Sutureless anastomotic devices present several advantages over traditional suture anastomosis, including expanded global access to microvascular surgery, shorter operation and ischemic times, and reduced costs. However, their adaptation for arterial use remains a challenge. This review aims to provide a comprehensive overview of sutureless anastomotic approaches that are either FDA-approved or under investigation. These approaches include extraluminal couplers, intraluminal devices, and methods assisted by lasers or vacuums, with a particular emphasis on tissue adhesives. We analyze these devices for artery compatibility, material composition, potential for intimal damage, risks of thrombosis and restenosis, and complications arising from their deployment and maintenance. Additionally, we discuss the challenges faced in the development and clinical application of sutureless anastomotic techniques. Ideally, a sutureless anastomotic device or technique should eliminate the need for vessel eversion, mitigate thrombosis through either biodegradation or the release of antithrombotic drugs, and be easily deployable for broad use. The transformative potential of sutureless anastomotic approaches in microvascular surgery highlights the necessity for ongoing innovation to expand their applications and maximize their benefits.

OBJECTIVE: Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years.
METHODS: Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization.
RESULTS: The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%.
CONCLUSIONS: We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass (TECAB) techniques may improve recovery and reduce hospital stay following coronary artery bypass surgery (CABG). However, working in a limited space with indirect visualisation would greatly benefit from a simple, high-quality and reproducible automated distal anastomotic method. Several devices have been developed; however, their uptake has been limited due to uncertainty around their impact on patient outcomes.
METHODS: A systematic review of the literature identified six studies, incorporating 139 subjects undergoing MIDCAB or TECAB surgery using a distal anastomotic device.
RESULTS: The overall 30-day mortality was 0.7% (1/137). No cardiac specific mortality was observed. For each outcome of perioperative myocardial infarction (MI), postoperative stroke and haemorrhage, only a single event was observed for each (n=1/136, 1/138 and 1/136, respectively). The overall device failure rates were low, with the use of additional sutures only reported in a single case with the Magnetic Vascular Port (MVP) device. Anastomotic time ranged from a mean of 3.32 minutes with the MVP device to 20 minutes with the C-Port device.
CONCLUSIONS: These results demonstrate the overall acceptable early outcomes of distal anastomotic devices for use in minimally invasive coronary bypass surgery. Future research should focus on designing adequately powered, comparative, randomised trials, focusing on major adverse cardiac and cerebrovascular events (MACCE) outcomes in both the short and long-term, with clear case-by-case reasons for device failure and a comparison of anastomotic times. In this way, we may determine whether such devices will facilitate the minimal access and robotic coronary procedures of the future.

BACKGROUND: Partial bypass of the GI tract may promote weight loss by decreased absorption of nutrients and changes in incretins. The aim of the study was to evaluate the safety and efficacy of performing a side-to-side duodeno-ileal anastomosis.
METHODS: Seven 40-50 kg female Yorkshire pigs were allocated to a duodeno-ileal anastomosis (DIA), and were compared to a control group (SHAM). Swine\'s weights were followed for 56 days. Gastroscopies were also performed at 28 days. Blood samples were also taken at regular intervals (CBC and Basic biochemistry profiles). At autopsy, gross changes and histological changes of the liver, duodenum and ileum samples were performed.
RESULTS: While the SHAM group gained 33.2 % more weight at 56 days, the DIA group had shown a weight loss of -6.8 %, for a difference of 40.0 % between the 2 groups (p < 0.05). One pig developed an incisional hernia. Gastroscopies demonstrated normal healing without ulceration or inflammation at 28 days. Histological examination of the anastomosis at 56 days showed normal and smooth healing, with absence of liver toxicity.
CONCLUSIONS: In this porcine model with short follow-up, a side-to-side duodeno-ileal anastomosis provided excellent weight loss without apparent nutritional or grossly aberrant histological changes.

