Ann Thorac Surg 2005;80:355-356
© 2005 The Society of Thoracic Surgeons
How to do it
Hydrodissection Technique of Harvesting Left Internal Thoracic Artery
Pankaj Saxena, MCh*,
Ross Mejia, MBBS,
Robert Tam, FRACS
Department of Cardiac Surgery, The Prince Charles Hospital, Chermside, Brisbane, Queensland, Australia
Accepted for publication February 3, 2004.
* Address reprint requests to Dr Saxena, Department of Cardiothoracic Surgery, The Prince Charles Hospital, Rode Rd, Chermside, Brisbane 4032, Australia; (Email: drpankajsaxena{at}hotmail.com).
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Abstract
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Use of internal thoracic arteries in coronary artery bypass surgery has become universal. Skeletonized internal thoracic artery is useful in coronary artery surgery for sequential anastomosis as it also provides a long length of graft. Skeletonizing the conduit is technically more difficult than harvesting it as a pedicle graft. We describe a technique of harvesting the internal thoracic artery in which 10 to 20 mL of normal saline is injected into the fascial plane of the left side of chest wall along the course of artery to develop a plane of dissection.
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Introduction
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The left internal thoracic artery (LITA) is the most important conduit in coronary artery bypass graft surgery (CABG). It can be harvested as a skeletonized or as a pedicle graft. Skeletonizing a LITA is technically more difficult. We present a method of skeletonizing the ITA in which normal saline is injected into the plane of chest wall anterior to endothoracic fascia to facilitate the dissection. This technique is called hydrodissection.
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Technique
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Median sternotomy is performed. The left sternal edge is elevated with an internal thoracic artery harvesting retractor. The left pleura is opened widely. The ITA is usually visible in the proximal or middle part along the course of the artery. This is the site where saline is injected. This injection is made at a spot a few millimeters away from the conduit to avoid any direct injury to the artery or the satellite vein. Using a 23G needle and a 20 mL syringe, normal saline is injected into the endothoracic fascia. The endothoracic fascia is raised along the whole length of the parasternal area. An opening is made in the raised endothoracic fascia. The incision in the endothoracic fascia is extended. Once the ITA is identified, this incision is carried along the length of the conduit. The injected saline also enters the plane between the ITA and its bed, creating a thin cushion of fluid along the length of artery. That helps in easy identification of the ITA and its branches.
The dissection of the conduit is started from the second intercostal space and proceeds distally (Figs 1 and 2). The most proximal part of the artery is dissected at the end. The dissection is done using a cold and hot tip of diathermy set at 20 W. A minimal touch technique is used. The artery is retracted with the closed tip of deBakey forceps or retracted by holding the periadventitial tissue. Hemoclips are used, and the branches are divided with scissors or diathermy. Heparin is administered after the dissection is completed. The distal end of the LITA is divided. The artery is inspected for any signs of injury, and the flow is checked. Papaverine solution is injected into the lumen of the divided artery with a 24G venous cannula. A hemoclip is applied at the distal end of the conduit, and the conduit is wrapped in gauze soaked in papaverine solution. The artery is allowed to dilate under systemic pressure while another part of the operation is carried out.
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Fig 1. Diagramatic representation of the hydrodissection technique used to harvest the internal thoracic artery.
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Comment
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The use of LITA to left anterior descending artery has been a gold standard in CABG. The use of LITA has been shown to decrease the incidence of late myocardial infarction, cardiac events, and need for reoperations and improves the late survival rate [1]. Use of bilateral ITA grafting improves the outcome in coronary artery surgery as compared with the use of a single ITA graft [2].
Compared with a pedicled graft, a skeletonized ITA has several advantages in the form of a longer conduit for sequential grafting, less trauma to the chest wall, less blood loss, lower incidence of sternal wound infections especially in obese and diabetic patients, and improved flow [3–5].
As the chances of injury are more while skeletonizing the graft, the dissection must be more meticulous. There is a higher risk of conduit injury and subsequent perioperative myocardial ischemia when the graft is skeletonized. Our technique of hydrodissection makes LITA harvesting easier as a skeletonized graft. Injection of normal saline into a plane anterior to endothoracic fascia not only raises the fascia from the ITA but also allows the entry of saline between the ITA and the chest wall. This maneuver also increases the distance between the ITA from its bed and develops the plane of dissection. The thin layer of saline also minimizes heat conduction to the conduit during the use of diathermy. Also of note is that once the endothoracic fascia has been opened up completely, tissues do not appear to be very edematous. It is not technically difficult to work through a thin film of saline adjacent to the conduit. The average time for harvesting the ITA with the present method has been 20 minutes. We find the present technique to be safe and simple. It does not require the use of any special instruments. It has been used in more than 30 patients, and there have been no instances of injury or dissection of the ITA. Histopathology analyses of distal segments of divided ITAs have shown the maintained integrity of the wall of the conduit (Fig 3).
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Fig 3. Microphotograph of a divided segment of the internal thoracic artery harvested with the hydrodissection technique (hematoxylin & eosin stain; original magnification, x100.
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We have used the present method of harvesting of ITA using diathermy. This technique could also be useful for videothoracoscopic harvesting of artery, possibly because of ease of dissection. Similarly, use of an ultrasonic scalpel may further minimize the chances of trauma during harvesting. Moreover, hydrodissection has also been found to be useful in procedures like cataract surgery and laparoscopic cholecystectomy [6, 7]. We recommend this technique of harvesting in bilateral ITA grafting in suitable clinical situations.
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References
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- Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft on 10-year survival and other cardiac events N Engl J Med 1986;314:1-6.[Abstract]
- Lytle BW, Blackstone EH, Loop FD, et al. Two internal thoracic artery grafts are better than one J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
- Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection Ann Thorac Surg 1992;54:947-951.[Abstract]
- Matsa M, Paz Y, Gurevitch J, et al. Bilateral skeletonized internal thoracic artery grafts in patients with diabetes mellitus J Thorac Cardiovasc Surg 2001;121:668-674.[Abstract/Free Full Text]
- Choi JB, Lee SY. Skeletonized and pedicled internal thoracic artery graftseffects on free flow during bypass. Ann Thorac Surg 1996;61:909-913.[Abstract/Free Full Text]
- Vasavada AR, Trivedi RH, Apple DJ, Ram J, Werner L. Randomized, clinical trial of multiquadrant hydrodissection in pediatric cataract surgery Am J Opthalmol 2003;135:84-88.[Medline]
- Naude GP, Morris E, Bongard FS. Laparoscopic cholecystectomy facilitated by hydrodissection J Laparoendosc Adv Surg Tech 1998;8:215-218.
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Abstract
Introduction
