Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302

Review

Microvascular anastomotic arterial

coupling: A systematic review
Georgios Pafitanis a,b,c,d,∗, Marios Nicolaides a,d,
Edmund Fitzgerald O’Connor a,b,c, Maria Raveendran a,e,
Panagiotis Ermogenous f, George Psaras g, Victoria Rose a,b,c,
Simon Myers a,d
a
Group for Academic Plastic Surgery, The Blizard Institute, Barts and The London School of Medicine
and Dentistry, Queen Mary University of London, London, UK
b
Department of Plastic Surgery, Guy’s and St Thomas’ Hospital, London, UK
c
Department of Orthoplastics Surgery, Kings College Hospital, London, UK
d
Department of Plastic Surgery, Emergency Care and Trauma Division, The Royal London Hospital, Bart’s
Health NHS Trust, London, UK
e
Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
f
Department of Plastic Surgery, Cyprus
g
Plastic Surgery Department, University of the Witwatersrand, Johannesburg, South Africa

Received 17 June 2020; accepted 22 December 2020

KEYWORDS Summary Introduction: There are several reasons microsurgeons may not use a coupler de-
Arterial coupler; vice in arterial anastomosis: may be thick-walled, non-pliable due to atherosclerotic calcifi-
Free flap anastomosis; cation or present vessel geometrical discrepancies. This review summarises the current appli-
End-to-end arterial cations, efficacy and troubleshooting of microvascular coupler devices in arterial end-to-end
anastomosis; anastomosis.
Microvascular coupler Methods: A systematic review of the literature was performed in November 2020 across 4
device; electronic databases and in accordance with the PRISMA guidelines. All studies comprised the
Anastomotic failure; data synthesis that reported the use of a microvascular coupler device for arterial end-to-
Hand sewn end anastomosis. Data were extracted and collected in three groups of standardised variables:
anastomosis study, anastomosis-related and technical characteristics.
Results: Out of the 7,690 articles identified, 20 were included in the final data synthesis.
Included studies involved a total of 1639 patients, who underwent 670 arterial and 1,124 venous
anastomoses. Out of all arterial anastomoses, 351 were performed in free tissue transfers in

∗ Correspondingauthor.
E-mail address: g.pafitanis@qmul.ac.uk (G. Pafitanis).

https://doi.org/10.1016/j.bjps.2020.12.090
1748-6815/© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302

head and neck, 117 in breast, 4 in upper extremity and 5 in lower extremity reconstruction,
whereas the remaining were not specified. The total arterial coupler anastomosis success rate
reported was 92.1% (617/670). Fifty-three (8%) arterial anastomoses were reported to result
in either troubleshooting events or intra- or post-operative failures, most being reported in
extremity reconstructions.
Conclusions: Arterial coupling is not widespread with predominant use in head and neck and
chest reconstructions, and total reported efficacy of 92.1%. Microsurgeons are reluctant to
routinely use current widespread coupler devices as a result of inherent arterial characteristics.
This study delivered collective recommendations, ‘do’s and don’ts’ of microvascular arterial
coupling.
© 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by El-
sevier Ltd. All rights reserved.

Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1287
Search strategy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Selection criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Data extraction and analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1288
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
Vessel geometry (calibre, wall thickness and intraluminal diameter) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1291
Vessels match (vessel/coupler size ratio and vessels mismatch) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1299
Microvascular haemodynamics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1299
Vessels quality and patients’ comorbidities. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300
The future: submillimetre or perforators coupling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1300
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
Conflict of Interest statement. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
Ethical Approval . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
Supplementary materials. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1301

Introduction may not select a coupler device to repair an arterial anas-

tomosis: arteries may be too thick-walled, they may have
The first microvascular anastomosis in arteries using pins non-pliable vessel walls due to radiation-induced fibrosis or
was described in 1759.1 Since then, many techniques have atherosclerotic calcification or have vessel diameter dis-
emerged to improve its efficiency and effectiveness.2 Mi- crepancies that are too large for the use of a coupling
crovascular anastomotic coupler devices are composed of device.9 A systematic review of existing literature that
two interlocking rings of pins, which precisely interpose the describes the use of coupler devices in arterial anasto-
vessel ends to provide intima-to-intima contact, without the moses is yet to be published. This systematic review sum-
entry of any foreign material (suture) into the lumen. Al- marises the current applications, efficacy and troubleshoot-
though failure rates in free tissue transfers are low, about ing of microvascular coupler devices in arterial end-to-end
1%–10%, most occur following technical errors.3 Coupler de- anastomosis.
vices decrease the rate of thrombosis, reduce the time of
a microvascular repair, manage vessel size mismatches and
provide better patency rates (Synovis Micro GEM Microvas- Methods
cular Anastomotic Coupler).4 Evidence in the literature sup-
port these manufacturer claims, as they have demonstrated This review was performed according to the Preferred Re-
increased patency rates,5 reduced free tissue ischaemic porting Items for Systematic Reviews and Meta-Analyses
time 6 and decreased overall operating time in venous anas- (PRISMA) statement of 2009, and is compliant with the As-
tomoses.7 Presently, the use of coupler devices has become sessment of Multiple Systematic Reviews’ (AMSTAR) 2 val-
the recommended and preferred technique for venous anas- idated tool.10 , 11 An electronic literature search was con-
tomoses.8 ducted in November 2020 across MEDLINE" R
(through Ovid),
The use of coupler devices for arterial anastomoses is EMBASE, SCOPUS and the Cochrane Central Register of Con-
not widespread. There are several reasons microsurgeons trolled Trials (CENTRAL).

