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Lasers in Surgery and Medicine 10:234-244 (1990)

Thermal Characteristics of Sapphire


Contact Probe Delivery Systems for
Laser Ang ioplasty
S. Ashley, FRCS, FICA, S.G. Brooks, FRCS, A.A. Gehani, MRCP, FACA,
R.C. Kester, MCh, MD, FRCS, and M.R. Rees, FRCR, MRCP, FICA
Cardiac Research Unit, Killingbeck Hospital United Kingdom (S.A., S.G.B., A.A.G.,
M.R.R.); Department of Vascular Surgery, St. Jamess University Hospital,
Leeds LS9 7TF, United Kingdom (R.C.K.)

Contact probes made from synthetic sapphire crystal, designed


for general laser surgery, are currently being evaluated for use in
laser angioplasty. Their mode of action and safety in the context
of arterial recanalisation is unknown, particularly with respect
to the degree of probe and catheter heating. Infrared thermal
imaging was used to investigate the surface temperature rise of
various rounded sapphire probes during emission of continuous
wave Nd-YAG (1,064 nm) laser energy. Catheter safety was addressed by analyzing the temperature of the metal interface between the optical fiber and sapphire, as well as the catheter proximal to this junction. Transmission of Nd-YAG energy through
each probe was also measured.
Five rounded probes of 1.8-3.0 mm diameter (three supplied by
Surgical Laser Technologies [SLTI, two by Living Technology
[LT]), along with their respective optical catheters, were compared. There was a large temperature gradient between the front
and rim of the probes. The maximum surface temperature rise of
the sapphire (at 20 W, 5-second exposure) was 314-339C (SLT)
and 90-108C (LT) [P<O.OOl, 3-way ANOVAI. The reason for this
difference may be related to crazing of the front surface of the
SLT sapphires. At all energy levels sapphire temperatures were
considerably lower than attained by metal laser thermal angioplasty probes. Forward transmission was slightly higher in the
SLT probes (7585%)than the LT sapphires (54-69%). With fiber
perfusion at 2 ml/minute, a minor degree of heating of the metal
sapphire holders was recorded (maximum rise 35C),but heating
of the catheter proximal to this was negligible. Therefore, it
would appear that the risk of tip detachment or arterial injury
due to heating of the connecting metal interface is extremely low.
Without perfusion, however, there was a greater degree of interface heating in the LT delivery system suggestive of more laser
backscattering by these sapphires compared with the SLT
probes [P<O.OOl, one-way ANOVAI. The SLT system is, therefore,
potentially safer in this respect. These results suggest that some

Accepted for publication January 30, 1990.


Address reprint requests to Mr. Simon Ashley FRCS, Cardiac
Research Unit, Killingbeck Hospital, York Road, Leeds. LS14
6UQ, UK.

0 1990 Wiley-Liss, Inc.

Sapphire Contact Probes in Laser Angioplasty


degree of surface heating of contact probes due to energy absorption within the sapphire does occur, but is localised to the front of
the probe. This effect may contribute to the process of arterial
recanalisation with this device. However, variation in the thermal and optical properties of sapphires from different sourceshas been demonstrated. The influence of these properties on
plaque ablation, and ultimately the clinical performance of different contact probe systems, requires further investigation.

235

Key words: laser recanalisation, Nd-YAG, sapphire probe, thermal energy

sequelae of the thermal injury thus created is


presently unknown.
The use of modified distal fibertips has imAn alternative delivery device suitable for
proved the overall safety and results of laser anuse with continuous wave Nd-YAG lasers is the
gioplasty in the treatment of occlusive arterial
sapphire contact probe. This is an optical probe
disease by reducing the incidence of mechanical developed for use in general surgical contact laser
and laser-mediated vessel wall perforation [ 11.
applications 151, its use for laser angioplasty beThe majority of clinical experience in the treating a recent development [61. It has potential adment of peripheral arterial occlusions has been vantages over metallic tips
171. Transmission of
achieved with the Metal Laser Probe (Trimecontinuous wave Nd-YAG energy through the
dyne-Hot-tip) [2,31. These metal capped probes
sapphire produces photo-thermal vaporisation of
convert all the laser energy into heat without any
at,heroma 181. In addition, surface and internal
transmission of laser light to the tissue, thereby
scattering effects will enhance energy absorption
producing a thermal as opposed t o laser angiowithin the sapphire and cause probe heating, but
plasty. Experiments with thermocouples attached
the magnitude of this effect and whether it cont o the metal probe have demonstrated temperatributes t o the process of recanalisation by melttures above 600C in air and blood 141, which may
ing and thermally compressing atheroma directly
produce an excessive degree of thermal damage to
in contact is presently unknown C91. Furthermore,
the surrounding arterial wall. Clinical success
a concern regarding the use of sapphire probes for
with this type of contact probe suggests that heat
arigioplasty has been potential back-heating of
alone is an effective means of ablating atheroma
the connecting metal interface between fiber and
and recanalising arteries, although the long-term
sapphire due to reflected energy. This could potentiate thermal damage t o surrounding arterial
INTRODUCTION

