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PubMed2003

Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries.

BACKGROUND: Advanced laparoscopic procedures have necessitated the development of new technology for vascular control. Suture ligation can be time-consuming and cumbersome during laparoscopic dissection. Titanium clips have been used for hemostasis, and recently plastic clips and energy sources such as ultrasonic coagulating shears and bipolar thermal energy devices have become popular. The purpose of this study was to compare the bursting pressure of arteries sealed with ultrasonic coagulating shears (UCS), electrothermal bipolar vessel sealer (EBVS), titanium laparoscopic clips (LCs), and plastic laparoscopic clips (PCs). In addition, the spread of thermal injury from the UCS and the EBVS was compared. METHODS: Arteries in three size groups (2-3, 4-5 and 6-7 mm) were harvested from freshly euthanized pigs. Each of the four devices was used to seal 16 specimens from each size group for burst testing. A 5-Fr catheter was placed into the open end of the specimen and secured with a purse-string suture. The catheter was connected to a pressure monitor and saline was infused until there was leakage from the sealed end. This defined the bursting pressure in mmHg. The ultrasonic shears and bipolar thermal device were used to seal an additional 8 vessels in each size group, which were sent for histologic examination. These were examined with hematoxylin and eosin stains, and the extent of thermal injury, defined by coagulation necrosis, was measured in millimeters. Analysis of variance was performed and, where appropriate, a Tukey's test was also performed. RESULTS: The EBVS's mean burst pressure was statistically higher than that of the UCS at 4 or 5 mm (601 vs 205 mmHg) and 6 or 7 mm (442 vs 175 mmHg). EBVS had higher burst pressures for the 4 or 5-mm group (601 mmHg) and 6 or 7-mm group (442 mmHg) compared with its pressure at 2 or 3 mm (128 mmHg) ( p = 0.0001). The burst pressures of the UCS and EBVS at 2 or 3 mm were not significantly different. Both clips were statistically stronger than the thermal devices except at 4 or 5 mm, in which case the EBVS was as strong as the LC (601 vs 593 mmHg). The PC and LC were similar except at 4 or 5 mm, where the PC was superior (854 vs 593 mmHg). The PC burst pressure for 4 or 5 mm (854 mmHg) was statistically higher than that for vessels 2 or 3 mm (737 mmHg) but not different from the 6 or 7 mm pressure (767 mmHg). Thermal spread was not statistically different when comparing EBVS and UCS at any size (EBVS mean = 2.57 mm vs UCS mean = 2.18 mm). CONCLUSIONS: Both the PC and LC secured all vessel sizes to well above physiologic levels. The EBVS can be used confidently in vessels up to 7 mm. There is no difference in the thermal spread of the LigaSure vessel sealer and the UCS.

Animals↗

PubMed2002

Endoscopic clipping versus band ligation in the management of bleeding esophageal varices.

BACKGROUND: The effectiveness of endoscopic clipping in the hemostasis of bleeding esophageal varices and the eventual variceal eradication was compared with that of band ligation. METHODS: Forty patients were enrolled in the study in a prospective manner, 19 of whom received endoscopic clipping (group I) and the remaining (n = 21 patients) received endoscopic band ligation (group II). All patients in this study presented with bleeding from esophageal varices. The patient characteristics (age, sex, Child-Pugh score, variceal grade) were comparable in the two groups. After initial hemostasis, the patients were assigned one of the two forms of endoscopic therapy which was continued in the follow-up sessions until varices were eradicated. Early and late results were compared. RESULTS: Initial hemostasis was achieved in all patients in group I but two patients in group II required clip ligation for initial hemostasis because of the failure in band ligation. Those two were treated with band ligation in the follow-up sessions. A total of 224 clips in 53 treatment sessions and 296 bands in 82 treatment sessions were placed in group I and group II, respectively. The rates of complete variceal eradication were 89% and 76% in group I and group II, respectively (p > 0.05). The median number of required treatment sessions for complete eradication of the varices was significantly lower in group I than group II (3 versus 4, p = 0.013). Three patients from group I (15%) and seven patients from group II (33%) were readmitted for variceal bleeding during the follow-up period (p > 0.05). CONCLUSIONS: With the advantages of high initial hemostasis rate, decreased risk of rebleeding, and fewer treatment sessions needed for variceal eradication, endoscopic clipping is as effective as band ligation, or perhaps more effective in the treatment of bleeding esophageal varices.