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 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.
Search strategy
Our search captured studies of any prior publication date,
and levels of evidence 1 to 5, as defined by the Oxford
Centre for Evidence-Based Medicine.12 A detailed keyword
strategy was used across all platforms with the follow-
ing terms: artery, microvascular, anastomosis and coupler
(suppl. appendix 1). A further manual search of the in-
cluded articles’ citation lists and previous related system-
atic reviews allowed the identification of relevant studies
not captured in the initial search. Identified studies were
exported into the EndNote X9.3 (Clarivate Analytics, Lon-
don, UK) reference manager for screening and the removal
of duplicates.
Selection criteria
Screening was performed at two levels (title/abstract and
full-text screening) by two independent reviewers (G.P. and
M.N.). The initial criteria for the full-text screening stage,
included articles describing the use of coupler devices for
anastomosis in any vessel (artery or vein). Studies demon-
strating the use of coupler anastomosis in veins only, experi-
mental animal or cadaveric studies, non-English, descriptive
studies and reviews were then excluded. Conference ab-
stracts or letters to the editor that did not report adequate
quantitative data were excluded during data extraction. All
studies finally included in the data synthesis reported the
use of a microvascular coupler device for arterial end-to-
end anastomosis in free tissue transfer, trauma or replan-
tation surgery. The reviewers’ decisions were recorded in
a digital spreadsheet using Microsoft" R
Excel for Mac 2020.
Any discrepancies in abstract/title screening were resolved
by including the article by default. At full-text screening,
discrepancies were resolved by the senior author. All rea-
sons for exclusion beyond the initial screening stage were
recorded in detail (Fig. 1).
Data extraction and analysis
All articles that passed through both stages of screening
were listed in Microsoft" R
Excel for Mac 2020 and read
in their entirety by two independent reviewers (G.P. and
M.N.). Data were extracted and collected in three groups
of standardised variables: study, anastomosis-related and
technical characteristics (Table 1). Data that were not avail-
able for extraction, or unclear in their relation to arterial
anastomosis alone, were recorded as ‘Not reported’. When
the country of origin of study was not listed in the article,
the last author’s institution was used instead. A descriptive
statistical methodology was used to synthesise extracted
data.
Results
From 7677 articles identified by initial electronic database
search and 13 from manual searching; 20 were included
in the final data synthesis (Fig. 1). The main reason for
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Table 1 Data extraction fields.
Characteristics Extraction Fields
Study Author
Title
Year
Journal
Study design
Study country
Patient number
Age
Anastomosis- Number of anastomoses
related Procedure type and number
Vessel name and number
Coupling device and size used
Number of anastomotic conversions
to hand-sewn technique
Number and type of troubleshooting
events
Patency rate and justification
Technical Considerations
Challenges
Recommendations
exclusion after the full-text eligibility assessment was ‘in-
tervention using venous couplers only’ (n = 54), followed
by ‘descriptive articles’ (n = 15) and ‘experimental study’
(n = 11). Included studies involved a total of 1639 patients,
who underwent 670 arterial and 1124 venous coupled anas-
tomoses. Main characteristics of the included studies are
outlined in Table 2. Included were 2 retrospective cohort
studies (level of evidence 2b) and 18 case series (level of
evidence 4). Ten studies took place in the United States, 5 in
China, 4 in Europe and 1 in Canada. Included articles’ year
of publication ranged from 1984 to 2020, with more than
86% of arterial coupler anastomosis reported after 2005.
Of 20 included articles, 12 reported the type of free tis-
sue transfer (FTT), 14 the vessels anastomosed (recipient or
donor, or both) and 14 the coupler size used; only 9 stud-
ies reported all of the above characteristics. All studies re-
ported the type of coupler device used. In 71% (478 out of
670) of all arterial anastomoses, the type of vessels (nomen-
clature) was reported and in 70% (470 out of 670), the size of
coupler used. Out of the 670 arterial coupler anastomoses,
351 were performed in FTT in the head and neck, 117 in FTT
in the breast, 4 in FTT of upper extremity and 5 in lower
extremity reconstruction, whereas the rest were not speci-
fied. Recipient vessels predominantly reported were the fa-
cial/lingual (285), thoracodorsal (93), superior thyroid (62)
and internal mammary (24) arteries. The commonest ves-
sels coupled were the thoracodorsal artery to the deep in-
ferior epigastric artery (TDA-DIEA) for breast reconstruction
(n = 72, reported). (Table 3) (Fig. 2)
The Synovis Global Excellence in Microsurgery (GEM) cou-
pler device (Synovis Micro Companies Alliance, Inc., Al-
abama, USA) was used in 60% (402 out of 670) of arte-
rial anastomoses, the Unilink MAS Synovis coupler device
(Synovis Micro Companies Alliance, Inc., Alabama, USA)
in 26% (177 out of 670) and the Unilink/3 M Microvascular
Anastomosis Coupler Device (MACD) (3 M, Minnesota, USA/
 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302
Fig. 1 PRISMA flow diagram illustrating the process of study selection.
Synovis Micro Companies Alliance Inc., Alabama, USA) in
10% (68 out of 670). The latter was mostly used before
2002, whereas the former more recently. The common-
est size of coupler used was 2.0 mm (n = 278), followed
by 2.5 mm (109), 1.5 mm (39), 3.0 mm (18), 4.0 mm (14),
1.0 mm (10) and 3.5 mm (1). The commonest free flaps cou-
pled were the radial forearm (n = 156), deep inferior epi-
gastric artery/transverse rectus abdominis myocutaneous
(n = 113) and the fibular flap (n = 73). Fig. 2 demonstrates
all reported recipient vessel sites, flaps and size of coupler
devices used. (Table 3)
The total arterial coupler anastomosis success rate re-
ported was 92.1% (617 / 670). Out of 20 included studies,
19 disclosed data regarding the frequency of troubleshoot-
ing events and coupler failures. Fifty-three (8%) of arterial
anastomoses were reported to result in troubleshooting (re-
vision or conversion to hand-sewn techniques) and intra- or
post-operative failures: 11 failed due to thrombosis, 8 re-
quired troubleshooting due to thick arterial vessel wall ev-
ersion errors or due to vessel wall and coupler luminal diam-
eter discrepancy (vessel/coupler size ratio), 6 failed after
1289
sustaining a traumatic injury or intimal tear due to instru-
ment handling and 4 failed due to the small arterial coupler
size (<1.5 mm). The remaining 24 events, reported by Spec-
tor et al. and McLaughlin et al., failed due to a mixture of
the above factors with no further details or were unjustified
for (Fig. 3).9 , 30 Based on the above, we calculated the trou-
bleshooting failure rate to be 12.8% (SD=13.23 and n = 19),
ranging from 0% to 50%. These rates were calculated from
a technical point of view, have not justified for the power
effect of each study and are not indicative for the anasto-
motic patency or for any other surgical outcomes. (Table 4)
The efficacy per recipient artery, flap and coupler size
used was reported only in 164, 168 and 56 out of the 670
anastomoses, respectively. The highest troubleshooting fail-
ure rate for recipient arteries was noted in the ulnar artery
(1/2, 50%), followed by the internal mammary artery (5/15,
33.3%), the TDA (13/81, 16.1%), the superior thyroid artery
(4/57, 7.0%) and the facial artery (1/46, 2.2%). The highest
troubleshooting failure rate per flap was noted in the latis-
simus dorsi (1/2, 50%) and the radial forearm flaps (12/144,
8.3%). There were no troubleshooting failure events for the
 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.

