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Ann Thorac Surg 1996;61:909-913
© 1996 The Society of Thoracic Surgeons
Department of Thoracic and Cardiovascular Surgery, Wonkwang University School of Medicine, Iksan, South Korea
Accepted for publication November 15, 1995.
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Abstract |
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 Top Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. The ITA pedicled grafts were sprayed and wrapped in sponges soaked in dilute papaverine solution in 14 patients and prepared with intraluminal papaverine injection in 18 patients. For 23 other patients, the ITA was skeletonized. We measured the first free flow from the distal ITA early after the start of cardiopulmonary bypass and the second free flow just before the ITA was grafted to the left anterior descending artery.
Results. The first flow was greater in the skeletonized ITAs than in the ITA pedicled grafts with topical application of papaverine alone (38.9 ± 15.8 versus 18.0 ± 6.8 mL/min; p < 0.001). For the second flow, the pedicle grafts with intraluminal papaverine injection and the skeletonized ITAs showed greater flow rate than the pedicled grafts with topical application of papaverine (67.4 ± 25.5 and 59.7 ± 22.5 versus 38.1 ± 13.1 mL/min; p < 0.005 and p < 0.05, respectively), but there was no significant difference between the former two groups (p = 0.53).
Conclusions. Skeletonization of the ITA is as efficient a strategy to increase the flow as intraluminal papaverine injection for the ITA pedicled graft. When the ITA is harvested in a skeletonized fashion, arterial spasm and reduced early flow can be avoided, even without intraluminal injection of papaverine.
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Introduction |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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The use of an internal thoracic artery (ITA) graft to the left anterior descending coronary artery (LAD) is associated with superior patency rates and longer survival when compared with saphenous vein grafts [1–4]. The arterial conduit can be used as a pedicled, free graft, or skeletonized vessel. There is no doubt that the ITA graft obtained as a pedicle functions well in myocardial revascularization procedures [1–5]. Despite these excellent results, a skeletonization technique of ITA dissection was adopted by some surgeons because of its potential advantages [5]. The dissection technique of ITA may effect a change in the graft flow capacity. The purpose of this study is to compare free flow between skeletonized ITA grafts and ITA pedicled grafts and to evaluate the effect of skeletonization technique on ITA flow.
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Patients and Methods |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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). Only elective operations were included in the study. Patients who were in hemodynamically unstable condition or showed evidence of ischemia before cardiopulmonary bypass were excluded from the study. All patients were operated on by the same surgeon familiar with both pedicle and skeletonization techniques of ITA harvesting. The patients were divided into three groups by the techniques used for preparation of the ITA.
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GROUP I.
Fourteen consecutive patients (12 men and 2 women) underwent a takedown of the left ITA with a wide pedicle (2 cm) in preparation for coronary bypass grafting. Body surface areas ranged from 1.46 to 1.84 m2, with an average area of 1.69 m2. The ITA was harvested from the subclavian vein superiorly to beyond the ITA bifurcation inferiorly and was transected only after the institution of cardiopulmonary bypass. Dilute papaverine (60 mg in 40 mL of lactated Ringer's solution) was sprayed on the ITA graft throughout its whole length with a small syringe and size 25 needle. The ITA pedicle was wrapped in a papaverine-soaked gauze, and it was set aside until cardiopulmonary bypass. The ITA was opened with fine scissors proximal to the bifurcation and at the point of the estimated locus for anastomosis to the LAD. Free flow was measured just before its anastomosis to the LAD [6]. For the remainder of the operation, a standard technique for coronary artery bypass grafting was used [7].
GROUP II.
Eighteen patients (10 men and 8 women) had a takedown of ITA pedicle as in group I. Body surface areas ranged from 1.30 to 1.88 m2, with a mean of 1.63 m2.
Dilute papaverine solution was sprayed on the ITA pedicle as in group I. The ITA was transected just proximal to its bifurcation after cardiopulmonary bypass was instituted and the first (early) free flow was measured at a mean arterial pressure of 50 to 55 mm Hg. A 22-gauge polytetrafluoroethylene catheter (BOC Ohmeda AB, Helsingborg, Sweden) was then introduced into the lumen of the distal ITA. Ten milliliters of dilute papaverine was injected intraluminally, and the pedicled graft was set aside during distal anastomoses of the vein grafts. The artery was allowed to dilate under the arterial pressure during the cardiopulmonary bypass, but hydrostatic (manual) or mechanical dilation was not performed. The second (final) free flow was recorded just before its anastomosis to the LAD. The papaverine-dilated size of the ITA graft was also measured with a calibrated probe.