Fig. 1. The five rounded sapphire contact probes studied (left


t o right Surgical Laser Technologies [SLTl 3.0 mm (MTRL),
SLT 2.2 mm (MTR),SLT 1.8 mm (SMTR),Living Technology
2.2 mm, Osada 2.2 mm. Each sapphire crystal is mounted in
a metal holder within which there is a small hole to emit the
saline perfusate.

Fig. 2. This shows how the contact probe screws onto the
connector assembly at the distal end of the optical catheter.
The catheter contains a 600 km optical core fibre which terminates 0.1 mm proximal to the distal end of the screw
threads.

236

Ashley et al.
Rear facet o f sapphire

TABLE 1. Dimensions (in mm) of Sapphire Probes (see


Fig. 3)
Probe

Fig. 3. Schematic diagram of sapphire contact probe indicating dimensions of probe components shown in Table 1.

wall and, if severe, result in intravascular tip detachment.


The purpose of this study was t o investigate
the thermal and optical properties of sapphire
probes during emission of continuous wave NdYAG laser energy. The study compares the characteristics of different types of rounded sapphire
contact probe which although designed primarily
for general medical applications are potentially
suitable for arterial recanalisation.
MATERIALS AND METHODS
Sapphire Contact Probes

Five different types of rounded sapphire contact probe potentially suitable for laser angioplasty were studied (Fig. 1). Three were supplied
by Surgical Laser Technologies (SLT, Malvern,
PA) [outer diameter of probes in parentheseslMTRL (3 mm), MTR (2.2 mm), and SMTR (1.8
mm) using an SLT CL60 CW Nd-YAG laser
(1,064 nm) and SLT optical fibers. Two were supplied by Living Technology (LT, Glasgow, UK)LT (2.2 mm) and Osada [OS] (2.2 mm), using an
LT Flexilase 100 CW Nd-YAG laser (1,064 nm)
and LT optical fibers. The synthetic sapphire
crystal is mounted in a metal holder which screws
onto a metal connector at the termination of the
optical fiber (Fig. 2). The metal holders have either two or one (LT probe) cooling ports situated
just behind the rear facet of the sapphire. The
dimensions of each probe according t o the schematic diagram in Figure 3 are shown in Table 1.
The catheter delivery system in each case
consisted of a 0.6 mm internal quartz optical core
surrounded by an outer Teflon catheter for saline

A. Diameter
B. Length of
protruding
sapphire
C. Total length
of sapphire
D. Length of
metal holder

SMTR

MTR

MTRL

LT

0s

1.8

2.2

3.0

2.2

2.2

1.0

1.5

3.5

1.5

2.5

3.2

3.0

5.0

3.2

6.0

3.5

3.5

3.5

3.5

6.2

perfusion which is expelled via the cooling ports


in the sapphire holder. Saline was administered
at a rate of 2 mllminute, which serves t o cool the
connecting metal interface between fiber and sapphire. In vivo this also prevents blood entering
the space between the distal optical fiber and the
rear facet of the sapphire.
Probe Temperature Measurement

