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J Thorac Cardiovasc Surg 2003;125:963-964
© 2003 The American Association for Thoracic Surgery

Brief Communications

A carbon dioxide insufflation technique for preparation of the internal thoracic artery

Mehmet Özkan, MDa, Alp Aslan, MDa, Mehmet Oguz, MDa, Celil Yildirim, MDa, Levent Oktar, MDb, Göksel Ergül, MDb, Ümit Özyurda, MDa Ankara, Turkey

From the Department of Cardiovascular Surgery, Yasam Hospital,a and the Department of Cardiovascular Surgery, Dr Muhittin Ülker Emergency and Traumatology Hospital,b Ankara, Turkey.

Received for publication July 24, 2002. Accepted for publication Aug 15, 2002. Address for reprints: Mehmet Özkan, MD, 347, Sokak 18708 Ada, Çamdali Sitesi C Blok No: 1/9, 4. Devlet, Mahallesi, Eryaman, Etimesgut 06793 Ankara, Turkey (E-mail: mehmetozk{at}hotmail.com).



The internal thoracic artery (ITA) has become the conduit of choice for coronary artery bypass grafting because of its superior patency rates and longer survival when compared with that of saphenous vein grafts.Go Go 1-4 The dissection technique of the ITA might affect the graft flow capacity.Go 5 In addition to the well-known pedicle preparation technique of this arterial conduit, alternative techniques have been explored to minimize chest wall trauma, with reduced risk of sternal wound infection. We herein present a carbon dioxide insufflation technique of pedicle preparation of the ITA that appears to be safe, simple, and reliable.

Technique

After a median sternotomy, carbon dioxide is insufflated into the endothoracic fascia and the ITA by using an injector with a 24-gauge needle to form subpleural emphysema (Figures 1 and 2). This leads to easier dissection of the ITA with minimal use of electrocautery. The ITA is never touched directly with the forceps. Perforating vessels and intercostal artery branches are occluded with hemoclips on the ITA side, and electrocautery is used on the chest wall side of the vessels. The dissection is proximally carried to the superior border of the first rib and caudally beyond the bifurcation into the superior epigastric and musculophrenic arteries by using the standard pedicle preparation technique. We have used this technique in 28 consecutive patients, with no incidence of any complications.



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  		Fig. 1. Carbon dioxide insufflation into the endothoracic fascia by using an injector with a 24-gauge needle.

 


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  		Fig. 2. Subpleural emphysema along the ITA.

 
Comment

The ITA can be used as a pedicled or skeletonized vessel conduit or a free graft.Go 5 There is no doubt that the ITA graft prepared as a pedicle functions well in myocardial revascularization procedures.Go Go 2,3 However, the hypoperfusion syndrome in coronary artery bypass grafting with the ITA is a well-known problem of a disproportion between ITA flow and myocardial demand and has a high mortality.Go 6 In this situation flow can be limited as a result of a vasospasm or mechanical irritation of the arterial conduit.Go 7 In our carbon dioxide insufflation technique, minimal use of electrocautery and a shorter dissection time and its vasodilator effect might reduce the risk of vasospasm of the ITA. This carbon dioxide insufflation technique for the pedicled ITA grafts is also sufficiently simple to adopt, even for inexperienced surgeons.

References

  1. Sigh RN, Sosa JA, Green GE. Long-term fate of the internal mammary artery and saphenous vein grafts. J Thorac Cardiovasc Surg. 1983;86:359-63.[Abstract]
  2. Okies JE, Page US, Bigelow JC, Krause AH, Salomon NW. The left internal mammary artery: the graft of choice. Circulation. 1984;70(suppl):I213-21.
  3. 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]
  4. Hilier C, Watt PA, Spyt TJ, Thurston H. Contraction and relaxation of human internal mammary artery intraluminal administration of papaverine. Ann Thorac Surg. 1992;53:1033-7.[Abstract]
  5. Choi JB, Lee SY. Skeletonized and pedicled internal thoracic artery grafts: effect on free flow during bypass. Ann Thorac Surg. 1996;61:909-13.[Abstract/Free Full Text]
  6. Jones EL, Lattouf AM, Weintraub WS. Catastrophic consequences of the internal mammary artery hypoperfusion. J Thorac Cardiovasc Surg. 1989;98:902-7.[Abstract]
  7. Wendler O, Tscholl D, Huang Q, Schäfers HJ. Free flow capacity of skeletonized versus pedicled internal thoracic artery grafts in coronary artery bypass grafts. Eur J Cardiothorac Surg. 1999;15:247-50.[Abstract/Free Full Text]



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