Introduction of a potent single-donor fibrin glue for vascular anastomosis: An animal study

Article (PDF Available)inJournal of research in medical sciences 17(5):461-5 · May 2012with 90 Reads
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Abstract
Vascular anastomosis is considered as a difficult surgical procedure. Although different alternative methods have been tried to tackle these difficulties, none were found to be successful. Commercial fibrin glue has recently been used for vascular anastomosis. However, it did not gain popularity due to some limitations such as low tensile strength, rapid removal by the immune system, and risk of transmission of blood-borne viral infections. In this article, we presented a novel method for producing single-donor human fibrin glue and determined its success rate for vascular anastomosis in an animal model. MATERIALS ANS METHODS: In this study, 3 mL of single-donor fibrin sealant was prepared from 150 mL of whole blood containing 50-70 mg/mL of fibrinogen. The study was performed on 10 dogs and 5 cats. After transection of the carotid artery, both ends were anastomosed by means of 3-4 sutures (Prolene 8-0). The suture line was then sealed with one layer of the new fibrin sealant. After 3-8 weeks, the site of anastomosis was evaluated angiographically and morphologically for healing and possible complications such as thrombosis or aneurysm. In evaluations 3 weeks after the surgery, all arterial anastomoses were patent in dogs, but some degree of subintimal hyperplasia was noted. After 8 weeks, all anastomoses were patent and the degree of subintimal hyperplasia was decreased. In cats on the other hand, after 4 weeks, all anastomoses were patent and subintimal hyperplasia was absent. Single-donor fibrin glue was a quite reliable and practical alternative to minimize suturing and therefore operative time in our animal model. This sealant can easily be obtained from the patient's whole blood. Its application in humans would require further studies.
O
riginal
a
rticle
Address for correspondence: Ali Shayesteh Moghadam, Resident, Department of Surgery, Medical Education Research Center, Isfahan Uni-
versity of Medical Sciences, Isfahan, Iran. Email: ali_shayesteh_moghadam@yahoo.com
Received: 15-04-2012; Revised: 15-05-2012; Accepted: 27-05-2012
| May 2012 | Journal of Research in Medical Sciences 461
Introduction of a potent single-donor fibrin glue
for vascular anastomosis: An animal study
Mehdi Rasti Ardakani1, Abdoljalil Kalantar Hormozi2, Jalal Rasti Ardakani3,
Amir Hossein Davarpanahjazi4, Ali Shayesteh Moghadam4
1Associate Professor, Department of Plastic Surgery, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
2Professor, Department of Plastic Surgery, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3Pathologist, Isfahan University of Medical Sciences, Isfahan, Iran. 4Resident, Department of Surgery, Medical Education Re-
search Center, Isfahan University of Medical Sciences, Isfahan, Iran.
Background: Vascular anastomosis is considered as a difficult surgical procedure. Although different alternative methods have been
tried to tackle these difficulties, none were found to be successful. Commercial fibrin glue has recently been used for vascular anas-
tomosis. However, it did not gain popularity due to some limitations such as low tensile strength, rapid removal by the immune sys-
tem, and risk of transmission of blood-borne viral infections. In this article, we presented a novel method for producing single-donor
human fibrin glue and determined its success rate for vascular anastomosis in an animal model. Materials ans Methods: In this
study, 3 mL of single-donor fibrin sealant was prepared from 150 mL of whole blood containing 50-70 mg/mL of fibrinogen. The
study was performed on 10 dogs and 5 cats. After transection of the carotid artery, both ends were anastomosed by means of 3-4 su-
tures (Prolene 8-0). The suture line was then sealed with one layer of the new fibrin sealant. After 3-8 weeks, the site of anastomosis
was evaluated angiographically and morphologically for healing and possible complications such as thrombosis or aneurysm.
Results: In evaluations 3 weeks after the surgery, all arterial anastomoses were patent in dogs, but some degree of subintimal hyper-
plasia was noted. After 8 weeks, all anastomoses were patent and the degree of subintimal hyperplasia was decreased. In cats on the
other hand, after 4 weeks, all anastomoses were patent and subintimal hyperplasia was absent. Conclusions: Single-donor fibrin glue
was a quite reliable and practical alternative to minimize suturing and therefore operative time in our animal model. This sealant can
easily be obtained from the patient's whole blood. Its application in humans would require further studies.