The temperature of the sapphire surface was


measured remotely using a sensitive video scanning infrared thermal imaging system (NEC Sanei Thermo Tracer 6T61). The infrared radiation
(effective wavelength 8-13 pm) from the probe
being measured is detected by a highly sensitive
detector (Cd-Hg-Te, liquid nitrogen cooling type)
and then scanned horizontally and vertically by
an optical scanner. The resulting pattern of temperature distribution is processed by computer
and displayed as a two-dimensional colour thermal image. The temperature range of the detector
is -50 t o + 2,O0O0C, with a spatial resolution of
0.4 mm, and minimum detectable temperature
difference of 0.1"C. A high accuracy of 0.5% of the
full range is achieved through automatic calibration and automatic correction for ambient temperature and ambient reflection. Because infrared radiation is not transmitted through saline or
blood, measurements were only permissible in
air. Sequential temperature measurements were
made at the point of maximum temperature development within the sapphire crystal viewed
side-on by the detector (image frame time 0.5 seconds, horizontal line scan time 8 ms).
The laser power settings were varied from 1
to 10 W (1 W increments) and 10 to 20 W (2 W
increments), and at each power, peak sapphire
temperatures were recorded during 0.5-, 1-,2-, 3-,
4-,and 5-second exposure times, individual measurements being made at each laser setting. The
laser power output was checked with an Ophir

Sapphire Contact Probes in Laser Angioplasty

237

, Sapphire Contact P r o b e mounted in black body

Heat gun u n i f o r m
heat source

Fig. 4. Diagram of experimental method used to determine


the emissivity of each sapphire probe. Uniform external heating of the sapphire together with a black body of known emissivity (Em 1) is continued until their temperatures equilibrate. Adjustment of the thermal imaging systems

F150-A DGHH power meter prior t o each exposure. Measurements were repeated three times at
each power/duration setting t o obtain a mean
temperature rise above ambient temperature. All
experiments were conducted a t room temperature.

I n f r a r e d thermal imaging camera


linked t o computer

en-iissivity setting corresponding to the sapphire and metal


components of each probe is made until there is no apparent
temperature difference between them and the black body.
The Em setting thus derived is then used for subsequent
probe temperature measurements.

blackbody and exposed to heated air from a heat


gun (Fig. 4).After allowing time for the temperature of the sapphire to equilibrate with that of
the blackbody (8OoC),the Thermo Tracer with Em
set to 1 was used t o measure the temperature of
the sapphire. The Thermo Tracers emissivity setting was then decreased (0.001 steps) until the
Interface Heating
sapphires temperature appeared the same as that
Back-heating was assessed by measuring the of the blackbody (the temperature of which had
temperature of the metal holder and catheter been determined a t Em 1). The resulting emissivproximal t o each sapphire. The maximum tem- ity setting was then used for the temperature
perature arising in the proximal most portion of measurements of that probe. This method was
the metal holders was measured during 5-second also used to determine the emissivity of the metal
exposures at 20 W, with saline perfusion at 2 ml/ mounting collar of each sapphire, and the Teflon
minute. Saline perfusion abolished distal fiber cladding surrounding the metal connector at the
heating, and therefore the potential risk of distal distal fiber end, in order t o measure metal interfiber heating was determined by measuring the face and catheter heating.
temperature of the distal catheter during 5second exposures of 1 W without saline (this low Optical Transmission
Transmission of continuous wave Nd-YAG
power setting was chosen to prevent burn out of
the unperfused fibers). Each measurement was laser light through the probes was measured usrepeated three times t o provide a mean tempera- ing an Ophir F150-A DGHH thermopile power
meter. The entire spot of forward-projected light
ture rise.
fell on the absorption surface. Power output was
Emissivity
measured at one level (1 W) during exposure
In order t o permit accurate temperature times of up t o 30 seconds, assuming that the physmeasurements using infrared thermal imaging it ical properties of the crystal are unaffected by the
was first necessary to determine the Emissivity amount of light transmitted or temperature rise
(Em) of each sapphire probe. Emissivity of a body at this level. The ratio of power transmitted
relates the ratio of radiant energy from that body through the sapphire to that by the same optical
t o that of a blackbody (Em 1)at the same temper- fiber without the sapphire mounted, was used t o
ature. Each sapphire probe was mounted in a express the percentage transmission. Measure-

