Everter-Assisted Arterial Coupling in Abdominal-Based Breast Reconstruction: A Preclinical Study and Retrospective Feasibility Case Series

Background/Objectives: Arterial coupling in microsurgery remains technically challenging despite widespread venous coupler adoption. We developed a novel everter device to facilitate arterial anastomosis using mechanical couplers and evaluated its feasibility and potential efficiency in abdominal-based breast reconstruction. Methods: Five pigs underwent paired superior epigastric artery flap reconstruction with everter-assisted and hand-sewn arterial anastomoses, analyzed using a paired t-test. A retrospective clinical series included 12 patients, 22 reconstructed breasts, 14 coupling attempts, and 8 primary hand-sewn recipient arterial anastomoses. The primary clinical outcome was successful coupling without revision or conversion. Clinical timing comparisons were descriptive. Results: All five porcine arterial couplings were successful. Mean arterial time was 8.47 ± 2.83 min versus 20.26 ± 3.32 min for hand-sewn controls, a paired reduction of 11.79 min (95% CI, 5.86 to 17.72; p = 0.005). Clinical coupling succeeded in 9 of 14 attempts (64.3%). Five attempts required conversion (35.7%), including three thrombotic and two technical failures. All were converted intraoperatively, with no flap loss. Mean arterial times were 9.2 ± 4.2 min for successful coupling (n = 8) and 20.2 ± 8.0 min for primary hand-sewn anastomosis (n = 6), an approximately 55% difference. Conclusions: Everter-assisted arterial coupling demonstrated clinical feasibility and shorter mean arterial times when successfully completed. These findings support further refinement and evaluation of the technique to establish safety and overall procedural efficiency.