, Korber described using
straightforward scissors to create a smooth opening in the
arterial wall with a reproducible technique and a minimal
number of steps. His simple 4-step vessel-cutting method
reduces damage to the vessel by reducing the need for repeated
handling [18].
Once the arteriotomy or arterectomy has been performed,
suturing can be challenging because of the inconsistent
exposure of the walls in the opening. Various tricks have been
described to make suturing easier; the main ones will be
described briefly below.
Tulleken et al. described an end-to-side anastomosis where
suturing is carried out over three-quarters of the circumference
in an unclamped recipient artery. The artery is clamped only to
 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94
Fig. 10. End-on-side anastomosis.
perform the arteriotomy and to finish suturing the last quarter.
The main advantage of this technique is the short occlusion
time (< 5 min); however, adventitia can be present in the
vessel’s lumen. They point out that although the adventitia is
theoretically thrombogenic, the presence of suture material in
the lumen of the anastomosis is clearly more disruptive for
endothelialization than the presence of adventitia or media
tissue [25].
Harashina described a trick for keeping a venotomy open
while performing end-to-side venous anastomosis; it involves
making a ring with four traction sutures to get around the
difficulties encountered when suturing a collapsed donor vessel
[26].
Tellioğlu described a relatively original end-on-side
anastomosis technique, in which a bilateral incision was made
in the proximal portion of the donor vessel and then four sutures
added to create the anastomosis [27] (Fig. 10).
Krishnan et al. described an end-to-side anastomosis
technique in which a microcatheter was used to create a
temporary intraluminal shunt to prevent any sutures from
completely crossing the vessel [28]. Karamürsel et al. used an
external silver ring to make it easier, faster and safer to place
sutures [29]. Verhelle and Heymans described a suturing trick
for incorporating damaged vessels into an end-to-side
anastomosis; a T-shaped arterial interposition is made using
an arterial branch from the pedicle [2].
5. Conclusion
Several arteriotomy methods, some of which are not yet well
known, are available to microsurgeons depending on the
situation encountered (vessel diameter, vascular condition,
available time, etc.). Being familiar with these various methods
allows surgeons to select the most suitable method for the
patient’s condition by weighing the advantages and disadvan-
tages of each. The quality of the arteriotomy or arterectomy can
determine the success of the microsurgery.
Disclosure of interest
L.O.: none directly related to this article, but he currently has
working relationships with the following companies: FX
Solutions, Zimmer, Medartis, Evolutis, Biotech Wright, Argo.
The other authors declare that they have no competing
interest.
93
References
[1] Pederson WC, Barwick WJ. Use of the vascular punch in microsurgery. J
Reconstr Microsurg 1989;5(2)115–8.
[2] Verhelle NAC, Heymans O. How to deal with difficult microsurgical end-
to-side anastomoses. Microsurgery 2005;25(3)203–8.
[3] Acland RD. Microsurgery practice manual. St. Louis: Mosby; 1980.
[4] Godina M. Preferential use of end-to-side arterial anastomoses in free flap
transfers. Plast Reconstr Surg 1979;64(5)673–82.
[5] Zoubos AB, Seaber AV, Urbaniak JR. Hemodynamic and histological
differences in end-to-side anastomoses. Microsurgery 1992;13(4)200–3.
[6] Hedén P. A triangular cutting arteriotomy scissors facilitating end-to-side
anastomoses. Plast Reconstr Surg 1992;89(2)353–5.
[7] Sen C, Agir H, Iscen D. Simple and reliable procedure for end-to-side
microvascular anastomosis: the diamond technique. Microsurgery
2006;26(3)160–4.
[8] Sen C, Hasanov A. Comparative geometric analysis of diamond and hole
techniques in end-to-side microvascular anastomosis. Microsurgery
2008;28(4)262–4.
[9] Tulleken CA, Verdaasdonk RM, Berendsen W, Mali WP. Use of the excimer
laser in high-flow bypass surgery of the brain. J Neurosurg 1993;78(3)477–80.
[10] Lynch JB, Hussey AJ, O’Sullivan ST. Using a punch biopsy to fashion an
arteriotomy for end-to-side anastomosis. J Reconstr Microsurg
2011;27(2)139–40.
