Nonpenetrating Titanium Clips Research Articles

The Use of Cranial Aneurysm Clips for Repair of Incidental Lumbar Durotomy: Operative Technique and Case Series

BackgroundIncidental durotomy is a common complication of posterior lumbar spine surgery, however effective and durable methods for primary repair remain elusive. Multiple existing techniques have previously been reported and extensively described including sutured repair and non-penetrating titanium clips. The use of cranial aneurysm clips for primary repair of lumbar durotomy serves as a safe and effective alternative to obtain watertight closure of a dural tear. MethodsWe performed a retrospective review of patients at a single institution who underwent primary repair of an incidental lumbar durotomy with use of an aneurysm clip during open posterior lumbar surgery between 2012 and 2023. Patient demographics, operative details, and postoperative metrics were collected and examined to evaluate the safety and efficacy of the novel technique. ResultsA total of 51 patients were included for analysis. Four patients underwent durotomy repair with aneurysm clip alone, 27 patients were repaired with aneurysm clip and fibrin glue, and 20 patients had repair with aneurysm clip, fibrin glue, and a collagen dural substitute. Three (5.9%) patients reported headaches, 2 (3.9%) with psuedomeningocele, and 1 (2%) with wound leakage. Two (3.9%) patients had treatment failure with return to OR for repair of CSF leak. ConclusionWe report the largest series of patients undergoing primary repair of incidental durotomy with the use of an aneurysm clip. Utilization of an aneurysm clip is noted to be a safe, quick and effective method of primary repair when compared to existing repair techniques such as sutured repair or non-penetrating titanium clips.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma.

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae. Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported. Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation. Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Repair of Incidental Durotomy Using Sutureless Nonpenetrating Clips via Biportal Endoscopic Surgery.

Study Design:Technical report.Objectives:Dural tear is one of the most common complications of endoscopic spine surgery. Although endoscopic dural repair of the durotomy area may be difficult, we successfully repaired the dural tear area using nonpenetrating clips during biportal endoscopic surgery. We introduce the surgical technique of dural repair using nonpenetrating titanium clips in biportal endoscopic spine surgery and report its clinical outcome.Methods:We retrospectively reviewed and analyzed 5 patients who were treated via primary dural repair using nonpenetrating titanium clips during biportal endoscopic lumbar surgery. The 2 methods of dural clipping and repair include 2 or 3 portals. We analyzed radiological parameters such as cerebrospinal fluid collection as well as clinical parameters, including postoperative clinical outcomes.Results:Five patients underwent biportal endoscopic dural repair using nonpenetrating clips. Incidental durotomy was successfully repaired using nonpenetrating titanium clips in all 5 patients. No cerebrospinal fluid collection was detected in the postoperative magnetic resonance images. Clinically, preoperative symptoms improved significantly after surgery (P < .05).Conclusions:We repaired the dural tear area completely using nonpenetrating titanium vascular anastomosis clips in biportal endoscopic lumbar surgery. Dural repair via clipping method may be an effective alternative for incidental durotomy.

Study on the Role of Non Penetrating Titanium Clips in Dural Repair

Study design: A Prospective study. Objective: Dural injuries (Durotomy) are a common complication often seen in spine surgeries. Primary repair of dura using conventional techniques with sutures (silk or prolene) is considered gold standard in management. Overview of Literature: The use of Non-penetrating Titanium clips as an alternate for the sutures in Dural closure has been described in literatures. The surgical use of titanium clips alone for the primary repair of dura in spine surgeries is yet to be substantiated. Aim of this study is to assess the role of non-penetrating Titanium clips in Dural repair surgeries. Methods: This is a study conducted from November 2017 to July 2019 involving a total of hundred forty one spine patients. Thirty seven patients who had undergone spinal epidural steroid injections and scoliosis surgeries were excluded from the study. Of the hundred and four cases, fifteen cases had undergone Dural repair. Non-penetrating Titanium clips were applied in five of the cases. Results: Among the five cases, three were female and two male patients. Three cases undergone spinal decompression and fusion, one case of microdiscectomy and one case of intradural extramedullary tumor excision. Size of Dural tear range from 0.5 cm to 3 cm. The number of clips applied ranges from one to fifteen numbers. Among the study group, four patients had a smooth post-operative period without any signs and symptoms. One patient who had undergone intradural tumor excision, developed post-operative wound leakage and postural headache. Conclusion: Non-penetrating titanium clips produce complete Dural closure with no suture holes. We conclude non-penetrating clips can be used as an alternative for conventional sutures for durotomy repair.

