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Ann Thorac Surg 2000;69:113-114
© 2000 The Society of Thoracic Surgeons

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Original Articles

Radial artery harvest: comparison of ultrasonic dissection with standard technique

^a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA

Address reprint requests to Dr Barner, Division of Cardiothoracic Surgery, Washington University School of Medicine, 3108 Queeny Tower, One Barnes-Jewish Hospital Plaza, St. Louis, MO 63108
e-mail: barnerh{at}msnotes.wustl.edu

	Abstract

Top Abstract Introduction Material and methods Comment References

 
Background. The radial artery (RA) is used increasingly for myocardial revascularization. Having an ultrasonic dissector available in our unit, we began to use it for RA harvest with the impression that harvest spasm might be less for the new technique.

Methods. We compared RA harvest using standard techniques (21 RA) with ultrasonic dissection (41 RA) in which all branches were divided between clips with scissors in the former and bleeding branches were clipped in the latter.

Results. Harvest times were not different. Conventional technique used 74 ± 18 (mean ± standard deviation) clips versus 3.2 ± 4.3 clips (p < 0.001). In situ free flow was 17.2 ± 20.7 mL/min for conventional technique versus 52.5 ± 48.1 for ultrasonic (p < 0.001). Free flow after the proximal anastomosis to the left internal thoracic artery was 38.5 ± 60.4 mL/min for conventional technique and 50.7 ± 29.6 for ultrasonic (p = 0.008). Free flow 10 minutes after intraluminal papaverine was 78.5 ± 45.9 mL/min for usual technique versus 102.8 ± 51.7 for ultrasonic (p = 0.016). No patient required reoperation for bleeding.

Conclusions. Ultrasonic dissection of the RA is associated with decreased RA spasm, good hemostasis, no additional harvest time, and has become our standard technique.

	Introduction

Top Abstract Introduction Material and methods Comment References

 
The radial artery (RA) has experienced rapidly expanding usage since being resurrected by Acar and colleagues [1], and we have used it in more than 800 patients since 1993. Conventional techniques have been utilized for harvesting including sharp and blunt dissection, electrocautery, and control of branches of the RA with small clips. Despite significant experience and what we would consider as meticulous, atraumatic methods, we have found significant spasm occurring in many RAs with loss of pulsation during harvesting and no distal flow after completion of the proximal anastomosis (before the distal anastomosis). Experience with ultrasonic dissection (Harmonic Scalpel; Ethicon, Cincinnati, OH) of 100 RA pedicles and avoidance of hemostatic clips suggested to us and to others [2] that there was reduced spasm in the conduit with this approach. To more properly address this observation we performed the following study.

	Material and methods

Top Abstract Introduction Material and methods Comment References

 
Study groups
Over a 3 month interval 62 patients undergoing coronary artery bypass had harvest of one RA by one of two surgical assistants (J.W.R, L.A.P) each of whom had prior experience with harvest of more than 100 RAs including use of ultrasonic dissection in at least 25 cases each. Assignment of patients to a group (conventional or ultrasonic) was based on the availability of the ultrasonic dissector (one or two instruments distributed over three operating rooms). In all instances the RA was used as a T-graft with proximal anastomosis to the internal thoracic artery (ITA).

Surgical technique
The RA was usually harvested from the nondominant arm after a negative (capillary refilling within 10 seconds) Allen test. The skin incision allowed harvest of the RA from its origin to the wrist crease. The skin was sharply incised, and low current electrocautery used for the subcutaneous tissue and the deep fascia in the proximal half of the incision, with the distal deep fascia incised with scissors. A self-retaining retractor was placed to separate the brachioradialis and flexor carpi radialis muscles and a silastic vessel loop was placed around the RA pedicle to include the RA venous comitantes and fatty areolar tissue. Placement of the vessel loop did not result in apparent spasm.

The subsequent dissection differed for the two groups. The 21 patients in the conventional harvest group underwent mobilization of the RA pedicle using a combination of blunt and sharp dissection with control of vessel branches using two clips and division of the branches with scissors.

The 41 patients with ultrasonic harvest had dissection of the RA pedicle with the hook blade (sharp pointed hook, HS2) using the variable mode at moderate intensity. RA branches that bled during or after transection were controlled with small clips.