Blood Transfusion↗

PubMed2000

Choledochal stenosis and lithiasis caused by penetration and migration of surgical metal clips.

A 71-year-old woman, who had undergone laparoscopic cholecystectomy 1 year previously at our hospital, presented with abdominal pain, high fever, and jaundice. She was diagnosed with choledochal stenosis caused by migration of the clips that were used at the previous operation. At reoperation, the common bile duct was successfully dissected, including the stenotic site, where a metal clip was found to be penetrating the duct wall. The stenotic site was sufficiently resected, when a black-brown gallstone was found proximally to the stenosis. Interestingly, the stone was found to contain two metal clips, which were considered to have migrated into the bile duct and to have acted as a nidus for stone formation. The common bile duct was reconstructed by direct end-to-end anastomosis. Surgeons must exercise caution in the use of metal clips, keeping in mind the potential risk of clip migration.

Aged↗

PubMed2005

Vascular closure stapler clips versus polypropylene sutures in end-to-end anastomoses of growing arteries and veins.

Alternatives are still being sought in vascular surgery to avoid the complications caused in growing vessels by the various suture techniques and materials currently in use. A major complication is arrested growth following anastomosis. Opinions differ widely regarding the best approach to this problem, and research is currently underway at our center on the latest generation of clip appliers (vascular closure stapler, or VCS) and their potential application as an alternative to the conventional suture technique in pediatric vascular surgery. This study compared vascular growth and reendothelialization following anastomosis of growing arteries and veins using VCS clips versus the conventional interrupted polypropylene suture technique. Thirty 55-day-old lambs underwent end-to-end anastomosis of the carotid artery and jugular vein. Serial ultrasonography and angiography were carried out over the ensuing 6-month growth period, after which the lambs were euthanized. Gross examination of the anastomosis site was followed by histologic examination involving light microscopy, immunohistochemical techniques, and transmission electron microscopy. Although both VCS clips and polypropylene sutures allowed transverse vessel growth, the clips did not penetrate the intima and thus provided enhanced reendothelialization. The satisfactory results obtained here, as in earlier studies, increasingly point to VCS clips as the method of choice in pediatric vascular surgery.

Anastomosis, Surgical↗

PubMed1984

Interruption of the inferior vena cava by clip or filter.

Interruption of the inferior vena cava is usually performed with either external clipping or transvenous filter placement. For patients unable to tolerate general anesthesia and laparotomy, the advantages of transvenous filters rather than clips are obvious. However, for some patients, the use of either clips or filters is possible. In general, retrospective observational studies of inferior vena caval interruption have not adequately accounted for baseline patient characteristics such as age, presence of cancer, and history of prior venous thromboembolism. These confounding factors can independently affect subsequent rates of both recurrent embolism and overall mortality. A comparative, controlled, prospective evaluation of inferior vena caval clipping versus transvenous filter placement among patients who are appropriate candidates for either procedure has not been undertaken. It is suggested that, among patients with good long-term prognoses, a randomized controlled trial would be necessary to help determine whether clipping or transvenous filter placement is more efficacious.

Clinical Trials as Topic↗

PubMed1991

Temporary clipping in aneurysm surgery: technique and results.

The use of temporary clipping has become an established tool in the armamentarium of the aneurysm surgeon. Our experience with 62 consecutive patients is presented, detailing operative protocols and results. Twenty-two had unruptured aneurysms (35%), 15 were grade I (24%), 16 grade II (25%), five grade III (8%), and four grade IV (7%). The aneurysms were mainly located in the middle cerebral artery (29 patients) and the anterior communicating artery (13 patients). Eleven of our 62 patients (17%) developed a new, persistent postoperative deficit. However, in only one case (2%) was temporary clipping felt to be implicated in the development of the deficit. In three other patients (5%), the effect of temporary clipping, although unlikely, could not be excluded. Overall, 92% of our patients with temporary clipping had good to excellent outcome, with 3% mortality and 5% morbidity. We believe that temporary clipping is a safe procedure that contributes significantly to a better outcome.

