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TWO SPECIALLY DESIGNED CLAMPS FOR USE IN THE SURGICAL RELIEF OF VASCULAR EMBOLISM AND THROMBOSIS
TWO SPECIALLY D E S I G N E D CLAMPS FOR USE I N T H E SURGICAL RELIEF OF VASCULAR EMBOLISM A N D THROMBOSIS Raymond C. Bonnabeau, Jr., M.D., and C. Walton Lillehei, Minneapolis,
M.D.,
Minn.
The following is a brief report of two instruments* designed to aid in the removal of vascular emboli and thrombi. DESCRIPTION
Both clamps, made of stainless steel, are of similar design, although of dif ferent lengths; the smaller measures 24 cm. in length, the larger, 49 cm. in length (Fig. 1). They are grasped, opened, and closed in a manner similar to that of hemostatic forceps, but differ from them since no ratchet exists for retaining the instrument in the closed position. The pivot screw allowing the clamp to open and close is 11 cm. from the distal tip in the smaller clamp and 26.5 cm. from the distal tip in the larger one. The pivot screw at this point allows the tips to open to a width of 0.7 em. in the smaller clamp and 1 cm. in the larger clamp while maintaining the open blades parallel to one another (Fig. 2). The closed distal ends measure 0.2 cm. in width and interlock in such a manner that they form a smooth tapering nontraumatic tip (Fig. 3). The open distal tip has been made into an effective grasping surface by constructing it as a small 0.2 by 1.1 cm. closed cup, surrounded by a flat serrated lip, 0.1 cm. in width (Fig. 4). COMMENT
We have had occasions during vascular operative procedures to make use of various instruments, considered standard operating room equipment, although not necessarily standard vascular equipment, in an attempt to facilitate the removal of thrombotic or atherosclerotic material. One instrument that we have . From the Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn. Supported by research grants from U. S. Public Health Service (Grant No. HE-830-12), Life Insurance Medical Research Fund, and Maria and Joseph Gales Ramsay, III, Cardiovascu lar Fund. Received for publication June 1, 1964. •Manufactured by Lawton Co., 425 Park Avenue, New York 16, N. T., and distributed by Physicians and Hospital Supply Co., 1400 Harmon Place, Minneapolis, Minn. 283
284
BONNABEATJ AND LILLEHEI
J. Thoracic and Cardiovas. Sur£.
'. \" Vnfci'3;1»rtfe*8i lAwtoluiLffiiil
Fig. 1.—A, The two stainless steel instruments photographed from above. The larger clamp is 49 cm. in length, the smaller is 24 cm. in length. The pivot screw has been placed 26.5 cm. from the distal end in the larger clamp and 11 cm. from the distal end in the smaller clamp. B, The two instruments photographed from the side. The gentle curve of the blades allows them to be inserted well into a vascular lumen facilitating removal of thrombotic material from as high as the aortic bifurcation that originally had necessitated a separate incision or one of greater magnitude. No ratchet exists as in hemostatic forceps, therefore, the clamps cannot be locked in the closed position.
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Fig. 2.—The smaller clamp in the open position photographed from above. This clamp is able to be opened to 0.7 cm. in width, the larger clamp to 1 cm. in width while maintaining the blade edges parallel to the vascular wall. The clamp then can be moved along the lumen of a vessel in the open position, the parallel tips limiting the danger of damage to the vascular intima. When closed, the distal tip is 0.2 cm. in width.
found useful in this regard has been the Randal stone forceps. These, however, were, in some cases, impractical, as in children, due to the large size of the distal tip and the small size of a child's arterial lumen. At other times, the lack of sufficient length or the curvature of this instrument made it difficult or impossible to reach thrombotic material some distance from the arteriotomy
Vol. 49, No. 2 February, 1965
METRIC 1
SPECIALLY D E S I G N E D CLAMPS
^
285
I METRIC 11 h
m i n i
i
2
i"T'i t »'f 1 i I i I"
Pig. 3.—A lateral view of the distal tip of the small clamp in the closed position. This is the same size as the shaft of the instrument and measures 0.5 cm. in height. As may be noted, the tip is essentially the same width and height as the shaft of the instrument, facilitating its use in the vessels of children. Pig. 4.—The internal surface of the distal end of the small clamp. As may be observed, this is the grasping portion of the clamp and contains a cup-like depression 0.2 cm. by 1.1 cm., surrounded by a flat serrated lip 0.1 cm. in width. This design helps in holding and removing thromboembolic material.
Pig. 5.—Patient I. B., a 60-year-old woman, and the first patient in whom the instruments were used. She developed a thrombosis of the left femoral, left common and external iliac, and right external iliac arteries following femoral arteriotomy for a diagnostic left-sided heart catheterization. The material illustrated is the thrombotic and atherosclerotic material removed from the left femoral artery. Several other large clots were also removed from the right iliac artery. These were all done by means of groin incisions. Permanent arterial pulsations were restored.
286
BONNABEATJ AND L I L L E H E I
J. Thoracic and Cardiovas. Surg.
site. By modifying the tip, curve, and length of these forceps, we developed the instruments being described, which we believe are better suited for vascular procedures. The pivot screw, being placed at the location already described, allows a relatively wide opening of the distal tip of each clamp while main taining the open tip parallel to the vascular wall. Movement into and along the vessel to grasp thrombotic material with the instruments in the open position can be done with a minimum danger of injury to the vascular intima, as might occur if the open tips did not remain parallel. We have used these instruments in clinical work in numerous embolectomies and thrombectomies over the past 2 years. During this period of time, we have removed thromboembolic material from the abdominal aorta and numerous iliac and femoral arteries, utilizing only a groin incision. Prior to the use of these instruments, retroperitoneal or mul tiple exposures of the diseased vascular channels generally had been necessary (Fig. 5). SUMMARY
Two specially designed vascular instruments, which have facilitated the removal of thromboembolic and atherosclerotic material, have been described.