Topical vasodilators were not used during RA harvest. After harvest, the RAs from both groups were placed in a 60 mL medicine glass containing 30 mL heparinized blood and 60 mg of papaverine for 5 minutes before anastomosis of the RA to the left ITA.

Data collection
The time from skin incision to complete harvest of the RA was recorded. The number of clip guns (20 clips per gun) used for each conventional harvest and the number of individual clips used for each ultrasonic harvest were recorded.

RA free flow was measured at three intervals: while in situ but completely mobilized with distal division; after completion of the proximal anastomosis to the left internal thoracic artery before cardiopulmonary bypass; and 10 minutes after filling the RA with heparinized blood containing papaverine 2 mg/mL blood, before cardiopulmonary bypass. Blood was collected for one minute at the initial measurement and for 30 seconds at the subsequent ones and measured with a syringe.

We also determined the need for clipping RA branches during later stages of the operation and the need for reoperation for bleeding.

Results
Data are expressed as mean ± standard deviations. Harvest times were comparable for standard technique (48.4 ± 17.6 min) and ultrasonic dissection (43.6 ± 17.6 min), p = not significant.

Standard harvest required 3.7 ± 0.9 clip guns (20 clips per gun) for each conduit and ultrasonic harvest utilized 3.2 ± 4.3 clips (includes clips placed during harvesting and subsequently) for each RA (Table 1).

No patient required reoperation for bleeding. Hypoperfusion was not recognized intraoperatively or postoperatively.

	Comment

Top Abstract Introduction Material and methods Comment References

 
This study demonstrates that ultrasonic dissection of the RA pedicle with control of branches by this methodology is associated with less conduit spasm than is a technique of blunt and sharp dissection with placement of two small clips across each branch. Bleeding from branches is uncommon and usually occurs when the branch is severed or is rarely recognized later in the operation after performance of the T-anastomosis.

Spasm occurs with harvesting of all arterial and venous conduits and appears to be related to mechanical and thermal trauma. Although ultrasonic dissection is associated with transformation of mechanical to thermal energy and protein denaturation there is less heat generated than with electrocautery. We carefully avoided use of electrocautery near the RA and used it minimally during the entire dissection. One would conclude from these data that dissection of the branches and clip application induces more trauma (and spasm) than does dividing of branches with the ultrasonic dissecting hook.

We had previously believed that intraluminal papaverine and 10 minutes of exposure would result in near maximal RA dilation [3]. Our data indicate that dilatation is not maximal, at least after conventional dissection, with this management. This would suggest that our pharmacologic management is not optimal or our technique of dissection can be improved.

We have never used calcium channel blocking agents for management of RA spasm, as we believe that their use emanated from the first report on an empirical basis [1]. There is now evidence to support nonuse of these agents [4, 5]. Similarly, we have not used hydrostatic dilation because intraluminal pressure is difficult to quantitate, and if excessive may lead to endothelial or mural injury [6]. This modality was used together with probe dilation in the early experience with the RA and may have contributed to conduit failure.

We believe there is indeed reduced RA spasm when the technique of ultrasonic dissection is utilized and this has become our standard practice.

	References

Top Abstract Introduction Material and methods Comment References

 

1. Acar C., Jebara V., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-659.[Abstract]
2. Posacioglu H., Atay Y., Cetindag B., et al. Easy harvesting of the radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.[Abstract/Free Full Text]
3. He G.-W., Yang C.-Q. Use of verapamil and nitroglycerin solution in preparation of radial artery for coronary grafting. Ann Thorac Surg 1996;61:610-614.[Abstract/Free Full Text]
4. Cable D.G., Caccitolo J.A., Pearson P.J., et al. New approaches to prevention and treatment of radial artery graft spasm. Circulation 1998;98(Suppl):II15-II22.
5. Shapira O.M., Xu A., Vita J.A., et al. Nitroglycerin is superior to diltiazem as a coronary bypass conduit vasodilator. J Thorac Cardiovasc Surg 1999;117:906-911.[Abstract/Free Full Text]
6. Van Son J.A.M., Tavilla G., Noyez L. Detrimental sequelae on the wall of the internal mammary artery caused by hydrostatic dilation with diluted papaverine solution. J Thorac Cardiovasc Surg 1992;104:972-976.[Abstract]

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