Thanks to all collaborators of the Department of Cardiovascular Surgery, Angiology Functional Unit of Humanitas Gavazzeni Hospital, Bergamo, Montallegro Clinic, Genova, BioMedical Institute, Genova.

The research was conducted in three different Italian Centers: Humanitas Research Hospital - Gavazzeni (BG), Montallegro Clinic (GE), and Biomedical Institute (GE) from February 2020 to February 2021, and approved by the hospital&#39;s Ethical Committee or Internal Review Board (IRB). The research was conducted in respect of the Helsinki rules for human rights and GCP. All patients were informed about the risk of the procedure and signed a written consent before being included in the study. Refer to Supplementary File 1 for the overview of the procedure.
1. Preparation
<ol>
	<li>Prepare the room and the operating table with all the materials listed in the Table of Materials. As it is commonly used in human surgical interventions, all the materials are packaged and sterilized at the origin by each manufacturer.</li>
	<li>Place 5% dextrose solution into a bowl and immerse a 3 mL and a 10 mL syringe, a needle (18 G), and either a 1 mL or 2 mL vial (see step 3.2.5) containing NBCA+MS surgical glue.</li>
</ol>
2. Anesthesiology technique and surgical preparation of the patient (Figure 1)
<ol>
	<li>Completely depilate the leg to be treated, from the groin to the foot.</li>
	<li>Disinfect the leg to be treated with an alcoholic solution of 2% chlorhexidine di-gluconate.</li>
	<li>Perform an ECD in the orthostatic and clinostatic positions. Set the instrument through the manufacturer&#39;s software, which provides various presets. 
	NOTE: The venous vascular preset is used for this procedure, and the ultrasound probe is set at 7.5 MHz.
	<ol>
		<li>First, position the patient upright on a step in front of the operator and map the entire venous vascular tree through the ultrasound probe.</li>
		<li>Subsequently, place the patient on the operating table in the supine position and perform the vascular scanning again. This preoperative procedure is necessary for a complete clinical evaluation of the vessels.</li>
	</ol>
	</li>
	<li>Map out the pathway of venous incompetence on the skin through ECD using a dermographic pen (Figure 1).</li>
	<li>Place the patient in the supine position for GSV treatment or the prone position for SSV treatment.</li>
	<li>Disinfect the leg again with an alcoholic solution of 2% chlorhexidine di-gluconate.</li>
	<li>Prepare the sterile field with a surgical drape.</li>
</ol>
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/64170/64170fig01.jpg" /> 
Figure 1: Preparation steps. On the right side, the figure shows the operating table preparation with the tools needed for the procedure, such as disinfectant, 5% dextrose solution, syringes, and an NBCA+MS surgical glue vial. The figure shows a schematic mapping of venous incompetence on the left side. Specifically, this is carried out under ECD guidance using a dermographic pen directly on the patient&#39;s skin. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/64170fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
3. Surgical technique
<ol>
	<li>Time of vascular study (Figure 2)
	<ol>
		<li>Perform the ultrasound-guided study of the lengths and diameters of the veins to be treated as described in step 2.3. Place the patient in the clinostatic position&#160;and perform the vascular study through the ultrasound probe.</li>
		<li>Evaluate the reflux time (RT) with the ultrasound, which defines the degree of incompetence of the terminal valve. The physiological values of RT are 0.1 s &#60; RT &#60; 0.5 s, while RT &#62; 0.5 s indicates a pathological condition4. Carry out the classification of severity by evaluation of the Galeandro quartile11.</li>
		<li>Using the ECD, identify the junction between the epigastric vein and preterminal valve for the treatment of the GSV (Figure 2), or the saphenous-popliteal junction for the treatment of the SSV.</li>
	</ol>
	</li>
	<li>Operative time (Figure 3)
	<ol>
		<li>Induce local anesthesia with 1-1.5 mL of 10 mg/mL mepivacaine in the area of needle insertion.</li>
		<li>Perform ultrasound-guided catheterization of the saphenous vein (GSV/SSV) according to the Seldinger technique12 (using an angiographic needle, a guidewire, and an introducer) 14-16 cm downstream of the relevant junction (Figure 3A).</li>
		<li>Percutaneously insert a 6Fr vascular introducer into the vessel with the help of a guidewire (Figure 3B).</li>
		<li>Under ultrasound guidance, place the tip of the introducer 2-3 cm from the bifurcation of the epigastric vein and preterminal valve (for GSV treatment) (Figure 3C) or 2-4 cm below the saphenous-popliteal junction (for SSV treatment).</li>
		<li>Draw 1 mL of NBCA+MS surgical glue in one syringe for veins with a diameter between 8-10 mm, or 2 mL of NBCA+MS surgical glue for veins over 10 mm.</li>
		<li>Draw 7-10 mL of 5% dextrose solution into one syringe.</li>
		<li>Connect the two syringes to the stopcock of the washing catheter of the introducer (Figure 3D).</li>
	</ol>
	</li>
	<li>Injection time (Figure 4)
	<ol>
		<li>Compress the leg with the ultrasound probe at the level of the bifurcation immediately downstream of the bifurcation itself to stop the blood flow in the saphenous vein (Figure 4A). 
		NOTE: Compression with the ultrasound probe must be strong and maintained throughout the procedure.</li>
		<li>Flush the dead volume of the introducer with dextrose solution (about 2 mL).</li>
		<li>Close the dextrose solution inlet through the stopcock and inject 1 mL of NBCA+MS surgical glue (Figure 4B).</li>
		<li>Through the stopcock, close the NBCA+MS surgical glue inlet and inject the dextrose solution to push the NBCA+MS surgical glue into the vein (Figure 4C).</li>
		<li>At the same time, retract the introducer until it is removed (Figure 4C) to perform a retrograde release of the liquid, adhesive, occlusive, and sclerosing agent (NBCA+MS). Perform a 10 cm occlusion for the GSV or a 7-10 cm occlusion for the SSV.</li>
	</ol>
	</li>
	<li>Closure time (Figure 5)
	<ol>
		<li>Immediately perform manual compression with the palm, starting from the insertion site and along the course of the vein for 3-5 min. At the same time, always keep the compression with the ultrasound probe at the level of the junction (Figure 5).</li>
	</ol>
	</li>
	<li>Conclusive time
	<ol>
		<li>At the end of the compression, raise the hand and verify that there is no bleeding from the insertion site.</li>
		<li>Perform an ECD (step 2.3) to check that there is no more blood flow in the saphenous vein (GSV/SSV).</li>
		<li>Under ultrasound guidance, occlude the varicose collateral veins by direct puncture with polidocanol foam, according to the normal and consolidated clinical practice for this treatment13,14.</li>
		<li>Perform an eccentric compression of the saphenous axis with latex strips or rolls of gauze, wrapping the leg from the groin to the knee.</li>
		<li>With the patient still in the clinostatic position, apply a Class II compression stocking (28-30 mmHg) with an open toe, fitting it like a normal pantyhose.</li>
		<li>At the end of the procedure, mobilize the patient immediately, making him take a few steps over a distance of 10-15 m.</li>
		<li>Before discharge, after 2 h, perform an ECD check.</li>
		<li>Discharge the patient with pain relief/anti-inflammatory therapy as needed (i.e., 200 mg of Ibuprofen, one to three times a day).</li>
		<li>Recommend the patient to wear the compression stocking day and night for 10 days, then only during the day for another 30 days.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/64170/64170fig02.jpg" /> 
Figure 2: Vascular study. ECD identification of the junction between the epigastric vein and the preterminal valve for the treatment of the GSV. The magnification highlights the ECD image showing the femoral artery (FA), femoral vein (FV), superficial epigastric vein (SEV), great saphenous vein (GSV), external circumflex vein (ECV), terminal valve (TV), and preterminal valve (PTV). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/64170fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/64170/64170fig03.jpg" /> 
Figure 3: Operative steps. (A) Ultrasound-guided catheterization of the saphenous vein (GSV/SSV) according to the Seldinger technique: a needle is percutaneously inserted 14-16 cm below the junction. Subsequently, a guidewire is inserted through the needle, which is then removed (not shown in the figure). (B) A 6Fr vascular introducer is inserted with the help of the guidewire. At this point, the guidewire is removed and the introducer is left in position (C) Under ultrasound guidance, the introducer tip is positioned 2-3 cm from the bifurcation of the epigastric vein and the preterminal valve (for GSV treatment). The femoral vein (FV), superficial epigastric vein (SEV), and great saphenous vein (GSV) are highlighted in the picture (D) One syringe loaded with 1 mL of NBCA+MS surgical glue and one syringe loaded with 7 mL of 5% dextrose solution are connected to the stopcock of the introducer washing catheter. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/64170fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/64170/64170fig04.jpg" /> 
Figure 4: Injection steps. (A) Compression of the leg using the ultrasound probe at the level of the bifurcation immediately downstream of it to stop the blood flow in the saphenous vein (GSV/SSV). (B) Closure of the 5% dextrose solution inlet and injection of 1 mL of NBCA+MS surgical glue (black arrow) (C) Closure of the NBCA+MS surgical glue inlet and injection of the 5% dextrose solution to inject the NBCA+MS surgical glue into the vein (black arrow). At the same time, the introducer is retracted to perform a retrograde injection of the NBCA+MS (red arrow). <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/64170fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/64170/64170fig05.jpg" /> 
Figure 5: Closure time. After removal of the introducer, 5 min of manual compression with the palm of the hand is performed at the level of the insertion site and along the course of the vein. Compression with the ultrasound probe is maintained at the level of the bifurcation during the 5 min manual compression. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/64170fig05large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>