Primary Dural Repair after Endoscopic Endonasal Approaches to the Cribriform Using Nonpenetrating Titanium Clips: Initial Experience and Surgical Technique

Primary Dural Repair after Endoscopic Endonasal Approaches to the Cribriform Using Nonpenetrating Titanium Clips: Initial Experience and Surgical Technique

Dural Closure In Confined Spaces of the Skull Base with Nonpenetrating Titanium Clips

Background Dural repair in areas with limited operative maneuverability has long been a challenge in skull base surgery. Without adequate dural closure, postoperative complications, including cerebrospinal fluid (CSF) leak and infection, can occur. Objective To show a novel method by which nonpenetrating, nonmagnetic titanium microclips can be used to repair dural defects in areas with limited operative access along the skull base. Methods We reviewed 53 consecutive surgical patients in whom a dural repair technique utilizing titanium microclips was performed from 2013 to 2016 at our institution. The repairs primarily involved difficult-to-reach dural defects in which primary suturing was difficult or impractical. A detailed surgical technique is described in 3 selected cases involving the anterior, middle, and posterior fossae, respectively. An additional 5 cases are provided in more limited detail to demonstrate clip artifact on postoperative imaging. Rates of postoperative CSF leak and other complications are reported. Results The microclip technique was performed successfully in 53 patients. The most common pathology in this cohort was skull base meningioma (32/53). Additional surgical indications included traumatic dural lacerations (9/53), nonmeningioma tumors (8/53), and other pathologies (4/53). The clip artifact present on postoperative imaging was minor and did not interfere with imaging interpretation. CSF leak occurred postoperatively in 3 (6%) patients. No obvious complications attributable to microclip usage were encountered. Conclusion In our experience, intracranial dural closure with nonpenetrating, nonmagnetic titanium microclips is a feasible adjunct to traditional methods of dural repair.

Evaluation of Metallic Artifacts Caused by Nonpenetrating Titanium Clips in Postoperative Neuroimaging

Nonpenetrating titanium clips create no suture holes and thereby reduce cerebrospinal fluid leakage after dural closure. However, no data exist regarding metallic artifacts caused by these clips during postoperative neuroimaging. We aimed to evaluate clip-related artifacts on postoperative magnetic resonance (MR) images of 17 patients who underwent spinal surgery. A phantom study evaluated the size of metallic artifacts, and a clinical study evaluated the quality of postoperative spinal MR images. Both 1.5-T studies used T1-weighted and T2-weighted fast spin echo sequences. The phantom study compared clip and artifact size for 10 clips. Artifacts were defined as signal voids surrounded by high signal amplitude that followed the clip shape. In the clinical study, 2 neurosurgeons assessed 22 images from 17 patients of the spinal cord, cauda equina, and paravertebral muscles adjacent to the nonpenetrating titanium clips, using 5-point scales. Mean metallic artifact sizes were 4.82 ± 0.16 mm (T1) and 4.66 ± 0.25 mm (T2; P < 0.001 vs. control). The former and latter were respectively 207% and 200% larger than the clip size. Both readers graded spinal cord and paravertebral muscles images as 3 or 4, indicating very good image quality regardless of clip-related artifacts, with excellent interobserver agreement (κ= 0.99 and 0.98, respectively). Metallic artifacts caused by nonpenetrating titanium clips were 200% larger than the actual clip but did not affect spinal cord and extradural tissue visualization. The use of these clips for closing the spinal dura mater does not alter postoperative radiologic evaluation quality.