Key words: Single-Donor Fibrin Glue, Commercial Fibrin Sealant, Vascular Anastomosis.
INTRODUCTION
So far, interrupted suturing has been the most pop-
ular and acceptable method for vascular anastomo-
sis. This technique however, does have some limita-
tions and adverse effects of its own.[1] Acland cate-
gorized the limitations leading to unsuccessful re-
sults into 5 main categories including tearing of
vascular edge, blood leakage from the suture line,
causing blood clot formation with intravascular ex-
tension, stricture formation due to the pressure im-
posed by the suture on the two ends, posterior ar-
terial wall interposition, and intraluminal adventi-
tial interposition.[2]
All of the above side effects are technical in nature.
Furthermore, blood leakage from the space between
sutures is not an uncommon problem. Because of
these limitations, different alternative methods such
as using rings, clips, laser, and tissue sealant have
been introduced. Rings or clips are good methods
but they are also technique-related and need train-
ing and expertise. In addition, variations in vascular
diameter necessitate devices of different sizes,
which is not practical for all centers. Inversion of
vascular edge is also a major challenge in these me-
thods. In laser surgery, high cost and aneurysm
formation are the main disadvantages.[3-5] In 1962,
Nakayama used a metallic ring that could be fixed
in place and was used as a permanent implant,[6]
but this method was only effective in smooth vascu-
lar edge with approximately equal size at both
ends.
Another option is to use tissue glues. Two main
types of glues, including cyanoacrylate glues and
fibrin-based glues, are currently being used in sur-
gery. Cyanoacrylate causes media necrosis. Moreo-
ver, this product causes irregularities in vessel wall
and induces severe inflammation.[7] This type of
glue is only applicable in dry fields which is not
consistent with most vascular surgery occasions. US
Food and Drug Administration (FDA) approved
this type of glue only for local and topical use and
disapproved it as an internal tissue glue.[5]
Fibrin glue is a general term to denote all fibrin-
based sealants. The first report of using this type of
glue dates back to early 20th century.[8] In 1940,
Young and Medawar used bovine thrombin and
www.mui.ac.ir
Rasti Ardekani, et al. Fibrin glue for vascular anastomosis
462 Journal of Research in Medical Sciences | May 2012 |
fibrinogen for nerve anastomosis[9] and Tidrick used
this type of glue for skin graft immobilization.[10] How-
ever, none of these studies were successful.
Matras et al.[11] and Pearl et al.[12] reported the first
clinical trials of fibrin sealant in microsurgery. The-
reafter, many articles have been published about
the effectiveness of this glue in vascular anastomo-
sis to reduce the number of sutures and time of sur-
gery, and to minimize trauma to vessel wall. How-
ever, the results have been controversial, from very
successful[13-15] to very unsatisfactory having com-
plications such as thrombosis and aneurysmal
changes at the site of anastomosis.[16]
Single-donor fibrin glue is identical to other fibrin
glues in nature and is derived from a single blood
sample. Hence, there is no risk of hyper-sensitivity
or infection transmission. The main challenge is to
obtain an effective sealing producing efficient adhe-
sion and tensile strength. The best protocol to pro-
duce the desired fibrin glue would be the one with
a high fibrinogen yield. An appropriate method
should have the following criteria:
1) It should be performed with a reasonable and
minimal amount of whole blood;
2) The processing equipment should be easily avail-
able and not complicated;
3) A close system should be used for preparation to
prevent contaminations.
In this article, a new preparing protocol for single-
donor fibrin glue with high fibrinogen content and
high growth factor is introduced. We determined
the application of this glue for vascular anastomo-
sis.
MATERIALS AND METHODS
This experimental study was performed on 10 dogs.
The dogs were of Iranian race, weighed 15-20 kg, and
aged 2-3 years old. The same anesthetic and surgical
procedures were performed on all dogs. Arterial anas-
tomosis was performed under general anesthesia with
ketamine (10 mg/kg) and acepromazine as sedative (2
mg/kg). Anesthesia was continued with tracheal intu-
bations and 1.5% halothane. With a longitudinal inci-
sion along the anterior border of the sternocleidomas-
toid muscle, the skin was incised and the carotid artery
was exposed. The study protocol was approved by our
local ethics committee.
