Response of constrained and unconstrained bubbles to lithotripter shock wave pulses

Shock wave-induced permeabilization of mammalian cells

Controlled permeabilization of mammalian cell membranes is fundamental to develop gene and cell therapies based on macromolecular cargo delivery, a process that emerged against an increasing number of health afflictions, including genetic disorders, cancer and infections. Viral vectors have been successfully used for macromolecular delivery; however, they may have unpredictable side effects and have been limited to life-threatening cases. Thus, several chemical and physical methods have been explored to introduce drugs, vaccines, and nucleic acids into cells. One of the most appealing physical methods to deliver genes into cells is shock wave-induced poration. High-speed microjets of fluid, emitted due to the collapse of microbubbles after shock wave passage, represent the most significant mechanism that contributes to cell membrane poration by this technique. Herein, progress in shock wave-induced permeabilization of mammalian cells is presented. After covering the main concepts related to molecular strategies whose applications depend on safer drug delivery methods, the physics behind shock wave phenomena is described. Insights into the use of shock waves for cell membrane permeation are discussed, along with an overview of the two major biomedical applications thereof-i.e., genetic modification and anti-cancer shock wave-assisted chemotherapy. The aim of this review is to summarize 30 years of data showing underwater shock waves as a safe, noninvasive method for macromolecular delivery into mammalian cells, encouraging the development of further research, which is still required before the introduction of this promising tool into clinical practice.

Comparing microbubble cavitation at 500 kHz and 70 kHz related to micellar drug delivery using ultrasound

We have previously reported that ultrasonic drug release at 70kHz was found to correlate with the presence of subharmonic emissions. No evidence of drug release or of the subharmonic emissions were detected in experiments at 500kHz. In an attempt to understand the difference in drug release behavior between low- and mid-frequency ultrasound, a mathematical model of a bubble oscillator was developed to explore the difference in the behavior of a single 10-μm bubble under 500- and 70-kHz ultrasound. The dynamics were found to be fundamentally different; the 500-kHz bubble follows a period-doubling route to chaos while a 70-kHz bubble follows an intermittent route to chaos. We propose that this type of "intermittent subharmonic" oscillation behavior is associated with the drug release observed experimentally.

Lithotripsy

Shock wave lithotripsy (SWL) is the process of fragmentation of renal or ureteric stones by the use of repetitive shock waves generated outside the body and focused onto the stone. Following its introduction in 1980, SWL revolutionized the treatment of kidney stones by offering patients a non-invasive procedure. It is now seen as a mature technology and its use is perceived to be routine. It is noteworthy that, at the time of its introduction, there was a great effort to discover the mechanism(s) by which it works, and the type of sound field that is optimal. Although nearly three decades of subsequent research have increased the knowledge base significantly, the mechanisms are still controversial. Furthermore there is a growing body of evidence that SWL results in injury to the kidney which may have long-term side effects, such as new onset hypertension, although again there is much controversy within the field. Currently, use of lithotripsy is waning, particularly with the advent of minimally invasive ureteroscopic approaches. The goal here is to review the state of the art in SWL and to present the barriers and challenges that need to be addressed for SWL to deliver on its initial promise of a safe, effective, non-invasive treatment for kidney stones.

Cavitation detection during shock-wave lithotripsy

A system was built to detect cavitation in pig kidney during shock-wave lithotripsy (SWL) with a Dornier HM3 lithotripter. Active detection using echo on B-mode ultrasound, and passive cavitation detection using coincident signals on confocal orthogonal receivers, were used to interrogate the renal collecting system (urine) and the kidney parenchyma (tissue). Cavitation was detected in urine immediately upon shock-wave (SW) administration in urine or urine plus X-ray contrast agent but, in native tissue, cavitation required hundreds of SWs to initiate. Localization of cavitation was confirmed by fluoroscopy, sonography and by thermally marking the kidney using the passive cavitation detection receivers as high-intensity focused ultrasound sources. Cavitation collapse times in tissue and native urine were about the same, but less than in urine after injection of X-ray contrast agent. The finding that cavitation occurs in kidney tissue is a critical step toward determining the mechanisms of tissue injury in SWL.

Cavitation bubble cluster activity in the breakage of kidney stones by lithotripter shockwaves

BACKGROUND AND PURPOSE

There is strong evidence that cavitation bubble activity contributes to stone breakage and that shockwave-bubble interactions are involved in the tissue trauma associated with shockwave lithotripsy. Cavitation control may thus be a way to improve lithotripsy.

