Directional microwave ablation in spine: experimental assessment of computational modeling.

BACKGROUND: Despite the theoretical advantages of treating metastatic bone disease with microwave ablation (MWA), there are few reports characterizing microwave absorption and bioheat transfer in bone. This report describes a computational modeling-based approach to simulate directional microwave ablation (dMWA) in spine, supported by ex vivo and pilot in vivo experiments in porcine vertebral bodies. MATERIALS AND METHODS: A 3D computational model of microwave ablation within porcine vertebral bodies was developed. Ex vivo porcine vertebra experiments using a dMWA applicator measured temperatures approximately 10.1 mm radially from the applicator in the direction of MW radiation (T1) and approximately 2.4 mm in the contra-lateral direction (T2). Histologic assessment of ablated ex vivo tissue was conducted and experimental results compared to simulations. Pilot in vivo experiments in porcine vertebral bodies assessed ablation zones histologically and with CT and MRI. RESULTS: Experimental T1 and T2 temperatures were within 3-7% and 11-33% of simulated temperature values. Visible ablation zones, as indicated by grayed tissue, were smaller than those typical in other soft tissues. Posthumous MRI images of in vivo ablations showed hyperintensity. In vivo experiments illustrated the technical feasibility of creating directional microwave ablation zones in porcine vertebral body. CONCLUSION: Computational models and experimental studies illustrate the feasibility of controlled dMWA in bone tissue.

Shaping the future of microwave tumor ablation: a new direction in precision and control of device performance.

Microwave ablation (MWA) is becoming an increasingly important minimally invasive treatment option for localized tumors in many organ systems due to recent advancements in microwave technology that have conferred many advantages over other tumor ablation modalities. Despite these improvements in technology and development of applicators for site-specific tumor applications, the vast majority of commercially available MWA applicators are generally designed to create large-volume, symmetric, ellipsoid or spherically-shaped treatment zones and often lack the consistency, predictability, and spatial control needed to treat tumor targets near critical structures that are vulnerable to inadvertent thermal injury. The relatively new development and ongoing translation of directional microwave ablation (DMWA) technology, however, has the potential to confer an added level of control over the treatment zone shape relative to applicator position, and shows great promise to expand MWA's clinical applicability in treating tumors in challenging locations. This paper presents a review of the industry-standard commercially available MWA technology, its clinical applications, and its limitations when used for minimally-invasive tumor treatment in medical practice followed by discussion of new advancements in experimental directional microwave ablation (DMWA) technology, various techniques and approaches to its use, and examples of how this technology may be used to treat tumors in challenging locations that may otherwise preclude safe treatment by conventional omni-directional MWA devices.

Directional Microwave Ablation: Experimental Evaluation of a 2.45-GHz Applicator in Ex Vivo and In Vivo Liver.

PURPOSE: To experimentally characterize a microwave (MW) ablation applicator designed to produce directional ablation zones. MATERIALS AND METHODS: Using a 14-gauge, 2.45-GHz side-firing MW ablation applicator, 36 ex vivo bovine liver ablations were performed. Ablations were performed at 60 W, 80 W, and 100 W for 3, 5, and 10 minutes (n = 4 per combination). Ablation zone forward and backward depth and width were measured and directivity was calculated as the ratio of forward to backward depth. Thirteen in vivo ablations were performed in 2 domestic swine with the applicator either inserted into the liver (80 W, 5 min, n = 3; 100 W, 5 min, n = 3; 100 W, 10 min, n = 2) or placed on the surface of the liver with a nontarget tissue placed on the back side of the applicator (80 W, 5 min, n = 5). The animals were immediately euthanized after the procedure; the livers were harvested and sectioned perpendicular to the axis of the applicator. In vivo ablation zones were measured following viability staining and assessed on histopathology. RESULTS: Mean ex vivo ablation forward depth was 8.3-15.5 mm. No backward heating was observed at 60 W, 3-5 minutes; directivity was 4.7-11.0 for the other power and time combinations. In vivo ablation forward depth was 10.3-11.5 mm, and directivity was 11.5-16.1. No visible or microscopic thermal damage to nontarget tissues in direct contact with the back side of the applicator was observed. CONCLUSIONS: The side-firing MW ablation applicator can create directional ablation zones in ex vivo and in vivo tissues.

Using microwave thermal ablation to develop a subtotal, cortical-sparing approach to the management of primary aldosteronism.

