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Background: A narrow working space, small diameters, and the tendency to collapse with clamps make cerebral microvascular anastomosis challenging. A retraction suture (RS) is a novel technique to keep the recipient vessel lumen open during the bypass., Objective: To provide a step-by-step overview of RS for end-to-side (ES) microvascular anastomosis on rat femoral vessels and successful use for superficial temporal artery to middle cerebral artery (STA-MCA) bypass in Moyamoya disease patients., Methods: A prospective experimental study with approval from the Institutional Animal Ethics Committee. Femoral vessels ES anastomoses were performed on Sprague Daley rats. The rat model used 3 types of RS (adventitial, luminal, and flap RSs). An ES-interrupted anastomosis was done. The rats were observed for an average period of 16.18 ± 5.65 days; the patency was assessed by reexploration. The immediate patency on the STA-MCA bypasses was confirmed with intraoperative indocyanine green angiography and micro-Doppler; delayed patency with magnetic resonance imaging and digital subtraction angiography after 3-6 months., Results: In the rat model, 45 anastomoses were performed, 15 each using the 3 subtypes. The immediate patency was 100%. Delayed patency was 42/43 (97.67%), and 2 rats died during observation. In the clinical series, 59 STA-MCA bypasses were done in 44 patients (average age, 18.14 ± 11.09 years) using RS. The follow-up imaging was available for 41/59 patients. Both immediate patency and delayed patency (41/41 at 6 months) were 100%., Conclusion: The RS allows continuous visualization of the vessel lumen, reduces the handling of intimal edges, and avoids incorporating the back wall in sutures, thus improving anastomosis patency., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: The use of the classic 2-ends anchoring technique is common in end-to side (ES) microvascular anastomosis. The literature on the toe-first (TF) technique is limited. In the current study we present the successful outcomes with the TF technique in ES anastomoses in rat femoral vessels model., Methods: ES microvascular anastomosis with the tf technique was performed in the femoral vessels of 10 Sprague Dawley rats. Two-throw reef knot interrupted sutures were used in all cases. Individual parameters during the procedure were recorded for analysis. The immediate and delayed (cut open technique after 2 weeks) patencies were confirmed. An illustrative case showing the use of this technique in superficial temporal artery to middle cerebral artery bypass in a pediatric moyamoya disease case is included., Results: The average suturing time was 40.14 ± 5.30 minutes, the procedures were completed with an average of 14.57 ± 1.90 sutures. The average time per suture was 2.78 ± 0.43 minutes. The immediate patency was 100% (10 of 10 cases). Two rats died of unknown cause in the observation period. The delayed patency was 100% in the remaining 8 cases (average observation: 29.6 days)., Conclusions: The TF interrupted suture technique of ES microvascular anastomosis with 2-throw reef knots is feasible with excellent immediate and delayed patency rates. The distinct advantages of the TF are the continuous visualization of the recipient lumen during anastomoses, avoiding back-wall bites, and the ability to correct any discrepancy in the recipient-donor lumens during the procedure., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The use of a 3-throw knot for anastomosis by microvascular neurosurgeons is the usual standard. There is an inherent belief that the third throw adds extra security to the knot; however, the third throw can make the knot heavy and unbalanced and can exert undue extra pressure on the opposing walls of the small-caliber intracranial vessels. This study evaluated the feasibility and efficiency of 2-throw reef knot interrupted sutures for an end-to-side microvascular anastomosis., Methods: A prospective observational study of end-to-side anastomosis using a femoral artery-to-vein model was performed in 30 Sprague-Dawley rats. All anastomoses were done using 2-throw reef knot interrupted sutures. Ten procedures each were done by the heel-first, toe-first, and classic 2-ends techniques. Individual parameters were recorded for analysis. The delayed patency was confirmed by reexploration after a mean duration of 19.82 ± 8.12 days., Results: The overall patency rates were 100% in the immediate period and 96.43% (27 of 28) in the delayed period. The average clamping time, average suturing time, and the average time per suture were 65.48 ± 16.93 minutes, 40.94 ± 11.22 minutes, and 3.18 ± 1.10 minutes, respectively. Two rats died in the postoperative period., Conclusions: The end-to-side microvascular anastomosis with 2-throw reef knots is feasible, with excellent immediate and delayed patency rates., (Copyright © 2020 Elsevier Inc. All rights reserved.)