Biodegradable polymer film reinforcement of an indocyanine green-doped liquid albumin solder for laser-assisted incision closure

Albumin solder covalently bound to a polymer membrane: New approach to improve binding strength in laser tissue soldering in-vitro

Laser tissue soldering (LTS) based on indocyanine green (ICG)-mediated heat-denaturation of proteins might be a promising alternative technique for micro-suturing, but up to now the problem of too weak shear strength of the solder welds in comparison to sutures is not solved. Earlier reports gave promising results showing that solder supported by carrier materials can enhance the cohesive strength of the liquid solder. In these studies, the solder was applied to the carriers by dip coating. Higher reliability of the connection between the solder and the carrier material is expected when the solder is bound covalently to the carrier material. In the present study a poly(ether imide) (PEI) membrane served as carrier material and ICG-supplemented albumin as solder substrate. The latter was covalently coupled to the carrier membrane under physiological conditions to prevent structural protein changes. As laser source a diode continuous-wave laser emitting at 808 nm with intensities between 250 mW and 1500 mW was utilized. The albumin functionalized carrier membrane was placed onto the tunica media of explanted pig thoracic aortae forming an overlapping area of approximately 0.5×0.5 cm2. All tests were performed in a dry state to prevent laser light absorption by water. Infrared spectroscopy, spectro-photometrical determination of the secondary and primary amine groups after acid orange II staining, contact angle measurements, and atomic force microscopy proved the successful functionalization of the PEI membrane with albumin. A laser power of 450 mW LTS could generate a membrane-blood vessel connection which was characterized by a shear strength of 0.08±0.002 MPa, corresponding to 15% of the tensile strength of the native blood vessel. Theoretically, an overlapping zone of 4.1 mm around the entire circumference of the blood vessel could have provided shear strength of the PEI membrane-blood vessel compound identical to the tensile strength of the native blood vessel. These in-vitro results confirmed the beneficial effects of solder reinforcement by carrier membranes, and suggest LTS with covalently bound solders on PEI substrates for further studies in animal models.

Ex vivo proof-of-concept of end-to-end scaffold-enhanced laser-assisted vascular anastomosis of porcine arteries

OBJECTIVE

The low welding strength of laser-assisted vascular anastomosis (LAVA) has hampered the clinical application of LAVA as an alternative to suture anastomosis. To improve welding strength, LAVA in combination with solder and polymeric scaffolds (ssLAVA) has been optimized in vitro. Currently, ssLAVA requires proof-of-concept in a physiologically representative ex vivo model before advancing to in vivo studies. This study therefore investigated the feasibility of ex vivo ssLAVA in medium-sized porcine arteries.

METHODS

Scaffolds composed of poly(ε-caprolactone) (PCL) or poly(lactic-co-glycolic acid) (PLGA) were impregnated with semisolid solder and placed over coapted aortic segments. ssLAVA was performed with a 670-nm diode laser. In the first substudy, the optimum number of laser spots was determined by bursting pressure analysis. The second substudy investigated the resilience of the welds in a Langendorf-type pulsatile pressure setup, monitoring the number of failed vessels. The type of failure (cohesive vs adhesive) was confirmed by electron microscopy, and thermal damage was assessed histologically. The third substudy compared breaking strength of aortic repairs made with PLGA and semisolid genipin solder (ssLAVR) to repairs made with BioGlue.

RESULTS

ssLAVA with 11 lasing spots and PLGA scaffold yielded the highest bursting pressure (923 ± 56 mm Hg vs 703 ± 96 mm Hg with PCL ssLAVA; P = .0002) and exhibited the fewest failures (20% vs 70% for PCL ssLAVA; P = .0218). The two failed PLGA ssLAVA arteries leaked at 19 and 22 hours, whereas the seven failed PCL ssLAVA arteries burst between 12 and 23 hours. PLGA anastomoses broke adhesively, whereas PCL welds failed cohesively. Both modalities exhibited full-thickness thermal damage. Repairs with PLGA scaffold yielded higher breaking strength than BioGlue repairs (323 ± 28 N/cm(2) vs 25 ± 4 N/cm(2), respectively; P = .0003).

CONCLUSIONS

PLGA ssLAVA yields greater anastomotic strength and fewer anastomotic failures than PCL ssLAVA. Aortic repairs with BioGlue were inferior to those produced with PLGA ssLAVR. The results demonstrate the feasibility of ssLAVA/R as an alternative method to suture anastomosis or tissue sealant. Further studies should focus on reducing thermal damage.

