The Venous Coupler:Is Time Money?

Pouria Moradi, Victoria Rose

Imperial College LondonCharing Cross Hospital, UK

The Ideal Non-Suture Anastomotic Device

• Minimal blood- exposed non-intimal surface

• Minimal inflammatory response

• Minimal vessel trauma

• Easy, quick & safe deployment (recovery)

• Multiple vessel sizes

• Patency equal or better than hand sewn

• Cost

Theoretical Benefits of Coupler by avoidance of

• Foreign body suture contact with blood flow

• Subendothelial collagen exposure from poor intimal contact

• Lumin narrowing prevented by stenting effect of coupler

Holt & Lewis, S Forum 1960:11:243

Holt & Lewis

• 2 rings

• Teflon

• Pinned

• Interlocking

• No FB within lumen

• Neo-endothelium lining

Nakayama K, Tamiya T, Yamamoto K, et al.A simple new method for small vessel anastomoses (free autograft of the

sigmoid included).Surgery. 1962;52:918–931

• Refined

• Applicator

• Lumen measuring tool

• Stainless steel

• 1.5mm

• End-to-side

• Vein patch

Östrup LT, Berggren A. The UNILINK instrument system for fast and safe microvascularanastomoses. Ann Plast Surg. 1986;17:521–525.

• Sweden (Unilink/3M Synovis/MAC)

• 2 Polyethylene rings

• 6 Stainless steel pins

• Push fit seal

• 90° eversion

How does it work?

Select Coupler Size

Flap Vessel

Closing The Coupler

Final Result

Animal Studies

• Rabbit Carotid artery & Facial veins

• End-to-End & End-to-Side

• Average times quoted 2-5 minutes

• 98-100% patency rates

• 2 year follow up

• Media thinning of artery and 40% aneurysm rate

• Tensile strength greater

Ostrup Berggren, Gilbert & Ragnarsson

Animal Studies• Artery:

– Initially no difference is seen between

coupled anastomoses micro and

macroscopically

–2 years significant media thinning was

seen in the artery for 10mm distal to

the coupler with possible aneurysm

formation in 40%

• No problems were detected with the

vein

1000 Consecutive Venous Anastomoses using the microvascularanastomotic coupler in breast reconstruction

PRS 2010 Jandali et al

• 6 instances of venous thrombosis (0.6%)

– Nil flap loss

– 2 partial flap losses

• Same institution (Vega PRS 2008)

– 500 free TRAMS

– 2.8% Hand sewn venous anastomosis thrombosis

Venous thrombosis in coupled versus sutured microvascularanastomoses

Ann PlastSurg 2006 Yap et al

• 139 anastomosis in coupler group

– 2/139 thrombosis (1.4%)

• 584 anastomosis in hand sutured group

– 19/584 thrombosis (3.3%)

Relative Contraindications

• Not for thick walled vessels

• Not for Arteries

• Not for Short vessel lengths

• Size mismatch

• Registrar training???

Purpose of the Study Is The Coupler Cost Effective?

Cost

Coupler• Instrumentation

– Coupler kit £950• Consumable

– Coupler £112

• In Australia $610 per case on consignment– Covered by Private Insurance

Suture• Consumable

– 8’0 ethilon £20 $Aus 19.12– 9’0 ethilon£40 $Aus 21.68– 10’0 ethilon £60 $Aus 26.28

Methods

• DIE vessels to IM vessels only

• Vein Coupler compared to Arterial Suture

2 Surgeons

• Registrar

~ 6 years Plastic Surgery

• Consultant

~ 11 years Plastic Surgery

Technique

• Artery

– From first suture puncture

– To clamps off

– Minutes

• Vein

– Coupler placed in microscope field

– To clamps off

– Minutes

RESULTS

Mean Time

0

5

10

15

20

25

30

Registrar Consultant

Mean Artery

Mean Coupler

Tim

e in

min

ute

s

• Definite improvement in hand tie times is

seen with increasing experience

• This is not seen with coupler

• All surgeons averaged similar coupler

times

% of Ischaemia Time

0

5

10

15

20

25

30

35

Reg Con

% Ischaemia Artery

% Ishaemia Coupler

• Over 28% of all ischaemia time was spent

on the artery

• An average of 11% of the total ischaemiatime was spent on the coupler

Complications

• No Coupler Leaks

• No Failed Deployments

• 100% Patency all Anastomoses

• No Flap Failures

• Extra Arterial Time in 5 Cases

– ie extra sutures for leaks

Time Conclusions

• Coupled Vein is quicker than sutured artery

• Consistent time for coupled anastomosis across grades

• % Ischaemia time of Coupler is less than sutured artery

Time is Money

• OR p/hr £800/hr $Aus1200/hr• Time (C) 5.50 mins• Time (S) 17.50 mins• Time saved 12.00 mins

– 12/60 x £800=£160– 12/60 x $1200= $aus240

• Coupler cost £112• 9‘0 cost £40

– £112-£40=£72

• Net saved per Case – £160-£72=£88.00

Conclusions

• Microvascular coupler is a safe alternative to suture for venous anastomosis

• Microvascular coupler is faster than suture

• Microvascular coupler has a shorter learning curve than suture

• Microvascular coupler is cost effective

Thank You