Interest in minimally invasive and off-pump cardiac surgical techniques has promoted the development of automated distal anastomotic devices (DADs) to facilitate construction of coronary artery anastomosis. Several DADs have been proposed for potential use in coronary surgery. However, a number of technical failures and uncertainty around both short-term morbidity and long-term patency have limited the generalized uptake of these devices. A systematic literature search identified 28 studies, incorporating 970 patients who underwent coronary artery bypass grafting using a DAD. Eight different devices were identified including Heartflo, St Jude, U-clip, vessel closure system, C-port, magnetic vascular positioner and coronary anastomosis coupler. Thirty-day mortality, cardiac-specific mortality and myocardial infarction were equal between DADs and hand-sewn cases (1.3, 0.3 and 0.8%, respectively). The overall proportion of postoperative haemorrhage was higher in the anastomotic device group (2.3%) than in the group with hand-sewn anastomoses (1.5%) although not statistically significant. Overall graft patency was 97.2% at <1 month, 94.6% at 1-3 months and 92.3% at >3 months. Of the currently available systems, the U-clip device was found to provide the best overall postoperative outcomes, which included a patency of 96.1% at >3months. The current literature is limited by its predominantly observational study design and lack of directly comparative studies. Furthermore, inter-study variation in patient selection, anticoagulation strategies and follow-up periods prevents quantitative comparison. Future research necessitates multicentre randomized, controlled studies to provide a direct comparison of current and future anastomotic device systems with established hand-sewn techniques in both the short and long term.

In 2001, a novel sutureless magnetic anastomotic device (MVP) for coronary anastomosis was introduced in Europe for both on-pump and off-pump procedures. The device has been implanted in more than 150 patients with encouraging short-term but less favorable mid-term results. However, to date long-term patency outcomes of those recipients have not been investigated. This is the first report on an excellent angiographic performance of this automated magnetic device ten years after left internal thoracic artery to left anterior descending grafting in a man who underwent coronary angiography prior to thymectomy.

BACKGROUND: Anastomotic microvascular device has gained popularity in reconstructive microsurgery over the last two decades. A systematic literature search has been carried out in the use of the venous coupler device in microsurgery to assess its impact on patency rate in microsurgery.
METHODS: Using key words related to the topic, a literature search of major databases was carried out. Selection was undertaken on two level screening. From the literature search 53 potential articles were identified. Of these 13 met both levels of screening for the final critical analysis.
RESULTS: A total of 2976 venous anastomoses with coupler device were carried out in the 13 studies with a combined thrombosis in 46 veins reported, giving an average 98.5% patency and a variation in thrombosis rate ranging from 0 to 3%.
CONCLUSIONS: The venous coupler device serves as a powerful instrument in microsurgery by achieving high patency rate. More importantly the data suggests less variation in thrombosis rate compared to hand-sewn venous anastomosis.

OBJECTIVE: The C-Port® Distal Anastomosis Systems (Cardica, Inc., Redwood City, CA, USA) demonstrated favourable results in feasibility trials. However, distal vein anastomoses created with the C-Port® or C-Port xA® system have never been compared with hand-sewn distal vein anastomoses. The objective of this study was to compare distal end-to-side anastomoses facilitated with the C-Port xA® System with the traditional hand-sewn method.
METHODS: This single-centre prospective randomized controlled study comprised 71 patients (device group n = 35, control group n = 36) who underwent primary elective coronary artery bypass grafting between June 2008 and April 2011. The primary study end-point was 12-month distal anastomotic patency, which was assessed with prospective ECG-gated 256-multislice computed tomographic coronary angiography using a step-and-shoot scanning protocol. For the primary end-point, a per-protocol analysis was used.
RESULTS: In the device group, four (11%) anastomoses were converted to hand-sewn anastomoses, and additional stitches to achieve haemostasis were necessary in 22 (76%) patients. There was no hospital mortality in either group. During the 12-month follow-up, a single death occurred in the Device group and was unrelated to the device. Twenty-nine patients in the device group and 32 in the control group completed 12-month CT coronary angiography. The overall patency of 160 studied distal vein graft anastomoses was 93%. Comparison of the end-to-side target anastomosis showed 12-month patencies of 86 and 88% in the device group and the control group, respectively.
CONCLUSIONS: According to these preliminary results and despite the limited number of patients, the use of the C-Port xA® System is safe enough to perform distal end-to-side vein graft anastomosis, with respect to 12-month end-to-side distal venous anastomotic patency. Although there are some technical challenges with this device, the incidence of complications is comparable to the traditional hand-sewn technique.