VASCULAR AND ENDOVASCULAR TECHNIQUES
Thomas L. Forbes, MD, Section Editor
ViPS technique as a novel concept for a sutureless
Stefano Bonvini, MD, PhD,aJoseph J. Ricotta, MD,bMichele Piazza, MD,aLuca Ferretto, MD,aand
Franco Grego, MD,aPadova, Italy; and Atlanta, Ga
Objective: To describe a novel technique (Viabhan Padova Sutureless [ViPS]) that connects a vascular prosthetic graft to
a target artery in a sutureless fashion.
Methods: The patient was a 74-year-old male with complete superficial femoral artery (FA) occlusion and reconstitution of
a circumferentially calcified above-knee popliteal artery (ANPA). The proximal end of a surgeon-modified 7-mm Viabahn
endoprosthesis was sutured to a 7-mm polytetrafluoroethylene graft (PTFEg). After surgical exposure, the ANPA was
transected, and the undeployed distal portion of the Viabahn was inserted, supported by a stiff guidewire. The distal
portion of the Viabahn graft was then deployed and ballooned with optimal apposition. Finally, the proximal end of the
PTFEg was sutured to the common FA.
Results: Operative time was 60 minutes. Completion angiogram and the computed tomography angiogram at 6 months
demonstrated a patent graft.
Conclusion: The ViPS technique provides an alternative for bypass creation when challenging arterial anastomoses are
required. (J Vasc Surg 2011;54:889-92.)
can present a significant challenge for lower extremity revas-
tion of distal target arteries. In the past, the majority of these
patients were treated with open surgical bypass. However, as
have acquired the skills and knowledge to perform these
procedures, a variety of endovascular techniques have been
endovascular device that has been demonstrated to be an
effective treatment for patients with PAOD is the Viabahn
stent graft (W. L. Gore & Associates, Inc, Flagstaff, Ariz).1
The difficulty with these patients is that they often have
long-segment occlusions in the femoral and popliteal arter-
ies that could preclude endovascular treatment. Therefore,
the only option is surgical bypass. This can be quite chal-
lenging when the distal target artery is extensively and
circumferentially calcified, making suturing of that artery
From the Clinic of Vascular and Endovascular Surgery, Padova University
School of Medicine, Padovaa; and Vascular Surgery and Endovascular
Therapy, Emory University School of Medicine, Atlanta.b
Competition of interest: none.
Reprint requests: Stefano Bonvini MD, PhD, Clinic of Vascular and Endo-
vascular Surgery, Padova University, Via Giustiniani 2, 35128 Padova,
Italy (e-mail: email@example.com).
The editors and reviewers of this article have no relevant financial relation-
ships to disclose per the JVS policy that requires reviewers to decline
review of any manuscript for which they may have a competition of
Copyright © 2011 by the Society for Vascular Surgery.
Fig 1. Preoperative angiographic detail of the above-knee popli-
very difficult. In these situations, a more distal suitable
target in the tibial vessels is sought, which is associated with
lower patency rates than when the target vessel is the
popliteal artery.2We describe a novel technique (Viabahn
Padova Sutureless [ViPS]) that connects a vascular pros-
thetic graft to a target artery in a sutureless fashion, using a
surgeon-modified Viabahn stent graft.
A 74-year-old male with known PAOD, on chronic
dialysis therapy, presented with a nonhealing right leg
ulcer. The preoperative computed tomography angiogram
(CTA) and the subsequent intraoperative angiography
demonstrated complete occlusion of the right superficial
femoral artery with reconstitution of a patent but circum-
ferentially calcified above-knee popliteal artery (AKPA; Fig
1) and single-vessel runoff to the foot via the peroneal
artery. A duplex ultrasound revealed no adequate vein for
autogenous bypass creation. Due to our concern over
inability to safely cross-clamp or place sutures into the
AKPA, we offered the patient a femoral-to-AKPA bypass
using the ViPS technique.
In the operating room, during induction of anesthesia,
on a sterile back table, we modified a standard Viabahn
endoprosthesis (W. L. Gore & Associates, Inc.) and man-
ually sutured it to an expanded polytetrafluoroethylene
graft (ePTFEg). First, the Viabahn stent with its releasing
wire system is withdrawn from its delivery system. To
accomplish this, the deployment knob is loosened and the
constraining string is pulled, thereby unsheathing only the
distal portion of the Viabahn stent. The string is cut with
scissors (Fig 2, A-D). At this point, the constraining string
is free to be removed from the proximal portion of the
delivery system catheter shaft where the device remains
undeployed within its sheath. The distal tip of the deliv-
ery system catheter is then cut with scissors, and the device
is removed from its delivery system (Fig 2, E). The con-
straining string is subsequently pulled, permitting further
unsheathing of the distal portion of the endoprosthesis for
a length of approximately 2 cm (Fig 2, F). Following this,
the operator sutures the unsheathed most distal portion of
the Viabahn stent to a similar diameter, standard ePTFEg
in an end-to-end fashion with monofilament nonabsorb-
Viabahn is reversed.
