Vessel loops made easy☆☆☆

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Abstract 

Vessel loops are invaluable in vascular surgery. Unfortunately, they frequently slide toward the ends of the arteriotomy, making precise stitch placement difficult. By bringing the vessel loops out separate stab wounds, we improve visualization at the heel and toe of the anastomosis while preserving arterial elevation and hemostasis. (J Vasc Surg 2001;34:172.)

Vascular surgery requires a bloodless field. To provide hemostasis when performing an anastomosis, we used modifications of Carrel's atraumatic vascular clamp, until Moore et al¹ demonstrated that they produce moderate-to-severe endothelial and medial vessel wall injury. However, they showed that silicon rubber loops produce no damage visible by means of electron microscopy. Their conclusion that “selective and preferential use of vessel loops for vascular occlusion and control is thus advocated” has influenced many clinical practices. Alternative methods that provide hemostasis include internal vessel occlusion and the use of a tourniquet.²

For various reasons, including familiarity and ease of use, many surgeons prefer vessel loops. In addition to being atraumatic, they have the advantage of elevating the artery, making the anastomosis easier to sew. One problem we have encountered is that the vessel loop occasionally interferes with the ability to sew the toe or heel of the anastomosis. Because of the angle of the artery and the vector forces, the vessel loop will slide toward the ends of the arteriotomy, making precise stitch placement difficult. One solution to this problem is the use of a removable clip to hold the vessel loop. This does not elevate the artery, however. While dealing with a particularly recalcitrant vessel loop, we made a simple stab wound in the skin several centimeters from the incision and bluntly passed the vessel loop through this tract. This kept the incision small, maintained arterial vessel elevation, distracted the vessel loop from the arteriotomy, and worked remarkably well (Figure).

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• Femoral anastomosis.

We have subsequently used this technique quite effectively in the neck, wrist, groin, and leg. When indicated, a drain can be brought out through the same stab wound.

There are many acceptable ways to occlude arterial vessels. Silastic vessel loops (Dow Corning Corp, Midland, Mich) have proven to be effective and atraumatic and enjoy widespread popularity. Occasionally, however, they may slide on the vessel and interfere with accurate and precise placement of stitches. This simple technique eliminates that problem by maintaining arterial elevation while pulling the vessel loop away from the arteriotomy.

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References 

1. Moore WM, Manship LL, Bunt TJ. Differential endothelial injury caused by vascular clamps and vessel loops, I: normal vessels. Am Surg. 1985;51:392–400
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2. Wagner WH, Treiman RL, Cossman DV, Cohen JL, Foran RF, Treiman GS, et al.  Tourniquet occlusion technique for tibial artery reconstruction. J Vasc Surg. 1993;18:637–647
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