| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
J Thorac Cardiovasc Surg 2004;128:463-466
© 2004 The American Association for Thoracic Surgery
Evolving technology |
a Department of Cardiovascular and Thoracic Surgery OLV Clinic, Aalst, Belgium
b Department of Anesthesia, OLV Clinic, Aalst, Belgium
Received for publication February 9, 2004; revisions received May 4, 2004; accepted for publication May 6, 2004.
* Address for reprints: Filip P. Casselman, MD, PhD, FETCS, Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Moorselbaan 164, 9300 Aalst, Belgium
Filip.Casselman{at}olvz-aalst.be
 |
Abstract |
|---|
 Top Abstract MethodsResultsDiscussionReferences |
|---|
METHODS: Between July 1, 2002, and October 1, 2003, a total of 54 patients underwent endoscopic radial artery harvesting at our institution. Standard endoscopic equipment and a Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) were used. Mean age of the patients was 63 ± 8.1 years, and 16% were female. All patients underwent a preoperative Allen test and duplex ultrasonography to demonstrate adequate ulnar collateral flow. The nondominant arm was used for radial artery harvesting. Mean clinical follow-up was 13 ± 4.6 months.
RESULTS: The artery was harvested through a 3-cm incision at the wrist and was divided at the elbow either through a small counterincision (n = 16) or endoscopically with the use of clips, Endoloop, and endoscopic scissors (n = 38). Mean harvest time was 42.2 ± 16.9 minutes but decreased from 85 minutes for the first cases to 25 minutes for the last 5 cases. Mean harvested length was 19.6 ± 1.7 cm. Harvesting complications included 1 conversion, 2 postoperative hematomas, 1 injury, 8 endoscopically controlled bleedings, and 15 cases of at least some superficial radial nerve paresthesia at 6 weeks (clinically relevant in 4 cases). Selective postoperative angiography revealed 1 occluded graft and 1 stenotic graft requiring percutaneous transluminal coronary angioplasty of the native vessel. Eighty-seven percent of the patients were enthusiastic about this new procedure.
CONCLUSIONS: Endoscopic radial artery harvesting is a feasible procedure that requires a definite learning curve. Although nerve paresthesias were not completely eliminated in our experience, the technique provided ample patient satisfaction. Further clinical follow-up is required to determine long-term patency rates.
|
Methods |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
Preoperative evaluation included a clinical Allen test and Doppler ultrasonography to check the integrity of the palmar arch and detect atherosclerosis. Five seconds was chosen as upper limit for recoloration of the fingers after release of the compression of the ulnar artery. We always used the nondominant arm for ERA.
Surgical technique
At the start of surgery, an intravenous infusion of Nitroglycerine was started at 0.25- to 0.5-µg/(kg · min) as an antispasmodic agent4 and continued for 24 hours unless the patient remained longer in the intensive care unit.
Equipment
In all cases we used the ERA kit provided by Cardiovations (a division of Johnson & Johnson, Somerville, NJ). The kit consists of a tissue dissector (ultraretractor), a vessel dissector, and a pair of curved endoscopic scissors. Within the ultraretractor, a 5-mm 30° endoscope can be introduced . The endoscope faces downward and is connected to a light source and a camera that allows the surgeon to follow the dissection on a monitor. Carbon dioxide at 5- to 6-L/min was used to flush the working channel to optimize visibility. The tissues were divided with the Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio), of which details of the clinical ease and safety have been published previously.5-9
Harvesting technique
A 3- to 4-cm longitudinal skin incision was made starting approximately 1 cm cephalad of the radial styloid. The subcutaneous tissues were divided, and the fascia overlying the RA was divided longitudinally. This division was extended a few centimeters below the skin incision in the cephalad direction. At the same time, some space was created in the subcutaneous tissue to allow subsequent introduction of the ultraretractor. The distal part of the RA was isolated under direct vision, and side branches were clipped. Care was taken to separate the RA from the superficial radial nerve (SRN) at this level.
Next, the ultraretractor (tissue dissector) was introduced and placed anteriorly to the RA fascia, heading toward the elbow crease. The retractor was then gently pushed forward into the subcutaneous tissues, just anteriorly to the fascia overlying the RA. Once a few centimeters of exposure was achieved, the longitudinal incision in the fascia (which was started at the level of the skin incision) was prolonged toward the elbow crease. This maneuver exposed the RA for a few centimeters. Once enough working space was created, the ultrasonic Harmonic Scalpel was used to divide the side branches. The two satellite veins were included in the harvested pedicle. When this segment of the RA was completely free, the ultraretractor was advanced further, and the whole sequence was repeated.
In the middle third of the forearm, at the junction of the brachioradial and flexor carpi radialis muscles, the ultraretractor remained positioned anteriorly to the RA, thus "diving" underneath these muscles. Although the working space is reduced in this muscular part of the forearm—rendering this the more difficult part of the dissection—the previously mentioned sequence of endoscopic dissection remained unchanged.
