HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mulay, A. V. Articles by Nair, R. U. Search for Related Content PubMed PubMed Citation Articles by Mulay, A. V. Articles by Nair, R. U.

Ann Thorac Surg 1997;64:564
© 1997 The Society of Thoracic Surgeons

---

How To Do It

Prevention of Internal Thoracic Artery Spasm

Department of Cardiothoracic Surgery, Killingbeck Hospital, Leeds, United Kingdom

Accepted for publication February 12, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Comment References

 
Perioperative spasm of the internal thoracic artery is a common experience in coronary artery bypass grafting. We describe a simple method of harvesting the internal thoracic artery with improved ease of dissection that helps to prevent the arterial spasm.

	Introduction

Top Footnotes Abstract Introduction Technique Comment References

 
The superiority of the internal thoracic artery graft as a conduit for myocardial revascularization is well established. However, suboptimal flow due to spasm of this conduit in the early postbypass period may be detrimental, particularly in cases of hypertrophied myocardium, poor left ventricular function, and recent myocardial infarction [1].

Different methods for relieving the spasm produced during harvesting of the internal thoracic artery have been described. Some of the techniques include use of vasodilators by external application to the pedicle, infiltration in the pedicle, and intraluminal injection with or without hydrostatic dilation [1, 2]. Recently, the importance of normothermia for the optimum action of papaverine has been elucidated [3].

John and associates [4] have described the injection of normal saline solution between the costal cartilages and adjacent tissue for separating the internal thoracic artery from the chest wall as a useful method in reducing surgical trauma. We describe a simple technique in which dilute papaverine in warm saline solution is injected into the endothoracic tissue around the internal thoracic artery before the dissection is commenced.

	Technique

Top Footnotes Abstract Introduction Technique Comment References

 
The exposure of the internal thoracic artery is achieved by an appropriate retractor and positioning of the operating table. The pleura is separated from the chest wall and opened widely, if necessary, for adequate exposure of the artery from the level of the subclavian vein above to the level of xiphoid cartilage below. Papaverine hydrochloride (McCarthy Lab, Romford, UK) diluted in warm 0.9% sodium chloride solution (1.25 mg/mL; pH 4.9) is injected with a fine 24-gauge metal needle through the endothoracic fascia, approximately 4 to 5 mm away from the internal thoracic artery. The point of the needle is placed between the costal cartilage and the adjacent tissue, and in total about 10 to 15 mL of this solution is infiltrated at three or four sites along the entire length of the internal thoracic artery. The dissection is then performed in large part by electrocautery and occlusion of the major side branches with hemostatic clips. The artery is mobilized as a pedicle from the first intercostal space proximally to the bifurcation below. Direct handling of the artery is avoided as much as possible. The pedicle is left intact and divided only at the time it is anastomosed to the coronary artery.

	Comment

Top Footnotes Abstract Introduction Technique Comment References

 
The injection of papaverine in the internal thoracic artery bed facilitates easy and minimally traumatic harvesting by hydrodissection. As the solution is injected into the space by the described technique, the internal thoracic artery stands out from the chest wall. In addition, dilation of the artery and its branches due to papaverine helps easy visualization and division. This has helped to expedite the harvesting of the internal thoracic artery without causing trauma and consequent spasm.

A significant reduction in the maximum contractile response of the internal thoracic artery after papaverine treatment has been demonstrated by Hillier and associates [5]. In our technique, as papaverine is injected even before the dissection is started, it dilates the artery and makes it less prone to severe spasm at the time of harvesting. Second, the mechanism of action of papaverine on the smooth muscle involves the inhibition of enzymatic activity and is optimum at 37°C [3]. Thus, infiltration around the internal thoracic artery with papaverine at the beginning allows it to act at the body temperature until the full length of the pedicle has been mobilized. Finally, keeping the pedicle intact avoids bathing of the internal thoracic artery in topical ice-cold saline solution.