MATERIALS AND METHODS

High-speed photography was used to analyze cavitation bubble activity at the surface of artificial and natural kidney stones during exposure to lithotripter shockwaves in vitro.

RESULTS

Numerous individual bubbles formed on the surfaces of stones, but these bubbles did not remain independent but rather combined to form clusters. Bubble clusters formed at the proximal and distal ends and at the sides of stones. Each cluster collapsed to a narrow point of impact. Collapse of the proximal cluster eroded the leading face of the stone, and the collapse of clusters at the sides of stones appeared to contribute to the growth of cracks. Collapse of the distal cluster caused minimal damage.

CONCLUSION

Cavitation-mediated damage to stones is attributable, not to the action of solitary bubbles, but to the growth and collapse of bubble clusters.

A theoretical study of acoustic cavitation produced by "positive-only" and "negative-only" pressure waves in relation to in vivo studies

This study investigated the responses of gas bubbles in water, "viscous water" or "lung surfactant" exposed to "positive-only" or "negative-only" pressure pulses. The computational results obtained were compared to the in vivo experimental findings of Bailey et al. (1996), for the thresholds for, and extents of, biological damage endpoints in Drosophila larvae and mouse lungs exposed to similar pressure pulses. It is shown that, if cavitation were the mechanism responsible for these biologic effects, the two pulse types would be expected to produce very different thresholds and amounts of damage unless: 1. the bubbles involved were larger than the linear resonance radius, or 2. the cavitational activity were located within a fraction of a wavelength of an air-tissue interface. A noncavitational, acoustic force mechanism for the effects also is considered. Finally, it is suggested that the mechanical index may require modification when the focus of the acoustic field lies near an air-tissue interface.

Suppression of large intraluminal bubble expansion in shock wave lithotripsy without compromising stone comminution: methodology and in vitro experiments

To reduce the potential of vascular injury without compromising the stone comminution capability of a Dornier HM-3 lithotripter, we have devised a method to suppress intraluminal bubble expansion via in situ pulse superposition. A thin shell ellipsoidal reflector insert was designed and fabricated to fit snugly into the original reflector of an HM-3 lithotripter. The inner surface of the reflector insert shares the same first focus with the original HM-3 reflector, but has its second focus located 5 mm proximal to the generator than that of the HM-3 reflector. With this modification, the original lithotripter shock wave is partitioned into a leading lithotripter pulse (peak positive pressure of 46 MPa and positive pulse duration of 1 micros at 24 kV) and an ensuing second compressive wave of 10 MPa peak pressure and 2 micros pulse duration, separated from each other by about 4 micros. Superposition of the two waves leads to a selective truncation of the trailing tensile component of the lithotripter shock wave, and consequently, a reduction in the maximum bubble expansion up to 41% compared to that produced by the original reflector. The pulse amplitude and -6 dB beam width of the leading lithotripter shock wave from the upgraded reflector at 24 kV are comparable to that produced by the original HM-3 reflector at 20 kV. At the lithotripter focus, while only about 30 shocks are needed to cause a rupture of a blood vessel phantom made of cellulose hollow fiber (i.d.=0.2 mm) using the original HM-3 reflector at 20 kV, no rupture could be produced after 200 shocks using the upgraded reflector at 24 kV. On the other hand, after 100 shocks the upgraded reflector at 24 kV can achieve a stone comminution efficiency of 22%, which is better than the 18% efficiency produced by the original reflector at 20 kV (p = 0.043). All together, it has been shown in vitro that the upgraded reflector can produce satisfactory stone comminution while significantly reducing the potential for vessel rupture in shock wave lithotripsy.

Measurements of bubble-enhanced heating from focused, MHz-frequency ultrasound in a tissue-mimicking material

Time-resolved measurements of the temperature field in an agar-based tissue-mimicking phantom insonated with a large aperture 1-MHz focused acoustic transducer are reported. The acoustic pressure amplitude and insonation duration were varied. Above a critical threshold acoustic pressure, a large increase in the temperature rise during insonation was observed. Evidence for the hypothesis that cavitation bubble activity in the focal zone is the cause of enhanced heating is presented and discussed. Mechanisms for bubble-assisted heating are presented and modeled, and quantitative estimates for the thermal power generated by viscous dissipation and bubble acoustic radiation are given.