Autologous fibrin was first prepared from the dogs'
whole blood. A modified version of the method intro-
duced by Thorn et al.[17] was employed to prepare fi-
brin glue from approximately 150 mL of whole blood.
Fibrin sealant derived by the classic method of Thorn
et al.[17] does not produce enough adhesiveness as it
will be discussed later. Because of low fibrinogen con-
centration in canine blood (36-40 mg/dL), the sealant
was not optimal for anastomosing purposes. In the
second phase, the glue was prepared from 150 mL of
human whole blood. Although this glue will be consi-
dered heterologous if applied to a canine case, it will be
autologous if approved for clinical practice (Figure 1).
The original method used by Thorn et al.[17] to prepare
the glue does not provide acceptable adhesiveness,
tensile strength, and pressure bearing at the site of
anastomosis. A new protocol has thus been invented to
prepare a more effective sealant. By modifying and
combining Thorn et al.'s and other commercial me-
thods, finally 3 mL byproduct was prepared from 150
mL of fresh whole blood with 50-70 mg/mL fibrinogen
content. Although basic principles of the procedure
were according to the original method by Thorn et
al.,[17] our modified method of fibrinogen precipitation
was also based on high recovery rate and minimal de-
naturation of plasma proteins. This hybrid method
consisted of multiple freeze and thawing phases, com-
bined with ethanol, acid, and cation precipitation.
Platelet-poor plasma (PPP) was initially prepared by
centrifuging plasma at 10000 rpm and 4°C. PPP was
then processed in a hybrid precipitation cascade.
Thrombin was also harvested with sequential activa-
tion of coagulation cascade before fibrinogen precipita-
tion (more details of the glue preparation will be dis-
coursed in future articles after registration of the pend-
ing international patent). The concentration of growth
factor in this method was about 8-12 times of that in
normal plasma.[18]
After exposing of the artery and proximal and distal
control, 3-5 cm of the vessels were exposed and tran-
sected by a vascular double clump. Figure 2 shows the
anastomosis site and the method of glue application.
The right carotid artery was anastomosed with four 8-0
Prolene sutures in 90-degree angles. Then, 120 seconds
after applying the glue, the clamps were removed and
the integrity of anastomosis was evaluated. The paten-
cy of the arterial lumen was evaluated by Acland's
scaling system immediately after the anastomosis.[ 1]
Surgical incision was closed, and dogs were treated
with appropriate dose of analgesics. In addition, a
complete course of antibiotic therapy was commenced.
After the operation, the dogs were visited by a veteri-
narian and the surgeon on a daily basis to check the
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Rasti Ardekani, et al. Fibrin glue for vascular anastomosis
| May 2012 | Journal of Research in Medical Sciences 463
general condition. All dogs completed the study up to
8 postoperative weeks.
Angiographic and morphological evaluations of the
vessels were performed 3 and 8 weeks after the opera-
tion. After angiography, a 20-mm biopsy including the
anastomosis site was resected for histopathological
examination (Figures 3 and 4). After hematoxylin and
eosin staining, samples were checked under light mi-
croscope. The site of anastomosis was evaluated histo-
logically after 3 weeks in 5 dogs and after 8 weeks in
the remaining 5 (Figure 4). The vascular lumen was
evaluated for thrombosis, aneurysm formation, medial
necrosis, and subintimal hyperplasia. Pathological
study was performed by two different pathologists.
We took biopsies in 2 intervals (after 3 weeks in half of
subjects and after 8 weeks in remaining) to outline ear-
ly and late morphological changes in histopathology.
Because after preparation of glue it was rapidly agglu-
tinated, tensile strength could not be measured objec-
tively.
RESULTS
After removing the vascular clamps, minimal bleeding
occurred around the site of anastomosis. Evaluations
by Acland's method revealed all anastomoses to be
patent.[1] Figure 1 shows the prepared sealant before
usage. Figure 2 depicts the gross appearance of the site
of arterial repair and Figure 3 shows the angiogram.
Histopathological examination did not suggest any
signs of medial necrosis, severe inflammation, or
pseudo-aneurysm. In all of the 15 cases, the lumen of
anastomotic site was patent (Figures 4). Subintimal
hyperplasia was present in 60% of samples 3 weeks
after the surgery. However, it was resolved in all cases
8 weeks post-operatively.