Adult↗

PubMed1990

Use of the inferior vena cava clip in patients at high risk for pulmonary embolism.

Sixteen gynecologic oncology patients at high risk of developing a postoperative pulmonary embolism underwent prophylactic clipping of the inferior vena cava during laparotomy for tumor resection. All patients had a prior history of deep venous thrombosis or pulmonary embolism or had an active deep venous thrombosis at the time of their surgery. Additionally, this group of 16 patients was characterized as being at high risk for recurrent thrombosis in the postoperative period based on traditional risk factors that are representative of most gynecologic oncology patients. The Adams-DeWeese or Moretz clip was used in this series. There were no pulmonary emboli in our 16 patients in the postoperative period or during follow-up. There were no signs of venous stasis attributable to clip placement. The procedure was quick, simple, and complication free and the external clip has the advantage of maintaining effectiveness throughout the patient's lifetime. Prophylactic clipping of the inferior vena cava at the time of laparotomy in patients at an increased risk of thrombosis deserves further study.

Constriction↗

PubMedDate not supplied

Removal of Arg1 and Phe22 from CLIP (ACTH18-39) by rodent pituitary and blood peptidases.

The major product on incubation of CLIP (ACTH18-39) with rat and mouse serum, rat plasma and whole blood, and soluble extracts of rat pituitary is [des-Arg1]-CLIP (ACTH19-39) while [des-Phe22]-CLIP (ACTH18-38) is the major product with pituitary particulate fraction. In both cases, p-chloromercuribenzoate-sensitive, metal-dependent peptidase activity appears to be responsible for the cleavage. The serum enzyme may be related to proline aminopeptidase. Material coeluting with [des-Arg]-CLIP on two HPLC solvent gradients is present in the superfusion media from neurointermediate lobes of genetically obese (ob/ob) mice but is not present in acid extracts of the lobe. This suggests that postsecretory processing of CLIP may involve removal of the N-terminal Arg residue.

Adrenocorticotropic Hormone↗

PubMedDate not supplied

Computed tomographic evaluation of surgical clip artifact: tissue phantom and experimental animal assessment.

Surgical clips in postoperative patients create streak artifact on computed tomographic (CT) studies which often significantly degrade image quality. We have evaluated three types of surgical clips: tantalum, stainless steel, and titanium in a phantom and animal model to assess their relative CT artifact. Tantalum clips showed the greatest artifact, stainless steel intermediate, and titanium the least artifact. Artifact could be reduced with the use of faster scan times. The type of clip used may enter into surgical decision making depending upon the need for high resolution scanning to detect small pathological processes in the area of surgical clips.

Animals↗

PubMed2004

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.

Anastomosis, Surgical↗

PubMed2005

Robotic mitral valve annuloplasty with double-arm nitinol U-clips.

PURPOSE: Robotic mitral valve repair increases precision however operative times are longer. Prior studies have indicated that robotic knot tying is time consuming and it is without potential room for improvement. We therefore investigated tissue approximation devices that may shorten operative times. DESCRIPTION: A 67-year-old female was approached through a right mini-thoracotomy with the da Vinci Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Using 12 nitinol U-clips (Coalescent Surgical, Sunnyvale, CA) an annuloplasty band was placed under robotic guidance. Clip placement and deployment times were recorded and statistical comparisons were assessed to prior suture annuloplasties. EVALUATION: Clip placement time was 1.3 +/- 0.9 (minutes +/- standard deviation), statistical comparison with first, most recent, and all prior suture annuloplasties proving no significance. Clip deployment time was 0.5 +/- 0.2, whereas knot-tying times and respective statistical comparison for first, most recent, and all prior suture annuloplasties were 2.0 +/- 0.7 (p = 0.003), 1.2 +/- 0.4 (p = 0.0004), and 1.6 +/- 0.6 (p < 0.00001). Follow-up echocardiography performed postoperatively, at 3 months, and at 9 months revealed valvular structural integrity with only minimal mitral regurgitation. CONCLUSIONS: U-clips considerably reduce time for annuloplasty over conventional suture and may help reduce operative times as well.