The search for cavitation in vivo

Until the mid 1970s, it was generally assumed that, with the short pulses of ultrasound (US) used in medical diagnosis, there was little need for concern about the possibility of inertial cavitation in vivo. This assumption came into question when experimental evidence indicated that killing of fruit fly larvae by diagnostically relevant US was associated with the presence of gas in the respiratory apparatus of the organisms. Independent theoretical contributions by Flynn and Apfel in the early 1980s made it clear that complacency in regard to cavitation was not warranted. Later, the mammalian lung, as with larva, was shown to be particularly vulnerable when it contained air. Yet, overall evidence suggests that lung hemorrhage is not consistent with the classical picture of inertial cavitation. Most recently, however, hemolysis and hemorrhage associated with the use of contrast agents have provided nearly incontrovertible evidence of the occurrence of cavitation in vivo.

Comparative sensitivity of human and bovine erythrocytes to sonolysis by 1-MHz ultrasound

This project tested the hypothesis that human erythrocytes, being larger than bovine erythrocytes, would be the more sensitive to sonolysis induced by inertial cavitation. The rationale behind this hypothesis was an earlier demonstration that, among sized populations of erythrocytes, an inverse relation existed between erythrocyte volume and mechanically-induced shear forces in the surrounding medium; viz, the larger the cell, the less shear force required to rupture the cell's membrane. At low erythrocyte densities (i.e., approximately 5% hematocrit) the hypothesis was supported; at high cell densities (i.e., approximately 35% hematocrit) it was not supported. The data are consistent with an ultrasound (US)-induced symmetric implosion of affected gas nuclei as causing the effect at low cell densities; under such conditions there is ample spacing among cells for US-induced symmetric growth and collapse of gas nuclei and the concomitant production of radially-expanding shock waves (which lyse the cells); at high cell densities there is not sufficient spacing among cells for US-induced symmetric growth and collapse of bubbles and an alternative mechanism, possibly asymmetric bubble collapse, becomes operational.

Bioeffects of positive and negative acoustic pressures in mice infused with microbubbles

This study provided one test of the hypothesis that hemorrhage in tissues containing ultrasound (US) contrast agents results from inertial cavitation. The test relied on the prediction of classical cavitation theory that the response of microbubbles to negative pressures is much greater than it is for positive pressures. An endoscopic electrohydraulic lithotripter was used to generate a spherically diverging positive pressure pulse. A negative pressure pulse was produced by reflection of the positive pulse from a pressure release interface. Mice were injected with approximately 0. 1 mL of Albunex(R) and exposed to 100 pulses at either + 3.6 MPa or -3.6 MPa pressure amplitude. For comparison, mice were also exposed to the same acoustic fields without injection of contrast agents. Sham animals experienced the same protocols, with or without Albunex(R) injections, but were not exposed to the lithotripter fields. Following exposure, mice were scored for hemorrhage to various organs and tissues. When Albunex(R) was present in the vasculature, negative pressure pulses produced significantly more hemorrhage than positive pressures in tissues such as the kidney, intestine, skin, muscle, fat, mesentery and stomach.

A dual passive cavitation detector for localized detection of lithotripsy-induced cavitation in vitro

A passive cavitation detector (PCD) identifies cavitation events by sensing acoustic emissions generated by the collapse of bubbles. In this work, a dual passive cavitation detector (dual PCD), consisting of a pair of orthogonal confocal receivers, is described for use in shock wave lithotripsy. Cavitation events are detected by both receivers and can be localized to within 5 mm by the nature of the small intersecting volume of the focal areas of the two receivers in association with a coincidence detection algorithm. A calibration technique, based on the impulse response of the transducer, was employed to estimate radiated pressures at collapse near the bubble. Results are presented for the in vitro cavitation fields of both a clinical and a research electrohydraulic lithotripter. The measured lifetime of the primary growth-and-collapse of the cavitation bubbles increased from 180 to 420 microseconds as the power setting was increased from 12 to 24 kV. The measured lifetime compared well with calculations based on the Gilmore-Akulichev formulation for bubble dynamics. The radiated acoustic pressure 10 mm from the collapsing cavitation bubble was measured to vary from 4 to 16 MPa with increasing power setting; although the trends agreed with calculations, the predicted values were four times larger than measured values. The axial length of the cavitation field correlated well with the 6-dB region of the acoustic field. However, the width of the cavitation field (10 mm) was significantly narrower than the acoustic field (25 mm) as bubbles appeared to be drawn to the acoustic axis during the collapse. The dual PCD also detected signals from "rebounds," secondary and tertiary growth-and-collapse cycles. The measured rebound time did not agree with calculations from the single-bubble model. The rebounds could be fitted to a Rayleigh collapse model by considering the entire bubble cloud as an effective single bubble. The results from the dual PCD agreed well with images from high-speed photography. The results indicate that single-bubble theory is sufficient to model lithotripsy cavitation dynamics up to time of the main collapse, but that upon collapse bubble cloud dynamics becomes important.