Ashley et al.
exposures of 10 W for 1 second being the usual
TABLE 2. Emissivity (Em) of Sapphires and Proximal
Metal Holders
parameters during clinical arterial recanalisaProbe
S a m h i r e Em
Metal holder Em tion). Figure 6 shows the time course of mean surface temperature rise for the different probes at
SMTR
0.74
0.35
the 20 W power level, the maximum used in this
MTR
0.76
0.35
study. Figure 7 shows the linear relationship beMTRL
0.77
0.35
LT
0.76
0.40
tween mean surface temperature rise of the
0s
0.73
0.16
probes with increasing power using 1 second exposure times (correlation coefficient r = 0.98,0.99,
0.98, 0.96, 0.96, for SMTR, MTR, MTRL, OS, and
ments were made with and without saline perfu- LT sapphires, respectively [ P < O . O O l , all probes]).
sion of the fibers. This method was chosen rather The effect of laser power and exposure on sapthan using an integrating sphere, as it only mea- phire temperature were highly significant using
sures the antegrade optical transmission, as op- 3-way analysis of variance (ANOVA) [P<O.OOl].
posed to the total transmission including laterally At all laser settings the three SLT sapphires
scattered light. These data therefore give an in- reached higher temperatures than the LT and
dication of how much light is either absorbed by sapphires (P<O.OOl), 3-way ANOVA and Sheffes
the probe, scattered outside the probe, or reflected method for comparing contrasts).
back up the optical fiber.
Interface Heating
Scanning Electron Microscopy (SEM) of Sapphire
Figure 8a is a thermal image showing heatProbe Surface
ing of the distal catheter just proximal to the
The front surface of each type of sapphire metal connector, with an Osada sapphire, lasing
probe was examined by scanning electron micros- at 1W for 5 seconds without saline perfusion. It is
copy. New probes were examined before any ex- at this point that excessive back-heating or inadposure to laser energy. Each probe was secured equate cooling may result in melting of the fiber
onto an aluminium stub with adhesive. Electrical and tip detachment (Fig. 8b). Mean distal cathecontact was made with Carbon Dag (suspension of ter and metal holder temperature rise above amcarbon in organic medium). The probes were sput- bient temperatures of all five delivery systems is
ter coated with gold using an Emscope SC 500
shown in Table 4.Distal catheter heating was sigGold Sputter Coater and scanning electron mi- nificantly greater with the LT and 0s probes
croscopy performed with a Cam Scan S.E.M. (Se(P<O.OOl, one-way AVOVA), it being virtually
ries 3 ) .
negligible with the SLT probes, even in the absence of saline perfusion. The maximum metal
holder temperature rise observed with perfusion
RESULTS
at 2 ml/minute was 35C (lasing a t 20 W for 5
Emissivity
seconds).
The emissivity of the sapphires and their
metal holders is shown in Table 2. The outer clad- Optical Transmission Characteristics
ding of all delivery catheters tested had an emisThe optical transmission of the sapphire consivity of 1.
tact probes expressed as a percentage of the light
Temperature of Sapphire Contact Probes
transmitted through the same optical fiber withPanels a and b of Figure 5 show typical ther- out the sapphire mounted is shown in Table 5. No
mal images of the 0s and MTR sapphire probes, difference was made by saline perfusion of the
respectively. Heat is localised within the crystal fibers.
and cross-hairs may be moved across the screen t o
provide a digital indication of the temperature at Scanning Electron Microscopy of
any point on the image. Table 3 shows the peak Sapphire Surface
surface temperature of each sapphire tip in air.
High power magnification views of the front
The results are expressed as the mean tempera- surface of LT, and MTR sapphires are shown in
ture rise above ambient temperature of each sap- panels a and b of Figure 9, respectively. The LT
phire a t 5, 10, and 20 W laser power for exposure sapphires have a smooth, highly polished regular
durations of 1, 2, 3 , 4, and 5 seconds (repeated surface. Although not shown, the
probes sim238

0s

0s

Sapphire Contact Probes in Laser Angioplasty

Fig. 5. a: Thermal image of an 0s 2.2 mm probe (sapphire to


left, metal collar and fiber to right) after a 2 second exposure
at 20 W power. Heat is localised within the sapphire crystal
which in this case has reached almost 94C (indicates temperature at cross-hair within hot-spotjust behind the centre
of the sapphire). Note the hot saline emerging from the port
in the metal collar behind the sapphire, demonstrating its

239

important action of cooling the connecting metal interface


between the optical fiber and sapphire. b: Thermal image of
SLT MTR probe after 2 second exposure at only 10 W, showing greater temperature than image a. Note the position of
the hot spot, which occurs towards the front surface of the
sapphire.