GROUP III.
In 23 patients (16 men and 7 women), the left ITA was harvested in a skeletonized fashion. Body surface areas ranged from 1.35 to 1.81 m2, with an average of 1.62 m2. The pleura was not opened and the ITA was harvested from its origin superiorly to beyond the ITA bifurcation inferiorly, by using the skeletonization technique [5]. The dissection of the ITA was made in large part with electrocautery, and the side branches were occluded with Ligaclips (Ethicon Ltd, Edinburgh, UK). The ITA was mobilized from the surrounding fat, veins, and endothoracic fascia. All mediastinal arterial branches including pericardicopleural artery were identified and divided. From the first intercostal space upward, the artery was freed without the use of cautery to avoid injury to the phrenic nerve.
Although the skeletonized ITAs showed a marked spasm during dissection, especially in the lower portions, mechanical or hydrostatic dilation to overcome the spasm was not performed. Dilute papaverine was sprayed on the graft, but the graft was not wrapped in the papaverine-soaked gauze to avoid injury to the vessel. Instead, with adequate dilute papaverine solution the wall stayed moist. The ITA was transected distally just proximal to its bifurcation after cardiopulmonary bypass was instituted, and the first free flow was then measured as in group II. The graft was set aside during distal anastomoses of the vein grafts and was allowed to dilate under arterial pressure. After the completion of the distal anastomoses of vein grafts, the distal end of the ITA was prepared for anastomosis on the LAD, and then the second free flow was measured.
Data Analysis
Data were analyzed using the StatView software package (Abacus Concepts Inc, Berkeley, CA). Continuous data were expressed as the mean ± standard deviation and compared by analysis of variance with Scheffé's F test and Student's t test. Statistical significance of differences between categoric parameters was evaluated by 
2 contingency analysis. A value of p less than 0.05 was considered statistically significant.
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Results |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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. There was no significant difference found among the three groups with respect to body surface area and number of distal anastomoses. The skeletonization technique for ITA dissection was used more commonly in older patients (p = 0.012). No patient showed early detrimental effects related to dissection technique and graft preparation method.
Flow and luminal diameter measurements of all three groups are shown in Table 2. The flow distribution in each group is displayed in Figure 1. The first flow rate was greater in the skeletonized ITA group than in the ITA pedicle group with topical application of papaverine alone (38.9 ± 15.8 versus 18.0 ± 6.8 mL/min; p < 0.001). The first flow rate of the skeletonized ITA group was similar to the second flow rate of the pedicle group with topical application of papaverine (38.9 ± 15.8 versus 38.1 ± 13.1 mL/min; p = 0.87). In comparison of the second flow among the three groups, the ITA pedicle group with intraluminal papaverine injection and the skeletonized ITA group showed greater flow rate than the ITA pedicle group with topical application of papaverine alone (67.4 ± 25.5 and 59.7 ± 22.5 versus 38.1 ± 13.1 mL/min; p < 0.005 and p < 0.05, respectively), but there was no significant difference between the former two groups (p = 0.53) (see Fig 1). In the skeletonized ITA group, there was also a significant increase in flow from the first flow to the second flow, even without any preparation (38.9 ± 15.8 versus 59.7 ± 22.5 mL/min; p < 0.0001), whereas it showed greater flow rate than the ITA pedicle group in the first flow measurement.
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Comment |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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This study showed an average flow of 38.1 mL/min in the ITA pedicled graft prepared only with topical application of papaverine via forceful spraying and wrapping with a soaked sponge. The flow rate is not acceptable for the LAD [6, 8]. The ITA pedicled graft may be still in residual spasm, causing the lesser flow. With intraluminal injection of dilute papaverine, the flow in the pedicled graft increased significantly during the distal anastomoses of vein grafts. Mills and Bringaze [8] reported many benefits of intraluminal administration of papaverine besides an increase in the ITA free flow. With a larger-diameter vessel to work with, the surgeon is less likely to make a technical error. Furthermore, potential bleeders from side branches can be readily identified.