The dural repair using the combination of polyglycolic acid mesh and fibrin glue and postoperative management in spine surgery

Accidental dural tears are iatrogenic complications during spine surgery. However, there is no established intraoperative method or postoperative management in this situation. To examine the efficacy of the intraoperative method of dural repair, which consists of using the combination of a polyglycolic acid (PGA) mesh and fibrin glue, and the postoperative management of accidental dural tear or intended durotomy. Seventy-five patients (34 males and 41 females; age range, 16-80 years; mean age, 57.1 years) underwent dural repair intraoperatively from December 2007 to January 2015 at our institution. We repaired dural tears using suture or nonpenetrating titanium clips, followed by reinforcement with a PGA mesh and fibrin glue intraoperatively. In all cases, epidural drains were placed in the wound, then taken off suction and maintained on gravity only. Postoperatively, patients were kept on flat bedrest until the drain was removed, and were allowed to elevate the head and ambulate as early as possible. Medical records were reviewed retrospectively. Only one patient with persistent cerebrospinal fluid (CSF) leakage underwent reoperation for dural repair 4 days after the initial operation. Another patient had irrigation and debridement for superficial surgical-site infection. The remaining patients had good clinical course without reoperation. Our method of dural repair (i.e., the combination of a PGA mesh with fibrin glue) and postoperative management appear to be effective and safe in this situation. Only one patient out of 75 (1.3%) required reoperation for dural repair.

Comparison of Nonpenetrating Titanium Clips versus Continuous Polypropylene Suture in Dialysis Access Creation

Nonpenetrating titanium surgical clips (clips) offer a theoretical advantage of inducing less intimal hyperplasia at an anastomosis because of less endothelial injury. Whether this translates into improved outcomes when used in the creation of arteriovenous fistulas (AVFs) remains unclear. We sought to compare the maturation, patency, and failure rates of anastomoses created using traditional continuous polypropylene suture and clips. All primary AVF created at a single Veterans Administration Medical Center were reviewed over a 6-year period. Anastomoses were created with either clips or suture based on surgeon preference. Patient characteristics and surgical outcomes were collected. Comparisons were made between the 2 groups. Over a 6-year period, 334 fistulas were created (29% suture and 71% clips) in 326 patients. The mean age was 64.8 ± 11 years with 98% males. Comorbidities included diabetes (70%), hypertension (96.1%), and tobacco use (52.9% previous or current). Approximately half the patients were predialysis. Comparison of patient characteristics showed no differences between the suture and clip groups. There was no significant difference in maturation rate (suture 79% versus clips 72%, P = 0.25), median time to maturation (suture 62 ± 35 versus clips 71 ± 13 days, P = 0.07), 1 year primary patency rate (suture 37.4% versus clips 39.6, P = 0.72), 1 year assisted primary patency rate (suture 82.4% versus clips 76.3%, P = 0.31), or overall failure rates (suture 62% versus clips 58%, P = 0.56). Median time to initial failure or reintervention was not significantly different in the clip group (suture 615 [range, 239-991] versus clips 812 [range, 635-989] days, P = 0.72). Compared to traditional polypropylene suture creation of upper extremity AVFs, nonpenetrating clips had equivalent maturation, 1-year patency, and overall failure rates. Neither clips nor suture offers any clear advantage in the creation of AVF.

36. Comparison of Non-Penetrating Titanium Clips Versus Continuous Polypropylene Suture In Dialysis Fistula Creation

Non-penetrating titanium clips (clips) offer a theoretical advantage of inducing less intimal hyperplasia at an anastomosis due to less endothelial injury. Whether this translates into improved outcomes when used in creating arteriovenous fistulas (AVF) remains unclear. We sought to compare the maturation, patency and failure rates of anastomoses created using traditional continuous polypropylene suture (suture) and clips.