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<li>Koramaz, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Ablation+of+the+great+saphenous+vein+with+nontumescent+n-butyl+cyanoacrylate+versus+endovenous+laser+therapy%5BTitle%5D)+AND+%22Journal+of+Vascular+Surgery%3A+Venous+and+Lymphatic+Disorders%22%5BJournal%5D)">Ablation of the great saphenous vein with nontumescent n-butyl cyanoacrylate versus endovenous laser therapy.</a> Journal of Vascular Surgery: Venous and Lymphatic Disorders. 5 (2), 210-215 (2017).</li>
<li>Kollury, L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Network+meta-analysis+to+compare+VenaSeal+with+other+superficial+venous+therapies+for+chronic+venous+insufficiency%5BTitle%5D)+AND+%22Journal+of+Vascular+Surgery%3A+Venous+and+Lymphatic+Disorders%22%5BJournal%5D)">Network meta-analysis to compare VenaSeal with other superficial venous therapies for chronic venous insufficiency.</a> Journal of Vascular Surgery: Venous and Lymphatic Disorders. 8 (3), 472-481 (2020).</li>
<li>Bissacco, D., Stegher, S., Calliari, F. M., Viani, M. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Saphenous+vein+ablation+with+a+new+cyanoacrylate+glue+device%3A+a+systematic+review+on+1000+cases%5BTitle%5D)+AND+%22Minimally+Invasive+Therapy+and+Allied+Technologies%22%5BJournal%5D)">Saphenous vein ablation with a new cyanoacrylate glue device: a systematic review on 1000 cases.</a> Minimally Invasive Therapy and Allied Technologies. 28 (1), 6-14 (2019).</li>
<li>Partsch, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Which+pressure+do+we+need+to+compress+the+great+saphenous+vein+on+the+thigh%5BTitle%5D)+AND+%22Dermatologic+Surgery%22%5BJournal%5D)">Which pressure do we need to compress the great saphenous vein on the thigh.</a> Dermatologic Surgery. 34 (12), 1726-1728 (2008).</li>
<li>Mosti, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Postinterventional+compression+in+phlebology%3A+Evidence+and+empirical+observations%5BTitle%5D)+AND+%22Presence+of+Varices+After+Operative+Treatment%3A+A+Review+%28Part+2%29%22%5BJournal%5D)">Postinterventional compression in phlebology: Evidence and empirical observations.</a> Presence of Varices After Operative Treatment: A Review (Part 2). 2 (1), 12-17 (2015).</li>
</ol>

The authors have nothing to disclose.

