1. Treatment before anastomosis
(1) Separation of broken ends of blood vessels: the two ends of the artery should be properly separated first, and the adjacent joints should be kept in the semi-flexion position to reduce tension. Sometimes some unimportant branches may be cut to increase the length of the main artery. The healthy arteries of young patients can be elongated 2 ~ 3cm to fill the gap of defect and be directly anastomosed.
(2) Check blood flow: When the damaged part is cut off according to the predetermined scope of vascular resection during debridement, the proximal artery should have active blood ejection. If spraying blood is not strong, it should be considered that there is still obstruction near the segment, and a plastic tube can be inserted into the artery to attract irrigation. If this does not work, a second segment must be removed. If spurting blood exuberant, reoccupy vascular clip blocks blood flow. Also temporarily open the distal clamp to check for good arterial reflux. If there is thrombus, it must be aspirated and anastomosed.
(3) Stripping of the outer membrane of the blood vessel: using vascular tweezers to clamp the outer membrane of the broken end of the blood vessel to pull outward after cutting, so as not to suture the outer membrane into the lumen and cause thrombosis; Or with small scissors meticulous stripping, cutting off the outer membrane of the broken end of the blood vessel, careful not to damage the blood vessel wall. Generally, the peel outer membrane of each broken end is 0.5 ~ 1cm long.
(4) Wash the lumen of broken ends: after the broken ends on both sides were trimmed neatly, the lumen of the two broken ends was washed with 0.1% heparin saline (0.5% procaine or 3.8% sodium citrate solution can also be used) to flush out the clot, in order to prevent thrombosis at the anastomosis.
2. Vascular anastomosis method
According to the size of blood vessels, the intermittent or continuous suture method is selected for anastomosis. Generally, the discontinuous suture is preferred if the diameter is less than 2mm. Continuous sutures can be used in cases above 2mm. The continuous suture has a better hemostasis effect, but if the suture line is too tight, it may shrink the anastomosis.
3. Post-anastomosis treatment
(1) Loosen the vascular clip: After the anastomosis, loosen the distal vascular clip first. If there is a little leakage of blood at the anastomosis, it can be stopped by gently pressing with gauze for a few minutes. If necessary, 1 ~ 2 stitches can be made at the places with more leakage, but such things should be avoided as far as possible to prevent thrombosis. Anastomosis should strive to perfect. If no blood is leaking, open the proximal clamp.
(2) Treatment of arterial spasm: check the pulsation of the upper and lower arteries of the anastomosis and the color, temperature and pulse of the distal limb. If the artery has a convulsive phenomenon, can apply with gauze of 2.5% poppy lye. If the blood flow of the injured limb is not good, procaine solution can be used for sympathetic ganglion or perivascular nerve block.
⑶ Treatment of parallel veins: if there is damage to parallel veins (especially the femoral vein and external iliac vein), repair should be done to reduce venous stasis. Cut off after ligation if not convenient.
4. Close the wound
(1) Covering anastomosis: Sutured arteries and veins should not be exposed, and must be well covered with surrounding tissues (preferably muscle, skin or subcutaneous tissue), which can protect and supply nutrition. When there is a fracture near the suture, muscle is used to separate the blood vessels from the fracture to prevent callus formation and compression of the blood vessels.
(2) Avoid dead cavity: dead cavity should be avoided during suturing to prevent infection caused by plasma retention.
(3) Drainage and suture: If the wound is clean and fresh, it is feasible to suture the wound in one stage and place the drainage strip from another small incision, but do not directly contact the vascular anastomosis. The drainage strip should be removed as soon as possible. If the wound is heavily contaminated, the skin must be left open for delayed suture 5 to 10 days later.
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