Objective: To investigate the feasibility and efficacy of localized, subtotal, cortical-sparing microwave thermal ablation (MTA) as a potential curative management for primary aldosteronism. The study investigated with equal importance the selected ablation of small volumes of adrenal cortex while sparing adjacent cortex. Method: An in-vivo study was carried out in swine (n = 8) where MTA was applied under direct visualization, to the adrenal glands at 45 W or 70 W for 60 s, using a lateral, side-firing probe and a non-penetrative approach. Animals were survived for 48 h post-procedurally. Animals were investigated for markers of histological, immunohistochemical and biochemical evidence of adrenal function and adrenal damage by assessing samples drawn intra-operatively and at the time of euthanasia. Results: Selected MTA (70 W for 60 s) successfully ablated small adrenocortical volumes (∼0.8 cm3) characterized by coagulative necrosis and abnormal expression of functional markers (CYP11B1 and CYP17). Non-ablated, adjacent cortex was not affected and preserved normal expression of functional markers, without increased expression of markers of heat damage (HSP-70 and HMGB-1). Limited adrenal medullary damage was demonstrated histologically, clinically and biochemically. Conclusion: MTA offers potential as an efficient methodology for delivering targeted subtotal cortical-sparing adrenal ablation. Image-guided targeted MTA may also represent a safe future modality for curative management of PA, in the setting of both unilateral and bilateral disease.

Effect of bandaging techniques on sub-bandage pressures in the equine distal limb, carpus, and tarsus.

OBJECTIVE: To determine the influence of 3 types of bandages on sub-bandage pressures over the distal limb, carpus, and tarsus. STUDY DESIGN: Observational study. ANIMALS: Eight healthy horses. METHODS: Each of the 6 following bandages was applied on each horse in randomized order: (1) distal limb compression bandage (DLC), (2) double layer bandage (DL), (3) inner sanctum bandage (IS), (4) carpal compression bandage (CC), (5) tarsal compression bandage (TC), and (6) adhesive elastic carpal bandage (C-ELA). Sub-bandage pressures were measured with the Picopress compression measuring system (Microlab Electonica, Nicolo, Italy) after bandage application. Carpal and tarsal bandage pressures were assessed before and after walking the horses approximately 50 m. TC pressures were also measured after creating a slit over the calcaneus. A generalized linear model was used to test the association of pressure with sensor location, bandage type, time, and potential interactions (P < .05). RESULTS: DLC (165 mmHg) and IS (167 mmHg) generated greater mean combined pressures compared with DL (146 mmHg; P = .0166). At application, CC (154 mmHg) created higher mean combined sub-bandage pressure compared with C-ELA (70 mmHg; P < .001). Pressures resulting from CC and TC decreased after walking (P < .001), whereas those associated with C-ELA were not affected. CONCLUSION: Variations to the standard DLC construct did not increase sub-bandage pressures. CC and TC pressures rapidly decreased with ambulation, whereas C-ELA pressures in healthy horses were not affected by walking. CLINICAL SIGNIFICANCE: Variations to the standard DLC offer no additional benefit in regards to increasing sub-bandage pressures. Carpal elastic bandages maintain sub-bandage pressures during ambulation and may be more appropriate for long term bandaging in ambulating horses. Creating a slit over the calcaneal tuber in TC bandages is discouraged due to rapid decreases in sub-bandage pressure.

Comparison of Arthroscopic Lavage and Needle Lavage Techniques, and Lavage Volume on the Recovery of Colored Microspheres From the Tarsocrural Joints of Cadaver Horses.

OBJECTIVE: To quantify recovery of colored microspheres from normal cadaver tarsocrural joints using arthroscopic or needle lavage with 1-5 L of fluid. STUDY DESIGN: Ex vivo experimental study. ANIMALS: Adult Quarter Horse cadavers (n = 8). METHODS: After euthanasia, 1.5 × 10(6) colored microspheres were injected into each tarsocrural joint. Each joint was randomly assigned to receive lavage (5 L 0.9% NaCl) with an arthroscope (dorsomedial arthroscope and dorsolateral egress cannula) or three 14 g needles (dorsomedial ingress, dorsolateral, and plantarolateral egress). Egress fluid from each liter was collected separately over time and the number of microspheres present in each recovered liter determined by spectrophotometry. RESULTS: A significant interaction was present between treatment group and liter of fluid (P < .01). The number of microspheres recovered in the first liter of lavage fluid was significantly higher in the needle lavage group than in the arthroscopic lavage group (P < .01). For both groups, the number of microspheres recovered in the first liter of lavage fluid represented a majority of the total microspheres collected and was significantly different from each subsequent liter collected (P < .01). The number of microspheres recovered did not differ between liters 2, 3, 4, and 5 within or between treatment groups. CONCLUSION: In this model, tarsocrural lavage with three 14 g needles was more effective at removing colored microspheres from the joint than arthroscopic lavage, suggesting that the number or placement of portals present may be more important than portal size and flow rate. No difference in microsphere recovery was seen with lavage volumes >1 L.