The outcomes of this preliminary research show that the described endovenous management of varicose veins by this new method using NBCA+MS surgical glue is a safe technique that allows for a persistent occlusion of the vein(s) at 1 year follow-up, with the resolution of painful legs and peripheral edema. The use of this procedure with the modified glue-indicated and authorized to embolize vessels-allowed for a quick recovery, and patients returned to their usual activities within 1 week after surgery.
The most critical and delicate steps of the procedure are those related to identifying the exact point where the catheter must be inserted to obliterate the saphenous vein (GSV/SSV). A precise ultrasound mapping is necessary to know where the glue must be released, avoiding being too proximal or distal to the saphenofemoral and/or saphenous-popliteal junction, which would make the procedure partially ineffective. A prior hemodynamic study of the saphenous axis must be performed to identify the degree of reflux and any incontinent branches and collateral refluxes.
The GSV was affected by varicose disease more than the SSV; however, the number of glue ampoules was never decided based on the vessel caliber/diameter, but rather always on the function of vein dilatation. In most cases, 2 mL of glue was needed to occlude the vein, because most of the patients had very dilated veins (&#62;10 mm in caliber/diameter); 1 mL of glue was sufficient to completely occlude the vein with a diameter &#60;10 mm in one-third of our patients. After the occlusion via NBCA+MS surgical glue, the various collateral veins were occluded through direct injection of polidocanol foam. One of the most recurrent side effects of polidocanol injections is postoperative pain. Specifically, there is no known minimum volume of polidocanol; it can cause pain even when injected in very low doses17 since it induces inflammatory wall damage. Thus, the postoperative pain experienced following polidocanol injections is independent of its dosage17,18. Moreover, the sensation of pain is patient-dependent. In the present study, none of the patients presented severe negative outcomes (i.e., paresthesia or ecchymosis), and only 7.7% of them needed painkillers to treat postoperative pain.
Cyanoacrylate-based glues have strong embolic or ablative capacities. From a histopathological point of view, the NBCA+MS surgical glue used here, thanks to its strong adhesive ability19,20, induces an instant occlusion of the vessel; when the glue comes into contact with the blood, it polymerizes rapidly21, thanks to the presence of hydroxyl ions. It forms a cast made of blood and adhesive, a plastic thrombus that adheres firmly to the vessel walls, occluding it permanently16,22.
In over 70% of cases, in the early control with ECD, we found that the caudal extension of the occlusion obtained from the NBCA+MS glue always went well beyond 10 cm of the trans-catheter deposition due to its density, which is similar to water. Since the venous flow is blocked, the cranial extension of the polymerization and the related phenomena of &#34;glue-induced thrombosis&#34; did not occur. In fact, compression with the ultrasound probe immediately downstream of the saphenous bifurcation occluded the lumen of the vein and, consequently, the flow in the cranial direction. Therefore, the high adhesiveness and biochemical properties of the NBCA+MS surgical glue cause not only injuries and mechanical collapses with the adhesion of the vessel walls, but also a pro-coagulant action in the treated vessel.
The choice to use the co-monomeric NBCA+MS surgical glue was both due to its described different endovascular behavior with respect to pure cyanoacrylate (NBCA)-based glues13 and its several documented and authorized indications in interventional radiology. It has been applied as a liquid embolic agent to permanently occlude vascular abnormalities such as cerebral and spinal arteriovenous malformations23,24, to perform embolization of the portal vein25,26, pre-operative renal-tumor27, endoleaks of the abdominal aorta28,29, and for bleeding control30, and in endoscopy as a sclerosing agent to treat gastroesophageal varices31,32.
However, thanks to the combination of safe and widely tested vein catheterization, NBCA+MS surgical glue, and vein compression after glue injection, we obtained better results here in terms of both vascular occlusion10 and safety10,33,34,35,36 compared to the aforementioned studies. Moreover, none of the patients in this study presented slight or severe post-surgical complications in the short and long term (as shown in Table 3).
Complete occlusion of the leg veins occurs in the supine position with a pressure of 20-25 mm Hg37,38 with the ultrasound probe, which is the necessary and sufficient force to compress the vessels and keep them effectively occluded. This pressure exerted in the procedure has never aroused discomfort in any of the patients treated.To refine and standardize the compressive phase of the method, a pneumatic or mechanical system, which can be calibrated on the bases of the individual diameters and the individual vascular tracts to be occluded, could be designed.
This technique does not involve particular procedural variations, thanks to the in-depth and detailed study of the patient&#39;s vascular system in the diagnostic phase. The only technique-related issue that may occur is the inability of catheterizing the vessel. In this case, the procedure cannot be done, and it is necessary to change the type of sclerosing procedure. One limitation of this technique is excessive patient body weight (over 100 kg), which does not allow for effective compression of the limb with the ultrasound probe to block venous flow in the saphenous veins.
Compared to other existing methods34,35,36, we believe this procedure is simpler and faster, is more standardizable thanks to the hemodynamic study, and possesses comparable results. In our personal experience, we have noticed that patients experience less pain, both intra- and post-procedurally, than when other sclerosing techniques are used (e.g., laser, radiofrequency, and other cyanoacrylates).
Although the preliminary results of this protocol are very encouraging, additional studies on larger sample sizes are necessary to confirm the validity of the novel method illustrated here. Given the reassuring results of this study, we hypothesize that in the future this technique could be used to implement embolization and venous occlusion in other pathological venous districts, through the use of more flexible and thinner catheters.

An erratum was issued for:&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/t/64170">Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane</a>. The Author section&#160;was&#160;updated from:
Pecis Claudio*123 
Bellandi-Alberti Pier Luca*23 
Fumagalli Miriam*1 
1Department of Cardiovascular Surgery, Angiology Functional Unit, Humanitas Gavazzeni Hospital 
2Department of Cardiovascular Surgery, Angiology Functional Unit, Montallegro Clinic 
3Department of Cardiovascular Surgery, Angiology Functional Unit, BioMedical Institute 
* These authors contributed equally
to:
Claudio Pecis*123 
Pier Luca Bellandi-Alberti*23 
Miriam Fumagalli*1 
1Department of Cardiovascular Surgery, Angiology Functional Unit, Humanitas Gavazzeni Hospital 
2Department of Cardiovascular Surgery, Angiology Functional Unit, Montallegro Clinic 
3Department of Cardiovascular Surgery, Angiology Functional Unit, BioMedical Institute 
* These authors contributed equally

An erratum was issued for:&#160;<a href="https://www-jove-com.remotexs.ntu.edu.sg/t/64170">Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane</a>. The Author section&#160;was&#160;updated.

Erratum: Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane

Varicose veins are a symptom of venous disease that may lead to severe complications1. The great saphenous vein (GSV) and small saphenous vein (SSV) are superficial veins, separated from the deep veins by a series of valves. These valves ensure that blood flows from the superficial system to the deep system, thus preventing backflow2. The incapacity of these valves results in varicose veins, which affects 16% of men and 29% of women3. Varicose veins are engorged, tortuous veins, that become enlarged, swollen, dilated, and overfilled with blood, often appearing blue or dark purple and tender to the touch2,3. In the veins of the lower limbs, healthy valves physiologically allow a small retrograde blood flow just before the valve closes. However, in a pathological condition, valve closure is absent or incompetent, thus increasing the time the blood needs to flow back4.
Furthermore, because varicose veins may rupture or develop into varicose ulcers on the skin in severe conditions, treatment always has to be considered5. After careful clinical evaluation and instrumental study through EcoColor-Doppler (ECD) examination, patients with saphenofemoral (SF) and/or saphenous-popliteal (SP) junctional incontinence, with pathological refluence along the GSV and/or SSV axis, along with the presence or absence of collateral extra-saphenous varices, are addressed by doctors for the treatment of saphenous occlusion.
The therapeutic management of chronic venous disease can be conservative or invasive6. Examples of conservative treatments include lifestyle changes, compression therapy, or pharmacotherapy (phlebotropic drugs)5,6,7. These treatments are not sufficient in the presence of severe varicose veins; in these cases, surgery is the only solution5,6,7. Traditionally, ligature and stripping of the saphenous veins have largely been used; however, today, less invasive treatments are preferred5. Varicose veins can be treated under eco-graphic guidance using foam sclerotherapy (ultrasound-guided foam sclerotherapy [UGFS]), endovenous thermal ablation using an endovenous laser (EVL) or radiofrequency (RF)8, and recently glue9. The latter allows for the obliteration of the damaged vein. Vein occlusion using N-butyl cyanoacrylate (NBCA)-based glues has the same, if not superior, therapeutic effectiveness compared to other endovascular methods like EVL and RF, for example, through lower anesthetic invasiveness (100% of treatments completed in a single local anesthesia)10. The treatment allows for a quick patient discharge, within 3-4 h after the procedure, and rapid recovery of daily and work activities, without post-procedural pain10. Furthermore, the use of glue has no diameter-related limitations, which is a problem in the case of large diameters (10-18 mm) for some of the above-mentioned techniques10.
This naturalistic study aims to assess the effectiveness of this method to obtain vascular occlusion of the GSV and SSV, affected by severe pathological reflux using an innovative modified cyanoacrylate NBCA+MS (N-butyl cyanoacrylate and methacryloxy sulfolane) surgical glue, at different short-term (6 h and 1 month post-treatment) and long-term (3 months, 6 months, and 1 year post-treatment) follow-ups, as well as its safety in terms of the occurrence of glue-related adverse events.