M.D.,
Minn.
The following is a brief report of two instruments* designed to aid in the removal of vascular emboli and thrombi. DESCRIPTION
Both clamps, made of stainless steel, are of similar design, although of dif ferent lengths; the smaller measures 24 cm. in length, the larger, 49 cm. in length (Fig. 1). They are grasped, opened, and closed in a manner similar to that of hemostatic forceps, but differ from them since no ratchet exists for retaining the instrument in the closed position. The pivot screw allowing the clamp to open and close is 11 cm. from the distal tip in the smaller clamp and 26.5 cm. from the distal tip in the larger one. The pivot screw at this point allows the tips to open to a width of 0.7 em. in the smaller clamp and 1 cm. in the larger clamp while maintaining the open blades parallel to one another (Fig. 2). The closed distal ends measure 0.2 cm. in width and interlock in such a manner that they form a smooth tapering nontraumatic tip (Fig. 3). The open distal tip has been made into an effective grasping surface by constructing it as a small 0.2 by 1.1 cm. closed cup, surrounded by a flat serrated lip, 0.1 cm. in width (Fig. 4). COMMENT
We have had occasions during vascular operative procedures to make use of various instruments, considered standard operating room equipment, although not necessarily standard vascular equipment, in an attempt to facilitate the removal of thrombotic or atherosclerotic material. One instrument that we have . From the Department of Surgery, University of Minnesota Medical School, Minneapolis, Minn. Supported by research grants from U. S. Public Health Service (Grant No. HE-830-12), Life Insurance Medical Research Fund, and Maria and Joseph Gales Ramsay, III, Cardiovascu lar Fund. Received for publication June 1, 1964. •Manufactured by Lawton Co., 425 Park Avenue, New York 16, N. T., and distributed by Physicians and Hospital Supply Co., 1400 Harmon Place, Minneapolis, Minn. 283
284
BONNABEATJ AND LILLEHEI
J. Thoracic and Cardiovas. Sur£.
'. \" Vnfci'3;1»rtfe*8i lAwtoluiLffiiil
Fig. 1.—A, The two stainless steel instruments photographed from above. The larger clamp is 49 cm. in length, the smaller is 24 cm. in length. The pivot screw has been placed 26.5 cm. from the distal end in the larger clamp and 11 cm. from the distal end in the smaller clamp. B, The two instruments photographed from the side. The gentle curve of the blades allows them to be inserted well into a vascular lumen facilitating removal of thrombotic material from as high as the aortic bifurcation that originally had necessitated a separate incision or one of greater magnitude. No ratchet exists as in hemostatic forceps, therefore, the clamps cannot be locked in the closed position.
*IC 11 " ' " ' ' T " " T! 'IH| '
! I ' ! I| I
Fig. 2.—The smaller clamp in the open position photographed from above. This clamp is able to be opened to 0.7 cm. in width, the larger clamp to 1 cm. in width while maintaining the blade edges parallel to the vascular wall. The clamp then can be moved along the lumen of a vessel in the open position, the parallel tips limiting the danger of damage to the vascular intima. When closed, the distal tip is 0.2 cm. in width.
found useful in this regard has been the Randal stone forceps. These, however, were, in some cases, impractical, as in children, due to the large size of the distal tip and the small size of a child's arterial lumen. At other times, the lack of sufficient length or the curvature of this instrument made it difficult or impossible to reach thrombotic material some distance from the arteriotomy
Vol. 49, No. 2 February, 1965
METRIC 1
SPECIALLY D E S I G N E D CLAMPS
^
285
I METRIC 11 h
m i n i
i
2
i"T'i t »'f 1 i I i I"
Pig. 3.—A lateral view of the distal tip of the small clamp in the closed position. This is the same size as the shaft of the instrument and measures 0.5 cm. in height. As may be noted, the tip is essentially the same width and height as the shaft of the instrument, facilitating its use in the vessels of children. Pig. 4.—The internal surface of the distal end of the small clamp. As may be observed, this is the grasping portion of the clamp and contains a cup-like depression 0.2 cm. by 1.1 cm., surrounded by a flat serrated lip 0.1 cm. in width. This design helps in holding and removing thromboembolic material.
Pig. 5.—Patient I. B., a 60-year-old woman, and the first patient in whom the instruments were used. She developed a thrombosis of the left femoral, left common and external iliac, and right external iliac arteries following femoral arteriotomy for a diagnostic left-sided heart catheterization. The material illustrated is the thrombotic and atherosclerotic material removed from the left femoral artery. Several other large clots were also removed from the right iliac artery. These were all done by means of groin incisions. Permanent arterial pulsations were restored.
286
BONNABEATJ AND L I L L E H E I
J. Thoracic and Cardiovas. Surg.
site. By modifying the tip, curve, and length of these forceps, we developed the instruments being described, which we believe are better suited for vascular procedures. The pivot screw, being placed at the location already described, allows a relatively wide opening of the distal tip of each clamp while main taining the open tip parallel to the vascular wall. Movement into and along the vessel to grasp thrombotic material with the instruments in the open position can be done with a minimum danger of injury to the vascular intima, as might occur if the open tips did not remain parallel. We have used these instruments in clinical work in numerous embolectomies and thrombectomies over the past 2 years. During this period of time, we have removed thromboembolic material from the abdominal aorta and numerous iliac and femoral arteries, utilizing only a groin incision. Prior to the use of these instruments, retroperitoneal or mul tiple exposures of the diseased vascular channels generally had been necessary (Fig. 5). SUMMARY
Two specially designed vascular instruments, which have facilitated the removal of thromboembolic and atherosclerotic material, have been described.