The impact of atherosclerosis and vascular collagen on energy-based vessel sealing



      Bipolar energy ligation of vessels in surgery is common. Although rare, serious failures occur. Atherosclerosis may contribute to seal failures by altering vascular compressibility and collagen content; however, no data exist.

      Materials and methods

      Femoral and iliac arteries of six Yucatan swine with an identified genetic locus predisposing them to atherosclerosis were denuded with a Fogarty catheter. Animals were fed a high-fat diet for 28 wk. A Yorkshire pig was used as a normal control and fed a standard diet. At 28 wk, arteries were measured for their diameters, sealed, and divided in vivo with LigaSure. The sealed artery sections were excised and subjected to burst pressure testing. Half of the seal distal to the aorta was kept intact for histology and collagen and elastin quantification. A multiple linear regression model was used to assess variables contributing to burst pressure. Covariates included were vessel diameter, degree of atherosclerosis, and collagen content.


      Experimental animals were hypercholesterolemic. Atherosclerosis occurred in 90% of seals in induced animals, with severe atherosclerosis in 62% of seals. There was site-selective deposition of atherosclerotic plaques in larger diameter iliac vessels. A model including collagen and size best predicted burst pressure. Every 10-U increase in collagen resulted in 15% increase in burst pressure (95% confidence interval = 0.2%–32%, P = 0.047, R2 = 0.36). Atherosclerosis was unrelated to burst pressure controlling for collagen and size.


      Collagen and size provide the best model fit for predicting burst pressure. Quantitative research in human vasculature is warranted to better understand the influence of atherosclerosis and collagen content on seal failures.


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        • Edwards S.D.
        • Peirce S.C.
        • Hedges A.
        • Crawford D.C.
        • Centre for evidence based purchasing. United Kingdom
        Electrosurgical vessel sealing systems. Report 06008.
        CEDAR Clinical Engineering Device Assessment and Reporting Cardiff Medicentre University Hospital of Wales Heath Park, London2006
        • Jarvinen O.T.
        • Tarkka M.R.
        Atherosclerosis of the visceral arteries.
        Vasa. 1995; 24: 9
        • Anselmo D.M.
        • Perez I.A.
        • Shaul D.B.
        Thoracoscopic pneumonectomy for severe bronchiectasis in a 9-year-old female.
        J Laparoendosc Adv Surg Tech A. 2008; 18: 775
        • Santini M.
        • Fiorello A.
        • Vicidomini G.
        • Laperuta P.
        The use of LigaSure for preservation of a previous coronary artery bypass graft by using the left internal thoracic artery in a left upper lobectomy.
        J Thorac Cardiovasc Surg. 2008; 136: 222
        • Meehan J.J.
        • Phearman L.
        • Sandler A.
        Robotic pulmonary resections in children: series report and introduction of a new robotic instrument.
        J Laparoendosc Adv Surg Tech A. 2008; 18: 293
        • Molnar T.F.
        (Video assisted) thoracoscopic surgery: getting started.
        J Minim Access Surg. 2007; 3: 173
        • Matsumura Y.
        • Kondo T.
        Indication and procedure of video-assisted thoracoscopic surgery to thymic disease.
        Kyobu Geka. 2006; 59: 742
        • Santini M.
        • Vicidomini G.
        • Baldi A.
        • et al.
        Use of an electrothermal bipolar tissue sealing system in lung surgery.
        Eur J Cardiothorac Surg. 2006; 29: 226
        • Shigemura N.
        • Akashi A.
        • Nakagiri T.
        • Ohta M.
        • Matsuda H.
        A new tissue-sealing technique using the Ligasure system for nonanatomical pulmonary resection: preliminary results of sutureless and stapleless thoracoscopic surgery.
        Ann Thorac Surg. 2004; 77 (discussion 1419): 1415
        • Tirabassi M.V.
        • Banever G.T.
        • Tashjian D.B.
        • Moriarty K.P.
        Quantitation of lung sealing in the survival swine model.
        J Pediatr Surg. 2004; 39: 387
        • Sugi K.
        • Kaneda Y.
        • Satoh Y.
        • Murakami T.
        Use of the bipolar vessel sealing system in lung resection.
        Kyobu Geka. 2003; 56: 551
        • Albanese C.T.
        • Sydorak R.M.
        • Tsao K.
        • Lee H.
        Thoracoscopic lobectomy for prenatally diagnosed lung lesions.
        J Pediatr Surg. 2003; 38: 553
        • Sindram D.
        • Martin K.
        • Meadows J.P.
        • et al.
        Collagen-elastin ratio predicts burst pressure of arterial seals created using a bipolar vessel sealing device in a porcine model.
        Surg Endosc. 2011; 25: 2604
      1. Manufacturer and User Facility Device Experience (MAUDE):

        • Martin S.T.
        • Heeney A.
        • Pierce C.
        • O'Connell P.R.
        • Hyland J.M.
        • Winter D.C.
        Use of an electrothermal bipolar sealing device in ligation of major mesenteric vessels during laparoscopic colorectal resection.
        Tech Coloproctol. 2011; 15: 285
      2. Covidien, 510k submission via FOI, 200–2012.