Fig. 2 Current reported microvascular arterial coupling on recipient and free flap pedicle arteries.

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Table 2 Characteristics of included studies.

Year Authors Study Country Study Design No. of Mean age No. of Anastomoses
Patients (range)
Arterial Venous
13
1984 Daniel & Olding Canada Case Series 20 NR 6 21
1989 Zhou et al.14 China Case Series 20 NR 17 25
(19–38)
1993 Berggren et al.15 Sweden Case Series 26 54 (7–78) 5 26
1994 Ahn et al.16 United States Case Series 74 44 (NR) 29 103
1995 DeLacure et al.17 United States Case Series 29 49 7 37
(20–74)
1996 De Bruijn & Marck18 Netherlands Case Series 72 44 (NR) 4 85
1996 Shindo et al.7 United States Case Series 76 NR 17 105
(19–86)
2001 Cope et al.19 United States Case Series 82 48 (NR) 5 88
2002 Zeebregts et al.20 Sweden Case Series 200 54 (3–88) 1 159
2005 Ross et al.21 United States Case Series 49 64 50 NR
(43–85)
2006 Spector et al.9 United States Case Series 60 45 (NR) 80 NR
2008 Chernichenko et al.22 United States Case Series 124 66 127 NR
(41–87)
2008 Rad et al.23 United States Case Series 9 51 10 9
(43–60)
2009 Camara et al.24 Germany Case Series 11 50 1 11
(41–62)
2015 Wang et al.25 China Case Series 64 NR 7 73
2016 Genther et al.26 United States Case Report 1 69 1 NR
(69–69)
2017 Assoumane et al.27 China Case Series 601 53 182 337
(13–91)
2019 Chen et al.28 China Case Series 45 52 45 45
(18–71)
2020 Guo et al.29 China Retrospective 56 NR 56 NR
Cohort
2020 McLaughlin et al.30 United States Retrospective 20 NR 20 NR
Cohort
Total reported 1639 670 1124

NR = not reported.

iliac crest, transverse rectus abdominis myocutaneous, an-
terolateral thigh, DIEA perforator, superficial inferior epi-
gastric artery perforator, fibular and deep circumflex iliac
artery flaps (0/66, 0%). The highest troubleshooting failure
rate per coupler size was noted for 1.5 mm (2/18, 11.1%)
and 2.0 mm (1/45, 2.2%), whereas a 0% failure was reported
for 2.5- and 3.0 mm calibres (0/37, 0%).
Discussion
Reconstructive microsurgeons often hesitate to use coupler
devices for microvascular arterial anastomoses. This sys-
tematic review has identified all reported applications of
coupler devices in arterial anastomoses, analysed charac-
teristics of their use with regard to anatomical sites and
type of operations and summarised their reported efficacy.
Furthermore, we defined technical challenges and devised
recommendations, which may encourage the use of current
coupler devices on arteries (Fig. 4).
Vessel geometry (calibre, wall thickness and
intraluminal diameter)
Couplers have found their place in venous microvascular
anastomosis, where the thin, pliable vessel wall is easily
passed through the rings and everted over the spike system
for the rings to join. The structure of the coupler device
splints the anastomosis open to avoid venous collapse and
thrombosis. On the other hand, coupler arterial anasto-
moses are less frequently performed: 12 out of the 14
studies report anastomoses in both arteries and veins,
which demonstrated more anastomoses performed in veins
(Table 2). Furthermore, the most commonly used coupler
devices in arterial anastomoses were the Synovis/GEM
(60%), Unilink MAS/Synovis (26%) and Unilink/3 M (10%) de-
vices. The above imbalance might be the result of inherent
differences of the artery as compared to vein, as it has a
thicker, non-pliable wall and is more prone to pathological
changes such as atherosclerosis.9 In our experience, the
higher arterial wall thickness-to-lumen diameter ratio, in

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 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.