Figure 1. Tensile strength of the new fibrin glue
Figure 2. Application of fibrin glue on the anastomotic site
Figure 3. Angiography 8 weeks after the operation
Figure 4. Microscopic view of biopsy specimen of the anastomotic
site in dogs 8 weeks after the operation
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Rasti Ardekani, et al. Fibrin glue for vascular anastomosis
464 Journal of Research in Medical Sciences | May 2012 |
DISCUSION
Finding an effective tissue sealant for end-to-end anas-
tomosis of an artery will be a great revolution in vascu-
lar surgery. Time effectiveness, simplicity, no tissue
necrosis, no foreign body reaction, and minimal trau-
ma to vessel wall all are the potential benefits of fibrin
glues. The main obstacles that hold back fibrin glue
from gaining popularity are controversial primary re-
sults of fibrin glue application in suture sites and
transmissible blood-borne infections by sealants de-
rived from pooled plasma. Although this risk has re-
cently been significantly reduced by introduction of
more reliable blood processing methods, it has not
been completely eliminated.[19]
The bovine thrombin, used in some available sealants,
might induce hypersensitivity and antibody formation
against the clotting factors and also carry the risk of
prion transmission.[20] Thrombus formation in lumen of
the vessel has also been reported in a few studies.[21,22]
Vascular anastomosis with single-donor fibrin glue is
of utmost importance in vascular surgery. Because of
difficulties in vascular surgery, particularly those seen
in small caliber vessels (< 2 mm) which occur in free
flaps, finger implantations, and revascularization pro-
cedures, many alternate methods have been intro-
duced in vascular surgery.
Although many studies have suggested the application
of fibrin glue for vascular anastomosis, the glue has
only been clinically trialed for this purpose in 2 re-
ports.[23,24] In one study in 1996, fibrin glue was used for
digital vascular anastomosis. Using fibrin sealant re-
duced the number of sutures from 8-10 to only 4. In
most studies, glue is employed to decrease the number
of sutures and as a dressing for the anastomosis site.[28]
Cho and Junior used fibrin glue for anastomosis of ca-
rotid artery in rats. As a result, they only made 6 su-
tures instead of the 10 stitches required in the tradi-
tional method.[1]
Until now, single-donor fibrin glue has not been used
for vascular anastomosis. It has only been used as a
biological dressing of suture line and hemostasis. Be-
cause of lysis of the former autologous glues within 24-
48 hours, they are not suitable for vascular surgeries.[26]
In our study, a new version of glue was introduced
which showed satisfactory results in anastomosis of
carotid artery in dogs and cats. The main advantage of
the new glue was the late time of lysis. It could persist
after 21 days in vivo. Another main advantage of our
glue over other glues was its tensile strength.
In this study, carotid arteries of dogs were anasto-
mosed with only 4 sutures along with our new fibrin
glue. A significant reduction in the number of needed
sutures was thus observed.
Cho and Junior used commercial fibrinogen (70-110
mg/mL) with 6 sutures for carotid anastomosis in
rats.[1] However, the diameter of carotid artery in dogs
is much larger than that of rat.
Like any other pooled plasma byproducts, the risk for
viral disease transmission is still present. In addition,
one of the main limitations in heterologous fibrin glue
usage is hypersensitivity reactions to the sealant ma-
terial particularly when bovine thrombin is used for
this purpose. Another shortcoming of non-autologous
glue is antibody formation against thrombin that may
cause bleeding diathesis. In our study, using single-
donor glue, such side effects could have been encoun-
tered.
We used hand-made fibrin glue using human blood.
While this glue would be autologous for humans, it
was really heterologous for the studied animals. The
subintimal hyperplasia and inflammation of adventitia
observed in some cases can probably be attributed to
this factor.
CONCLUSIONS
Single-donor fibrin glue utilized in this study was
found to produce reliable vascular anastomosis and
minimize the number of sutures as well as the opera-
tion time. It did not cause hypersensitivity reactions
and aneurysm formation. This method particularly
decreased the risk of transmission of blood-borne in-
fections.
REFERENCES
1. Cho AB, Junior RM. Effect of fibrin adhesive application in
microvascular anastomosis: a comparative experimental study.
Plast Reconstr Surg 2007; 119(1): 95-103.