<table><tbody><tr><td>5% Dextrose injection</td><td>BBraun Milano S.p.A., Milan,&amp;nbsp; Italy</td><td>S5104-5384</td><td>Dextrose solution for intravenous administration</td></tr><tr><td>Angiographic needle</td><td>Merit Medical, Utah, USA</td><td>AN18T72SH</td><td>Suitable needle for the Selding procedure</td></tr><tr><td>Atossisclerol 1%</td><td>Chemische Fabrik Kreussler &amp;amp; Co. GmbH, Wiesbaden, Germany</td><td>22199071</td><td>Polidocanol foam for venous sclerosis</td></tr><tr><td>Avanti</td><td>Cordis, Miami, Florida, USA</td><td>504-606X</td><td>Vascular Introducer</td></tr><tr><td>BD microlance 3</td><td>BD Company, Drogheda, Ireland</td><td>304622</td><td>Needle 18 G</td></tr><tr><td>BD syringe</td><td>BD Company, Drogheda, Ireland</td><td>300912</td><td>10 mL syringe</td></tr><tr><td>BD syringe</td><td>BD Company, Drogheda, Ireland</td><td>309658</td><td>3 mL syringe</td></tr><tr><td>Carbosen (10 mg/mL)</td><td>Galenica Senese, Siena, Italy</td><td>33640640</td><td>Mepivacaine solution 10 mg/mL</td></tr><tr><td>Clorexinal (2%)</td><td>Nuova Farmec, Verona, Italy</td><td>PF373</td><td>Solution of 2% chlorhexidine and 70% isopropanol alcohol</td></tr><tr><td>Dermographic pen</td><td>Novatech SA, La Ciotat, France</td><td>18996</td><td>Sterile pen for writing on the patient&#039;s skin during surgery</td></tr><tr><td>Glubran 2</td><td>GEM Srl, Viareggio, Italy</td><td>G-NB-2</td><td>Synthetic cyanoacrylate liquid modified by addition of a monomer synthesized by the manufacture (NBCA+MS)</td></tr><tr><td>MyLabGamma</td><td>Esaote, Genova, Italy</td><td>101741000</td><td>Portable Ultrasound Machine</td></tr><tr><td>Sterile bowls</td><td>Delta Med Spa, Viadana (MN), Italy</td><td>82.H8428.00</td><td>Sterile bowls used for keep the tools for the procedure submerged in 5% dextrose solution</td></tr><tr><td>Sterile gauzes</td><td>Delta Med Spa, Viadana (MN), Italy</td><td>82.H8428.00</td><td>Sterile gauzes commonly used during surgery</td></tr><tr><td>Sterile surgical drape</td><td>MedLine, Firenze, Italy</td><td>CPU29017 CE</td><td>Sterile drapes commonly used during surgery</td></tr></tbody></table>

occlusion of the great and small saphenous vein using copolymeric glue based on n-butyl cyanoacrylate and methacryloxy sulfolane

We present the preliminary results of a longitudinal observational study aimed at evaluating the effectiveness and safety at different short- and long-term follow-ups of vascular occlusion of the great saphenous vein (GSV) and small saphenous vein (SSV) affected by severe pathological reflux, using an innovative modified cyanoacrylate surgical glue composed of N-butyl cyanoacrylate and methacryloxy sulfolane (NBCA+MS). Ninety patients, prospectively recruited for 1 year, underwent the study with EcoColor-Doppler (ECD) to evaluate the maximum diameters of the GSV and SSV in the orthostatic position and the reflux time (RT). An RT greater than 0.5 s was considered pathologic. Clinical, etiology, anatomy, and pathophysiology (CEAP) assessment was used for the complete evaluation of each patient in the study. All the patients were treated by NBCA+MS glue to obtain vein occlusion and observed before treatment (baseline; T0), within 6 h after treatment (T1), 1 month after treatment (T2), 3 months after treatment (T3), 6 months after treatment (T4), and 1 year after treatment (T5). Chi-square (&#967;) analysis was performed to evaluate the effectiveness and safety of the treatment. All the patients participated in the entire duration of the study. Complete occlusion was maintained in 100% of patients at T1, 98.9% at T2 and T3, and 97.8% at T4 and T5 (p &lt; 0.001). None of the patients suffered from post-surgical thrombosis. No blue hyperpigmentation, or paresthesia was observed during the entire observation period. Immediately after treatment, 7.7% of patients needed painkillers; 1 week after treatment, 100% of patients returned to normal life. Vascular occlusion of the great or small saphenous vein using NBCA+MS glue is a safe procedure with persistent benefits after a 1 year follow-up. This procedure can be performed with local anesthesia, allowing a quick return to normal life. Thanks to its low invasiveness, the treatment is not painful.