The ePTFEg is then punctured with a standard 16-
gauge access needle. A 0.035-inch stiff guidewire is placed
through this needle into the ePTFEg and through the
modified Viabahn stent in order to support the entire
system (Fig 2, I). The modified graft is then ready to be
implanted, and standard surgical exposure of the common
femoral artery (CFA) and AKPA is performed. Proximal
control was achieved at the CFA, and the calcified AKPA
was transacted. Adequate suction of the minimal back-
bleeding guaranteed clear visualization of the inner wall of
the artery (Fig 3, A). The undeployed portion of the
Viabahn was manually inserted under direct vision into the
target artery for a length of approximately 2.5 cm, sup-
ported by the stiff guidewire that does not protrude outside
of the undeployed Viabahn.
Deployment of the remainder of the stent was ac-
complished by pulling the constraining string and un-
sheathing the entire device from the ePTFE side toward
the artery (Fig 3, B). The proximal end of the ePTFEg
was tunneled to the groin and sutured to the CFA in
standard end-to-side fashion.
Fig 2. Description of the on-bench surgeon-modified Viabahn stent graft steps procedure for Viabahn Padova
Sutureless (ViPS) technique.
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890 Bonvini et al
To better ensure the complete apposition of the Viabahn
to the wall of the AKPA, balloon angioplasty was performed
through the preloaded stiff guidewire. Completion angio-
gram demonstrated a patent graft with no evidence of dissec-
tion in the landing zone of the Viabahn (Fig 4, A) and
preserved single-vessel runoff to the right foot. The total
operative time from skin incision to skin closure was 60
minutes, while the on-bench ViPS system preparation was 7
The patient’s ulcer resolved after 2 weeks with com-
plete functional recovery. CTA performed after 6 months
revealed a patent graft with no signs of kinking of the stent,
distal embolization, endoleak, loss of device integrity, or
popliteal artery dissection (Fig 4, B).
Sutureless anastomotic techniques have been previ-
ously described. The Viabahn Open Revascularization
Technique (VORTEC) was first used to facilitate renal
revascularization.3With this technique, the Viabhan stent
target artery through a guidewire using the Seldinger tech-
nique. The end of the stent graft outside of the target artery
is then sutured intraoperatively in an end-to-side fashion to
an ePTFEg limb that is to be used for extra-anatomic
bypass during aortic debranching.
The ViPS technique is different than the VORTEC
procedure in that it allows the operator to prepare the
ment without the need for additional anastomoses or cum-
bersome deployment of the device in the operative field.
Furthermore, with the VORTEC procedure, arterial wall
calcification could represent a challenging condition at the
time of puncture in the anterior wall of the target vessel,
and access site complications should be considered. An-
other advantage of the ViPS technique is that with transec-
inside of the artery and therefore can safely introduce the
Viabahn device with minimal risk of damaging the vessel
(Fig 5), making it particularly useful in calcified or heavily
In addition, the ViPS technique is a “true” end-to-end
sutureless anastomosis with no site along the device at risk
for constriction. In fact, the VORTEC technique requires
balloon dilatation after deployment along its entire length,
especially at the site where the Viabahn enters the puncture
site in the side wall of the target artery. The customized
ViPS system also has the potential to dramatically reduce
operative time in both cases of challenging anastomosis and
calculated 7 minutes for the on-bench preparation of the
ViPS system, 36 seconds for the AKPA transaction and
Fig 3. A, Intraoperative characteristics of the circumferentially calcified above-knee popliteal artery. B, Final result
after Viabhan stent graft deployment.
Fig 4. A, Final angiographic imaging after Viabahn Padova Su-
tureless (ViPS) technique (.035 hydrophilic guidewire inserted).
B, Follow-up computed tomography angiogram at 6 months.
JOURNAL OF VASCULAR SURGERY
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Bonvini et al 891
complete Viabahn deployment, and 60 minutes for the
entire procedure to be completed.
way as a standard ePTFEg bypass. Compared with the
traditional end-to-side PTFE anastomosis, the end-to-end
ViPS system has the disadvantage of potentially excluding
some collateral blood flow to the AKPA, although this is a
risk also present during normal vessel dissection for end-to-
side anastomosis creation with a standard PTFE bypass.
Because the ViPS technique requires target vessel dissec-
tion, we always try, where feasible, to spare large collateral
vessels and introduce the system distally to them.
The ViPS technique is easily performed with common
bypass creation, and may significantly reduce operative
time, particularly in cases where challenging arterial anas-
tomoses are required.
Conception and design: SB, LF
Analysis and interpretation: SB, JR, MP, FG
Data collection: MP
Writing the article: JR, MP
Critical revision of the article: SB, JR, MP, LF, FG
Final approval of the article: SB, JR, MP, LF, FG
Statistical analysis: Not applicable
Obtained funding: Not applicable
Overall responsibility: SB
1. Lammer J, Dake MD, Bleyn J, Katzen BT, Cejna M, Piquet P, et al.
Peripheral arterial obstruction: prospective study of treatment with a
transluminally placed self-expanding stent-graft. International Trial
Study Group. Radiology 2000;217:95-104.
2. Dalman RL. Expected outcome: Early results, life table patency, limb
salvage, In Mills JL (ed). Management of chronic lower limb ischemia.
London: Arnold; 2000, p. 106-12.
3. Lachat M, Mayer D, Criado FJ, Pfammatter T, Rancic Z, Genoni M, et
al. New technique to facilitate renal revascularization with use of tele-
scoping self-expanding stent grafts: VORTEC. Vascular 2008;16:69-72.
Submitted Feb 8, 2011; accepted Apr 5, 2011.
Fig 5. VisuallyguidedinsertionoftheViabahnPadovaSutureless
(ViPS) system into the target artery.
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892 Bonvini et al