The needle-and-thread suturing process surgeons use to create anastomoses has been a staple in the OR, largely unchallenged for nearly a century. New developments in minimally invasive and endoscopic surgery, particularly in coronary bypass procedures, have created the need for a tissue-closure technique that can produce high-quality anastomoses in small spaces with limited visualization. As a result, anastomotic device technology, a long dormant area of product development, has become a hot subject at clinical meetings, and numerous companies, from major device firms to start-ups, are exploring a range of different approaches. Coalescent Surgical, a start-up, is one of the first to market in this area, with an anastomotic device that uses an approach different than its competitors--a proprietary self-closing clip that replaces traditional sutures. Coalescent's challenge: to gain acceptance from surgeons, who are notoriously slow adopters of new technology. The company is betting that the advantages of its device, combined with being first to market, will enable it to survive what appears will be a stampede of competitors, including major players that have superior resources and existing relationships with surgeons.