Ninety patients (62 women and 28 men), with a mean age of 59.8 + 12.8 years, were selected for this observational research. For each patient, the following information was collected: age, sex, major and minor systemic disease, drug usage, and voluptuary habits (e.g., smoking) (Table 1); diagnostic data of the disease (Table 2); data about the condition of the vein at the different observational-points, presence of ulcerations, or negative outcomes (Table 3); time to return to normal activities and work (Table 4); patients&#39; sensation of &#34;heavy and painful legs&#34; by the Numeric Pain Rating Scale (Table 5).
Six observation points were chosen: T0 = baseline, before treatment; T1 = immediately after treatment (within 6 h); T2 = 1 month after treatment; T3 = 3 months after treatment; T4 = 6 months after treatment; T5 = 1 year after treatment. The main evaluated outcome was the occlusion of the vein.
Table 1 summarizes the comorbidities observed in our sample; some patients were suffering from more than one disease. 14.4% of patients (13 subjects) were under treatment with anticoagulant therapy, six subjects took acetylsalicylic acid (ASA), three subjects took novel oral anticoagulants (NOACs), two subjects took traditional oral anticoagulants, and two subjects took low-molecular-weight heparin.
The subjects underwent ECD in orthostatic and clinostatic postures at the first consultation (T0) and in all consecutive follow-ups (T1-T5). All patients with at least second-degree varicose veins of the lower limbs were enrolled in the study. Traditional CEAP classification was used because it allowed for a complete evaluation of the clinical aspect, etiology of the disease, and anatomical and pathophysiological classification15. Maximum diameters of the GSV and SSV in the orthostatic position and the RT were evaluated by ECD. In the lower limb veins, non-pathological valves allow for a small retrograde flow of blood just before the valve closes. In contrast, in a pathological condition, valve closure is incompetent or totally absent, increasing the time it takes for the blood to flow back4. The degree of the incompetence of a valve is described by the RT. Specifically, RT values between 0.1 s and 0.5 s are physiological, while RT values &#62; 0.5 s represent a pathological condition4. The classification of the severity was done by Galeandro&#39;s quartile assessment11.
Exclusion criteria included the presence of both deep and superficial active thrombosis and the simultaneous presence of neoplastic disease. All patients underwent the same procedure, performed by the same surgical team. The procedure was performed under local anesthesia.
NBCA+MS surgical glue was used to generate the occlusion. NBCA+MS is an original surgical glue, Conformit&#233; Europ&#233;enne (CE) marked, developed and authorized to be used for endovascular applications. NBCA is combined with another monomer, methacryloxy-sulpholane (MS), to generate a more plastic polymer whose milder exothermic reaction (45 &#176;C) results in better biocompatibility with less inflammation and histotoxicity16.
The NBCA+MS surgical glue was applied for the occlusion of GSV and/or SSV and incontinent perforating voluminous veins, while polidocanol foam was used only for extra-saphenous varices by percutaneous injection.
During the early control with ECD (T1), in more than 70% of cases, a caudal extension of the occlusion beyond 10 cm was found. This can be attributed to the related polymerization times of the NBCA+MS surgical glue, which begins to react with the blood after 2 s from its release into the vessel and can therefore expand for a short distance.
Results are expressed in terms of prevalence (%) calculated on the number of patients. Chi-square was used to evaluate nominal data by comparing the different follow-ups (T1, T2, T3, T4, and T5). All 90 patients completed the five follow-ups and were included in the final analysis. Following CEAP classification, 57 patients were in class 2, 23 in class 3, and 10 in class 6 (Table 2). A total of 79 patients (88.8%) were treated to occlude GSV and 11 for SSV (11.2%). Mean GSV caliber/diameter in the orthostatic posture was 12.4 mm (SD: 3.6; 95% CI: 7-20 mm) and mean SSV caliber/diameter was 11.4 mm (SD: 3; 95% CI: 5-15 mm).
All patients had an RT &#62; 10 s; 60 were in the second quartile, 24 were in the third quartile, and six were in the fourth quartile. Of the patients, 66.7% (60 patients) needed two ampoules of glue to completely fill the vessels, corresponding to 2 ml of product. In the rest, (33.3%, 30 patients), a single vial (1 mL of glue) was sufficient to obtain a total vein occlusion (Table 3). A caudal extension of the thrombosis was observed in 62.2% (57 patients) and absent in 37.8% (33 subjects).
All patients obtained the complete occlusion of the treated vein at T1, one patient (1.1%) had a re-canalization of the vessel at T2, one patient at T3 (1.1%), two patients (2.2%) at T4, and two patients (2.2%) at T5 (Table 3) (: p &#60; 0.0001). None of the patients presented a re-canalization of the vessel &#62;50% of its diameter, and none showed blood reflux in the orthostatic posture (Table 3). None of the patients were affected by post-surgical thrombosis. No other adverse events (i.e., blue hyperpigmentation or paresthesia) occurred during the observation period (Table 3).
We found that the patients were satisfied with the treatment. The NPRS (Numeric Pain Rating Scale) showed a score of 3 in seven patients, while the rest of the scores were between 0 and 2. The seven patients with score 3, indicative of pain, were treated with 200 mg of Ibuprofen, one to three times a day as needed, for 4 days. The resolution of leg pains was maintained for all the follow-up times (Table 5), and 70% of patients (63 subjects) had a notable reduction of leg edema. All patients returned to their normal routine in 2 days, and all restarted their work activity (light or heavy) within 1 week (Table 4).
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Sample size</td>
			<td></td>
			<td>90</td>
		</tr>
		<tr>
			<td>Sex</td>
			<td></td>
			<td>62 women</td>
		</tr>
		<tr>
			<td>Age (mean)</td>
			<td></td>
			<td>59.8 &#177; 12.8</td>
		</tr>
		<tr>
			<td>Comorbidity (n)</td>
			<td>Heart Attack</td>
			<td>40</td>
		</tr>
		<tr>
			<td></td>
			<td>Diabetes</td>
			<td>16</td>
		</tr>
		<tr>
			<td></td>
			<td>Cardiomiopathy</td>
			<td>25</td>
		</tr>
		<tr>
			<td></td>
			<td>COPD</td>
			<td>16</td>
		</tr>
		<tr>
			<td></td>
			<td>Chronic Kidney Disease</td>
			<td>4</td>
		</tr>
		<tr>
			<td></td>
			<td>Fibrillar Atrial Disease</td>
			<td>4</td>
		</tr>
		<tr>
			<td></td>
			<td>Surgery of Mitral Valve</td>
			<td>1</td>
		</tr>
		<tr>
			<td>Drugs used (n)</td>
			<td>ASA</td>
			<td>6</td>
		</tr>
		<tr>
			<td></td>
			<td>NOACs</td>
			<td>3</td>
		</tr>
		<tr>
			<td></td>
			<td>Traditional oral anticoagulants&#160;&#160;</td>
			<td>2</td>
		</tr>
		<tr>
			<td></td>
			<td>Low-molecular weight heparin</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Alcool&#160; and/or psychotropic substances user (n)</td>
			<td></td>
			<td>0</td>
		</tr>
	</tbody>
</table>
Table 1: Demographic and anamnestic data. Patient recruitment for the observational study. All patients with at least second-degree varicose veins of the lower limb were enrolled in the study. For each patient, the following information was collected: age, sex, major and minor systemic disease, drug usage, and voluptuary habits. Abbreviations: n = number of subjects; COPD = chronic obstructive pulmonary disease; ASA = acetylsalicylic acid; NOACs = novel oral anticoagulants.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Mean GSV caliber (mm) at T0</td>
			<td></td>
			<td>12.4</td>
		</tr>
		<tr>
			<td></td>
			<td>SD</td>
			<td>3.6</td>
		</tr>
		<tr>
			<td></td>
			<td>95% CI</td>
			<td>&#160;7&#8211;20</td>
		</tr>
		<tr>
			<td>Mean SSV caliber (mm) at T0</td>
			<td></td>
			<td>11.4</td>
		</tr>
		<tr>
			<td></td>
			<td>SD</td>
			<td>3</td>
		</tr>
		<tr>
			<td></td>
			<td>95% CI</td>
			<td>&#160;5&#8211;15</td>
		</tr>
		<tr>
			<td>RT &#62; 10 s (%) at T0</td>
			<td></td>
			<td>100</td>
		</tr>
		<tr>
			<td></td>
			<td>First quartile</td>
			<td>0</td>
		</tr>
		<tr>
			<td></td>
			<td>Second quartile</td>
			<td>60</td>
		</tr>
		<tr>
			<td></td>
			<td>Third quartile</td>
			<td>24</td>
		</tr>
		<tr>
			<td></td>
			<td>Fourth quartile</td>
			<td>6</td>
		</tr>
		<tr>
			<td>CEAP classification (n) at T0</td>
			<td>Class 2</td>
			<td>57</td>
		</tr>
		<tr>
			<td></td>
			<td>Class 3</td>
			<td>23</td>
		</tr>
		<tr>
			<td></td>
			<td>Class 6</td>
			<td>10</td>
		</tr>
		<tr>
			<td>Treatment for GSV (%)</td>
			<td></td>
			<td>88.8</td>
		</tr>
	</tbody>
</table>
Table 2: Diagnostic data. For each patient, ECD was performed before the treatment to acquire the following baseline parameters: mean GSV caliber (mm) at T0, mean SSV caliber (mm) at T0, RT &#62;10 s (%) at T0, CEAP classification (n) at T0, and treatment for GSV (%). Abbreviations: GSV = great saphenous vein; SSV = small saphenous vein; T0 = baseline, before treatment; SD = standard deviation; CI = confidence interval; RT = reflux time; CEAP = clinical, etiological anatomical and pathophysiological; n = number of subjects.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="3"></td>
			<td colspan="2"></td>
			<td>T1</td>
			<td>T2</td>
			<td>T3</td>
			<td>T4</td>
			<td>T5</td>
		</tr>
		<tr>
			<td colspan="3">1 mL of glue used for the occlusion (n)</td>
			<td colspan="2"></td>
			<td>30</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">2 mL of glue for the occlusion (n)</td>
			<td colspan="2"></td>
			<td>60</td>
			<td></td>
			<td></td>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td colspan="3">Occlusion of the vein (n)</td>
			<td colspan="2"></td>
			<td>90</td>
			<td>89</td>
			<td>89</td>
			<td>88</td>
			<td>88</td>
		</tr>
		<tr>
			<td colspan="3"></td>
			<td colspan="2">Re-canalization of the vessel &#62;50% of its diameter</td>
			<td></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="3"></td>
			<td colspan="2">Blood reflux in orthostatic posture</td>
			<td></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="3">Presence of ulceration (n)</td>
			<td colspan="2"></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="3">Post-surgical thrombosis (n)</td>
			<td colspan="2"></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="3">Paresthesia (n)</td>
			<td colspan="2"></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
		<tr>
			<td colspan="3">Hyperpigmentation (n)</td>
			<td colspan="2"></td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
			<td>0</td>
		</tr>
	</tbody>
</table>
Table 3: Follow-up data. All the patients completed the five follow-ups and were included in the final analysis. The table shows data about the condition of the vein at the different post-treatment observational points and the presence of complications. A total of 33.3% of patients needed 1 ml of (NBCA+MS) surgical glue to completely fill the vessel; 66.7% of patients (n = 60) needed 2 ml of (NBCA+MS) surgical glue to completely fill the vessel. All patients obtained the complete occlusion of the treated vein at T1. One patient (1.1%) had a re-canalization of the vessel at T2, one patient (1.1%) at T3, two patients (2.2%) at T4, and two patients (2.2%) at T5 (: p &#60; 0.0001). None of the patients presented a re-canalization of the vessel &#62;50% of its diameter, and none of them showed blood reflux in the orthostatic posture. None of the patients were affected by post-surgical thrombosis. No other adverse events occurred during the entire observation period. Abbreviations: T1 = immediately after treatment (within 6 h); T2 = 1 month after treatment; T3 = 3 months after treatment; T4 = 6 months after treatment; T5 = 1 year after treatment; n = number of subjects.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td></td>
			<td>n = 90</td>
		</tr>
		<tr>
			<td>Return to normal life (days)</td>
			<td>2</td>
		</tr>
		<tr>
			<td>Return to work (days)</td>
			<td>7</td>
		</tr>
	</tbody>
</table>
Table 4: Recovery time. The amount of time, expressed in days, the patients needed to return to normal life and restart work activities. Abbreviations: n = number of subjects; d = days.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td style="min-width: 80px;"></td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">1</td>
			<td style="min-width: 80px;">2</td>
			<td style="min-width: 80px;">3</td>
			<td style="min-width: 80px;">4</td>
			<td style="min-width: 80px;">5</td>
			<td style="min-width: 80px;">6</td>
			<td style="min-width: 80px;">7</td>
			<td style="min-width: 80px;">8</td>
			<td style="min-width: 80px;">9</td>
			<td style="min-width: 80px;">10</td>
		</tr>
		<tr>
			<td style="min-width: 80px;">T1</td>
			<td style="min-width: 80px;">83</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">7</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
		</tr>
		<tr>
			<td style="min-width: 80px;">T2</td>
			<td style="min-width: 80px;">90</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
		</tr>
		<tr>
			<td style="min-width: 80px;">T3</td>
			<td style="min-width: 80px;">90</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
		</tr>
		<tr>
			<td style="min-width: 80px;">T4</td>
			<td style="min-width: 80px;">90</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
		</tr>
		<tr>
			<td style="min-width: 80px;">T5</td>
			<td style="min-width: 80px;">90</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
			<td style="min-width: 80px;">0</td>
		</tr>
	</tbody>
</table>
Table 5: Pain assessment. Evaluation of the pain intensity at each follow-up time point, according to the Numeric Pain Rating Scale (NPRS), an 11-point numeric scale in which 0 indicates no pain and 10 is the worst possible pain. Numbers in the table represent the number of subjects. Abbreviations: T1 = immediately after treatment (within 6 h); T2 = 1 month after treatment; T3 = 3 months after treatment; T4 = 6 months after treatment; T5 = 1 year after treatment.
Supplementary File 1: Overview of the procedure. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/64170/Scheme_pba.pdf" target="_blank">Please click here to download this File.</a>