This technique allows longer duration of action by papaverine on the internal thoracic artery, at near body temperature, before, during, and after harvesting, thereby preventing or minimizing the arterial spasm.

	Footnotes

Top Footnotes Abstract Introduction Technique Comment References

 
Address reprint requests to Mr Nair, Department of Cardiothoracic Surgery, Killingbeck Hospital, York Rd, Leeds, UK LS14 6UQ.

	References

Top Footnotes Abstract Introduction Technique Comment References

 

1. Mills NL, Bringaze WL. Preparation of the internal mammary artery graft. Which is the best method? J Thorac Cardiovasc Surg 1989;98:73–9.[Abstract]
2. Cooper GJ, Wilkinson GAL, Angelini GD. Overcoming perioperative spasm of the internal mammary artery: which is the best vasodilator? J Thorac Cardiovasc Surg 1992;104:465–8.[Abstract]
3. Bilgen F, Yapici MF, Serbetçiolu A, Tarhan A, Çoruh T, Özler A. Effect of normothermic papaverine to relieve intraoperative spasm of the internal thoracic artery. Ann Thorac Surg 1996;62:769–71.[Abstract/Free Full Text]
4. John LCH, Edmondson SJ, Rees GM. Modified technique of internal mammary artery harvest. Ann Thorac Surg 1991;52:157–8.[Abstract]
5. Hillier C, Watt PAC, Spyt TJ, Thurston H. Contraction and relaxation of human internal mammary artery after intraluminal administration of papaverine. Ann Thorac Surg 1992;53:1033–7.[Abstract]

This article has been cited by other articles:

				P. K. Hol, K. Andersen, H. Skulstad, P. S. Halvorsen, P. S. Lingaas, R. Andersen, J. Bergsland, and E. Fosse Epicardial Ultrasonography: A Potential Method for Intraoperative Quality Assessment of Coronary Bypass Anastomoses? Ann. Thorac. Surg., September 1, 2007; 84(3): 801 - 807. [Abstract] [Full Text] [PDF]

				M. Bahcivan, F. Kolbakir, H. Karamustafa, and H T. Keceligil Endothoracic Papaverine Application for Internal Thoracic Artery Harvest Asian Cardiovasc Thorac Ann, June 1, 2007; 15(3): 234 - 237. [Abstract] [Full Text] [PDF]

				I. Koramaz, M. Ozkan, G. Altun, K. Y. Guven, M. K. Duman, N. I. Kalyoncu, E. Yaris, and F. Ozcan Effects of papaverine and carbon dioxide alone or in combination on the blood flow of internal thoracic artery. J. Thorac. Cardiovasc. Surg., November 1, 2006; 132(5): 1126 - 1130. [Abstract] [Full Text] [PDF]

				U. R. Nair, K. Javangula, and A. V. Mulay Papaverine dissection for harvesting internal mammary artery. Ann. Thorac. Surg., May 1, 2006; 81(5): 1945 - 1945. [Full Text] [PDF]

				P. Saxena and R. Tam Reply. Ann. Thorac. Surg., May 1, 2006; 81(5): 1945 - 1946. [Full Text] [PDF]

				H. Jeanmart, L. P. Perrault, N. Desjardins, O. Chavanon, M. Carrier, and J. D. Fonger Arterial balloon catheter: a new atraumatic device for dilating arterial grafts Ann. Thorac. Surg., September 1, 2001; 72(3): 810 - 815. [Abstract] [Full Text] [PDF]

				M. J. Reardon, G. V. Letsou, J. E. Anderson, H. J. Safi, R. Espada, and J. C. Baldwin ORTHOTOPIC CARDIAC TRANSPLANTATION AFTER MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS J. Thorac. Cardiovasc. Surg., February 1, 1999; 117(2): 390 - 391. [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Mulay, A. V. Articles by Nair, R. U. Search for Related Content PubMed PubMed Citation Articles by Mulay, A. V. Articles by Nair, R. U.