Aged↗

PubMed2005

Overexpression and preliminary X-ray crystallographic analysis of prophenoloxidase activating factor II, a clip domain family of serine proteases.

A clip domain family of serine proteases has been identified in invertebrates as a crucial enzyme involved in diverse biological processes including immune responses and embryonic development. Although these proteins contain at least one clip domain at the N-terminal of the serine protease domain, the roles and three-dimensional structure of the clip domain are unknown. Prophenoloxidase activating factor-II (PPAF-II), a clip domain family of serine proteases, derived from the beetle Holotrichia diomphalia larvae, was overexpressed in the baculovirus system, and crystallized using the hanging-drop vapor-diffusion method. High-quality single crystals of PPAF-II were obtained in a precipitant solution containing 0.15 M ammonium sulfate, 1.25 M lithium sulfate monohydrate, and 0.1 M sodium citrate dehydrate (pH 5.5). These crystals belong to space group C2 with unit-cell parameters a=107.84, b=76.78, c=70.49 A and beta=113.93 degrees , and contain one or two molecules in the asymmetric unit. Determination of the three-dimensional structure of PPAF-II would clarify the functions of the clip domains.

Crystallography, X-Ray↗

PubMed2006

Microtubule binding proteins CLIP-170, EB1, and p150Glued form distinct plus-end complexes.

Microtubule plus-end proteins CLIP-170 and EB1 dynamically track the tips of growing microtubules in vivo. Here we examine the association of these proteins with microtubules in vitro. CLIP-170 binds tubulin dimers and co-assembles into growing microtubules. EB1 binds tubulin dimers more weakly, so no co-assembly is observed. However, EB1 binds to CLIP-170, and forms a co-complex with CLIP-170 and tubulin that is recruited to growing microtubule plus ends. The interaction between CLIP-170 and EB1 is competitively inhibited by the related CAP-Gly protein p150Glued, which also localizes to microtubule plus ends in vivo. Based on these observations, we propose a model in which the formation of distinct plus-end complexes may differentially affect microtubule dynamics in vivo.

Animals↗

PubMed2006

Endoluminal closure of large perforations of colon with clips in a porcine model (with video).

BACKGROUND: Endoluminal clip closure of small perforations of the colon is possible. It is unclear whether large perforations of the colon can be closed with clips deployed through a colonoscope. OBJECTIVES: To evaluate the technical feasibility and outcome of endoluminal closure of large perforations of the colon with clips. DESIGN: Pilot study. SUBJECTS: Eight pigs. INTERVENTIONS: Endoluminal clip closure of large perforations of the colon. MAIN OUTCOME MEASUREMENTS: Technical feasibility of endoluminal closure was evaluated in 8 animals. A dye leak test was performed to evaluate quality of endoluminal sealing immediately after closure and 2 weeks after closure. The animals in the survival group were monitored daily for 2 weeks for sepsis and peritonitis. Necropsy was done on day 14 to check for fecal peritonitis, wound dehiscence, and histological healing of perforation. RESULTS: Endoscopic closure of colon perforation was successful in 6 of 8 animals; in 2 animals closure was unsuccessful due to prolapse of adjacent viscera into the colon (n = 1) and severe bleeding that obscured the view (n = 1). There was a leak-proof sealing of the perforation site in 2 animals tested immediately and in all the animals tested (n = 3) 2 weeks after closure. All 4 animals in the survival group recovered well, without any sepsis or peritonitis. Necropsy did not reveal fecal peritonitis or pericolonic abscess formation. The perforation site demonstrated a thin scar and there was histological healing. CONCLUSIONS: Endoluminal application of clips is successful in the closure of a large perforation of the colon in a porcine model.

Animals↗

PubMed2006

Comparison of suture ligation and clip application for the treatment of patent ductus arteriosus in preterm neonates.