2. Acland R. Technical prerequisites and tramingin microsurgery:
technique of small vessel anastomosis. In: Meyer V, Black M,
editors. Microsurgical procedures. Philadelphia: Saunders;
1991. p. 123-36.
3. Wolf-de Jonge IC, Beek JF, Balm R. 25 years of laser assisted
vascular anastomosis (LAVA): what have we learned? Eur J
Vasc Endovasc Surg 2004; 27(5): 466-76.
www.mui.ac.ir
Rasti Ardekani, et al. Fibrin glue for vascular anastomosis
| May 2012 | Journal of Research in Medical Sciences 465
How to cite this article: Rasti-Ardakani M, Kalantar-Hormozi A, Rasti-
Ardakani J, Hosein Davarpanah Jazi AH, Shayesteh Moghadam A. Intro-
duction of a potent single-donor fibrin glue for vascular anastomosis: An
animal study. J Res Med Sci 2012; 17(5): 461-5.
Source of Support: Nil, Conflict of Interest: None declared.
4. Sartorius CJ, Shapiro SA, Campbell RL, Klatte EC, Clark SA.
Experimental laser-assisted end-to-side microvascular anasto-
mosis. Microsurgery 1986; 7(2): 79-83.
5. Zeebregts CJ, Heijmen RH, van den Dungen JJ, van SR. Non-
suture methods of vascular anastomosis. Br J Surg 2003; 90(3):
261-71.
6. Nakayama K, Yamamoto K, Tamiya T. A new simple appara-
tus for anastomosis of small vessels. Preliminary report. J Int
Coll Surg 1962; 38: 12-26.
7. Wippermann J, Konstas C, Breuer M, Kosmehl H, Wahlers T,
Albes JM. Long-term effects in distal coronary anastomoses us-
ing different adhesives in a porcine off-pump model. J Thorac
Cardiovasc Surg 2006; 132(2): 325-31.
8. Huh JY, Choi BH, Zhu SJ, Jung JH, Kim BY, Lee SH. The
effect of platelet-enriched fibrin glue on bone regeneration in
autogenous bone grafts. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod 2006; 101(4): 426-31.
9. Young JZ, Medawar PB. Fibrin suture of peripheral nerves.
Lancet 1940; 1: 126-34.
10. Tidrick RT, Warner ED. Fibrin fixation of skin transplant. Sur-
gery 1944; 15: 90-5.
11. Matras H, Jesch W, Watzek G, Dinges HP. Use of fibrin adhe-
sives in mouth, jaw, and face surgery. Osterr Z Stomatol 1978;
75(12): 433-7.
12. Pearl RM, Wustrack KO, Harbury C, Rubenstein E, Kaplan
EN. Microvascular anastomosis using a blood product sealant-
adhesive. Surg Gynecol Obstet 1977; 144(2): 227-31.
13. Doillon CJ, Dion YM. Comparison of a plasma-based compo-
site biologic sealant with fibrin glue (Tisseel) for vascular anas-
tomoses. Surg Laparosc Endosc Percutan Tech 2004; 14(6):
335-9.
14. Kheirabadi BS, Field-Ridley A, Pearson R, MacPhee M, Dro-
han W, Tuthill D. Comparative study of the efficacy of the
common topical hemostatic agents with fibrin sealant in a rab-
bit aortic anastomosis model. J Surg Res 2002; 106(1): 99-107.
15. Spotnitz WD, Prabhu R. Fibrin sealant tissue adhesive--review
and update. J Long Term Eff Med Implants 2005; 15(3): 245-
70.
16. Nguyen LP, Wang ZX, Molina J, Tellez A, Chemoriya T.
Complications of fibrin glue in pterygium surgery with amniot-
ic membrane transplant. Yan Ke Xue Bao 2012; 27(1): 19-24.
17. Thorn JJ, Sorensen H, Weis-Fogh U, Andersen M. Autologous
fibrin glue with growth factors in reconstructive maxillofacial
surgery. Int J Oral Maxillofac Surg 2004; 33(1): 95-100.
18. Foster KN, Kim H, Potter K, Matthews MR, Pressman M, Ca-
ruso DM. Acquired factor V deficiency associated with expo-
sure to bovine thrombin in a burn patient. J Burn Care Res
2010; 31(2): 353-60.
19. Valbonesi M. Fibrin glues of human origin. Best Pract Res Clin
Haematol 2006; 19(1): 191-203.