Watch this Scientific Journal Video about Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane at JoVE.com

Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane

Here, we present a protocol to treat the great saphenous vein (GSV) and the small saphenous vein (SSV) affected by severe pathological reflux, using an original sclerosing and embolizing cyanoacrylate-based glue composed of N-butyl cyanoacrylate and methacryloxy sulfolane (NBCA+MS).

We present the preliminary results of a longitudinal observational study aimed at evaluating the effectiveness and safety at different short- and ...

occlusion-great-small-saphenous-vein-using-copolymeric-glue-based-on

Nanyang Technological University

Research

JoVE Journal

Medicine

3.9K Views.  Humanitas Gavazzeni Hospital. Ons protocol maakt gebruik van een eenvoudig en gemakkelijk verkrijgbaar apparaat om een uitstekende saphena-sluiting te verkrijgen met behulp van NBCA plus MS. Het voordeel van deze techniek is eenvoud, snelheid en precisie van gebruik voor een deskundige operator, Helpen om aan te tonen dat de procedure zal zijn Pier Luca Bellandi-Alberti. Bereid om te beginnen de kamer en de operatietafel voor met alle benodigde materialen. Doe de 5% dextrose-oplossing in een kom en dompel er een injecties...

Video: Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane

Microsurgical Venous Pouch Arterial-Bifurcation Aneurysms in the Rabbit Model: Technical Aspects

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials have shown disappointing long-term results with unacceptable high rates of aneurysm recanalization and delayed aneurysm rupture.2 To overcome these problems, animal experimental studies are crucial for the development of better endovascular devices.3-5
Several animal models in rats, rabbits, canines and swine are available.6-8 Comparisons of the different animal models showed the superiority of the rabbit model with regard to hemodynamics and comparability of the coagulation system and cost-effectiveness.9-11 
The venous pouch arterial bifurcation model in rabbits is formed by a venous pouch sutured into an artificially created true bifurcation of both common carotid arteries (CCA). The main advantage of this model are true bifurcational hemodynamics.12 The major drawbacks are the sofar high microsurgical technical demands and high morbidity and mortality rates of up to 50%.13 These limitations have resulted in less frequent use of this aneurysm model in the recent years. These shortcomings could be overcome with improved surgical procedures and modified peri- and postoperative analgetic management and anticoagulation.14-16 Our techniques reported in this paper demonstrate this optimized technique for microsurgical creation of arterial bifurcation aneurysms.

An optimized technique for the microsurgical creation of arterial bifurcation aneurysms mimicking bifurcation human cerebral aneurysms is described. A venous pouch is sutured into an artificially created true bifurcation of both common carotid arteries. Facilitated microsurgical techniques and aggressive postoperative anticoagulation and analgesia lead to minimized morbidity rates and high aneurysm patency rates.

For ruptured human cerebral aneurysms endovascular embolization has become an equivalent alternative to aneurysm clipping.1 However, large clinical trials ...