Durotomy repair in minimally invasive transforaminal lumbar interbody fusion by nonpenetrating clips.

Background:Closure of the dura defect may be easy to perform in open lumbar surgery but could be difficult in minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) since MIS-TLIF was done through a small tube, which limited the use of standard dural repair instruments. We used nonpenetrating titanium clips that were originally designed for the vascular anastomoses to repair the dura defect, which is never described in the literature.Methods:We presented a case of spinal stenosis with incidental durotomy while performing MIS-TLIF. We closed the dura laceration with three medium-sized nonpenetrating titanium clips (AnastoClip Vessel Closure System, LeMaitre Vascular, Inc., Burlington, MA).Results:Nonpenetrating titanium clips have the benefits of being technically easy to use, reduced durotomy repair time, decreased bed rest due to related medical complications, superior postoperation with immediate hydrostatic strength, and better reapproximation if it fails to clip successfully. As for the postoperation follow up, clips are tiny and reveal no obvious artifact, especially in cases where the pedicle screws are already causing much artifact.Conclusion:Primary dural closure during MIS-TLIF with clips is an effective way in cases that involve limited tubular space.

Combined petrosal approach for resection of petroclival meningioma

The authors demonstrate a step-by-step surgical technique of the combined petrosal approach for resection of petroclival meningioma. The basic concept of this approach is the combination of the anterior- and posterior-petrosal approaches uniting the infra- and supratentorial surgical fields, thereby providing wide surgical exposure. Our techniques are featured by 1) mastoidectomy preceding craniotomy for minimal bone loss; 2) removal of the tentorium over the tumor for achieving devascularization and wide exposure; 3) water-tight dural closure by using autologous fascia graft, non-penetrating titanium clips, and multi-layered technique for avoiding postoperative cerebrospinal fluid leakage. The video can be found here: http://youtu.be/zMlNE8kMcHA .

Reconstruction of the Dura Using Nonpenetrating Titanium Clips after Removal of Skull Base Tumors

Objective: Prevention of cerebrospinal fluid (CSF) leakage after removal of skull base tumors is very important to avoid postoperative complications. However, dural repair by suturing with conventional needles and stitches is sometimes difficult and time consuming in deep and/or narrow surgical fields. The authors report a reconstruction technique of the skull base dura with nonpenetrating titanium clips in combination with autologous fascia.

Hydrostatic Comparison of Nonpenetrating Titanium Clips Versus Conventional Suture for Repair of Spinal Durotomies

Biomechanics. To compare the hydrostatic strength of suture and nonpenetrating titanium clip repairs of standard spinal durotomies. Dural tears are a frequent complication of spine surgery and can be associated with significant morbidity. Primary repair of durotomies with suture typically is attempted, but a true watertight closure can be difficult to obtain because of leakage through suture tracts. Nonpenetrating titanium clips have been developed for vascular anastomoses and provide a close apposition of the tissues without the creation of a suture tract. Twenty-four calf spines were prepared with laminectomies and the spinal cord was evacuated leaving an intact dura. After Foley catheters were inserted from each end and inflated adjacent to a planned dural defect, the basal flow rate was measured and a 1-cm longitudinal durotomy was made with a scalpel. Eight repairs were performed for each material, which included monofilament suture, braided suture, and nonpenetrating titanium clips. The flow rate at 30, 60, and 90 cm of water and the time needed for each closure were measured. There was no statistically significant difference in the baseline leak rate for all 3 groups. There was no difference in the leakage rate of durotomies repaired with clips and intact specimens at any pressure. Monofilament and braided suture repairs allowed significantly more leakage than both intact and clip-repaired specimens at all pressures. The difference in leak rate increased as the pressure increased. Closing the durotomy with clips took less than half the time of closure with suture. Nonpenetrating titanium clips provide a durotomy closure with immediate hydrostatic strength similar to intact dura whereas suture repair with either suture was significantly less robust. The use of titanium clips was more rapid than that of suture repair.