Table 3 Arterial coupler anastomoses reported in relation to vessels, devices and coupler sizes used.
Author (Year) Procedure Recipient-Pedicle Total Coupler Coupler size (mm)
Artery (n) (n) device 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Daniel and Olding Trauma - Ulnar-Ulnar (2) 6 Absorbable 0 1 1 0 0 0 0
13
(1984) ∗ Extremities Posterior anastomotic
Tibial-Posterior device
Tibial (2) (Polyglactin
910)
FTT – Latissimus Medial
Dorsi Sural-Thoracodorsal
(1)
Anterior
Tibial-Thoracodorsal
(1)
Zhou et al.14 FTT – NR NR-NR 17 Vascular NR
(1989) Anastomotic
Rings
(Titanium
alloy)
Berggren et al.15 FTT – Latissimus Thoracodorsal-NR 5 Unilink/3 M 0 3 2 0 0 0 0
(1993) ∗∗ Dorsi (2) MACD
FTT – RFF Radial-NR (2)
FTT – DCIA Deep Circumflex
Iliac-NR (1)
Ahn et al.16 FTT – NR NR-NR 29 Unilink/3 M 0 14 15 0 0 0 0
(1994) MACD
DeLacure et al.17 FTT – Head & NR-NR 7 Unilink/3 M NR
(1995) Neck – NR MACD
De Bruijn and FTT – NR NR-NR 4 Unilink/3 M NR
Marck 18 (1996) MACD
Shindo et al.7 FTT – NR Superior Thyroid 17 Unilink/3 M 0 5 6 6 0 0 0
(1996) (13); Lingual (l); MACD
Facial (l);
Superficial Temporal
(l); Occipital (l) - NR
Cope et al.19 FTT – TRAM Thoracodorsal-Deep 5 Unilink/3 M 0 0 4 0 0 0 0
(2001) Inferior Epigastric MACD
(4)
FTT – NR NR-NR (1) 0 1 0 0 0 0 0
20
Zeebregts et al. FTT – NR NR-NR 1 Unilink 0 0 1 0 0 0 0
(2002) Meteko
Instrument
AB
Ross et al.21 FTT – RFF Superior 50 Unilink MAS 0 0 2 41 7 0 0
(2005) Thyroid-Radial (25) Synovis
Facial-Radial (11)
FTT – Fibular Superior
Thyroid-Peroneal (5)
Facial-Radial (7)
FTT – TRAM Superior
Thyroid-Deep
Inferior Epigastric
(1)
Facial-Deep Inferior
Epigastric (1)
(continued on next page)

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Table 3 (continued)
Author (Year) Procedure Recipient-Pedicle Total Coupler Coupler size (mm)
Artery (n) (n) device 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Spector et al.9 FTT – TRAM Thoracodorsal-Deep 80 Synovis GEM 0 0 34 26 0 0 0
(2006) ∗∗∗ Inferior Epigastric Coupler
(68)
Internal
Mammary-Deep
Inferior Epigastric
(1)
FTT – DIEAP
FTT – Gluteal Thoracodorsal-
Superior/Inferior
Gluteal (6)
Internal Mammary-
Superior/Inferior
Gluteal (5)
Chernichenko FTT – RFF NR-NR (90) 127 Unilink MAS NR
et al.22 (2008) † Synovis
FTT – Fibular NR-NR (26)
FTT – TRAM NR-NR (9)
FTT – DCIA NR-NR (2)
Rad et al.23 FTT – DIEAP Internal 10 Synovis GEM 0 8 2 0 0 0 0
(2008) Mammary-Deep Coupler
Inferior Epigastric
(9)
FTT – SIEAP Internal
Mammary-Superior
Inferior Epigastric
(1)
Camara et al.24 FTT – NR Thoracodorsal-NR 1 Synovis GEM NR
(2009) (1) Coupler
Wang et al.25 FTT – DCIA NR-NR (6) 7 Synovis GEM 0 2 4 1 0 0 0
(2015) Coupler
FTT – Fibular NR-NR (1)
26
Genther et al. FTT – DIEAP Facial-Deep Inferior 1 Synovis GEM 0 0 1 0 0 0 0
(2016) Epigastric (1) Coupler
Assoumane FTT – NR Lingual-NR (NR) 182 Synovis GEM 10 0 158 0 0 0 14
et al.27 (2017) Facial-NR (NR) Coupler
Chen et al.28 FTT – RFF, Fibular Superior Thyroid-NR 45 Synovis GEM 0 4 30 11 0 0 0
(2019) and ALT (14) Coupler
Lingual-NR (2)
Transverse
Cervical-NR (2)
Facial-NR (27)
Guo et al.29 FTT – ALT, AMT, Facial-NR (50) 56 Synovis GEM 0 2 18 24 11 1 0
(2020) Fibular, Iliac, RFF, Superior Thyroid-NR Coupler
Latissimus Dorsi, (4)
DIEAP and Lateral Submental-NR (1)
Arm Lingual-NR (1)

(continued on next page)

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 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.