20. Leclere FM, Schoofs M, Mordon S. [Historical review and
future orientations of the conventional vascular microanasto-
moses]. Ann Chir Plast Esthet 2011; 56(3): 232-40.
21. Dascombe WH, Dumanian G, Hong C, Heil BV, Labadie K,
Hessel B, et al. Application of thrombin based fibrin glue and
non-thrombin based batroxobin glue on intact human blood
vessels: evidence for transmural thrombin activity. Thromb
Haemost 1997; 78(2): 947-51.
22. Cho AB, Junior RM. Application of fibrin glue in microvascu-
lar anastomoses: comparative analysis with the conventional
suture technique using a free flap model. Microsurgery 2008;
28(5): 367-74.
23. Han SK, Kim SW, Kim WK. Microvascular anastomosis with
minimal suture and fibrin glue: experimental and clinical study.
Microsurgery 1998; 18(5): 306-11.
24. Isogai N, Cooley BG, Kamiishi H. Clinical outcome of digital
replantation using the fibrin glue-assisted microvascular anas-
tomosis technique. J Hand Surg Br 1996; 21(5): 573-5.
25. Kheirabadi BS, Acheson EM, Deguzman R, Crissey JM, Del-
gado AV, Estep SJ, et al. The potential utility of fibrin sealant
dressing in repair of vascular injury in swine. J Trauma 2007;
62(1): 94-103.
26. Buchta C, Hedrich HC, Macher M, Hocker P, Redl H. Bio-
chemical characterization of autologous fibrin sealants pro-
duced by CryoSeal and Vivostat in comparison to the homo-
logous fibrin sealant product Tissucol/Tisseel. Biomaterials
2005; 26(31): 6233-41.
www.mui.ac.ir
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    Microvascular surgery has become an important method for reconstructing surgical defects due to trauma, tumors or after burn. The most important factor for successful free flap transfer is a well-executed anastomosis. The time needed to perform the anastomosis and the failure rate are not negligible despite the high level of operator's experience. During the history, many alternatives were tried to help the microsurgeon and to reduce the complications. A Medline literature search was performed to find articles dealing with non-suture methods of microvascular anastomosis. Many historical books were also included. The non-suture techniques can be divided into four groups based on the used mechanism of sutures: double intubation including tubes and stents, intubation–eversion including simple rings, double eversion including staples and double rings, and wall adjustement with adhesives or laser. All these techniques were able to produce a faster and easier microvascular anastomosis. Nevertheless, disadvantages of the suturless techniques include toxicity, high cost, leakage or aneurysm formation. More refinement is needed before their widespread adoption. Thus, laser-assisted microvascular anastomosis using 1,9 μm diode laser appeared to be a safe and reliable help for the microsurgeon and may be further developed in the near future.
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    In this experimental model, we have shown that a four suture repair with a biologic sealant adhesive significantly reduces hemorrhage and reduces operative time, while allowing a flap survival comparable to that obtained with standard techniques in rats undergoing a microvascular anastomosis. In heparinized rats undergoing the same procedure, the sealant adhesive significantly decreases hemorrhage and increases flap survival. Of significance is the fact that the platelet-fibrinogen-thrombin adhesive is biodegradable and does not induce a tissue reaction. We believe that this physiologic adhesive may become a useful adjunct in digital reimplantation. It appears to reduce operative time and heparin-induced bleeding.
  • Article
    The authors present a new technique of end-to-side microvascular anastomosis in a rat carotid artery model, employing a milliwatt CO2 laser. Both carotid arteries were isolated and approximated in an end-to-side fashion by the placement of four 10-0 nylon stay sutures. The milliwatt CO2 laser was used to effect vessel anastomosis between the sutures, using 70-100 mW of power. Animals were killed 8 weeks postoperatively. Angiography of each anastomosis was performed in all animals. All anastomoses were then harvested, and submitted for histological analysis. Anastomotic patency was 100%, both intraoperatively and angiographically. There was no evidence of intravascular thrombus, anastomotic stenosis, or pseudoaneurysm formation. Early in the experiment, some anastomoses showed localized dilatation at the anastomotic site. The histologic changes at the anastomotic site are described. Laser-assisted microvascular anastomosis is a feasible technique, and a potential alternative to conventional suture techniques.