Long-term reendothelialization of excimer laser—assisted nonocclusive anastomoses compared with conventionally sutured anastomoses in pigs

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Object. In contrast to conventional anastomosis methods, the excimer laser—assisted nonocclusive anastomosis (ELANA) technique involves a platinum ring and intima—adventitia apposition with a rim of medial and adventitial layers exposed to the bloodstream. The authors assessed the reendothelialization of porcine carotid arteries through ELANA compared with conventional anastomosis by using scanning electron microscopy.

Methods. In 28 pigs a bypass with one ELANA and one conventional anastomosis was made on the left common carotid artery. All patent anastomoses were evaluated intraoperatively with the aid of an ultrasonographic flowmeter and postoperatively by using scanning electron microscopy at 2 weeks, 2 months, 3 months, and 6 months thereafter. Twenty-four of 28 bypasses (48 of 56 end-to-side anastomoses) were fully patent at the time of evaluation. On scanning electron microscopic evaluation of the bypasses, all 48 patent anastomoses showed complete reendothelialization, including all 24 ELANAs in which the endothelium covered the rim and the laser-ablated edge completely. No endothelial difference was observed between conventional anastomoses and ELANAs, aside from the obvious anatomical differences like the platinum ring, which had been completely covered with endothelium. At 6 months postsurgery, remodeling of the ELANA was observed, leaving the ring covered with a layer of endothelium as the most narrow part of the anastomosis.

Conclusions. In long-term experiments, ELANA allows reendothelialization comparable to that achieved with conventional anastomosis. Considering its nonocclusive and high-flow characteristics, the ELANA technique is preferable in cerebral revascularization procedures.

Article Information

Address reprint requests to: H. J. N. Streefkerk, M.D., Department of Neurosurgery, University Medical Center—Utrecht, Heidelberglaan 100, Huispost Nr. G03.124, 3584 CX, Utrecht, The Netherlands. email: H.J.N.Streefkerk@ELANA-online.org.

© AANS, except where prohibited by US copyright law.

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Figures

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    Illustrations featuring the ELANA technique. a: A platinum ring is attached to the wall of the recipient artery. b: The graft is stitched to the wall of the recipient artery by using the ring as a guide. c: The ELANA catheter is introduced into the graft. d: The tip of the catheter is positioned within the platinum ring so that the laser fibers are in contact with the wall of the recipient artery. Vacuum suction is then applied through the catheter, ensuring firm fixation of the wall of the recipient artery to the laser fibers. e: When the laser is activated, a disc of arterial wall (flap) is punched out of the recipient artery. f: When the catheter is withdrawn, the flap is also withdrawn with the catheter because of the continued vacuum suction. The anastomosis is now completed, leaving a rim of medial and adventitial layers exposed to the bloodstream within the anastomosis inside the lumen of the platinum ring.

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    Photograph depicting the ELANA catheter. This catheter consists of 180 laser fibers with a diameter of 60 µm each, configured in two circles around a vacuum suction tube with a diameter of 2 mm, and a small metal grid with holes of 0.2 mm within the vacuum tube. The metal grid is located 0.45 mm from the laser fiber tips, preventing the flap from disappearing within the vacuum suction tube. Around the laser fibers is located a large ring (diameter 3 mm) to prevent the catheter from falling through the platinum ring (inner diameter 2.8 mm), thus preventing the catheter from burning the posterior wall of the recipient artery.

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    A: Photograph illustrating the conventional anastomoses and ELANAs immediately on completion. The bypass consists of a transplant of the right CCA onto the left CCA of the pig. The rightmost anastomosis was made using a conventional method. The anastomosis on the left was made using the ELANA technique. Both portions of the bypass were connected using a conventional end-to-end procedure. At specific times (here at 2 months) the bypass was exposed (B) and the pig was killed. The hemoclip between both anastomoses is visible. Intraoperatively, after completing the anastomoses, the bypass was evaluated using angiography (C). During surgical exposition after the death of the animals, severe vasospasm was often observed (D). Local administration of papaverine solution successfully countered the vasospasm.