Although we have performed the intraluminal papaverine injection to increase the free flow of ITA pedicle grafts with few problems, we have been concerned about a possible adverse interaction between papaverine, which is a potent, acidic vasodilator, and the delicate, friable ITA intima. Recently, we have used the skeletonization technique for ITA dissection in the consecutive patients undergoing coronary bypass grafting. With the technique, only the ITA is teased away from the chest wall, accompanying veins, fascia, lymphatics, and adipose tissue [5, 10]. The vessels have a wall thickness of less than 500 µm, being nourished entirely by luminal diffusion [10, 11]. There are no vasa in the media of a normal ITA. Therefore, careful skeletonization should not exert any detrimental effects on ITA viability [5, 10]. Excellent long-term results have been reported using both free and skeletonized ITA grafts [12, 13]. When preparing the skeletonized graft, we did not perform intraluminal papaverine injection or mechanical or hydrostatic dilation to identify the character of natural flow and to avoid injury to the intima. We used a so-called intraluminal no-touch technique in preparing the skeletonized graft.
Our result confirms a previous observation that intraluminal papaverine preparation of the pedicled ITA offers the best flow to the myocardium with an improvement of the ITA size [8]. In our study, manual (hydrostatic) dilation was not performed in the pedicled or the skeletonized graft, and the flow was measured at a low mean arterial pressure of 50 to 55 mm Hg on cardiopulmonary bypass. In addition, the mean body surface area in our group of patients was much smaller when compared with patients in the previous studies [8, 9]. Therefore, average ITA flow rates might be expected to be lower in our patients because of their smaller size.
In the present study, the early flow rate was greater in the skeletonized ITAs as compared with the pedicled grafts. In the skeletonization technique, the ITA is denuded of the perivascular tissue, which may limit the free flow. An absence of excessive perivascular tissue may allow topical papaverine to minimize spasm while awaiting cardiopulmonary bypass. Therefore, the skeletonized graft can provide sufficient early flow. Moreover, the skeletonized ITA dilates easily with time and shows an insignificant difference in the final flow when compared with the pedicled graft with the intraluminal papaverine injection.
The luminal diameter at the prepared distal end of ITA was larger in the skeletonized ITA group than in the pedicle group with topical application of papaverine, although it was less than in the pedicled grafts with intraluminal papaverine injection. By skeletonizing the ITA, the artery is functionally lengthened [14]; therefore, the distal portion of the artery can be trimmed off to obtain a larger diameter with an optimal length. This allows resection of the muscular segment of the ITA and minimization of spasm [15]. This may be another factor providing the greater flow at the second measurement, especially in the skeletonized ITA grafts. In our series, however, a several-centimeter difference in distance above the ITA bifurcation site made little change in the free flow rate.
From the first intercostal space upward, the artery was freed without the use of cautery to avoid injury of the phrenic nerve. After the division of the mediastinal arterial branches, the phrenic nerve is identified by bluntly dissecting the proximal mediastinal pleura off the mediastinal structures. O'Brien and associates [16] described a significant impairment of phrenic nerve function and perfusion in an adult swine model if the pericardicophrenic artery is divided during ITA harvesting. In our series, however, permanent or transient phrenic nerve paralysis did not occur. We have never seen direct cold trauma to the phrenic nerve since using cold lactated Ringer's solution instead of iced slush for topical cooling.
We used the retractor adapter that was introduced by Brown and Dougenis [17] to dissect the ITA, and modified their pedicle technique. The endothoracic fascia and internal thoracic vessels are dissected away from the chest wall through a longitudinal incision that is made just medial to the internal thoracic artery and veins. The internal thoracic artery and veins are then freed from the inner surface of the fascia, using the tip of the cold cautery, and the ITA is skeletonized with the veins removed. The time required for dissection does not increase in comparison with the pedicle technique. The parietal pericardium is incised along its visceral reflection onto the transverse aortic arch, the bifurcation of the pulmonary artery, and the hilum of the left lung. The shortest pathway for descent of the left ITA is made behind the thymus [10, 17].
In summary, skeletonization of the ITA is as efficient a strategy to increase ITA flow as intraluminal papaverine injection for the pedicled graft. It also provides a reasonable diameter for its anastomosis to the LAD, even without intraluminal papaverine injection. These advantages may offset the slight increase in difficulty required to harvest the vessel.
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Acknowledgments |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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TopAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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