End to Side

---

- Discussion:
    - indicated when there is vessel size discrepancy or when sacrifice of donor
          vessel in free tissue transfer is not desirable;
    - end to side anastomosis preserves   blood flow to distal part of the limb;
    - end-to-side anastomosis is more difficult technically;
    - esp making of the arteriotomy is considered demanding, unless only
          single incision is made;
- Technique:
    - side of the recipitent vessel is prepared by elliptical excision;
    - end of the donor vessel is beveled to produce an angle of 30-45 deg
          or less for arterial anastomosis;
    - donor vessel or graft is beveled to create an elliptical orifice at
          least twice its diameter;
    - length of this orifice is matched to the length of arteriotomy in recipient vessel;
    - begin by placing sutures at proximal & distal ends of ellipse;
    - leave suture ends long for traction and complete the anastomosis by
          placing sutures evenly along the opening between traction sutures;
    - horizontal matress suture is placed at the heel and toe of anastomosis;
    - after passage thru the artery, the needles are passed thru small
          pledgets of Teflon felt to reinforce these critical areas;
    - after matress sutures are tied, a needle from each end is used to
          run the suture line down to the middle of each side of anastomosis,
          where they are tied together;
    - release the occluding clamps or release the tourniquet and assess
          patency and flow;
    - guide sutures are placed at 180 deg apart from each other, oriented in
          such a way that a right hand wall and a left hand wall are created,
          this avoids the difficulty of a front wall and a back wall situation;
    - begin w/ interrupted sutures;
        - smaller vessel is then flipped & opposite side wall is then sutured;