Abstract
The excimer laser assisted non-occlusive anastomosis (ELANA) technique is used to make anastomoses on intracerebral arteries. This end-to-side anastomosis is created without temporary occlusion of the recipient artery using a 308-nm excimer laser with a ring-shaped multi-fiber catheter to punch an opening in the arterial wall. Over 500 patients have received an ELANA bypass. However, the vessel wall perforation mechanism of the laser catheter is not known exactly and not 100 % successful. In this study, we aimed to understand the mechanism of ELANA vessel perforation using specialized imaging techniques to ultimately improve its effectiveness. High-speed imaging, high-contrast imaging, and high-sensitivity thermal imaging were used to study the laser wall perforation mechanism and reveal the mechanical and thermal effects involved. In vitro, rabbit arteries were exposed with the special designed laser catheter in a setup representative for the clinical setting, in which blood was replaced with a transparent UV absorbing liquid for visualization. We observed that laser vessel wall perforation was caused by explosive vapor bubbles tearing through the vessel wall, mostly within the first 20 of the total 200 pulses. Thermal effects were minimal. Unsymmetrical tension in the vessel wall inducing migration of the flap during laser exposure was observed in case of unsuccessful wall perforations. The laser wall perforation mechanism in the ELANA technique is primarily mechanical. Symmetric tension in the recipient vessel wall is essential and should be trained by neurosurgeons.
Highlights
In very difficult-to-treat intracranial diseases, like giant aneurysms, tumors encasing cerebral arteries, or cerebral hemodynamic insufficiency caused by occluded cerebral arteries, it is sometimes indicated to create a high-flow bypass in the brain [1,2,3,4]
We developed a technique that facilitates the creation of an anastomosis to a large brain artery without having to temporary occlude it: the excimer laser-assisted non-occlusive anastomosis (ELANA) technique [5, 6] (Fig. 1)
The exact working mechanism of the ELANA technique is still unknown. It was only studied in parts, and the knowledge was based on the original research using the 308-nm excimer for laser angioplasty [7,8,9,10]
Summary
In very difficult-to-treat intracranial diseases, like giant aneurysms, tumors encasing cerebral arteries, or cerebral hemodynamic insufficiency caused by occluded cerebral arteries, it is sometimes indicated to create a high-flow bypass in the brain [1,2,3,4]. We developed a technique that facilitates the creation of an anastomosis to a large brain artery without having to temporary occlude it: the excimer laser-assisted non-occlusive anastomosis (ELANA) technique [5, 6] (Fig. 1). The exact working mechanism of the ELANA technique is still unknown. It was only studied in parts, and the knowledge was based on the original research using the 308-nm excimer for laser angioplasty [7,8,9,10]. The ELANA technique showed excellent clinical results [1,2,3,4], it was shown that the full-thickness flap of recipient artery tissue was not retrieved in 12 % of all cases [11]. Not retrieving the flap seemed not to be Lasers Med Sci (2016) 31:1169–1175
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