Table 3 (continued)
Author (Year) Procedure Recipient-Pedicle Total Coupler Coupler size (mm)
Artery (n) (n) device 1.0 1.5 2.0 2.5 3.0 3.5 4.0
McLaughlin FTT – Internal 20 Synovis GEM NR
et al.30 (2020) DIEAP/TRAM, Mammary-NR (8) Coupler
Gracillis Thoracodorsal-NR
(12)
Total 670 10 39 278 109 18 1 14
Abbreviations: AMT = Anteromedial Thigh, ALT = Anterolateral Thigh, DCIA = Deep Circumflex Iliac Artery, DIEAP = Deep inferior epigastric
artery perforator, FTT = Free Tissue Transfer, GEM = Global Excellence in Microsurgery, MACD = Microvascular Anastomotic Coupler De-
vice, N = number, NR = Not Reported, RFF = Radial Forearm Fasciocutaneous, SIEAP = Superficial inferior epigastric artery perforator and
TRAM = Transverse Rectus Abdominis Myocutaneous.
∗ Daniel and Olding (1984) A total of 6 arterial coupler anastomoses were reported; 1 of 1.5 mm, 1 of 2.0 mm and 4 of either 1.5 or

2.0 mm.
∗∗ Berggren et al. (1993) Further 4 revascularisations and 3 pedicle lengthening with vein grafts reported.
∗∗∗ Spector et al. (2006) Coupler sizes not reported for failed anastomoses.
† Chernichenko et al. (2008) A detailed description of coupler size and troubleshooting of failures is reported; however, the total number

of anastomoses per coupler size were not reported.

Fig. 3 Arterial coupler reported troubleshooting or failure events aetiology.

combination with a non-expansile coupler ring, will result
into a smaller intraluminal space as compared to a venous
anastomosis. In addition, the non-expansile coupler rings
can interrupt the arterial pulsatile flow, cause turbulence
and subsequently, thrombosis. In contrast, interrupted
hand-sutured anastomoses can maintain the pulsatile
nature of the vessel wall and maintain arterial flow.
These innate arterial characteristics challenge microvas-
cular coupling and become particularly important in a free
flap vascular pedicle when the outer diameter of a simi-
larly sized artery and vein should not be an accurate indica-
tor of the intraluminal diameter. Conventionally, surgeons
plan free flap procedures according to the expected cali-
bre of the recipient and the pedicle arteries. However, the
anatomical location and nomenclature may not always be
an indicator of the wall thickness, which may cause dis-
crepancy during coupling.32 In this review, microsurgeons
were forced to convert to hand-sewn techniques because
of thick non-pliable arterial walls, which did not evert well
over the coupler pins and reduced the luminal diameter and
consequently, volume flow (Table 4). In response to these
errors, authors have extensively discussed the value of ad-
ventitiectomy before anastomosing the vessels.14–16 , 21 One
approach is to thin down the vessel to reduce its wall thick-
ness from the outside,33 making it pliable, less bulky and
ensuring secure intimal interposition within the rings. Nev-
ertheless, extra care should be taken during adventitiec-
tomy, as traumatic injury due to instrument handling was

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302
Table 4 Troubleshooting/failure and patency rates of arterial coupling and technical considerations, challenges and authors’
recommendations.
Year Author Troubleshooting/Failures Comments, Technical
Considerations & Challenges
Frequency Rate∗
1984 Daniel & Olding 1 16.7% Thrombosis of a <2.0 mm
13
coupler.
1989 Zhou et al. 14 2 11.8% Four alloy rings and thick
vessel eversion leading to
reduced lumen diameter and
flow insufficiency, and one
traumatic tear of vessel wall
edge.
1993 Berggren et al. 1 20.0% Thrombosis (1.5 mm
15
Unilink/3 M MACD) of the TDA
in an LD muscle flap. TDA has
thick wall for the 1.5 mm
coupler and, thus, vessel wall
thickness to coupler size
ratio should be considered.
1994 Ahn et al. 16 5 17.2% All five Unilink/3 M MACD
couplers failed intraoperatively
and were successfully
converted to the hand-sewn
technique. Four were due to
difficulty in the eversion of
the thick walls within the
coupler device. This caused a
reduction in the lumen
diameter and subsequent
no-flow or diminished flow
phenomena. One was due to
traumatic tear of vessel
edge. There were no
post-operative failures. This
device was not used on vessels
less than 1 mm. The size
mismatch between
instruments manipulating the
vessel walls within the bulky
nature of the rings was
challenging.
1995 De Lacure 2 28.6% Two Unilink/3 M MACD arterial
et al. 17 coupler anastomoses were
abandoned intra-operatively
and converted to hand-sewn.
Thick and less pliable vessel
walls, that did not evert, had
reduced lumen diameter and
consequently, flow. Did not use
on vessels less than 1 mm in
diameter.
1295
Recommendations from the
authors
! Always attempt to upgrade
coupler size (above 2.0 mm).
! Perform meticulous
adventitiectomy to reduce wall
thickness.
! Avoid manipulation of the
intimal surface not included
within the rings surface area.
! Re-evaluate precise coupler
sizing as per vessel luminal
diameter following
adventitiectomy.
! Always attempt to upgrade
coupler size after vessel
dilatation.
! Perform meticulous
adventitiectomy
! Use fine smooth instrument
(i.e. vessel dilator) to handle
the vessel edges outside of the
coupler rings.
! Avoid manipulation of the
intimal surface not included
within the rings surface area.
! Utilise the novel coupler pusher
device.31
! Extra care must be applied
when handling thickened,
friable vessels during pinning of
vessel wall (i.e. atherosclerosis
and irradiation).
! Perform fine and precise
microsurgical handling.
(continued on next page)
 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.
Table 4 (continued)
Year Author Troubleshooting/Failures Comments, Technical
Considerations & Challenges
Frequency Rate∗
1996 De Bruijn & 2 50% Two Unilink/3 M MACD 1.5 mm
Marck 18 arterial couplers failed to
properly function and were
converted to hand-sewn
anastomoses. Thick wall
vessel and small coupler.
1996 Shindo et al. 7 2 11.8% Two Unilink/3 M MACD
thrombosis caused by intimal
tear due to tension during
coupler application.
2001 Cope et al. 19 1 20% A less than 1.5 mm artery was
intraoperatively abandoned
while using 1.5 mm Unilink/3 M
MACD coupler and converted to
hand-sewn technique.
2002 Zeebregts 0 0% One 2.0 mm Unilink/3 M MACD
et al.20 was used in a single
anastomosis with no
troubleshooting events.
2005 Ross et al.21 2 4% One intraoperative thrombosis
of a 2.0 mm Unilink/3 M MACD
coupler requiring further
vessel dilatation and
upgrade of coupler size to
2.5 mm. One anastomosis
ruptured and caused a
haematoma on post-operative
day 12 (steroid-dependant and
immunosuppressed patient).
1296
Recommendations from the
authors
! The use of small coupler
(<1.5 mm internal luminal
diameter) is prone to failures
when used in thick wall vessels.
! When a small artery (<1.5 mm)
is coupled and fail,
intra-operative troubleshooting
or conversion to hand-sewn
anastomosis.
! Extra care when tension is
applied in distributing the first
3 axial pins during coupler
application (triangulation).
! Avoid manipulation of the
intimal surface not included
within the rings surface area.
! The use of coupler below
1.5 mm is prone to failures
when used in thick wall vessels;
there must be low threshold in
abandoning and
intraoperatively convert to
hand-sewn techniques.
! Arterial anastomosis should be
only attempted with coupler
devices >2.0 mm.
! Ensure precise sizing of the
vessel lumen/wall and attempt
upgrade by 0.5 mm coupler
when possible.
! Apply gentle stretch with the
vessel dilator after meticulous
adventitiectomy to upgrade to
a larger coupler device.
! Extra care during perivascular
dissection in patients with
co-morbidities (i.e.
immunosuppressed, long-term
steroid use and irradiation).
(continued on next page)
 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302