TABLE 3. Sapphire Probe Surface Temperature Rise


(C; mean f S.E.M.) in Air at Various Powers and
Exposure Durations*
Sap- Power
(W)
phire
SMTR
5
10
20
MTR
5
10
20
MTRL
5
10
20

0s

Duration (seconds~
2
3
4

*
*

2 7 2 1 3 9 2 1 4 5 2 1 4810
4920
65 f 2 104 f 1 148 2 3 161 z 12 175 ? 8
139 2 8 257 2 6 315 f 4 319 z 2 339 2 2
3 3 t 0 4921 5620 64-1
63 2 2 94 2 3 118 2 1 138 z 0
1 1 7 k 2 209 t 4 278 2 1 316 = 6

SMTR
MTR
MTRL

iz-0 s

LT

7020
149 f 2
327 2 1
0

3 8 2 1 6 1 2 2 8 6 2 3 1 0 8 ~ 21 2 9 2 1
74 2 4 112 2 1 141 2 2 180 I
1 232 2 18
130 2 6 175 2 1 229 2 7 280 2 10 314 2 7

5
10
20

4021
1 1 2 0 2 0 t O 2 7 2 0 3110
2020 3020 4322 5 1 ~ 254f4
3 6 2 4 7 3 2 2 9 0 2 1 9 7 ~ 51 0 8 2 1

5
10
20

2220 2620 22tO 2 6 ~ 23122


2 0 f 1 2 9 f 1 3 2 2 1 40-22 4 7 2 3
5 3 2 3 7 9 2 6 9 0 2 2 94-23 9Ok2

LT

*At all laser settings the temperatures of the three SLT sapphires were higher than the 0s and LT sapphires (3-way
ANOVA, p< 0 .OO 1).

ilarly have a smooth polished appearance. In contrast, the surface of the MTR probes which are
identical t o the other SLT probes examined, have

E X W s J r p t l d r a t L I IS, L h e r

2:) W

Fig. 6. Graph showing the mean surface temperature rise of


the five sapphires with increasing exposure durations (power
constant at 20 W).

a crazed, appearance which appears to be


roughened and irregular at high magnifications.
DISCUSSION

The application of continuous wave Nd-YAG


laser energy in general medicine and surgery has
been enhanced by the development of contact
probes made from transparent artificial sapphire
crystal. The advantage of the contact probe over
conventional non-contact delivery catheters is the

Ashley et al.

240

,5
10
It
Laser Power ( a )DJratior 1 s

20

Fig. 7. Graph showing linear relationship between sapphire


surface temperature rise and laser power, using 1 second exposure duration. At all energy levels the temperature of the
SLT sapphires was greater than the 0s and LT probes
(P<O.OOl, 3-way ANOVA, and Sheffe's method of comparing
contrasts). The individual data points have been omitted for
clarity. Correlation coeficients (r) in parenthesis.

creation of a localised region of high power density right at the tip of the probe, which may be
placed precisely against the target tissue without
risk of contaminating the optical fiber. This reduces the total energy required to achieve the desired therapeutic effect, thereby reducing damage
t o neighbouring tissue [lo]. Sapphire contact
probes are available in a variety of geometric
shapes. The rounded probes, developed for vaporisation of tissue, are atraumatic and therefore potentially suitable for laser delivery within arteries. The probe helps to maintain a coaxial position
within the vessel and reduces the risk of lasermediated and mechanically induced perforation
[ll]. The sapphire may be placed in contact with
occlusive plaque providing tactile feedback to the
operator. Ablation is more efficient than with a
bare fiber, and the probe produces a wider lumen
[8]. Early clinical trials using the combination of
contact probes with continuous wave Nd-YAG energy are encouraging and have shown that recanalisation of long occlusions may be effected using repeated 1 second bursts of energy at powers
between 10 and 15 W [12,131.
The suitability of artificial sapphire probes
for laser angioplasty, with respect to their physical properties, has been discussed previously [9].
The interaction of laser energy with the sapphire
may be complex as the transparent crystal will
modify the laser energy in various ways. The
beam profile is focused by refraction at the distal
surface of the sapphire concentrating the photo-

