Study comparing sutures and nonpenetrating titanium clips for arteriotomy closure after embolectomy E. Pikoulis, 1 D. Koronarchis, 2 K. Filis, 2 A. Leppa ¨niemi, 3 S. Papas, 2 N. Xiromeritis, 2 E. Papalambros, 2 E. Bastounis 2 1 Second Department of Surgery, Asklepeion Voulas Hospital, Vasileos Pavlou 1 Str. Voula 16673, Athens, Greece 2 First Department of Surgery, University of Athens Medical School, Laikon General Hospital, Saint Thomas 17 Str. Goudi, 11527 Athens, Greece 3 Department of Surgery, Meilahti Hospital, P.O. Box 340, University of Helsinki, 00029 HUS, Finland Received: 4 February 2000/Accepted in final form: 31 July 2000/Online publication: 25 April 2001 Abstract Background: The vascular closure staple (VCS) clip applier system is an alternative to suture for closing arteriotomies and performing vascular anastomoses. This study was de- signed to evaluate the possible advantages of its use in closing arteriotomies after embolectomy. Methods: In this study, 26 patients with upper or lower extremity embolism underwent embolectomy, and the arte- riotomy was closed using either VCS clips (group A) or sutures (group B). Results: The time required for arteriotomy closure with clips (11.2 ± 2.7s) was considerably shorter than the time required with sutures (241.2 ± 48.7s; p < 0.0001), resulting also in shorter clamp times (380.8 ± 127.3s vs 612.7 ± 112.6s; p < 0.0001). No hemodynamically significant ste- noses or pseudoaneurysms were detected at the arteriotomy sites in any of the patients up to 1 year after embolectomy. Conclusions: The VCS clip applier system, a quick and easy method for closing arteriotomies, is as safe as sutures in terms of narrowing of the artery and formation of pseudo- aneurysm. Key words: Surgical staplers — Sutures — Titanium — Vascular surgical procedures The original idea of using clips for arterial repair was pre- sented by Samuels [5], who in 1955 used stainless steel clips to close longitudinal arteriotomies while performing sin- gle and double anastomoses of the aorta in dogs. Despite his good results, this method never gained acceptance in vascular surgery. In the early 1980s, Kirsch and Zhu de- veloped a new type of clip, the vascular closure staple (VCS) clip, which was used originally to perform a micro- vascular anastomosis of the superficial temporal artery to the middle cerebral artery for the purpose of brain revascu- larization [1, 7]. The VCS clip is an arcuate-legged, titanium clip that does not penetrate the vessel wall, thus minimizing intimal damage. When applied correctly on everted vessel walls, VCS clips produce a firm, “blood-tight” closure. The use of VCS clips in microvascular anastomoses has been well de- scribed previously [1]. Recently published experimental studies [2, 4] suggest their applicability also in larger ves- sels. The purpose of this study was to evaluate the use of VCS clips for arteriotomy closure after embolectomy. Materials and methods The study was conducted between September 1997 and November 1999 with 21 patients who had acute lower limb ischemia caused by common femoral artery embolism and 5 patients who had acute upper limb ischemia caused by brachial artery embolism. All these patients, admitted to our hospital within 6 h of the first symptoms, underwent standard embolec- tomy. The patients were randomly allocated for clip or suture closure of the arteriotomy before initiation of the operation. The characteristics and un- derlying diseases of the patients in the two groups are summarized in Table 1. Because of insufficient data on the use of VCS clips with atherosclerotic vessels, patients with severe atherosclerotic findings at operation were excluded from the study. After prompt heparinization and preoperative care, the patients were subjected to surgery under local anesthesia with intravenous sedation. The occluded common femoral and brachial arteries were exposed, and both proximal and distal control were obtained. A transverse arteriotomy was made approximately 5 mm above the origin of the deep femoral artery or the bifurcation of the brachial artery, and a balloon embolectomy catheter was inserted through the incision. After the removal of emboli and the restoration of blood circulation, the arteriotomy was closed using clips or sutures according to randomization protocol. For clip arteriotomy closure, large VCS clips were used (Fig. 1). With special VCS forceps, the edges of the artery were approximated and slightly everted by the first surgeon while the second surgeon placed the clips using the clip applier device. Symmetric tissue eversion is essential to Presented at the XXII World Congress of the International Society of Cardiovascular Surgery, Kyoto, Japan, 10–15 September Correspondence to: E. Pikoulis Surg Endosc (2001) 15: 726–728 DOI: 10.1007/s00464-001-0003-9 © Springer-Verlag New York Inc. 2001