Table 4 (continued)
Year Author Troubleshooting/Failures Comments, Technical Recommendations from the
Considerations & Challenges authors
Frequency Rate∗
2006 Spector et al.9 18 22.5% It is notable that gluteal flaps Hand-sewn anastomosis is
require a sutured anastomosis mandatory when:
more frequently, likely because
I. Either the donor or recipient
of their relatively thick walls
artery is too thick-walled, as
and the fact that there often
adequate eversion of the edges
exists a significant luminal
over the device becomes
diameter discrepancy (1.5:1)
technically difficult, which
between the donor superior
leads to either intimal injury or
gluteal artery and the recipient
significant reduction in
internal mammary artery.
intraluminal diameter/flow.
Successful coupling in gluteal
II. There is existing donor and
flaps mandated the use of one
recipient arterial luminal
of the distal branches of the
diameter discrepancies of
superior gluteal artery, which
greater than a 1.5:1 ratio. A
allowed for donor and
distal branch may prove
recipient vessels of comparable
suitable.
diameter. Similarly, no
III. In the presence of nonpliable
couplings were attempted
vessels stiffened by either
using the internal mammary
radiation-induced fibrosis or
artery as a recipient in this
atherosclerotic calcification.
series because of size
IV. In any artery with a luminal
mismatches. The overall flap
diameter < 1.5 mm.
survival rate was 100%;
however, there was 1 return to
the operating room for the
revision of an arterial
anastomosis. In one case, a
small partial flap necrosis
required minor revision.
2008 Chernichenko 9 7.1% Six arterial insufficiencies (out ! Avoid performing arterial
et al.22 of which 3 failed) and 3 coupling in atherosclerotic
conversions to hand-sewn. In vessels.
one patient, a 2.0-mm coupler ! Avoid extra-adventitiectomy in
did not provide adequate higher pressure and larger
flow. In another patient, an vessels as this may weaken the
adequate splaying of the arterial wall.
superior thyroid artery over
the pins could not be achieved
because of the presence of
extensive atherosclerotic
plaques. In the third patient,
arterial anastomosis was first
attempted with 2.5-mm
coupler; however, this
procedure resulted in the
formation of a
pseudoaneurysm of the medial
arterial wall intraoperatively.
2008 Rad et al.23 0 0% n/a n/a
2009 Camara et al.24 0 0% n/a n/a
(continued on next page)

1297
 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.

Table 4 (continued)
Year Author Troubleshooting/Failures Comments, Technical Recommendations from the
Considerations & Challenges authors
Frequency Rate∗
2015 Wang et al.25 0 0% One arterial coupled ! Arteriospasm requires patience.
anastomosis led to ! The use of vessel vasodilating
Arteriospasm; however, this agents such as papaverine or
did not result in anastomotic lidocaine may improve flow.
patency failure.
2016 Genther 0 0% n/a n/a
et al.26
2017 Assoumane NR NR n/a n/a
et al.27
2019 Chen et al.28 1 2.2% One arterial coupled ! Use vessel dilator to upgrade to
anastomosis (2.0 mm) of a a larger 2.5 mm coupler device.
radial forearm free flap to the ! Be able to master
facial artery was thrombosed decision-making in venous
intraoperatively. The coupler mismatches before
anastomosis was revised using using the coupling technique in
the hand-sewn technique. arterial anastomoses.