Fig. 8. Thermal image of an 0s sapphire demonstrating


back-heating of the optical catheter (to right of image) immediately proximal to the metal sapphire connector due to reflected energy, lasing at 1 Watt for 5 seconds without saline
perfusion (a). Excessive back-heating at this point may lead
to melting of the fiber and detachment of the sapphire tip (b).

thermal effect at the probe tip. Surface and internal scattering effects may promote energy absorption within the probe resulting in heating of the
sapphire, but this potential effect has not previously been measured directly. Furthermore, backreflection and scattering may give rise to undesirable and possibly dangerous effects such as
heating of the metal holder and fiber just behind
the sapphire. The thermal and optical characteristics of sapphire probes may be influenced by
many factors such as shape, surface geometry,
and the presence of surface coatings, as well as
optical alignment and connection with the optical
fiber. In these respects one might expect variation

Sapphire Contact Probes in Laser Angioplasty


24 1
TABLE 4. Mean Temperature Rise Recorded in Distal
to the intrinsic properties peculiar to each probe,
Fiber Proximal to Metal Connector of Each Delivery
as opposed to heat conduction from the surroundSystem (5 Second Exposure at 1 W Power and No
ing medium. In this way, thermography provides
Saline Perfusion); and Mean Temperature Rise of
a potential basis on which to compare the characMetal Sapphire Holders During Maximal Laser
tteristicsof different sapphires and relate these t o
Exposure (5 Second Exposure at 20 W With
Perfusion at 2 mumin)
in vitro and in vivo tissue effects. Furthermore,
measurement of sapphire probe temperature in
C (mean 2 S.E.M.)
air allows comparison with similar studies examProbe
Distal fiber*
Metal holder ining other types of laser probe.
0s
14 ? 0.3
30 2 2
Emissivity of the sapphires was found to be
LT
950
32 +- 2
airly
constant for all probes studied as expected.
SMTR
340
29 ? 3
Failure to appreciate that sapphire and other maMTR
220
7*0
terials may have an emissivity less than 1 would
MTRL
220
6kO
result in temperatures of the various probe com*P<O.OOl, one-way ANOVA.
ponents being underestimated by infrared thermal imaging. This emphasises the importance of
TABLE 5. Optical Transmission of Sapphire
taking
emissivity into consideration when using
Contact Probes
thermal imaging t o study temperature in laser
% Transmission Nd-YAG
applications.
Sapphire
(1,064 nm) energy
The peak temperature at the surface of each
SMTR
85
type of sapphire was proportional t o the power
MTR
83
input for a given laser exposure time. The time
MTRL
75
course of temperature rise shows thermal satura69
LT
tion after around 4 seconds of laser exposure. This
0s
54
effect was observed at all power levels with all
probes and was, therefore, temperature indepenin the properties of sapphires from different dent. It may be explained by thermal equilibrium
sources which could result in important differ- with the surrounding atmosphere as opposed to
ences both in terms of the potential safety of the increasing thermal radiation. Peak temperatures
at any given power and exposure duration were
device and its clinical efficacy.
Heat generation within sapphires will occur much higher in the SLT sapphires compared t o
due to direct absorption of light by the crystal. the two types of LT probe (P<O.OOl), and temperAlthough the amount of energy absorbed is pre- atures of the different probes within these two
dicted t o be in the region of 1%[9], it will be groups were similar. In this respect the sapphires
influenced by the intrinsic properties peculiar to fall in to two distinct groups. This raises two queseach type of contact probe. In addition, heat gen- tions. Firstly, what is the explanation for the sigeration will occur due t o conduction from particles nificant thermal difference between these probes?
on the surface of the probe which convert light Secondly, does the increased thermal effect at the
into heat, as well as from tissue in front of the tip of the SLT sapphires enhance tissue penetraprobe absorbing light. Thermography is an effec- tion without increasing damage during laser antive means of studying the thermal characteris- gioplasty?
Addressing first the question of different
tics of contact probes because it demonstrates
physical
properties, it was observed during the
temperature distribution within the device in adexperiments
that heat develops at the centre of
dition t o absolute temperature measurement a t
the
front
surface
of the SLT sapphires and propany point on the image. But the major disadvanagates
backwards
(compare Fig. 5a and b). This is
tage with this technique is the inability to meaindicative
of
a
high
temperature gradient besure probe temperature when immersed in blood,
tween
the
front
and
rim
of the sapphire and corsaline, or tissue, as in the in vivo situation. Reresponds
to
the
changes
seen
a t the surface of the
mote temperature measurement was necessary,
probe
and
tissue
immediately
after laser exposure
however, as thermocouples cannot reliably be
[14].
The
irregular
surface
of
the SLT sapphires
made to adhere t o the sapphire surface. Although
not necessarily predictive of absolute tempera- produces scattering and reflection of light such
tures in vivo, this method does allow determina- that absorption of energy is enhanced and heat
tion of sapphire heating which occurs due purely production is concentrated and usefully localised