Fabrication of a light-emitting shape memory polymeric web containing indocyanine green

Dye-containing polymers are highly desired for a number of commercially and medically relevant applications, such as sensors, medical devices, and drug delivery. In particular, dyes that emit light in the NIR region of the electromagnetic spectrum are of great interest due to the window of transparency for mammalian soft tissue in this range. While the incorporation of dyes into polymeric hosts by diffusion is a method that has been widely used, this approach is problematic in that it lacks uniformity and control over the incorporation. Here, we sought to develop NIR-emitting polymeric materials with high fluorescence intensity, addressing the problem of uniformity by incorporating the dye in a polymer host using dissolution in a mutual solvent and subsequent electrospinning into a fibrous web. This web could be prepared as a free-standing film, a coating or, as we will show, a shrink-wrap medical device label. The primary findings of this study were that an optimal concentration of dye in the polymer host exists, that the fluorescence intensity for fibrous webs greatly exceed that of comparable cast films, and that the dye-containing webs feature water-triggered contraction of use for application to medical devices, such as feeding tubes or catheters.

Biodegradable polymer scaffold, semi-solid solder, and single-spot lasing for increasing solder-tissue bonding in suture-free laser-assisted vascular repair

We recently showed the fortifying effect of poly-caprolactone (PCL) scaffold in liquid solder-mediated laser-assisted vascular repair (ssLAVR) of porcine carotid arteries, yielding a mean ± SD leaking point pressure of 488 ± 111 mmHg. Despite supraphysiological pressures, the frequency of adhesive failures was indicative of weak bonding at the solder-tissue interface. As a result, this study aimed to improve adhesive bonding by using a semi-solid solder and single-spot vs. scanning irradiation. In the first experiment, in vitro ssLAVR (n=30) was performed on porcine abdominal aorta strips using a PCL scaffold with a liquid or semi-solid solder and a 670-nm diode laser for dual-pass scanning. In the second experiment, the scanning method was compared to single-spot lasing. The third experiment investigated the stability of the welds following hydration under quasi-physiological conditions. The welding strength was defined by acute breaking strength (BS). Solder-tissue bonding was examined by scanning electron microscopy and histological analysis was performed for thermal damage analysis. Altering solder viscosity from liquid to semi-solid solder increased the BS from 78 ± 22 N/cm(2) to 131 ± 38 N/cm(2) . Compared to scanning ssLAVR, single-spot lasing improved adhesive bonding to a BS of 257 ± 62 N/cm(2) and showed fewer structural defects at the solder-tissue interface but more pronounced thermal damage. The improvement in adhesive bonding was associated with constantly stronger welds during two weeks of hydration. Semi-solid solder and single-spot lasing increased welding strength by reducing solder leakage and improving adhesive bonding, respectively. The improvement in adhesive bonding was associated with enhanced weld stability during hydration.

Enhanced laser tissue soldering using indocyanine green chromophore and gold nanoshells combination

Gold nanoshells (GNs) are new materials that have an optical response dictated by the plasmon resonance. The wavelength at which the resonance occurs depends on the core and shell sizes. The purposes of this study were to use the combination of indocyanine green (ICG) and different concentration of gold nanoshells for skin tissue soldering and also to examine the effect of laser soldering parameters on the properties of repaired skin. Two mixtures of albumin solder and different combinations of ICG and gold nanoshells were prepared. A full thickness incision of 2 × 20 mm(2) was made on the surface and after addition of mixtures it was irradiated by an 810 nm diode laser at different power densities. The changes of tensile strength (σ(t)) due to temperature rise, number of scan (Ns), and scan velocity (Vs) were investigated. The results showed at constant laser power density (I), σ(t) of repaired incisions increases by increasing the concentration of gold nanoshells in solder, Ns, and decreasing Vs. It was demonstrated that laser soldering using combination of ICG + GNs could be practical provided the optothermal properties of the tissue are carefully optimized. Also, the tensile strength of soldered skin is higher than skins that soldered with only ICG or GNs. In our case, this corresponds to σ(t) = 1800 g cm(-2) at I ∼ 47 Wcm(-2), T ∼ 85 [ordinal indicator, masculine]C, Ns = 10, and Vs = 0.3 mms(-1).