2020 Guo et al.29 1 1.8% No intraoperative ! Surgeons should be aware of

troubleshooting or failures
were reported; however, 1
arterial coupled anastomosis
found thrombosed in a revision
surgery at post-operative day 6
following total flap failure
(both arterial and venous
anastomoses were
thrombosed).
the time efficiency discrepancy
between arterial and venous
anastomotic coupling.
! Arterial coupling is technically
more challenging than venous
and requires specialised
training. Training and expertise
are required to effectively
mount the arterial vessel walls
to the coupler rings and avoid
repeated eversions that can
result in tearing.
! Selection of an appropriately
large-sized coupler is the most
crucial component – coupler
sizes of 2.0–3.0 mm reported an
efficacy of 94.6%.

2020 McLaughlin 6 30% A total of 6 arterial coupler ! When multiple troubleshooting

et al.30 anastomoses required events occurred in either
intra-operative primary or revision
troubleshooting. No flap anastomoses, further attempts
failures were reported. were performed under the
microscope. Arterial coupling
should preferably be performed
with microscopic magnification
(> x3.5) rather than loupe
magnification.
! Do not perform arterial
coupling in non-pliable, thick,
brittle or calcified vessels.
! Extra care should be taken
during eversion to avoid
spiralling and intimal trauma.

Total 53
MACD = Microvascular Anastomosis Coupler Device, NR = not reported, n/a = not available.
∗ No. of failures/total arterial anastomoses and N=number.

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 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302
Fig. 4 The Do’s and Don’ts of microvascular arterial coupling.
evident in our review. (Table 4) In addition, our results have
shown that several relatively large arteries had high trou-
bleshooting rates (the ulnar artery 50%, internal mammary
artery 33.3% and TDA 16.1%). Although these were just 18
cases in total and the overall success rate in the reported
arterial anastomoses was high (91.8%), we speculate, and
according to our experience, that technical errors during
vessel preparation and adventitiectomy may have played a
major role. Technical challenges or inexperience in arterial
coupling, can hinder any advantages gained by the use of
coupler devices in terms of operating time.
Vessels match (vessel/coupler size ratio and
vessels mismatch)
One of the key benefits of a coupler device is the abil-
ity to anastomose an unequally sized vessel, allowing for
a discrepancy of up to 50%.34 However, this is dependant on
both vessels having low vessel wall thickness. In our expe-
rience, venous mismatch is often seen in superficial recip-
ient veins, such as the long saphenous or cephalic, which
have longitudinal bundles of smooth muscle cells in the ad-
ventitia and inner media layers, which contribute to a high
wall thickness-to-lumen diameter ratio. This relative differ-
ence in vessel wall thickness is also seen in arteries.35 In
our results, 8 cases of troubleshooting were reported due to
vessel wall and coupler luminal diameter discrepancy (ves-
sel/coupler size ratio) (Table 4). This technical considera-
tion may not be present as the arterial calibre reaches the
perforators’ size.
Arterial coupling requires manoeuvres to calibrate ves-
sels’ size discrepancies between the pedicle and recipient
site. There are various technical recommendations for ef-
1299
fective vessel matching, always with a preference to up-
sizing the smaller artery site following adventitiectomy, di-
lation or even longitudinal slitting of the arterial wall to
increase its circumference to fit the largest feasible cou-
pler device. Vessels-coupler sizing should always aim to
match the chosen pedicle branch and recipient artery, and
to upscale the coupler size to above 2.0 mm, as a 0% trou-
bleshooting failure rate was reported (0/41). An artery can
be upsized by using the microvascular dilators with extra
care to avoid intimal injuries; however, larger arteries have
an inherently thicker media layer that requires higher force.
This review identified 6 out of 45 troubleshooting events
due to intimal tearing, which led to failure or conversion
to a hand-sewn technique.7 , 14 , 16 These technical consider-
ations could be easily avoided during elective free flap pro-
cedures with meticulous preoperative planning.36 In lower
extremity reconstruction, it is important to protect axial
vessels’ flow and therefore, end-to-side anastomosis may be
the preferred method of hand-sewn anastomoses in a given
case (i.e. traumatic injury of a single vessel lower extrem-
ity reconstruction).37 On the other hand, end-to-side arte-
rial coupling is nearly impossible; only some approaches us-
ing current devices have been described, such as utilising
a side branch/stump or the ‘X-arteriotomy’ technique. We
speculate that these methods may hold a higher risk of fail-
ing when applied to arterial end-to-end anastomoses, due
to their non-pliable, thick walls.
Microvascular haemodynamics
Normal arterial flow is laminar, with secondary flow pat-
terns created at curves, branches or anastomotic sites. Any
caused turbulence will change the arterial volume flow, as
seen in atherosclerotic disease, and create sheer stress os-
 G. Pafitanis, M. Nicolaides, E.F. O’Connor et al.