242

Ashley et al.

Fig. 9. Scanning electron microscopy views (magnification X 3,000) of the front surface of an
LT sapphire (a) and an SLT sapphire (b). The irregular surface of the SLT probe enhances
absorption of energy and promotes surface heating.

to the sapphire-tissue interface. Furthermore, the rear facet of the 0s sapphire may also explain its
transmission data suggest that this effect is poor forward transmission (54%) and the greatest
achieved without compromising forward light degree of distal fiber heating (observed at only 1
transmission. In contrast, the surface of the LT W laser power). The greater length of the 0s crysand 0s sapphires is extremely smooth, and sur- tal and metal holder relative t o the other probes,
face heating is, therefore, less pronounced. In the probably explains these latter effects. Although
0s probe maximal heating was in fact noted t o some light may be scattered laterally by this
arise within the posterior region of the exposed probe, being diffuse and poorly absorbed by tissue
sapphire. Excessive reflection of light from the at this wavelength, it is unlikely t o produce any

Sapphire Contact Probes in Laser Angioplasty


243
significant lateral tissue vaporisation. The the combination of forward photo-thermal effects
slightly lower forward transmission observed in in addition t o heating of the front of the sapphire
the LT probe compared with the SLT sapphires promotes axial tissue ablation, and in these remay be explained by the presence of an anti-re- spects this study suggests that the properties of
flective coating on the rear facet of the latter rounded SLT sapphires are more suitable for laser
probes [91 (this is unknown).
angioplasty than the other contact probes tested.
With regard t o the second question, we have In contrast, metal laser probes produce circumferdemonstrated in vitro that the SLT sapphires pro- ential thermal energy distribution and, in this reduce greater penetration of vascular tissue and spect, sapphire contact probes may cause less
more efficient tissue ablation than the LT and 0s thermal injury t o the surrounding vessel wall.
probes [ X I . Moreover, we have attempted two Supporting this hypothesis are preliminary in
clinical recanalisations with the 0s sapphires. vitro studies demonstrating that metal probes
These were non-calcified femoral occlusions in produce a greater volume of thermal necrosis
which recanalisation failed due to lack of penetra- than sapphires probes [7]. Also, percutaneous antion of the probe through the lesion at powers be- gioscopic inspection of occluded femoral arteries
tween 10 and 15 W. This difficulty has not been after laser angioplasty with continuous wave Ndexperienced during subsequent treatment of over YAG energy and SLT sapphires has revealed minimal charring [16], further supporting the loca30 similar lesions using the SLT probes.
In view of potential lateral damage to the lised nature of heat transfer to tissue by this
vessel wall during recanalisation, heating of the device.
connecting metal interface behind the sapphires
is important. With saline perfusion at 2 mll
minute (the minimum imposed by the integral ACKNOWLEDGMENTS
fluid pump on the SLT laser), a laser exposure of
We wish to thank Mr G.A. Davies (Director,
20 W for 5 seconds (the maximum in the study) Cardiac Research Unit) and the National Heart
produced a peak temperature rise of 35C in one Research Fund for providing facilities and concollar. These results are similar to those obtained tributing towards the funding of this project. We
using a thermocouple t o measure the temperature also thank Miss Anne Schofield for research asrise of the metal connector during lasing in blood sistance.
[141. It probably occurs due t o conduction of heat
from the sapphire, as well as due t o back-scattered energy, and will be related to the mass and REFERENCES
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