Optimization of suture-free laser-assisted vessel repair by solder-doped electrospun poly(ε-caprolactone) scaffold

Poor welding strength constitutes an obstacle in the clinical employment of laser-assisted vascular repair (LAVR) and anastomosis. We therefore investigated the feasibility of using electrospun poly(ε-caprolactone) (PCL) scaffold as reinforcement material in LAVR of medium-sized vessels. In vitro solder-doped scaffold LAVR (ssLAVR) was performed on porcine carotid arteries or abdominal aortas using a 670-nm diode laser, a solder composed of 50% bovine serum albumin and 0.5% methylene blue, and electrospun PCL scaffolds. The correlation between leaking point pressures (LPPs) and arterial diameter, the extent of thermal damage, structural and mechanical alterations of the scaffold following ssLAVR, and the weak point were investigated. A strong negative correlation existed between LPP and vessel diameter, albeit LPP (484±111 mmHg) remained well above pathophysiological pressures. Histological analysis revealed that thermal damage extended into the medial layer with a well-preserved internal elastic lamina and endothelial cells. Laser irradiation of PCL fibers and coagulation of solder material resulted in a strong and stiff scaffold. The weak point of the ssLAVR modality was predominantly characterized by cohesive failure. In conclusion, ssLAVR produced supraphysiological LPPs and limited tissue damage. Despite heat-induced structural/mechanical alterations of the scaffold, PCL is a suitable polymer for weld reinforcement in medium-sized vessel ssLAVR.

Characterization of skin tissue soldering using diode laser and indocyanine green: in vitro studies

Laser tissue soldering based on protein as biological glues and other compounds can provide greater bond strength and less collateral damage. Endogenous and exogenous materials such as indocyanine green (ICG) are often added to solders to enhance light absorption. The purpose of this in vitro study was to examine the impact of different parameters of laser soldering on the thermo-physical properties of the skin. A mixture of albumin solder and ICG was prepared, and then the coated samples were irradiated by an 810 nm diode laser under different conditions. The temperature rise, number of scans (N(s)), and scan velocity (V(s)) were investigated in this study. The results showed that, at each laser irradiance (I), the tensile strength (sigma) of incisions repaired in static mode was higher than in dynamic mode and that the sigma increased with both increasing N(s) and increasing I. It is therefore important to consider the trade off between scan velocity and surface temperature for achieving an optimum operating condition.

Microvascular anastomosis using a photochemical tissue bonding technique

BACKGROUND AND OBJECTIVES

Photochemical tissue bonding (PTB) combines photoactive dyes with visible light to create fluid-tight seals between tissue surfaces without causing collateral thermal damage. The potential of PTB to improve outcomes over standard of care microsurgical reanastomoses of blood vessels in ex vivo and in vivo models was evaluated.

STUDY DESIGN

The mechanical strength and integrity of PTB and standard microsurgical suture repairs in ex vivo porcine brachial arteries (n = 10) were compared using hydrostatic testing of leak point pressure (LPP). Femoral artery repair in vivo was measured in Sprague-Dawley rats using either standard microvascular sutures (n = 20) or PTB (n = 20). Patency was evaluated at 6 hours (n = 10) and 8 weeks post-repair (n = 10) for each group.

RESULTS

PTB produced significantly higher LPPs (1,100+/- 150 mmHg) than suture repair (350+/-40 mmHg, P<0.001) in an ex vivo study. In an in vivo study all femoral arteries in both suture and PTB repair groups were patent at 6 hours post-repair. At 8 weeks post-repair the patency rate was 80% for both groups. No evidence of aneurysm formation was seen in either group and bleeding was absent from the repair site in the PTB-treated vessels, in contrast to the suture repair group.

CONCLUSION

PTB is a feasible microvascular repair technique that results in an immediate, mechanically robust bond with short- and long-term patency rates equal to those for standard suture repair.

Progress Towards Seamless Tissue Fusion for Wound Closure

Tissue fusion shows great promise in creating the ideal wound closure;however devices and materials are still at an early stage of development.Energy-based closure methods, such as laser tissue welding, have proven that a thermal-mediated tissue fusion can result in a closure that is physiologically and mechanically seamless, and has sufficient tensile strength.However, the techniques are not easily reproducible and are not cost effective, and therefore they are not gaining wide acceptance. Nevertheless,the work of the scientists who have been exploring tissue welding has laid the foundation for more rapid development of new systems that can deliver energy more efficiently and with greater control. Some additional energy-based systems are available or are being developed that show great promise;however, clinical efficacy has yet to be demonstrated.

Intraluminal laser light source and external solder: In vivo evaluation of a new technique for microvascular anastomosis

BACKGROUND AND OBJECTIVES

Current laser-assisted end-to-end anastomoses are performed by irradiating the vessel wall from outside after additional fixation with three to six sutures. These sutures are needed to provide adequate approximation of the vessel stumps. We present a new laser soldering technique that is based on an intraluminal laser light source centered in a balloon catheter, and external application of a solder. This technique was applied in vivo in order to test its feasibility under clinical conditions.

