Fig. 1 The device relies on a number of metallic wires, arranged in circular loops and sewn to a Dacron cuff. Traction on the wires by an actuating guide expands and tightens the loops to create a rigid cylindrical ring with a variable and controllable diameter. Two different versions of this device (Types I and II) are generally used for the 1st and the 2nd anastomosis, respectively.
Type I: Before clamping, the expandable device (a) is sutured to one end of a vascular prosthesis (b) in such a way that the device, once retracted (c, d), can be inserted into the vascular stump (e) and then expanded to the final diameter.
Type II: A different arrangement of the metallic wires enables the device to be used as a double-anastomosis ring, with both ends activated by the same guide. This version is better used for the 2nd anastomosis; when used with the type II device, the prosthesis can be cut in position, precisely to the desired length.
With both types, external ligature is required for hemostasis and device stabilization. After blood flow is re-established, the activating guides are folded as close as possible to the prosthesis and then cut; the acute fold of the wires within the guides' polypropylene conduits prevents their sliding backwards.
Both types I and II have been prepared in 3 sizes, yielding the following internal-diameter ranges: SMALL, from 13 to 22 mm; MEDIUM, from 20 to 28 mm; and LARGE, from 25 to 34 mm.
(Modified from Nazari S, Luzzana F, Banfi C, Mourad Z, Salvi S, Gaspari A, Nazari-Coerezza F. Expandable prosthesis for sutureless anastomosis in thoracic aorta prosthetic substitution. Eur J Cardiothorac Surg 1996;10:1003–9. © 1996 Springer-Verlag GmbH & Co. With permission from Elsevier Science.)

Fig. 2 Operative view of the prosthesis in place. Small blue arrows outline the limit of the expandable end and long black arrows indicate the 2 external ligatures used to stabilize the prosthesis and to achieve hemostasis; white arrows mark the limits of the activating wires, cut and folded within their polypropylene sheaths to prevent the wires from sliding backwards. Inset: Operative specimen including the left upper lobe (white arrows = bronchial stump) resected en bloc with the aortic wall (black arrows).

Fig. 3 Postoperative chest radiograph showing the metallic loops of the expandable end (short arrows) and the cut and folded activating wires (larger arrows).

Fig. 4 The expandable end also can be positioned against aneurysmal wall, provided that its distal end reaches healthy vascular wall. Thrombosis of the tract between the ligature and the prosthesis will soon move the effective anastomosis line (*) to the point where a standard suture line would be.
(Reprinted with permission from the Society of Thoracic Surgeons. From Nazari S, Salvi S, Aluffi A, Visconti E, Rescigno G, Buniva P. Prosthesis for aortic arch substitution. Ann Thorac Surg 1997;64:1339–44. © 1997 The Society of Thoracic Surgeons.)