Study comparing sutures and nonpenetrating titanium clips for arteriotomy closure after embolectomy

Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue

Objective

Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips.

Methods

The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed.

Results

The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H₂O, FG/CMG was 12.413 ± 5.114 cm H₂O, and TC/FL was 8.330 ± 3.483 cm H₂O. There were statistically significant differences in mean failure pressures among the 3 repair methods.

Conclusion

In this ex vivo model comparing skull base repairs’ ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP’s. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.

Rapid M1 Hemoclips Arteriotomy Repair After Emergency Coil Embolectomy

BACKGROUND

The vascular closure staple clips have been studied in animal models and shown to have comparable results with sutured repair when it comes to the healing process, degree of vessel narrowing, and risk of thrombosis. However, they are clearly superior when the speed of application is taken into account, and they were clinically used in many vascular repair processes. Nevertheless, their usefulness in intracranial vascular surgery has not been described.

OBJECTIVE

To describe the usefulness of hemoclips in fast and efficient repair of medium-sized and large intracranial vessels.

METHODS

Two female patients diagnosed with giant symptomatic cavernous sinus aneurysms were undergoing elective endovascular procedures that were complicated by the dislodgement of coils into the M1 segment of the middle cerebral artery. Both patients were treated performing M1 arteriotomies and coil embolectomy. To avoid prolonged temporary occlusion in the M1 perforator's territory, the arteriotomies were repaired using microhemoclips in less than 10 min with re-establishment of flow.

RESULTS

In both patients, flow was re-established in the M1 segments. In 1 patient, the coils extended to the temporal M2 causing intimal injury and leading to diminished flow. M1 segments in both patients were patent on later angiographic studies.

CONCLUSION

We describe the advantage of emergent cerebrovascular arteriotomy and embolectomy in a rapid repair process that helped avoid massive ischemic injury. We believe this technique should be added to the armamentarium of neurosurgical cerebrovascular options.

Vascular Closure Stapler Clip Anastomosis Decreases Aortic Cross-Clamping Time Compared to Interrupted Nonabsorbable and Running Absorbable Sutures in Growing Pigs

The latest generation in titanium clip application systems, the vascular closure staples (VCS) system avoids intimal lesions and therefore minimizes the subsequent hyperplastic reaction, while at the same time enhancing distensibility and vascular growth. Moreover, VCS clips allow the surgeon to perform vascular anastomosis easily and faster than conventional suture. This system may become the option of choice for vascular reconstruction in pediatric surgery where, as in the case of aortic and transplant surgery, decreasing vascular occlusion times may influence the outcomes. The aim of this study was to determine whether VCS metallic clips would allow shorter anastomosis times than conventional interrupted polypropylene or running Dexon suturing in end-to-end anastomosis performed in the abdominal aorta of young pigs. Twenty-four domestic swine, 45 days old, were used for this study. All animals were subjected to an end-to-end anastomosis in the abdominal aorta using VCS clips, interrupted polypropylene, or running Dexon suture. Aortic cross-clamping time was significantly shorter in the VCS clips group (4.02 +/- 0.72 min), compared to interrupted polypropylene (21.89 +/- 1.93 min) or running Dexon (9.82 +/- 3.97 min) suture. VCS clips are easy to use, and therefore may aid surgeons to significantly decrease the time needed for performing an end-to-end anastomosis in the abdominal aorta, thus decreasing cross-clamping time when compared to interrupted polypropylene or running Dexon sutures.

Five years' world experience with nonpenetrating clips for vascular anastomoses

BACKGROUND

A new sutureless technique has been introduced clinically to facilitate the process of vascular reconstruction and improve patency. The Vessel Closure System (VCS) is nonpenetrating, creates an elastomeric everted anastomosis, and is easily and reproducibly applied. The objective of this report is to review the published world experience that has accrued regarding these clips with attention to the assets, liabilities, and pitfalls associated with the new technology.

DATA SOURCES

Medline search and manual cross-referencing were performed, after which 61 original articles were identified on the use of VCS clips for vascular anastomoses.

RESULTS

Advantages of the clips compared with sutures include the technical ease of application, the reduced anastomotic time, the superior hemodynamics, and the improved healing pattern of the anastomosis. Disadvantages include the potential problems in atherosclerotic vessels, lack of prospective randomized long-term follow-up, and initial costs. The best clinical results have been achieved in microvascular repair, as well as with vascular access and transplantation surgery.

CONCLUSIONS

The VCS clip technology has become an accepted vascular anastomosing technique, which in future could lead to the use of clips as a standard approach and the use of sutures only in case of severe atherosclerosis and other circumstances in which vessel edges are difficult to evert.

Direct repair of a blisterlike aneurysm on the internal carotid artery with vascular closure staple clips. Technical note

Vascular closure staple clips made of titanium were originally developed for microvascular anastomosis. Clinical applications for these clips include arteriotomy closure for carotid endarterectomy, extracranial-intracranial bypass, and dural closure. This is the first report in which vascular closure staple clips have been used successfully for direct repair of a tear on the internal carotid artery (ICA). This report involves a 65-year-old man who presented with sudden onset of headache. Admission computerized tomography scans demonstrated a diffuse and thick subarachnoid hemorrhage in the basal cisterns. Cerebral angiograms demonstrated a broad-based, small bulge on the superomedial wall of the left ICA. Intraoperatively, an extremely thin-walled aneurysm was seen on the segment of the ICA at the C-2 vertebral level. The aneurysm ruptured abruptly, although no surgical manipulation was being performed on the aneurysm itself. After temporary clips were applied on the vessel, a large tear of the ICA was repaired with vascular closure staple clips. Reconstruction with the vascular closure staple clips required only a short period of temporary occlusion of the ICA. Postoperative angiograms revealed reduction of the aneurysm bulge and good patency of the ICA. The postoperative course was uneventful, and the patient has been free of symptoms. The vascular closure staple clipping procedure is useful for urgent repair of an aneurysm tear. This method is a new treatment option for these fragile aneurysms in cases in which other options, such as encircling clips or bypass procedures, may have drawbacks or be impossible.