STUDY DESIGN/MATERIALS AND METHODS

Seven white pigs were treated with a total of fourteen end-to-end laser-anastomoses of their saphenous arteries having outer diameters of 2 mm. The vessels were stented over an intraluminal balloon catheter, which was maximally dilated and which allowed for a precise approximation of the vascular stumps. An 808 nm diode laser was coupled into a specially designed optical fiber producing a 360 degrees radiation ring inside the balloon catheter. An indocyanine green (ICG) doped liquid albumin solder was applied on the external surface of the vascular stumps. Laser soldering was achieved by irradiating with a 808 nm laser diode for 75 seconds. Tightness of the anastomoses was evaluated by clamping the artery distal to the anastomosis for 1 hour, and patency was tested over an observation period of 3 hours, during which the animals were heparinized. Thereafter, the anastomoses were harvested for histomorphological examination.

RESULTS

All anastomoses remained patent over the entire observation period. Some leakage was observed in three anastomoses, which was explained by a deviation of the illumination fiber from the center of the balloon leading to an inhomogeneous irradiation of the vessel wall. Histology revealed perfect adaptation of the vascular stumps. A segment of denaturated vascular collagen was observed, that corresponded to the irradiated, solder-covered zone.

CONCLUSION

Patent, maximally dilated and well adapted microvascular anastomoses could be obtained without the need of stay sutures. A well centered laser light source is indispensable for avoiding inhomogenous welding, thus causing leakage.

25 Years of Laser Assisted Vascular Anastomosis (LAVA): What Have We Learned?

OBJECTIVES

Laser assisted vascular anastomosis (LAVA) has been developed to a stage where clinical use is within reach. Advantages of LAVA are minimal vessel damage, faster operation and the potential for minimally invasive application.

DESIGN

A Medline literature search was performed on vessel welding combined with cross-referencing.

RESULTS

Four different lasers have mostly been used for LAVA, always in combination with stay sutures. The CO(2) laser has only been used in the early period. Without solder, mean leaking point pressures (LPP) of 754 mmHg (n=75) were obtained, only slightly lower than in suture controls (LPP=915 mmHg, n=82). At follow-up the percentage of aneurysms was high (overall 12% in n=486). Although Argon LAVA showed moderate success (LPP=146 mmHg, n=125), the first clinical application has been successfully performed. Diode LAVA in combination with solder and dye resulted in an acceptable LPP of 409 mmHg (n=163) in larger vessels, with a low incidence of aneurysm formation (1% in n=107).

CONCLUSION

At present the diode laser is the most popular. Solder developments resulted in stronger welds and might make stay sutures redundant. The combination of CO(2) laser and solders has not been evaluated and deserves further investigation.

Preliminary biocompatibility experiment of polymer films for laser-assisted tissue welding

BACKGROUND AND OBJECTIVES

The purpose of this study was to examine the impact of a polymer film for liquid solder strength reinforcement on the short term healing of a wound closed by laser-tissue soldering.

MATERIALS AND METHODS

Full thickness incisions created on the dorsum of Sprague-Dawley rats were closed by laser-tissue soldering: albumin solder with Indocyanine Green (ICG) dye was inserted between the incision edges and photothermally coagulated with a diode laser. A poly(DL-lactic-co-glycolic acid) (PLGA) polymer film was implanted subcutaneously in the bottom of the incision (controls had no film). Specimens were harvested at 0, 3, 7, and 14 days for breaking strength testing and histological analysis.

RESULTS

Breaking strengths of the controls at 0 and 14 days were statistically stronger than the specimens with the implanted films (t-test, P < 0.05). A slight difficulty in apposing the wound edges due to the film presence may have contributed to the low acute strengths. Interference with the wound contraction process by the films possibly contributed to the lower breaking strength at 14 days. Wound histology indicated a mild foreign body reaction to the polymer film material.

CONCLUSIONS

The polymer film was well tolerated by the tissue, and the tissue response to the material was consistent with that seen in the literature. The breaking strength differences between control and film-implanted specimens at 0 and 14 days were probably the result of mechanical complications (tissue apposition and wound contraction) due to the presence of the film, and not due to the film material itself. The use of polymer film patches for liquid solder reinforcement and breaking strength enhancement may have certain application specific issues that need to be addressed. Strategies to account for these issues require further research.