Effect of a collateral ligament sparing surgical approach on mechanical properties of equine proximal interphalangeal joint arthrodesis constructs.

OBJECTIVE: To (1) compare the effect of a collateral ligament sparing surgical approach with an open surgical approach on mechanical properties of proximal interphalangeal joint (PIPJ) arthrodesis, and (2) to determine the percentage of articular cartilage surface removed by transarticular (TA) drilling with different diameter drill bits. STUDY DESIGN: Randomized paired limb design. SAMPLE POPULATION: Cadaveric equine limbs (n=76). METHODS: Cadaveric PIPJ were drilled using a 3.5, 4.5, or 5.5 mm drill bit at 80-84° to the dorsal plane to remove articular cartilage and subchondral bone from the distal articular surface of the proximal phalanx (P1) and the proximal articular surface of the middle phalanx (P2). Bone ends were photographed and the percentage of the projected surface area that was denuded of cartilage was measured. PIPJ arthrodesis constructs (3-hole dynamic compression plate [DCP], two 5.5 mm TA screws inserted in lag fashion, medial and lateral to the DCP; DCP-TA) were created using 2 surgical approaches in paired limbs. A conventional open approach was used in 1 limb and a collateral ligament sparing approach used in the other limb. Constructs were tested to failure in single-cycle 3-point dorsopalmar/plantar or lateromedial bending. Maximum load, yield load, and composite stiffness were compared between techniques. RESULTS: The 3.5, 4.5, and 5.5 mm drill bits removed 24±4%, 35±5%, and 45±7% of total PIPJ articular cartilage surface, respectively. Constructs with the collateral ligament sparing approach had significantly greater mean yield load (11.3±2.8 versus 7.68±1.1 kN, P=.008) and mean maximum load (13.5±3.1 versus 10.1±1.94 kN, P=.02) under lateromedial bending. Under dorsopalmar/plantar bending there was no significant difference between surgical approaches. The collateral ligament sparing arthrodesis technique had a shorter surgical time (19±3 minutes) compared with the open technique (31±3 minutes). CONCLUSION: A collateral ligament sparing surgical approach to the PIPJ with removal of articular cartilage by TA drilling and arthrodesis by DCP-TA was faster and stronger in mediolateral bending than arthrodesis constructs created with an open surgical approach. CLINICAL RELEVANCE: Preservation of the collateral ligaments and TA drilling for cartilage removal during PIPJ arthrodesis may be a superior approach to the conventional open approach and warrants clinical evaluation.

Microwave ablation of lung tumors: A probabilistic approach for simulation-based treatment planning.

PURPOSE: Microwave ablation (MWA) is a clinically established modality for treatment of lung tumors. A challenge with existing application of MWA, however, is local tumor progression, potentially due to failure to establish an adequate treatment margin. This study presents a robust simulation-based treatment planning methodology to assist operators in comparatively assessing thermal profiles and likelihood of achieving a specified minimum margin as a function of candidate applied energy parameters. METHODS: We employed a biophysical simulation-based probabilistic treatment planning methodology to evaluate the likelihood of achieving a specified minimum margin for candidate treatment parameters (i.e., applied power and ablation duration for a given applicator position within a tumor). A set of simulations with varying tissue properties was evaluated for each considered combination of power and ablation duration, and for four different scenarios of contrast in tissue biophysical properties between tumor and normal lung. A treatment planning graph was then assembled, where distributions of achieved minimum ablation zone margins and collateral damage volumes can be assessed for candidate applied power and treatment duration combinations. For each chosen power and time combination, the operator can also visualize the histogram of ablation zone boundaries overlaid on the tumor and target volumes. We assembled treatment planning graphs for generic 1, 2, and 2.5 cm diameter spherically shaped tumors and also illustrated the impact of tissue heterogeneity on delivered treatment plans and resulting ablation histograms. Finally, we illustrated the treatment planning methodology on two example patient-specific cases of tumors with irregular shapes. RESULTS: The assembled treatment planning graphs indicate that 30 W, 6 min ablations achieve a 5-mm minimum margin across all simulated cases for 1-cm diameter spherical tumors, and 70 W, 10 min ablations achieve a 3-mm minimum margin across 90% of simulations for a 2.5-cm diameter spherical tumor. Different scenarios of tissue heterogeneity between tumor and lung tissue revealed 2 min overall difference in ablation duration, in order to reliably achieve a 4-mm minimum margin or larger each time for 2-cm diameter spherical tumor. CONCLUSIONS: An approach for simulation-based treatment planning for microwave ablation of lung tumors is illustrated to account for the impact of specific geometry of the treatment site, tissue property uncertainty, and heterogeneity between the tumor and normal lung.