cillations in the endothelial intimal lining, which leads to intraluminal diameter from the thick arterial walls, a con-
delamination. In arterial coupling, the presence of the anas- clusion similarly reached by the findings of Spector et al.9
tomotic rings alters the flow haemodynamic. The inelastic and Chernichenko et al.22 Pre-operative workups prior to
constriction from the fixed diameter of the plastic coupler surgery can assess the patient’s cardiovascular risk factors
rings cause iatrogenic stenosis, turbulence flow and laminar and past medical history, and may predict the likelihood of
blood stasis, which in turn may lead to thrombosis. Very high having non-pliable vessels. In such cases, hand-sewn anas-
shear stress forces near the afferent arterial wall may acti- tomoses are preferred.
vate platelets, reduce flow and thereby, induce thrombosis.
This could potentially contribute to the increased anasto-
motic failure rate seen in arterial couplers as compared to
The future: submillimetre or perforators coupling
venous (≈8.2% vs <5%).38 The recipient vessels in the head
and neck and chest are generally considered high flow be-
The presence of endothelial delamination is rarely seen in
cause of their proximity to the heart. High pressure ves-
perforating arterial vessels and smaller calibre arteries such
sel sites may improve coupler arterial anastomoses patency
as perforators. These submillimetre arterial vessels have
rates, and this might provide the theoretical explanation
more compliance than larger vessels, and it is our experi-
behind the high efficacy observed in head and neck and
ence in hand reconstructive microsurgery that submillime-
chest reconstructions.
tre upper extremity arteries can handle dilation higher than
It is believed that the outcome of using the current cou-
50% of their resting intraluminal diameter. It is this increase
pler devices in arterial anastomosis may cause aneurysmal
of 50% or more which allows eversion onto a coupler ring
dilatation and intimal thinning upstream to an end-to-end
without compromising the remaining lumen. We have ob-
anastomosis, particularly when wall-thinning adventitiec-
served that upper extremity arteries have less than 1.5:1
tomy has been performed as described by Ross et al.21 In this
external to intraluminal diameter ratio, even though, mi-
study, a head and neck arterial coupled anastomosis pre-
crosurgeons are reluctant to couple these vessels. It is the
sented with a belated rupture and subsequent haematoma
experience of the authors that smaller calibre arteries may
on post-operative day 12. Nonetheless, this was reported in
provide a thin, more pliable vessel wall, which technically
a steroid-dependant and immunosuppressed patient, which
allows coupling and further allows efficiency in arterial cou-
are relative contraindications for arterial coupling in com-
pler anastomosis. Nevertheless, the application of a small
mon practice. There is no objective evidence to support
calibre (1.0) coupler requires meticulous manipulation and
this theory or the fate of such an anastomotic attempt, and
refined instrumentation (superfine forceps), to allow pre-
there is a lack of studies demonstrating their outcomes ei-
cision in splaying the tissue on the coupler spikes without
ther radiologically or histologically.39
collateral injury. The current widespread coupler applica-
tion kit includes a ‘pusher’ instrument [specialised forceps
with a holed, distal angled micro handle to enable the ev-
Vessels quality and patients’ comorbidities ersion of the vessel wall circumference over the coupler
rings]. These forceps may prove redundant for smaller or
One of the key challenges during arterial coupler anasto-
perforator-sized vessels. We recommend extra care and pre-
mosis in patients with peripheral vascular disease is the
cision during manipulation to avoid intimal tears, such as by
presence of delamination of the intimal lining of endothe-
using the ‘quadrupod’ grip for holding supermicrosurgical
lial cells from the supporting elastin and collagen scaffold.
instruments.40 Moreover, a novel ‘pusher’ device has been
This delamination occurs with the loss of elastin and choles-
reported to make eversion easier and more efficient when
terol deposition within the media. Microsurgeons pin up the
used in combination with the Synovis Coupler, which may al-
fragile intima against the media, during microsurgical su-
low the widespread use of current available coupler devices
ture anastomosis, in an inside to outside fashion to prevent
on arteries.31
further delamination and enable vessels apposition on the
We believe that current widespread coupler devices
anastomotic line.29 These fragile vessels have little compli-
are safe when used on arteries; however, there are clini-
ance and almost no elastic properties, making them non-
cal vessel-related decision-making considerations; and the
pliable and hard to bend. During arterial microvascular cou-
more demanding coupler application technique may prove
pling, the eversion of the vessel over the rings becomes in-
to be extremely valuable, particularly in the hands of unfa-
creasingly difficult as the vessel quality worsens. This chal-
miliar and inexperienced microsurgeons.
lenge of eversion process invariably potentiates the further
delamination injury, to provide a nidus for thrombosis de-
velopment. Delamination changes are not seen in veins and
therefore, the vast insights of a microsurgeon gained by the Conclusion
experience in venous coupling does not allow the routine
use in arteries. This systematic review revealed the lack of arterial coupling
Several studies included in this review suggest that the in current literature with predominant use in head and neck
arterial coupler is not indicated for use when the vessels and chest reconstructions, and the total reported efficacy
have a degree of pathological changes, such as radiation- of 92.1%. Microsurgeons are reluctant to routinely use cur-
induced fibrosis or atherosclerotic calcifications, as those rent widespread coupler devices as a result of the inherent
result in inelastic non-pliable vessel walls. De Lacure et al.17 differences of arteries as compared to veins, as they have
described how friable arteries could not be easily everted a thicker, non-pliable wall, which makes eversion techni-
over the coupler rings without the resultant compromised cally difficult. Arterial geometry, arterial pulsatile flow and

1300
 Journal of Plastic, Reconstructive & Aesthetic Surgery 74 (2021) 1286–1302
specifically the higher external to intraluminal diameter ra-
tio are the key technical challenges in coupler application,
particularly in atherosclerotic or post-radiation fibrotic ves-
sels. Adventitiectomy, careful upsizing and precise coupler
calibre decision-making towards larger sizes, can be effec-
tive in reducing failure events. Herein, we delivered collec-
tive recommendations ‘do’s and don’ts’ of arterial coupling
in microvascular surgery, as relative indications and abso-
lute contraindications. Furthermore, future developments
of specialised instrumentation, finer techniques and cou-
pler devices would enable the routine arterial coupling and
transfer the beneficial effects of microvascular coupling to
arterial microvascular anastomosis.
Acknowledgements
None.
Conflict of Interest statement
None.
Funding
None.
Ethical Approval
Not required.
Supplementary materials
Supplementary material associated with this article can be
found, in the online version, at doi:10.1016/j.bjps.2020.12.
090.
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