Can thermal lasers promote skin wound healing?

Lasers are now widely used for treating numerous cutaneous lesions, for scar revision (hypertrophic and keloid scars), for tissue welding, and for skin resurfacing and remodeling (wrinkle removal). In these procedures lasers are used to generate heat. The modulation of the effect (volatilization, coagulation, hyperthermia) of the laser is obtained by using different wavelengths and laser parameters. The heat source obtained by conversion of light into heat can be very superficial, yet intense, if the laser light is well absorbed (far-infrared:CO(2) or Erbium:Yttrium Aluminum Garnet [Er:YAG] lasers), or it can be much deeper and less intense if the laser light is less absorbed by the skin (visible or near-infrared). Lasers transfer energy, in the form of heat, to surrounding tissues and, regardless of the laser used, a 45-50 degrees C temperature gradient will be obtained in the surrounding skin. If a wound healing process exists, it is a result of live cells reacting to this low temperature increase. The generated supraphysiologic level of heat is able to induce a heat shock response (HSR), which can be defined as the temporary changes in cellular metabolism. These changes are rapid and transient, and are characterized by the production of a small family of proteins termed the heat shock proteins (HSP). Recent experimental studies have clearly demonstrated that HSP 70, which is over-expressed following laser irradiation, could play a role with a coordinated expression of other growth factors such as transforming growth factor (TGF)-beta. TGF-beta is known to be a key element in the inflammatory response and the fibrogenic process. In this process, the fibroblasts are the key cells since they produce collagen and extracellular matrix. In conclusion, the analysis of the literature, and the fundamental considerations concerning the healing process when using thermal lasers, are in favor of a modification of the growth factors synthesis after laser irradiation, induced by an HSR. An extensive review of the different techniques and several clinical studies confirm that thermal lasers could effectively promote skin wound healing, if they are used in a controlled manner.

Tissue welding with biodegradable polymer films-demonstration of acute strength reinforcement in vivo

BACKGROUND AND OBJECTIVES

To demonstrate, in vivo, acute strength reinforcement benefits of polymer film patches.

STUDY DESIGN/MATERIALS AND METHODS

Full thickness incisions created in a dorsal skin flap of Sprague-Dawley rats were closed by laser-tissue welding: albumin solder was topically applied to the incision on the dermal surface, and a poly(lactic-co-glycolic acid) (PLGA) polymer film placed on the solder as a patch (controls had no film). Breaking strength was tested acutely (15-20 minutes after sacrifice).

RESULTS

The patched incisions were statistically stronger than the controls (ANOVA, P < 0.05).

CONCLUSIONS

Polymer film patches may be a viable method to increase acute breaking strengths of welds using topically applied solder.

Laser-tissue soldering with biodegradable polymer films in vitro: film surface morphology and hydration effects

BACKGROUND AND OBJECTIVE

Previous research introduced the concept of using biodegradable polymer film reinforcement of a liquid albumin solder for improvement of the tensile strength of repaired incisions in vitro. In this study, the effect of creating small pores in the PLGA films on the weld breaking strength is studied. Additionally, the effect of hydration on the strength of the reinforced welds is investigated.

STUDY DESIGN/MATERIALS AND METHODS

A 50%(w/v) bovine serum albumin solder with 0.5 mg/mL Indocyanine Green dye was used to repair an incision in bovine aorta. The solder was coagulated with an 806-nm CW diode laser. A poly(DL-lactic-co-glycolic acid) (PLGA) film was used to reinforce the solder (the controls had solder but no reinforcement). Breaking strengths were measured acutely and after hydration in saline for 1 and 2 days. The data were analyzed by ANOVA (P < 0.05) and multiple comparisons of means were performed using the Newman-Keuls test.

RESULTS

The creation of pores in the PLGA films qualitatively improved the film flexibility without having an apparent adverse effect on the breaking strength, while the actual technique of applying the film and solder had more of an effect. The acute maximum average breaking strengths of some of the film reinforced specimens (114.7 g-134.4 g) were significantly higher (P < 0.05) than the acute maximum average breaking strength of the unreinforced control specimens (68.3 g). Film reinforced specimens were shown to have a statistically significantly higher breaking strength than unreinforced controls after 1- and 2-day hydration.

CONCLUSIONS

Reinforcement of liquid albumin solders in laser-assisted incision repair appears to have advantages over conventional methods that do not reinforce the cohesive strength of the solder in terms of acute breaking strength and after immersion in moist environments for short periods of time. Using a film with the solder applied to one surface only may be advantageous over other techniques.