A Chitosan Based, Laser Activated Thin Film Surgical Adhesive, 'SurgiLux': Preparation and Demonstration

Sutures are a 4,000 year old technology that remain the 'gold-standard' for wound closure by virtue of their repair strength (~100 KPa). However, sutures can act as a nidus for infection and in many procedures are unable to effect wound repair or interfere with functional tissue regeneration.1 Surgical glues and adhesives, such as those based on fibrin and cyanoacrylates, have been developed as alternatives to sutures for the repair of such wounds. However, current commercial adhesives also have significant disadvantages, ranging from viral and prion transfer and a lack of repair strength as with the fibrin glues, to tissue toxicity and a lack of biocompatibility for the cyanoacrylate based adhesives. Furthermore, currently available surgical adhesives tend to be gel-based and can have extended curing times which limit their application.2 Similarly, the use of UV lasers to facilitate cross-linking mechanisms in protein-based or albumin 'solders' can lead to DNA damage while laser tissue welding (LTW) predisposes thermal damage to tissues.3 Despite their disadvantages, adhesives and LTW have captured approximately 30% of the wound closure market reported to be in excess of US $5 billion per annum, a significant testament to the need for sutureless technology.4
In the pursuit of sutureless technology we have utilized chitosan as a biomaterial for the development of a flexible, thin film, laser-activated surgical adhesive termed 'SurgiLux'. This novel bioadhesive uses a unique combination of biomaterials and photonics that are FDA approved and successfully used in a variety of biomedical applications and products. SurgiLux overcomes all the disadvantages associated with sutures and current surgical adhesives (see Table 1).
In this presentation we report the relatively simple protocol for the fabrication of SurgiLux and demonstrate its laser activation and tissue weld strength. SurgiLux films adhere to collagenous tissue without chemical modification such as cross-linking and through irradiation using a comparatively low-powered (120 mW) infrared laser instead of UV light. Chitosan films have a natural but weak adhesive attraction to collagen (~3 KPa), laser activation of the chitosan based SurgiLux films emphasizes the strength of this adhesion through polymer chain interactions as a consequence of transient thermal expansion.5 Without this 'activation' process, SurgiLux films are readily removed.6-9 SurgiLux has been tested both in vitro and in vivo on a variety of tissues including nerve, intestine, dura mater and cornea. In all cases it demonstrated good biocompatibility and negligible thermal damage as a consequence of irradiation.6-10

The fabrication of a novel, flexible thin film surgical adhesive from FDA approved ingredients, chitosan and indocyanine green is described. Bonding of this adhesive to collagenous tissue through a simple activation process with a low-powered infra-red laser is demonstrated.

Sutures are a 4,000 year old technology that remain the 'gold-standard' for wound closure by virtue of their repair strength (~100 KPa). However, sutures ...

Bioengineering

Tissue Engineering by Intrinsic Vascularization in an In Vivo Tissue Engineering Chamber

In reconstructive surgery, there is a clinical need for an alternative to the current methods of autologous reconstruction which are complex, costly and trade one defect for another. Tissue engineering holds the promise to address this increasing demand. However, most tissue engineering strategies fail to generate stable and functional tissue substitutes because of poor vascularization. This paper focuses on an in vivo tissue engineering chamber model of intrinsic vascularization where a perfused artery and a vein either as an arteriovenous loop or a flow-through pedicle configuration is directed inside a protected hollow chamber. In this chamber-based system angiogenic sprouting occurs from the arteriovenous vessels and this system attracts ischemic and inflammatory driven endogenous cell migration which gradually fills the chamber space with fibro-vascular tissue. Exogenous cell/matrix implantation at the time of chamber construction enhances cell survival and determines specificity of the engineered tissues which develop. Our studies have shown that this chamber model can successfully generate different tissues such as fat, cardiac muscle, liver and others. However, modifications and refinements are required to ensure target tissue formation is consistent and reproducible. This article describes a standardized protocol for the fabrication of two different vascularized tissue engineering chamber models in vivo.

Tissue Engineering by Intrinsic Vascularization in an In Vivo Tissue Engineering Chamber

This is a guideline for constructing in vivo vascularized tissue using a microsurgical arteriovenous loop or a flow-through pedicle configuration inside a tissue engineering chamber. The vascularized tissues generated can be employed for organ regeneration and replacement of tissue defects, as well as for drug testing and disease modeling.

In reconstructive surgery, there is a clinical need for an alternative to the current methods of autologous reconstruction which are complex, costly and ...

Procedure for Human Saphenous Veins Ex Vivo Perfusion and External Reinforcement

The mainstay of contemporary therapies for extensive occlusive arterial disease is venous bypass graft. However, its durability is threatened by intimal hyperplasia (IH) that eventually leads to vessel occlusion and graft failure. Mechanical forces, particularly low shear stress and high wall tension, are thought to initiate and to sustain these cellular and molecular changes, but their exact contribution remains to be unraveled. To selectively evaluate the role of pressure and shear stress on the biology of IH, an ex&#160;vivo perfusion system (EVPS) was created to perfuse segments of human saphenous veins under arterial regimen (high shear stress and high pressure). Further technical innovations allowed the simultaneous perfusion of two segments from the same vein, one reinforced with an external mesh. Veins were harvested using a no-touch technique and immediately transferred to the laboratory for assembly in the EVPS. One segment of the freshly isolated vein was not perfused (control, day 0). The two others segments were perfused for up to 7 days, one being completely sheltered with a 4 mm (diameter) external mesh. The pressure, flow velocity, and pulse rate were continuously monitored and adjusted to mimic the hemodynamic conditions prevailing in the femoral artery. Upon completion of the perfusion, veins were dismounted and used for histological and molecular analysis. Under ex&#160;vivo conditions, high pressure perfusion (arterial, mean = 100 mm Hg) is sufficient to generate IH and remodeling of human veins. These alterations are reduced in the presence of an external polyester mesh.

Procedure for Human Saphenous Veins Ex Vivo Perfusion and External Reinforcement

The mechanisms leading to the development of intimal hyperplasia (IH) and vein graft failure are still poorly understood. This study describes an ex&#160;vivo system to perfuse human veins under controlled flow and pressure. Furthermore the efficiency of external mesh reinforcement to limit the development of IH was evaluated.

The mainstay of contemporary therapies for extensive occlusive arterial disease is venous bypass graft. However, its durability is threatened by intimal ...

Decellularization and Recellularization Methodology for Human Saphenous Veins

Vascular conduits used during most vascular surgeries are allogeneic or synthetic grafts that often lead to complications caused by immunosuppression and poor patency. Tissue engineering offers a novel solution to generate personalized grafts with a natural extracellular matrix containing the recipient&#39;s cells using the method of decellularization and recellularization. We show a detailed method for performing decellularization of the human saphenous vein and recellularization by perfusion of peripheral blood. The vein was decellularized by perfusing 1% Triton X-100, 1% tri-n-butyl-phosphate (TnBP) and 2,000 Kunitz units of deoxyribonuclease (DNase). Triton X-100 and TnBP were perfused at 35 mL/min for 4 h while DNase was perfused at 10 mL/min at 37 &#176;C for 4 h. The vein was washed in ultrapure water and PBS and then sterilized in 0.1% peracetic acid. It was washed again in PBS and preconditioned in endothelial medium. The vein was connected to a bioreactor and perfused with endothelial medium containing 50 IU/mL heparin for 1 h. Recellularization was performed by filling the bioreactor with fresh blood, diluted 1:1 in Steen solution, and adding endocrine gland-derived vascular endothelial growth factors (80 ng/mL), basic fibroblast growth factors (4 &#181;L/mL), and acetyl salicylic acid (5 &#181;g/mL). The bioreactor was then moved into an incubator and perfused for 48 h at 2 mL/min while maintaining glucose between 3 - 9 mmol/L. Later, the vein was washed with PBS, filled with endothelial medium and perfused for 96 h in the incubator. Treatment with Triton X-100, TnBP and DNase decellularized the saphenous vein in 5 cycles. The decellularized vein looked white in contrast to normal and recellularized veins (light red). The hematoxylin &#38; eosin (H&#38;E) staining showed the presence of nuclei only in normal but not in decellularized veins. In the recellularized vein, H&#38;E-staining showed the presence of cells on the luminal surface of the vein.