        • Gal D.
        • Isner J.
        Atherosclerotic Yucatan microswine: an animal model with high-grade, fibrocalcific, nonfatty lesions suitable for testing catheter-based interventions.
        Am Heart J. 1990; 119: 291
        • Solanes N.
        • Rigol M.
        • Ramírez J.
        • et al.
        Histological basis of the porcine femoral artery for vascular research.
        Anat Histol Embryol. 2005; 34: 105
        • Diamantis T.
        • Gialikaris S.
        • Kontos M.
        • et al.
        Comparison of safety and efficacy of ultrasonic and bipolar thermal energy: an experimental study.
        Surg Laparosc Endosc Percutan Tech. 2008; 18: 384
        • Harold K.L.
        • Pollinger H.
        • Matthews B.D.
        • Kercher K.W.
        • Sing R.F.
        • Heniford B.T.
        Comparison of ultrasonic energy, bipolar thermal energy, and vascular clips for the hemostasis of small-, medium-, and large-sized arteries.
        Surg Endosc. 2003; 17: 1228
        • Lamberton G.R.
        • Hsi R.S.
        • Jin D.H.
        • Lindler T.U.
        • Jellison F.C.
        • Baldwin D.D.
        Prospective comparison of four laparoscopic vessel ligation devices.
        J Endourol. 2008; 22: 2307
        • Newcomb W.L.
        • Hope W.W.
        • Schmelzer T.M.
        • et al.
        Comparison of blood vessel sealing among new electrosurgical and ultrasonic devices.
        Surg Endosc. 2009; 23: 90
        • Person B.
        • Vivas D.A.
        • Ruiz D.
        • Talcott M.
        • Coad J.E.
        • Wexner S.D.
        Comparison of four energy-based vascular sealing and cutting instruments: a porcine model.
        Surg Endosc. 2008; 22: 534
        • Krugman K.A.
        • Martin K.E.
        • Cosgriff N.
        • Slakey D.P.
        In search of the autologous clip: a case for experimental standardization.
        J Laparoendosc Adv Surg Tech A. 2011; 21: 721
        • Stary H.C.
        • Chandler A.B.
        • Dinsmore R.E.
        • et al.
        A definition of advanced types of atherosclerotic lesions and a histological classification of atherosclerosis. A report from the Committee on Vascular Lesions of the Council on Arteriosclerosis, American Heart Association.
        Arterioscler Thromb Vasc Biol. 1995; 15: 1512
        • Edwards C.A.
        • O'Brien W.
        Modified assay for determination of hydroxyproline in a tissue hydrolyzate.
        Clin Chim Acta. 1980; 104: 161
        • Reddy G.K.
        • Enwemeka C.S.
        A simplified method for the analysis of hydroxyproline in biological tissues.
        Clin Biochem. 1996; 29: 225
        • Baron R.M.
        • Kenny D.A.
        The moderator-mediator variable distinction in social psychological research: conceptual, strategic, and statistical considerations.
        J Pers Soc Psychol. 1986; 51: 1173
        • Stary H.C.
        Lipid and macrophage accumulations in arteries of children and the development of atherosclerosis.
        Am J Clin Nutr. 2000; 72: 1297S
        • VanderLaan P.A.
        • Reardon C.A.
        • Getz G.S.
        Site specificity of atherosclerosis: site-selective responses to atherosclerotic modulators.
        Arterioscler Thromb Vasc Biol. 2004; 24: 12
        • Abdelhalim M.A.
        • Alhomida S.N.
        • Al-Ayed M.S.
        The changes in various hydroxyproline fractions in aortic tissue of rabbits are closely related to the progression of atherosclerosis.
        Lipids Health Dis. 2010; 9: 1476
        • Chee K.
        • Chin W.
        • Hung W.
        • Chuen L.
        • Richards M.
        • Sorokina V.
        Characteristics of aortic wall extracellular matrix in patients with acute myocardial infarction: tissue microarray detection of collagen I, collagen III and elastin levels.
        Interact Cardiovasc Thorac Surg. 2013; 16: 11
        • Nili N.
        • Zhang M.
        • Strauss B.H.
        • Bendeck M.P.
        Biochemical analysis of collagen and elastin synthesis in the balloon injured rat carotid artery.
        Cardiovasc Pathol. 2002; 11: 272
        • Strauss B.H.
        • Chisholm R.J.
        • Keeley F.W.
        • Gotlieb A.I.
        • Logan R.A.
        • Armstrong P.W.
        Extracellular matrix remodeling after balloon angioplasty injury in a rabbit model of restenosis.
        Circ Res. 1994; 75: 650
        • Burton A.C.
        Relation of structure to function of the tissues of the wall of blood vessels.
        Physiol Rev. 1954; 34: 619
        • Fischer G.M.
        • Llaurado J.G.
        Collagen and elastin content in canine arteries selected from functionally different vascular beds.
        Circ Res. 1966; 19: 394
        • Richter S.
        • Kollmar O.
        • Neunhoeffer E.
        • et al.
        Differential response of arteries and veins to bipolar vessel sealing: evaluation of a novel reusable device.
        J Laparoendosc Adv Surg Tech A. 2006; 16: 149