Spinal dural closure with nonpenetrating titanium clips in pediatric neurosurgery

The authors report a retrospective review of their experience using nonpenetrating titanium anastomotic clips for dural closure in 27 pediatric cases (26 patients) of spinal surgery for a variety of diagnoses. The goal of this review was to define the utility of these clips in pediatric neurosurgical spinal procedures, identify complications of their use, and assess the effects on postoperative imaging because of their use. Institutional review board approval was obtained for a retrospective chart review of all patients in whom titanium dural clips had been utilized. Patients were identified over a 2-year period using hospital and clinic records, and data were collected on the patient demographics, surgical diagnosis and procedure, durotomy location and length, and adjunctive closure methods. Postoperative complications were assessed. When available, postoperative imaging data were reviewed. Twenty-six patients underwent 27 operations over a 20-month period. They ranged in age from 2.5 months to 18.5 years, with a median age of 3.2 years and an average age of 5.8 years. The operative diagnosis was some form of spinal dysraphism in 19 patients, with a syrinx or dural tear in 2 patients each, and an arachnoid cyst in 3 cases; 1 patient had a tumor resected. Operative levels included lumbosacral (19), thoracic (7), and cervical (1). Dural exposure was limited to 1 laminar level in 16 cases, 2 levels in 8, and 3 levels in 1; 2 cases involved focal dural tears. A combination of additional hemostatic and tissue sealant materials was applied over the clips in 16 cases. One patient required reoperation 13 months after clip placement. Prior clip use did not make subsequent exposure and opening more complicated. No significant complications were identified in the follow-up period ranging from 1 to 24 months. There were no documented CSF leaks. The clips are not easily seen on plain radiographs and did not cause artifacts or distortion on either CT or MR imaging. Nonpenetrating titanium anastomotic clips afford an effective means of closure while limiting the exposure needed, and thus allowing more minimally invasive approaches. In tight spaces, dural closure is accomplished more easily and faster with the clips as compared with conventional suturing. No significant complications were seen from clip use, and the clips did not interfere with postoperative imaging.

A new technique for management of intercavernous sinus bleeding with titanium clips in transsphenoidal surgery

Venous bleeding induced by intercavernous sinus injury during sellar dural opening is a challenging intraoperative complication and is difficult to treat in transsphenoidal surgery. To date, few studies concerning the management of intercavernous sinus bleeding have been reported. Our aim was to assess the clinical outcomes of a new hemostasis technique utilizing nonpenetrating titanium clips for management of intercavernous sinus bleeding. From January 2007 to July 2008, 242 pituitary tumors were operated using a transnasal transsphenoidal approach. A new technique involving a specially devised clip applier and titanium clips was used to control venous bleeding in 13 (5.4%) patients who exhibited a prominent intercavernous sinus. All patients were evaluated clinically and radiologically at 9 to 24 months, and postoperative magnetic resonance imaging (MRI) was performed at 3 to 18 months. No operation was interrupted or aborted due to ineffective bleeding control, and there was no delayed bleeding noted as a complication. No complications related to the use of the device occurred. Imaging studies revealed no evidence of significant clip artifact. Our surgical experience has revealed that this new hemostasis technique can be a safe, rapid and effective method for control of intercavernous sinus bleeding during sellar dural opening in transsphenoidal surgery. However, a further prospective study to evaluate this method more fully is planned.