Shock wave-inertial microbubble interaction: a theoretical study based on the Gilmore formulation for bubble dynamics

The Gilmore formulation for bubble dynamics coupled with zeroth-order gas diffusion were used to investigate theoretically the cavitation activity produced by a modified XL-1 lithotripter [J. Acoust. Soc. Am. 105, 1997-2009 (1999)]. The model calculation confirms many of the basic features in bubble dynamics observed experimentally, in particular the strong secondary shock wave emission generated by in situ lithotripter shock wave-inertial microbubble interaction. In addition, shock wave-inertial microbubble interaction produced by a Dornier HM-3, the most commonly used clinical lithotripter, was evaluated. It was shown that the forced collapse of inertial microbubbles with strong secondary shock wave emission could be produced consistently, provided that an appropriate preceding shock wave and interpulse delay were used. Further, it was demonstrated that truncation of the tensile stress of the lithotripter shock wave could significantly reduce the large expansion of the bubble following shock wave-inertial microbubble interaction, which may alleviate the risk for vascular injury during shock wave exposure.

Comparison of electrohydraulic lithotripters with rigid and pressure-release ellipsoidal reflectors. II. Cavitation fields

Dramatically different cavitation was produced by two separate acoustic pulses that had different shapes but similar duration, frequency content, and peak positive and negative pressure. Both pulses were produced by a Dornier HM-3 style lithotripter: one pulse when the ellipsoidal reflector was rigid, the other when the reflector was pressure release. The cavitation, or bubble action, generated by the conventional rigid-reflector pulse was nearly 50 times longer lived and 3-13 times stronger than that produced by the pressure-release-reflector pulse. Cavitation durations measured by passive acoustic detection and high-speed video agreed with calculations based on the Gilmore equation. Cavitation intensity, or destructive potential, was judged (1) experimentally by the size of pits in aluminum foil detectors and (2) numerically by the calculated amplitude of the shock wave emitted by a collapsing bubble. The results indicate that the trailing positive spike in the pressure-release-reflector waveform stifles bubble growth and mitigates the collapse, whereas the trough after the positive spike in the rigid-reflector waveform triggers inertially driven growth and collapse. The two reflectors therefore provide a tool to compare effects in weakly and strongly cavitating fields and thereby help assess cavitation's role in lithotripsy.

Dynamic behavior of bubbles during extracorporeal shock-wave lithotripsy

The interaction of air bubbles attached to gelatin surfaces, extirpated livers or abdominal aortas of rats with underwater shock waves was investigated to help clarify the tissue-damage mechanism associated with cavitation bubbles induced during extracorporeal shock-wave lithotripsy. The overpressure of the shock wave was 10.2 +/- 0.5 MPa. The initial bubble radii varied from 0.12 to 3.06 mm. The subsequent collapse of the bubbles was recorded by a high-speed camera. The liver-cell damage was histochemically evaluated. The bubble attached to gelatin or rat's liver surface migrates away from the surface with an oscillatory growth/collapse behavior after the shock-wave interaction. The penetration depth of the liquid jet into the gelatin and the radius of the subsequent damage pit on the surface depend on the initial bubble radius. The elongation and split of the nuclei in the liver parenchymal cells in the direction of the liquid jet and the increase in the cell density within the circumference of the injured region are revealed histologically.

Thresholds for intestinal hemorrhage in mice exposed to a piezoelectric lithotripter

The threshold for hemorrhage in mouse intestine was determined using the fields of a piezoelectric lithotripter. Exposures were controlled by variation of the position of the animal relative to the focus and by variation of the voltage used to charge the lithotripter. The range of peak positive pressure for exposures was approximately 50 MPa to 1 MPa. Each exposure consisted of 200 pulses at a repetition rate of approximately 1 Hz. Depending upon the exposure level, intestinal lesions ranged in size from small petechiae to hemorrhagic regions extending 5 cm or more along the intestine. Threshold for intestinal hemorrhage with this exposure protocol was in the range of 1 to 3 MPa. At threshold, the lithotripter waveform was nearly sinusoidal.