[11] Hallock GG, Rice DC. Use of a micropunch for arteriotomy in end-to-side
anastomosis. J Reconstr Microsurg 1996;12(1)59–62 [discussion 62–3].
[12] Legagneux J, Gilbert A. Apprentissage de la microchirurgie vasculaire.
EMC – Techniques chirurgicales – Chirurgie plastique reconstructrice et
esthétique; 2007;1–15 [Article 45-025].
[13] Auquit-Auckbur I, Revol M, Rives JM, Servant JM. [Latissimus dorsi free
flap with « Y » anastomoses. Technical variant and use in leg reconstruc-
tion]. Ann Chir Plast Esthet 1999;44(2)195–8.
[14] Storrie A, McGeachie J, Samuels R, Hunneybun B, Bartlett N. Transverse
or longitudinal arteriotomies in end-to-side microvascular anastomoses
for small vessels (1–2 mm). Microsurgery 1990;11(2)108–13.
[15] Adams Jr WP, Ansari MS, Hay MT, Tan J, Robinson Jr JB, Friedman RM,
et al. Patency of different arterial and venous end-to-side microanasto-
mosis techniques in a rat model. Plast Reconstr Surg 2000;105(1)156–61.
[16] Gu H, Chua A, Tan B-K, Chew Hung K. Nonlinear finite element
simulation to elucidate the efficacy of slit arteriotomy for end-to-side
arterial anastomosis in microsurgery. J Biomech 2006;39(3)435–43.
[17] Dash H, Kononov A, Maloney 3rd J, Browne E. A simple arteriotomy
method for microsurgical end-to-side anastomoses: technical aspects of
use in training and laboratory applications. J Reconstr Microsurg
1993;9(5)381–4.
[18] Korber KE, Kraemer BA, Li Z. Angled side wall microarteriotomy
scissors: a new end-to-side microvascular anastomosis instrument. Mi-
crosurgery 1990;11(3)217–9.
[19] Lazzarini-Robertson Jr AA. Hemodynamic principles and end-to-side
vascular anastomoses. Arch Surg 1961;82:384–6.
[20] Phelan JT, Herrick JF. Some rheologic principles as applied to vascular
surgery. Proc Staff Meet Mayo Clin 1958;33(5)108–14.
[21] Tan B-K, Wong C-H, Chew W, Hong S-W. Use of the slit arteriotomy for
end-to-side arterial anastomosis in free-tissue transfers to the extremities.
J Plast Reconstr Aesthet Surg 2009;62(11)1519–23.
[22] Greenhalgh RM, Rossi LF, Hoare MR. The precise technique of end-to-
side microvascular anastomosis with a suitable experimental model. Ann
R Coll Surg Engl 1981;63(1)28–30.
[23] Yoleri L, Songür E. Different venous end-to-side microanastomotic
techniques: comparative study in a new rat model. Ann Plast Surg
2002;48(4)410–4.
[24] O’Brien T, Walsh M, McGloughlin T. Altering end-to-side anastomosis
junction hemodynamics: the effects of flow-splitting. Med Eng Phys
2006;28(7)727–33.
[25] Tulleken CA, Schilte GF, Berendsen W, van Dieren A. New type of end-to-
side anastomosis for small arteries: a technical and scanning electron
microscopic study in rats. Neurosurgery 1988;22(3)604–8.
94 S. El Rifaï et al. / Hand Surgery and Rehabilitation 35 (2016) 85–94

[26] Harashina T. End-to-side anastomosis of the vein: a technical innovation.
Microsurgery 1983;4(2)113–4.
[27] Tellioğlu AT. End-on-side microvascular anastomosis: an experimental
study. Ann Plast Surg 1997;39(2)137–40.
[28] Krishnan KG, Tsirekidze P, Pinzer T, Schackert G. A novel minimally
occlusive microvascular anastomosis technique using a temporary intra-
luminal shunt: a prospective technique to minimize brain ischemia time
during superficial temporal artery-to-middle cerebral artery bypass. Neu-
rosurgery 2008;62(6 Suppl. 3)1450–5.
[29] Karamürsel S, Kayikçioğlu A, Safak T, Keçik A. End-to-side microvas-
cular anastomosis using an external metal ring. Br J Plast Surg
2000;53(5)423–6.