Effect of position on transdiaphragmatic pressure and hemodynamic variables in anesthetized horses.

Recumbency affects respiratory mechanics and oxygenation in anesthetized horses. Changes in pleural and abdominal pressures that can impair ventilation have not been described in all recumbencies. The objective of this study was to determine the effects of patient positioning on transdiaphragmatic pressure and selected hemodynamic variables. Horses were maintained under total intravenous general anesthesia with nasal oxygen supplementation. Transnasal balloon catheters in the stomach and thoracic esophagus were used to measure intrathoracic and gastric pressures in standing horses and in anesthetized horses positioned in right and left lateral recumbency, dorsal recumbency, reverse Trendelenburg position, and Trendelenburg position. Transdiaphragmatic pressure was calculated as the difference between gastric and intrathoracic pressures. Measurements of oxygen saturation (SpO2), heart rate, systolic, diastolic and mean arterial pressures, and respiratory rate were obtained every 5 minutes. When compared to dorsal recumbency, gastric expiratory pressure is decreased in the standing position. Thoracic expiratory pressure is decreased in standing and reverse Trendelenburg. Transdiaphragmatic expiratory pressure and SpO2 are decreased in Trendelenburg. Heart rate is increased in reverse Trendelenburg. Systolic, diastolic, and mean arterial pressures are decreased in reverse Trendelenburg and increased in left lateral and right lateral recumbency. We found that there is wide variation in respiratory pressures between horses and positions and they are not predictive of associated changes in hemodynamic variables.

Le décubitus affecte la mécanique respiratoire et l'oxygénation chez les chevaux anesthésiés. Les changements dans les pressions pleurales et abdominales qui peuvent affecter la ventilation n'ont pas été décrites dans tous les décubitus. L'objectif de la présente étude était de déterminer les effets du positionnement du patient sur la pression trans-diaphragmatique et une sélection de variables hémodynamiques. Des chevaux furent maintenus sous anesthésie intraveineuse générale totale avec supplémentation en oxygène par voie nasale. Des cathéters à ballon intra-nasal placés dans l'estomac et l'oesophage thoracique furent utilisés pour mesurer les pressions intrathoracique et gastrique chez des chevaux en position debout et des chevaux anesthésiés positionnés en décubitus latéral droit et gauche, en décubitus dorsal, en position renversée de Trendelenburg et en position de Trendelenburg. La pression trans-diaphragmatique fut calculée comme étant la différence entre les pressions gastrique et intrathoracique. Les mesures de saturation en oxygène (SpO2), du rythme cardiaque, des pressions artérielles systolique, diastolique et moyenne, ainsi que le rythme respiratoire furent obtenues à toutes les 5 minutes. Lors de la comparaison avec le décubitus dorsal, la pression expiratoire gastrique est diminuée dans la position debout. La pression thoracique expiratoire est diminuée en position debout et en position renversée de Trendelenburg. La pression expiratoire trans-diaphragmatique et la SpO2 sont diminuées en position Trendelenburg. Le rythme cardiaque est augmenté en position renversée de Trendelenburg. Les pressions artérielles systolique, diastolique et moyenne sont diminuées en position renversée de Trendelenburg et augmentées en décubitus latéral gauche et droit. Nous avons trouvé qu'il y avait de grandes variations dans les pressions respiratoires entre les chevaux et les positions et qu'elles ne sont pas prédictives de changements associés dans les variables hémodynamiques.(Traduit par Docteur Serge Messier).

Bronchoscopically delivered microwave ablation in an in vivo porcine lung model.

