Application of the Horizontal Mattress Techniques in Side-to-Side Microvascular Anastomoses Maximizes Intima...

In side-to-side microvascular anastomoses, it's challenging to achieve vessel intima eversion on the back wall. It is sometimes necessary to lengthen the arteriotomy to compensate the elevated risk of thrombosis formation. This note demonstrates application of the horizontal mattress techniques with an illustrative case to maximize intima eversion, which has not been widely adopted in open vascular micro-neurosurgical practice.

A 50-year-old female with multiple strokes with transient right sided weakness was diagnosed as bilateral moyamoya syndrome, we present a side-to-side bypass with the horizontal mattress technique. The indocyanine green angiography showed patency of the anastomosis. The patient remained neurologically intact postoperatively. In side-to-side anastomoses, this technique starts with an outside-in (extraluminal-to-intraluminal) stitch at the proximal aspect of the arteriotomy. An aneurysm clip is applied to anchor the suture, the horizontal mattress techniques are subsequently applied to the back wall with suture loops loose, an "outside-in" stitch is followed by an "inside-out" stitch on the contralateral side, and an "inside-out" stitch is followed by an "outside-in" stitch on the ipsilateral side. The suture loops were tightened sequentially proximal-to-distally. A simple tight stitch was then placed at the distal aspect as the inferior anchor, to which the inferior free end of the suture is tightened. Similarly, the proximal free end was tightened after the aneurysm clip is released to complete the backwall.

Although technically challenging, the horizontal mattress technique can optimize the intima eversion on the back wall in side-to-side microvascular anastomoses.