The difference from the technique used on similar size vessels is the calculation of pitch, which must be proportional to the size of the vessel. Using a 9-0 nylon suture, the authors started with a backhand pass of the HM suture on the larger vessel and returned with the forehand pass. Any overhanging adventitia was carefully cleaned however, a complete adventicectomy was not performed. In the case of size-mismatched anastomoses, the technique is similar, with the exception of the variable pitch from one side of the vessel to the other. The HM technique for end-to-end anastomosis has been previously described by the authors ( 4). We believe this can overcome the problem of size mismatched arteries without excessive manipulation of the vessels in an end-to-end fashion. We describe a simple technique using horizontal mattress (HM) sutures based on our previously published work in size-appropriate arteries ( 4). Multiple, technically demanding techniques to overcome this problem have been described including coupling devices, forced dilation of the smaller vessel, oblique cuts, fish-mouth incisions, end-to-side anastomoses and interpositional grafts ( 1). Mismatch, defined as a vessel diameter ratio of ≥1.5:1, is typically encountered in 33% of arterial and 50% of venous anastomoses ( 3). Unfortunately, microsurgeons occasionally encounter cases in which mismatched vessels must be anastomosed, which is a situation at high risk for flow turbulence and thrombosis ( 1). In addition to endothelial dysfunction and hypercoagulability, flow turbulence is an essential part of Virchow’s triad and must be minimized to prevent anastomotic thrombosis ( 2). The patency of the microvascular anastomosis is paramount for flap survival in microsurgery ( 1).
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