Vein Patch Angioplasty with Non-Penetrating Titanium Clips. Comparison to Standard Suture Technique

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angio-graphically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 ± 1.8 min. for clips vs. 8.5 ± 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 ± 1.5 min. vs. 10.1 ± 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histologi-cal differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

The use of titanium non-penetrating clips to close the spinal dura

We present the results of our initial experience in the use of non-penetrating titanium clips in the closure of spinal dura. A retrospective analysis of case notes of patients identified from the unit database was carried out, limited to adults. A proforma that included demographic details, the diagnosis, the procedure undertaken, whether or not additional dural closure methods were used, the use of bed rest and any complications, including cerebrospinal fluid (CSF) leak. There were 58 patients with a mean age of 53 years. The commonest diagnoses were meningioma, ependymoma and neurofibroma. Eight patients had additional methods of dural closure used and approximately half the patients had a period of postoperative bed rest. Eight patients (13.7%) had a CSF leak. Our early experience with the use of non-penetrating clips for the closure of the spinal dura is presented. We have found them easy to use, especially in anatomically-restricted spaces and rapid in their application. However, our results have revealed an unexpectedly high complication rate. A further prospective study to evaluate them more fully is planned.

Novel proximal and distal anastomotic devices for coronary artery bypass surgery

THE CURRENT LITERATURE describes many varied experimental and clinical applications of minimally invasive techniques to enhance outcomes after coronary artery bypass grafting (CABG). Many techniques facilitating anastomotic procedures are described, but long-term data supporting improved patency rates, efficiency of surgical technique, and outcomes are limited. The growing need for minimally invasive procedures and means of reducing the complexity of endoscopic suturing will be the impetus that drives the development and implementation of such anastomotic devices. Applications of simultaneous suturing, stapling, clipping, stenting, and sealing devices have provided insight toward the development of clinically acceptable procedures to facilitate positive outcomes in minimally invasive CABG surgery. Proximal anastomotic devices not only decrease operative time but also allow the surgeon to avoid using a partial occlusion clamp on the ascending aorta during CABG.1 Successful reports of an aortic anastomotic device (AAD) for sutureless anastomosis to the proximal aorta of saphenous vein grafts without aortic manipulation2,3 may provide the technologic basis to pursue distal anastomotic devices in coronary surgery. However, applying such techniques to create distal anastomoses may prove more difficult and require development of unique technologies; robotic assistance toward totally endoscopic CABG makes these goals more challenging. The ideal distal anastomotic device would have applicability to all potential conduits with interchangeable proximal/distal order and a safe bailout in the case of device malfunction.4 The ability to decrease operative time, create superb anastomoses without technical imperfection, and improve long-term patency rates lends excitement to the developing frontier of distal anastomotic devices in minimally invasive CABG surgery. The objective of this review is to compare the existing devices and provide a basis for continued development of novel anastomotic devices. The anesthetic implications will be considered.

Favorable scanning electron microscopic findings of stapled saphenous vein–carotid artery anastomoses

Background. In the progress toward “off-pump” endoscopic coronary artery surgical procedures, new techniques for coronary artery anastomoses are being developed. One such approach is the use of nonpenetrating titanium clips. We evaluated the quality of anastomoses achieved using this technique in a porcine model of saphenous vein–carotid artery grafting using scanning electron microscopy. Methods. Bilateral saphenous vein–carotid artery interposition grafts were implanted in 10 “white race” pigs, using the nonpenetrating clips in one side of the neck and conventional hand suturing on the opposite side. One week after operation, the grafts were harvested. Results. All grafts were patent 7 days after operation, and 40 anastomoses underwent scanning electron microscopic study. In all samples, the luminal surfaces of both the carotid artery and vein graft were covered by a continuous layer of endothelial cells up to the anastomosis. Anastomotic sites in all clipped samples and most of the sutured anastomoses were completely endothelialized, and anastomotic clefts were indistinguishable. However, in 25% of sutured specimens, the suture material remained clearly visible inside the lumen of the vessel, and the subendothelial matrix remained exposed, with extensive fibrin, red blood cells, and platelet deposition on its surface. Conclusions. Because the endothelial coverage consistently appeared to be complete and the subendothelial matrix was not exposed, it is likely that the risk of early anastomotic thrombosis is reduced by using the nonpenetrating titanium clips.