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Ann Thorac Surg 1998;65:984-985
© 1998 The Society of Thoracic Surgeons

Easy Harvesting of Radial Artery With Ultrasonically Activated Scalpel

Hakan Posacolu, MD^a, Yüksel Atay, MD^a, Bülent Çetinda, MD^a, Osman Sarbülbül, MD^a, Suat Buket, MD^a, Ahmet Hamulu, MD^a

^a Cardiovascular Surgery Department, Ege University Medical Faculty, Bornova-zmir, Turkey

Accepted for publication October 15, 1997.

Address reprint requests to Dr Hamulu, Cardiovascular Surgery Department, Ege University Medical Faculty, 35100 Bornova-zmir, Turkey

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. The radial artery was proposed and then abandoned as a coronary artery bypass graft in the 1970s. Development of new pharmacologic antispasmodic agents and minimally traumatic harvesting techniques has led to a revival of the use of the radial artery in coronary artery bypass surgery. Usually the main reasons for the spasm are thermal injury caused by electrocautery and traumatic harvesting technique.

Methods. In our technique an ultrasonically activated scalpel (Harmonic Scalpel; Ultracision Inc, Smithfield, RI) was used for radial artery harvesting without using hemostatic clips for vessel side branches. The patients in the study were divided into two groups of 10 patients each. In the first group radial arteries were harvested with this technique, and in the second group with hemostatic clips, scissors, and minimal electrocautery. Harvesting time, frequency of spasm, and use of hemostatic clips were compared between the two groups.

Results. The Harmonic Scalpel decreased the harvesting time, frequency of spasm, and excessive use of hemostatic clips.

Conclusions. Good coagulation capacity with markedly decreased use of hemostatic clips and minimized thermal injury offers the surgeon the ability to perform less traumatic, spasm free, and rapid radial artery harvesting.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
In the 1970s the radial artery was introduced as an alternative conduit for coronary artery bypass grafting [1]. Graft occlusion secondary to spasm from traumatic harvesting and preparation led to abandonment of this artery as a coronary artery graft by the mid 1970s [2]. Using calcium channel blockers and a modified surgical technique, which avoids skeletonization and excessive dilation, prevents arterial spasm [3].

In our clinic, we have developed a technique for radial artery harvesting using an ultrasonically activated scalpel (Harmonic Scalpel; Ultracision Inc, Smithfield, RI). The Harmonic Scalpel is an ultrasonic surgical instrument for cutting and coagulating tissues, operating at a frequency of 55.5 kHz. Coagulation and cutting mechanisms are also different from electrocautery and laser. Bleeding vessels are coapted by tamponading and then sealed with a denaturated protein coagulum. Electrocautery forms the coagulum by heating tissues to denature protein. The Harmonic Scalpel denatures the protein by the transfer of mechanical energy to the tissue, which is sufficient to break tertiary hydrogen bonds, and by the generation of the heat from internal cellular friction, which results from the high-frequency vibration of the tissue [4]. Also the blood within the vessel has a high heat capacity and acts as a sink. This allows one side to coagulate before the other with resultant bleeding from a hole in the wall of the vessel that was in contact with electrocautery. In contrast, reduction in power density cannot happen with the Harmonic Scalpel. Therefore, the vessel is sealed together without bleeding from the surface closest to the blade [5].

Initial thermal studies indicated that heat generated as a result of stress and friction in the tissue is limited when a short period of energy is used. Therefore, depth of heat penetration and lateral heat spread to the tissues is increased directly proportional with time when the pressure applied to the tissues is held constant by the Harmonic Scalpel. This provides control of tissue effect in the hands of the surgeon. But the electrocautery provides very little control because the tissue effect is almost instantaneous. The Harmonic Scalpel can also be used near hemostatic clips without any harmful effects to the vessel [5]. These advantages over an electrocautery provide fast, safe, and spasm-free harvesting without using hemostatic clips for vessel side branches.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Study groups
In this study we harvested 20 radial arteries for coronary artery bypass grafting. We divided the patients into two equal groups. In the first group, radial arteries were harvested using the Harmonic Scalpel, and in the second group, hemostatic clips, scissors, and minimal electrocautery were used. The two groups were compared for harvesting time (the time spent between the radial artery skin incision and being fully prepared for anastomosis), frequency of spasm (the disappearance of visible and palpable pulsation, constriction of the radial artery diameter which is clearly seen with the eye, and the color change from dark red to white), and use of hemostatic clips.

Technique of radial artery harvesting with the harmonic scalpel
The nondominant arm is usually selected for radial artery harvesting. Only the skin incision was performed with a surgical blade. A Harmonic Scalpel with a 5-mm dissecting hook (DH085) was used to cut subcutaneous tissue, muscle, and overlying fascia of the radial artery. The dissecting hook’s outer edge is blunt and it has an inner sharp edge with a 60-degree angle. A self-retaining retractor was placed between the brachioradialis and flexor carpi radialis muscles. Careful retraction of these muscles reveals the entire course of the radial artery in the forearm. Initial dissection was started from the medial side of the artery. The two satellite veins and the surrounding adipose tissue were left attached to the radial artery to preserve its blood supply as much as possible and to prevent spasm. First, the radial artery and satellite vein side branches along the entire length of the radial artery were coagulated using the blunt edge of the dissecting hook (Fig 1). After that, the medial side was freed from adjacent tissue using the dissecting hook; subsequently minimal upward traction was applied to the underside of the radial artery with the dissecting hook (Fig 1). Finally, the lateral side was dissected. To avoid spasm, the radial artery was covered with a papaverine- and diltiazem-soaked warm sponge. The radial artery was divided just before cardiopulmonary bypass.

View larger version (50K): [in this window] [in a new window]   Fig 1. Radial artery harvesting with the Harmonic Scalpel.

	Results

Top Abstract Introduction Material and methods Results Comment References

	Comment

Top Abstract Introduction Material and methods Results Comment References

This ultrasonically activated scalpel causes minimal thermal injury, and satisfactory coagulation eliminates the need to use hemoclips for side branches [4, 5]. Harvesting technique without using hemostatic clips facilitates handling of the radial artery during the anastomosis procedure and decreases the harvesting time. Long-term patency rates, however, need to be evaluated. With appropriate hooks and hand pieces, the Harmonic Scalpel can be used for harvesting other conduits in coronary artery bypass surgical procedures.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Carpentier A., Guermonprez J.L., Deloche A., Frechette C., DuBost C. The aorta-to-coronary radial artery bypass graft: a technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111-121.[Medline]
2. Chiu C.J. Why do radial artery grafts for aortocoronary bypass fail? A reappraisal. Ann Thorac Surg 1976;22:520-523.[Abstract]
3. Acar C., Jebara V.A., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660.[Abstract]
4. Amaral J.F. Ultrasonic dissection. Endosc Surg Allied Technol 1994;2:181-185.[Medline]
5. Hambley R., Hebda P.A., Abell E., Cohen B.A., Jegasothy B.V. Wound healing of skin incisions produced by ultrasonically vibrating knife, scalpel, electrosurgery, and carbon dioxide laser. J Dermatol Surg Oncol 1988;14:1213-1217.[Medline]

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This Article Abstract Full Text (PDF) 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 Author home page(s): Hakan Posacioglu Yüksel Atay Suat Buket Ahmet Hamulu Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Posacioglu, H. Articles by Hamulu, A. Search for Related Content PubMed PubMed Citation Articles by Posacioglu, H. Articles by Hamulu, A.