BACKGROUND: Percutaneous microwave ablation is clinically used for inoperable lung tumour treatment. Delivery of microwave ablation applicators to tumour sites within lung parenchyma under virtual bronchoscopy guidance may enable ablation with reduced risk of pneumothorax, providing a minimally invasive treatment of early-stage tumours, which are increasingly detected with computed tomography (CT) screening. The objective of this study was to integrate a custom microwave ablation platform, incorporating a flexible applicator, with a clinically established virtual bronchoscopy guidance system, and to assess technical feasibility for safely creating localised thermal ablations in porcine lungs in vivo. METHODS: Pre-ablation CTs of normal pigs were acquired to create a virtual model of the lungs, including airways and significant blood vessels. Virtual bronchoscopy-guided microwave ablation procedures were performed with 24-32 W power (at the applicator distal tip) delivered for 5-10 mins. A total of eight ablations were performed in three pigs. Post-treatment CT images were acquired to assess the extent of damage and ablation zones were further evaluated with viability stains and histopathologic analysis. RESULTS: The flexible microwave applicators were delivered to ablation sites within lung parenchyma 5-24 mm from the airway wall via a tunnel created under virtual bronchoscopy guidance. No pneumothorax or significant airway bleeding was observed. The ablation short axis observed on gross pathology ranged 16.5-23.5 mm and 14-26 mm on CT imaging. CONCLUSION: We have demonstrated the technical feasibility for safely delivering microwave ablation in the lung parenchyma under virtual bronchoscopic guidance in an in vivo porcine lung model.

Evidence-based equine upper respiratory surgery.

The purpose of this article is to review the veterinary literature for various surgical procedures of the equine upper respiratory tract in an effort to evaluate the evidence supporting various therapies. This article focuses on the therapeutic benefit from more widely occurring conditions, such as laryngeal hemiplegia, dorsal displacement of the soft palate, arytenoid chondritis, and epiglottic entrapment.

Pharmacokinetics of intramuscularly administered morphine in horses.

OBJECTIVE: To determine the pharmacokinetics of morphine after IM administration in a clinical population of horses. DESIGN: Prospective clinical study. ANIMALS: 77 horses. PROCEDURES: Morphine sulfate (0.1 mg/kg [0.045 mg/lb], IM) was administered to horses, and blood samples were obtained at predetermined time points. Plasma morphine concentrations were measured via liquid chromatography and mass spectrometry. In preliminary investigations, samples were obtained from 2 healthy horses at 12 time points (up to 12 hours after drug administration) and analyzed via 2-stage pharmacokinetic analysis. In the clinical phase, blood samples were obtained from 75 hospitalized horses at various times (total, 2 to 3 samples/horse) up to 9 hours after drug administration, and data were analyzed via a naïve pooled pharmacokinetic model. RESULTS: In the clinical phase, the apparent terminal half-life (t(½)) of morphine was approximately 1.5 hours, volume of distribution per bioavailability was approximately 4.5 L/kg, and clearance per bioavailability was approximately 35 mL/kg/min. Peak plasma concentration in naïve pooled analysis was 21.6 ng/mL and occurred approximately 4 minutes after administration. Morphine concentrations were below the limit of quantification ≤ 7 hours after administration in 74 horses. Adverse effects attributed to morphine administration were uncommon and considered mild. CONCLUSIONS AND CLINICAL RELEVANCE: The short t(½) of morphine in horses suggested frequent administration may be needed to maintain targeted plasma concentrations. Variations in plasma concentrations suggested optimal dosages may differ among horses. The drug was well tolerated at the described dose, but patients receiving morphine should be monitored carefully.

Evaluation of survival rate and athletic ability after nonsurgical or surgical treatment of cleft palate in horses: 55 cases (1986-2008).

OBJECTIVE: To determine survival rate and athletic ability after nonsurgical or surgical treatment of cleft palate in horses. DESIGN: Retrospective case series. ANIMALS: 55 horses with cleft palate. PROCEDURES: 13 of the 55 horses died or were euthanized without treatment and were not included in all analyses. Medical records were reviewed for signalment, history, method of diagnosis, soft or hard palate involvement, type of surgical procedure performed, postoperative complications, and survival to hospital discharge. Information on athletic ability was acquired from race records and follow-up conversations with owners, trainers, or referring veterinarians. RESULTS: The predominant reason for initial evaluation was milk or feed in the nostrils (60%). The diagnosis was confirmed by means of videoendoscopy of the upper portion of the airway in all cases. Most cases involved the soft palate only (92.7%). Twenty-six of the 55 (47.3%) horses underwent surgical repair, and 12 of these had dehiscence at the caudal edge of the soft palate. Among potential racehorses, 14 of 33 had surgery. Of these, 12 of 14 survived to discharge and 2 horses raced. Among potential racehorses, 10 of 33 were discharged without surgery and 2 of these raced. Among nonracehorses, 12 of 22 underwent surgery and 11 survived to discharge. All horses that were discharged and for which follow-up information was available survived to 2 years of age or older without ill thrift despite dehiscence at the caudal edge of the soft palate and continued mild nasal discharge. CONCLUSIONS AND CLINICAL RELEVANCE: Horses with cleft palate had a higher survival rate than previously reported.