OBJECTIVE: We reviewed the experience of 2 centers performing surgical ligation of patent ductus arteriosus in preterm neonates to identify whether the choice of surgical technique--suture ligation or clip application--affected outcome. METHODS: Between 2000 and 2005, 67 newborn infants had open surgical closure of patent ductus arteriosus: 33 by suture ligation and 34 by clip application. The groups were similar in age and sex. RESULTS: The average length of the procedure was 55.8 +/- 13.7 minutes for suture ligation and 30.8 +/- 8.7 minutes for clip application (P < .05). Six neonates had intraoperative bleeding in the suture ligation group. Four patients had significant postoperative complications in the suture ligation group, compared with 2 in the clip application group. CONCLUSIONS: This study demonstrates that clip application results in a significant reduction in the operative time and, possibly, in less morbidity.

Cardiac Surgical Procedures↗

PubMed2005

Using on-line video clips to enhance self-efficacy toward dealing with difficult situations among nursing students.

The aim of the study was twofold. The first aim was to develop on-line video clip material that showed examples of nurses dealing with potentially difficult and delicate patient groups. The second aim was to evaluate the effectiveness of video clip materials for enhancing nursing student's self-efficacy to effectively communicate with the type of patients described above. The production of contextually relevant video clip material involved the identification of relevant material based on real experiences, writing appropriate scripts, recruiting actors, recording the performances and producing them in a form that could be accessed on-line. Self-report questionnaires were used to assess the effectiveness of video clip material. Level 1 (n = 145) nursing students completed a self-efficacy measure that assessed confidence to deal with situations such as breaking news of death, working with children, people with disability and aggressive behaviour at the start and the end of the module. Results indicated that student's self-efficacy increased noticeably over the course of the module. Differences between increases in self-efficacy attributed to watching videos or attending lectures were marginal. Findings suggest that using video clips that show students effectively coping with adverse situations provide an effective teaching approach for enhancing self-efficacy. Future research is needed to test the extent to which self-efficacy measures relate with nursing performance.

Adaptation, Psychological↗

PubMed2006

Arterial suturing followed by clip reinforcement with circumferential wrapping for blister-like aneurysms of the internal carotid artery.

OBJECTIVE: Blister-like aneurysms of the internal carotid artery (ICA) are very fragile, thin-walled aneurysms. These lesions are susceptible to premature rupture intraoperatively. We describe two cases of successful arterial suturing of these blister-like aneurysms of the ICA, followed by a clip reinforcement technique and circumferential wrapping with a silastic sheet. METHODS: Two young men presented with a diffuse and dense subarachnoid hemorrhage (SAH) in the basal cistern. The initial angiogram obtained soon after the SAH showed a broad-based, small bulging appearance of the dorsal wall of the ICA. Intraoperatively, a very thin-walled aneurysm was identified on the C2 and C1 segment of the ICA. The aneurysms ruptured abruptly during surgical manipulation. After application of temporary clips, an aneurysmal tear of the ICA was repaired with 8-0 nylon. To prevent the regrowth of the aneurysm, clip reinforcement, by circumferential wrapping with a transparent silicone sheet, was added. RESULTS: The postoperative clinical course was uneventful, although one patient showed transient right hemiparesis due to cerebral vasospasm. Angiographic studies performed postoperatively showed complete obliteration of the aneurysm as well as a patent ICA lumen in one case and total occlusion of the ICA in the other case. Both patients were discharged with no neurological deficits. CONCLUSION: This technique can be a useful treatment option for these fragile aneurysms in cases where other options, such as direct clips or encircling clips, may be impossible.

Adult↗

PubMed1998

Rapid arterial anastomosis with titanium clips.

BACKGROUND: The obvious advantages of rapid arterial anastomoses have prompted the continuing search for more rapid anastomotic techniques to complement the standard sutured anastomosis. Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses. The purpose of this study was to compare VCS clips with sutured arterial end-to-end anastomosis in larger vessels. METHODS: In 6 pigs, transacted iliac arteries were reanastomosed with VCS clips on one side and continuous 6-0 polypropylene suture on the other. RESULTS: The reconstruction time was 8.4+/-5.2 minutes for clip closure and 12.0+/-6.6 minutes for suture closure (P = 0.033). All vessels were patent half an hour after completing the anastomoses with no signs of early thrombosis. CONCLUSIONS: Arterial end-to-end anastomosis can be performed more rapidly with VCS clips than continuous sutures, and are potentially useful in situations where the clamp time of the vessel is critical.

Anastomosis, Surgical↗