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    A: Operating microscopic image of the inside of a conventional anastomosis after 2 weeks. The recipient artery has been cut open and the point of view is directed inside the graft. B: Scanning electron microscopic image of the same conventional anastomosis, longitudinal view. Some irregular wall deformities are visible within the lumen. The boltlike structure on the right is an artefact. C: Scanning electron microscopic image, high magnification detail, of the same anastomosis. The endothelial lining of the graft (upper right side) is completely continuous with the recipient artery. D: Operating microscopic image depicting the inside of an ELANA after 2 weeks. Notice that several stay sutures of the ring can be seen shining through. The innermost circle is the lumen of the graft several millimeters away from the anastomosis. Outside this circle, the rim of the real anastomotic site (with the platinum ring shining through) can be observed. E: Scanning electron microscopic image of the same ELANA. The platinum ring has been cut in two for the image. Both ends of the ring can be seen clearly, as well as a thickening of the endothelium, which protrudes into the lumen of the recipient artery just below the platinum ring. The rim of medial and adventitial layers is visible medial of the platinum ring. F: High-magnification detail of the ELANA. There seems to be an accumulation of tissue around the platinum ring. Note, however, that the endothelial surface is completely continuous from the graft, covering the platinum ring, covering the rim, to the recipient. Original magnification × 19 (B), × 112 (C), × 20 (E), × 39 (F).

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    A: Operating microscopic image demonstrating a conventional anastomosis after 2 months, with a point of view from inside the recipient artery, looking through the anastomosis into the graft. The running suture is clearly visible and covered with endothelium. Although the anastomosis is not perfectly round, no irregularity of the anastomosis can be observed. B: Longitudinal scanning electron microscopic image of the same conventional anastomosis demonstrating how the endothelial lining of the graft seems to be continuous with the recipient artery, despite some folding of the graft wall. C: A high-magnification image of the same anastomosis at the transition of recipient to graft revealing that the endothelialization of the anastomosis seems to be complete, with no trace of any transition between graft and recipient. D: Operating microscopic image exhibiting an ELANA after 2 months. The stay sutures for the ring as well as the sutures fixating the graft onto the recipient around the ring are clearly visible and covered with a thin, transparent layer of endothelium. A small portion of the rim is visible in the lower right quadrant, although it has disappeared in the other three quarters of the anastomosis. E: Longitudinal scanning electron microscopic image of the ELANA demonstrating no thickening of the vessel wall below the ring (as seen in Fig. 4E). On top of the ring, the endothelial lining can be seen to have become very thin. F: Scanning electron microscopic image, high magnification, and a small oblique point of view, revealing a ring completely covered with endothelium. Note that the upper surface (graft side) of the ring is covered with several folded layers of endothelium. Original magnification × 19 (B), × 149 (C), × 34 (E), × 133 (F).

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    Scanning electron microscopic image, very high magnification, demonstrating the platinum ring featured in Fig. 5. This image represents a close-up of the rim, which has been created during the laser ablation process. The excimer laser has been activated from the top side downward, first passing the adventitial layer, then the medial layer, and finally the intimal layer. Both adventitial and medial layers are indistinguishable and have been covered with endothelial cells in which the protruding nuclei can be clearly seen. Original magnification × 2127.

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    A: Longitudinal operating microscopic image of a conventional anastomosis after 3 months. Again, the running suture can vaguely be seen shining through a layer of endothelium. B: Scanning electron microscopic image of the same conventional anastomosis revealing that aside from the lumen being somewhat wider, this anastomosis is similar to conventional anastomoses at earlier termination moments. C: Longitudinal operating microscopic image of an ELANA after 3 months. The ring and the sutures can be clearly seen despite being covered with a transparent layer of endothelium. D: Oblique scanning electronic microscopic image of the ELANA demonstrating that the rim has disappeared and the ring is covered with a very thin lining of endothelium, which consists of a very small layer all around the ring. The 9-0 Prolene sutures are also covered with endothelium. The lumina of both recipient and graft appear to be very wide. Original magnification × 20 (B), × 63 (D).

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    A: Overview scanning electron microscopic image of a conventional anastomosis after 6 months. Here, the graft lumen is somewhat wider than the recipient. Nevertheless, the reendothelialization is similar to conventional anastomoses at earlier termination periods. B: High-resolution scanning electron microscopic image of the conventional anastomosis demonstrating that the transition of graft (upper right) to CCA (left) is only distinguishable because of the different muscle contraction direction, which creates the grooved surface of the CCA. The endothelial lining is completely uninterrupted. C: Overview scanning electron microscopic image of an ELANA after 6 months. The laser ablation rim has completely disappeared, leaving the ring covered with a layer of endothelium that is entirely continuous from graft, over the ring, to the CCA. D: High-magnification scanning electron microscopic image of the ELANA demonstrating that the platinum ring has been covered completely with endothelial cells. The 9-0 Prolene sutures once were pulled tight around the tissue of the graft, the ring, and the tissue of the CCA and pulled free from their endothelial cover during the fixation process. Original magnification × 16 (A), × 375 (B), × 25 (C), × 120 (D).

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