Here, we describe a protocol for the saphenous vein decellularization using detergents and recellularization by perfusion of the peripheral blood and the endothelial medium.

Vascular conduits used during most vascular surgeries are allogeneic or synthetic grafts that often lead to complications caused by immunosuppression and ...

Vein Interposition Model: A Suitable Model to Study Bypass Graft Patency

Bypass grafting is an established treatment method for coronary artery disease. Graft patency continues to be the Achilles heel of saphenous vein grafts. Research models for bypass graft failure are essential for a better understanding of pathobiological and pathophysiological processes during graft patency loss. Large animal models, such as pigs or sheep, resemble human anatomical structures but require special facilities and equipment. This video describes a rat vein interposition model to investigate vein graft patency loss. Rats are inexpensive and easy to handle. Compared to mouse models, the convenient size of rats permits better operability and enables a sufficient amount of material to be obtained for further diverse analysis. In brief, the inferior epigastric vein of a donor rat is harvested and used to replace a segment of the femoral artery. Anastomosis is conducted via single stitches and sealed with fibrin glue. Graft patency can be monitored non-invasively using duplex sonography. Myointimal hyperplasia, which is the main cause for graft patency loss, develops progressively over time and can be calculated from histological cross sections.

This video demonstrates a model to study the development of myointimal hyperplasia after venous interposition surgery in rats.

Bypass grafting is an established treatment method for coronary artery disease. Graft patency continues to be the Achilles heel of saphenous vein grafts. ...

Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg

Antegrade endoscopic harvesting of autografts for bypass grafting may be an optimal strategy addressing excellent graft quality and reduced post-operative wound complications. This standardized protocol for antegrade endoscopic vein harvesting (EVH) from the lower leg has the potential to be introduced to routine coronary artery bypass grafting (CABG). Patients undergoing CABG surgery are positioned on a surgical table with two additional foam rollers below the extended legs, enabling antegrade EVH from the lower leg. Following minimally invasive surgical access through a bridging vein harvest technique, an endoscopic optical dissector is inserted antegrade into the wound. The main vessel and side branches are dissected under continuous optical control of vein quality status and the working channel. After, an endoscopic optical retractor is inserted with an internal bipolar electrocoagulation device for precise, safe, and tissue-protective interruption of side branches. After release of the vein, the vessel is cut off at the proximal and distal ends under optical control, retrieved from the wound, then cannulated and flushed with heparinized saline. Finally, all side branches of the vein graft are double-clipped. Vascular histology is analyzed in a randomized selection of vein samples. After applying this standardized EVH protocol, the learning curve was shown to be steep, and graft quality was sufficient for coronary artery bypass grafting in every case. There was no conversion to surgical harvesting and low risks for tissue damage and bleeding. Leg positioning and synergizing EVH with bridging vein harvesting improved procedural success and vein graft quality. In our hands, antegrade EVH from the lower leg was feasible, demonstrating straightforward graft dissection as well as adequate macroscopic and microscopic graft quality with preserved endothelial integrity. In conclusion, the introduced technique is safe, shows excellent vein autograft quality, and illustrates feasibility for elective and urgent isolated CABG and combined CABG scenarios.

Presented here is a protocol for antegrade endoscopic vein harvesting from the lower leg, which can safely be introduced in routine coronary artery bypass grafting. Vein grafts present excellent graft quality following this standardized protocol with positioning of the legs, minimally invasive access to the vein, and antegrade endoscopic vein harvesting.

Antegrade endoscopic harvesting of autografts for bypass grafting may be an optimal strategy addressing excellent graft quality and reduced post-operative ...

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

Preclinical Evaluation of Coronary Artery Stents

Coronary artery disease is a major contributor to morbidity and mortality worldwide. While lifestyle changes and medication are the cornerstones of treatment, coronary artery balloon angioplasty and stenting are routinely performed on patients with acute coronary syndromes and chronic coronary artery disease who remain symptomatic with optical medical treatment. Several generations of coronary stents have been developed over recent decades. Balloon angioplasty and stenting are supported by the use of pharmaceutical agents applied onto balloons and the stent surface, either to advance the healing properties of the artery post-intervention or to prevent the formation of restenosis. New devices need to be rigorously tested for safety and efficacy before acceptance into clinical practice; thus, there is a continuing need for reliable and reproducible preclinical methods of stent evaluation. We describe here a pig coronary artery model as well as an atherosclerotic rabbit model for coronary artery stent research and describe basic steps in intravascular imaging and stent histology.

New coronary artery stent designs and materials must be tested before clinical use in relevant preclinical models. Here we describe an atherosclerotic rabbit aorta model and a pig coronary artery model for stent research with in vivo and histological analyses.

Coronary artery disease is a major contributor to morbidity and mortality worldwide. While lifestyle changes and medication are the cornerstones of ...

Combination of High Ligation and Intraoperative Embolization using Polidocanol for Treatment of Varicoceles

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches in the scrotal segment and then gradually merges into 1-2 trunks after passing through the internal inguinal ring. The key to a successful varicocelectomy is to ligate all the spermatic veins while protecting the testicular arteries and spermatic lymphatic vessels from damage. The small veins, including the branches of spermatic veins and collateral veins, are easily missed for ligation during conventional high ligation of varicocele, which has been suggested as a major cause of postoperative recurrence. Although microsurgery effectively reduces the risk of missing ligation of the spermatic veins during surgery, it has several shortcomings, such as long operation time and a steep learning curve. More importantly, this technique is difficult to carry out in primary hospitals due to the requirement of specialized equipment. Therefore, an attempt to modify the traditional high ligation aiming to reduce the postoperative recurrence rate has been carried out here. The protocol here combines traditional high ligation with intraoperative embolization to seal off the branches of the spermatic vein and collateral veins. We rapidly injected foamed sclerosant into the internal spermatic vein under direct observation after separation of the spermatic vein and then ligated all the veins. The foamed sclerosant through the varicose vein hampers endothelial cell growth, promotes the growth of thrombus and fibrosis, and ultimately forms fibrous streaks that permanently fill the venous. The results showed a more satisfactory effect on reducing the postoperative recurrence rate compared with traditional high ligation. Since this protocol is simple to carry out and has better results in reducing the recurrence rate, this can be an alternative surgical method for the treatment of varicocele, especially in primary hospitals.

To reduce the postoperative recurrence rate of varicocelectomy, we combined high ligation of varicocele with intraoperative embolization. We injected polidocanol from the spermatic vein during surgery to embolize the branches of the spermatic vein and collateral veins. This is an alternative surgical method for the treatment of varicocele.

Varicoceles are dilated veins within the pampiniform plexus and are relatively common in the general male population. The spermatic vein has many branches ...

Occlusion of the Great and Small Saphenous Vein Using Copolymeric Glue Based on N-Butyl Cyanoacrylate and Methacryloxy Sulfolane

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