Direct measurement of clamping forces in cardiovascular surgery

Pilot study of minimum occlusive force of vascular clamps on arterial vessels in rats

Our aims were to determine the accuracy of an improved formula for determining the minimum occlusive force (MOF) of a vascular clamp on rats' abdominal aortas, compare our findings with the calculated theoretical MOF, and provide reference data for clinical research and development of medical instruments that cause minimal damage. We created a vessel closure model and developed a formula for calculating the theoretical MOF of arterial vessels when they are occluded. This formula utilises the blood pressure in the blood vessel, its diameter, and the width of the vascular clamp. We then measured the actual MOF in 24 rat abdominal aortic segments with different diameters and different blood pressures and compared the theoretical and actual MOFs. Analysis of the experimental data showed a probability of 0.315, which means that, under the condition of normal distribution, the difference between the theoretical and actual MOF is not significant at the α = 0.05 level. Thus, the actual measured MOF tended to be consistent with the theoretical MOF calculated by the formula we developed. The improved formula will provide a reference for clinical research and development of medical instruments that cause minimal injury, thus contributing to the development of microsurgery.

Three-dimensional Printed Microvascular Clamps: A Safe, Cheap, and Effective Instrumentation for Microsurgery Training

Microsurgical training involves practice in ex vivo models during the early learning curve, and poor instrument handling by the inexperienced microsurgeons can cause damage to microsurgical instrumentation or clamps, which is particularly costly. To address this, we demonstrate the development, design, manufacturing, and application of 3 different types of 3-dimensional printed microvascular clamps in an ex vivo simulation training model. This report provides evidence of a low-cost and easily accessible device that facilitates the process of microsurgical training. The clamps were found to provide advantages akin to normal stainless-steel microvascular clamps in training settings.

Preparation of the Neck for Advanced Flap Reconstruction

Microvascular free tissue transfer has revolutionized the reconstruction of complex maxillofacial defects. These cases often necessitate a 2-teamed approach, with an ablative surgeon at the head and a reconstructive surgeon at a distant site for flap harvest. Careful attention to recipient vessel identification and preservation establishes the foundation for successful reconstruction. This article describes the surgical landmarks of the frequently utilized arteries and veins, vessel handling techniques, and general principles for the preparation of free tissue transfer recipient sites in head and neck reconstruction.

Computational evaluation of aortic occlusion and the proposal of a novel, improved occluder: Constrained endo-aortic balloon occlusion

Because aortic occlusion is arguably one of the most dangerous aortic manipulation maneuvers during cardiac surgery in terms of perioperative ischemic neurological injury, the purpose of this investigation is to assess the structural mechanical impact resulting from the use of existing and newly proposed occluders. Existing (clinically used) occluders considered include different cross-clamps (CCs) and endo-aortic balloon occlusion (EABO). A novel occluder is also introduced, namely, constrained EABO (CEABO), which consists of applying a constrainer externally around the aorta when performing EABO. Computational solid mechanics are employed to investigate each occluder according to a comprehensive list of functional requirements. The potential of a state of occlusion is also considered for the first time. Three different constrainer designs are evaluated for CEABO. Although the CCs were responsible for the highest strains, largest deformation, and most inefficient increase of the occlusion potential, it remains the most stable, simplest, and cheapest occluder. The different CC hinge geometries resulted in poorer performance of CC used for minimally invasive procedures than conventional ones. CEABO with a profiled constrainer successfully addresses the EABO shortcomings of safety, stability, and positioning accuracy, while maintaining its complexities of operation (disadvantage) and yielding additional functionalities (advantage). Moreover, CEABO is able to achieve the previously unattainable potential to provide a clinically determinable state of occlusion. CEABO offers an attractive alternative to the shortcomings of existing occluders, with its design rooted in achieving the highest patient safety. Copyright © 2016 John Wiley & Sons, Ltd.

Comparison of laparoscopic aortic clamps in a pulsatile circulation model

PURPOSE

This study was designed to evaluate the fatigue characteristics and the safety and effectiveness of laparoscopic aortic clamps in a pulsatile circulation model.

METHODS

A heart-lung machine was used to create a pulsatile circulation model with bovine aortas resembling the vessels being cross-clamped. Four different models (A-D) of laparoscopic aortic clamps were investigated, and three identical probes of each model underwent testing. Preliminary examinations were conducted to define the size and thickness of the bovine aortas that would allow effective cross-clamping and to detect gross material or functional deficits of the clamps. Then, the instruments were placed in the circulation model, which was set at a frequency of 82/min and a pressure of 200/120 mm Hg. Each clamp was subjected to these conditions for 120 hours and was opened and closed 40 times to stimulate real-life conditions. Clamping failures and mechanical defects were recorded, and the clamp parts were afterward examined with an electron microscope.

RESULTS

Two clamp models had to be eliminated from the study after the preliminary examinations. All three probes of model B displayed mechanical defects after a few applications. All probes of model D were excluded because none effectively occluded the aortas. All probes of model A and one probe of model C provided effective cross-clamping during the 120-hour test phase and showed no signs of mechanical failure. Two probes of model C broke after 51 and 57 hours of testing, respectively. Both times, the defect occurred during application of the clamps. The detailed analysis of all instruments after the testing, including electron microscope imaging, revealed that several construction deficits and weak points were responsible for the mechanical failures.

CONCLUSION

A surprisingly high incidence of clamping failures and mechanical deficits were encountered during the testing. Of the four clamps tested, only one (model A) seemed to be safe and effective enough for routine clinical use. These disappointing results demonstrate the need for further cooperation between vascular surgeons and instrument manufacturers to develop safe and effective laparoscopic vascular clamps.

Nonfluoroscopic localization of an amagnetic stimulation catheter by multichannel magnetocardiography

This study was performed to: (1) evaluate the accuracy of noninvasive magnetocardiographic (MCG) localization of an amagnetic stimulation catheter; (2) validate the feasibility of this multipurpose catheter; and (3) study the characteristics of cardiac evoked fields. A stimulation catheter specially designed to produce no magnetic disturbances was inserted into the heart of five patients after routine electrophysiological studies. The catheter position was documented on biplane cine x-ray images. MCG signals were then recorded in a magnetically shielded room during cardiac pacing. Noninvasive localization of the catheter's tip and stimulated depolarization was computed from measured MCG data using a moving equivalent current-dipole source in patient-specific boundary element torso models. In all five patients, the MCG localizations were anatomically in good agreement with the catheter positions defined from the x-ray images. The mean distance between the position of the tip of the catheter defined from x-ray fluoroscopy and the MCG localization was 11 +/- 4 mm. The mean three-dimensional difference between the MCG localization at the peak stimulus and the MCG localization, during the ventricular evoked response about 3 ms later, was 4 +/- 1 mm calculated from signal-averaged data. The 95% confidence interval of beat-to-beat localization of the tip of the stimulation catheter from ten consecutive beats in the patients was 4 +/- 2 mm. The propagation velocity of the equivalent current dipole between 5 and 10 ms after the peak stimulus was 0.9 +/- 0.2 m/s. The results show that the use of the amagnetic catheter is technically feasible and reliable in clinical studies. The accurate three-dimensional localization of this multipurpose catheter by multichannel MCG suggests that the method could be developed toward a useful clinical tool during electrophysiological studies.