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Ann Thorac Surg 2000;70:307-308
© 2000 The Society of Thoracic Surgeons

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How to do it

Skeletonization and harvest of the internal thoracic artery with an ultrasonic scalpel

^a Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan

Address reprint requests to Dr Higami, Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, 520 Saisho-ko, Himeji 670-0981, Japan
e-mail: thigami{at}hbhc.hiabcd.go.jp

	Abstract

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A new method to skeletonize and harvest the internal thoracic artery using an ultrasonic scalpel is presented. The technique is simple, safe, and minimally invasive. It is possible to obtain sufficient vessel length for anastomosis to most coronary arteries for bypass grafting.

	Introduction

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The internal thoracic artery (ITA) has proved to be very useful in coronary artery bypass grafting. Harvesting this artery as a skeletonized conduit for more effective use is an established method [1, 2]. However, skeletonization is technically difficult compared with pedicle harvesting. We have developed a skeletonization technique using an ultrasonic scalpel that is technically easy to perform.

	Surgical technique

Top Abstract Introduction Surgical technique Comment References

 
A median sternotomy is performed. After the dissection of the reflection of the mediastinal pleura from the endothoracic fascia, the ITA and both satellite veins are visualized. The endothoracic fascia is incised longitudinally just medial to one of the satellite veins using an ultrasonic scalpel (Harmonic Scalpel, dissecting-hook type; Ethicon Endo-Surgery, Cincinnati, OH) (Fig 1A). The space between the medial satellite vein and the ITA is carefully dissected using the ultrasonic scalpel (output level, 2). Only the ITA is targeted for dissection. The fatty tissue around the ITA is covered with foam and easily removed by lightly sweeping it away, moving the ultrasonic scalpel along the length of the vessel to expose the adventitia of the ITA (cavitation phenomenon). It is important to set the contact time of the ultrasonic scalpel to 0.1 to 0.2 seconds and to move quickly along several centimeters of the vessel using a light touch along the main trunk ("quick touch" method). In this way, the main trunk of the ITA can be skeletonized safely and quickly.

View larger version (51K): [in this window] [in a new window]   Fig 1. (A) The endothoracic fascia is incised longitudinally just medial to one of the satellite veins using the Harmonic Scalpel. The space between the medial satellite vein and the internal thoracic artery (ITA) is carefully dissected. (B) The endothoracic fascia is pulled back carefully, thus exposing the sternal branch. The tip of the blade is placed on the branch at least 1 mm from the trunk. The branch is obstructed and divided by ultrasonic protein coagulation. (C) Pulling the fascia down, exposes the perforating cutaneous branch on the back side of the vessel for treatment. (D) Turning the ITA 90 degrees exposes the anterior intercostal branch. Thus it is possible to treat all of the branches from the same angle with the same field of view.

	Comment

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The Harmonic Scalpel is a disposable instrument that produces mechanical vibration at 55,500 cycles per second and ultrasonic coagulation by denaturation of proteins [3]. The temperature in the tissue increases to about 80°C compared with more than 300°C with electrocautery. Therefore, the Harmonic Scalpel causes minimal charring and thermal injury to the surrounding tissues. Histologically, the depth volume and the lateral thermal damage are much less severe after use of the ultrasonic scalpel [4]. The Harmonic Scalpel has been used mainly during laparoscopic procedures. Its safety for harvest of the ITA has not been established.

In a separate experimental study in pigs, we have shown that branches of the ITA can be coagulated 1 mm from the trunk by complete protein coagulation using the ultrasonic scalpel without causing histologic damage to the arterial wall of the main vessel [5]. The mean length of intimal tissue damage from the edge of stump was only 0.58 mm. In addition, the obliterated stump did not burst at physiologic blood pressures.

We have applied this method of harvesting the ITA in more than 150 patients since 1998. The skeletonized ITA averages 4 cm longer than the pedicled conduit. The harvest time is 20 to 25 minutes, approximately the same time required for pedicled dissection. The mean free flow rate of the skeletonized ITA grafts is greater than 100 mL/min, which is at least 20% higher than that of the pedicled ITA. Postoperative hemorrhage from the obliterated branch stumps has not been observed. Anastomosis to the left anterior descending coronary artery and circumflex artery has been possible with only bilateral ITA grafts. In early postoperative follow-up (at 3 weeks after operation), 99.5% patency (209 of 210 grafts) was confirmed. None of the patients had development of mediastinitis. At the 1-year midterm follow-up of 16 patients, 100% patency (26 of 26 grafts) and no graft failure were confirmed.

In conclusion, skeletonization and harvest of the ITA using the Harmonic Scalpel is simple, safe, and minimally invasive.

	References

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1. Cunningham J.M., Gharavi M.A., Fardin R., Meek R.A. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg 1992;54:947-950.[Abstract/Free Full Text]
2. Calafiore A.M., Vitolla G., Iaco A.L., et al. Bilateral internal mammary artery grafting. Ann Thorac Surg 1999;67:1637-1642.[Abstract/Free Full Text]
3. Amaral J.F. Ultrasonic dissection. Endosc Surg Allied Technol 1994;2:181-185.[Medline]
4. McCarus S.D. Physiologic mechanism of the ultrasonically activated scalpel. J Am Assoc Gynecol Laparosc 1996;3:601-608.[Medline]
5. Higami T, Maruo A, Yamashita T, Shida T, Ogawa K. Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting using an ultrasonic scalpel. J Thorac Cardiovasc Surg 2000; in press.

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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): Tetsuya Higami Tatsuro Asada Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Higami, T. Articles by Ogawa, K. Search for Related Content PubMed PubMed Citation Articles by Higami, T. Articles by Ogawa, K.