The proximal part, the antecubital space, was recognized endoscopically by the abundance of fat. Care was taken here to visualize side branches adequately before dividing them. This of course was intended to avoid injury to the ulnar artery. We usually respected the laterally located recurrent branch, unless we needed maximum length of the RA conduit.
Once the conduit was completely dissected, the Harmonic Scalpel was removed, and the vessel dissector was introduced to verify that all side branches have been divided. We then clipped the proximal RA endoscopically and divided it with the long curved endoscopic scissors. Alternatively, we first divided the RA distally and slid an Endoloop (Ethicon Endo-Surgery) over the RA. The Endoloop was then advanced around the RA until the proximal end and tightened. Transection was achieved with the curved endoscopic scissors.
In the beginning of the experience, we routinely made a 2-cm counterincision in the antecubital space. This was done to increase vascular control in the antecubital space. However, with increased experience, the counterincision ceased being applied unless exposition or anatomic landmarks were uncertain.
Once the conduit was removed, the RA was flushed with a heparinized solution and checked for hemostasis. Only rarely have we needed to apply an extra clip to a side branch. The conduit was then stored in a papaverine solution. Hemostasis of the working channel was ensured, and the wound was closed in layers. Systemic heparinization was never given before the arm wound was closed and the arm had a circumferential compressive bandage placed.
During ERA harvesting, the sternotomy and harvesting of the left internal thoracic artery and saphenous vein could be done simultaneously.
Statistical methods
All routine preoperative, intraoperative, and postoperative variables were extracted from our database. An ERA-specific follow-up chart registered all variables related to the ERA procedure and ERA follow-up data, including a patient satisfaction inquiry. The first author (F.P.C.) examined all patients postoperatively by light touch, and any sensation abnormalities were rigorously registered. Another clinical examination occurred at 6 weeks (100% complete). Longer follow-up was achieved by telephone interview during the first half of January 2004 (100% complete). In this way, the shortest follow-up obtained reached 3 months, with a mean of 13 ± 4.6 months (range 3.8-18.8 months). In case of clinical events, the cardiologist was contacted to determine the nature of the event.
|
Results |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
In 8 cases, some bleeding occurred from a side branch during dissection. All of these episodes could be managed endoscopically.
Mean harvest time was 42.2 ± 16.9 minutes (range 20-90 minutes). The harvest time decreased from 85 minutes for the first cases to 30 minutes or less for the last 15 cases. Mean harvested length of the conduit was 19.6 ± 1.7 cm (range 16-24 cm). This was dependent more on arm length than the harvesting technique.
Division of the conduit at the elbow crease was done through a 2-cm counterincision in 16 cases and endoscopically in the remainder. All harvested RAs were used as a bypass conduits.
Of all isolated coronary artery bypass grafting procedures (n = 42), 30 were performed off pump (71%). A total of 175 anastomoses were performed (mean 3.2 ± 0.9 per patient), of which 151 were arterial and 64 were with RA.
Postoperative follow-up
One patient had sternitis develop after the operation. Two ERA tunnel hematomas occurred, one of which required drainage through the wrist incision. No ischemic complications of the hand occurred. None of the patients had either cellulitis or infection.
Twenty-one patients reported some sensation alteration in the distribution of the SRN at discharge. None of the patients had alterations in the distribution of the lateral antebrachial cutaneous nerve (LABCN). At 6 weeks, some alterations were still present in 15 patients (27.8%). However, this was clinically relevant in only 4 patients (7.4%). This figure has remained unchanged at the latest follow-up.
Overall patient satisfaction rate with the ERA technique was very high: 87% both at 6 weeks and at follow-up.
Conduit quality and short-term patency
Histologic analysis of 6 biopsy specimens revealed no intimal damage to any of the conduits. Predischarge imaging of the bypass conduits was performed with angiographic computed tomography (CT) in 5 patients and coronary angiography in 4 patients. All the bypass conduits were revealed to be open.
One patient had recurrence of angina 5 months after the operation. He underwent repeated coronary angiography, which revealed an occluded RA bypass graft to a small posterior descending branch of an occluded right coronary artery. Because all other bypass conduits were open, the patient was treated conservatively.
Another 2 patients underwent 6-month follow-up angiography. The first RA was patent, but in the second patient the sequential RA to a first diagonal branch and an obtuse marginal branch showed a proximal stenosis and an occlusion beyond the first distal anastomosis. This patient underwent percutaneous transluminal coronary angioplasty of the native branches.
Another patient had vague chest discomfort at exertion 9 months after the operation, but all conduits were patent according to coronary angiography. No other cardiac follow-up events occurred.
|
Discussion |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
The ERA harvesting technique avoids the LABCN because the dissection is performed underneath the brachioradialis muscle. We have therefore not encountered LABCN nerve injury in this series, confirming a previous report.19 However, the occurrence of SRN related paresthesia unfortunately has not been eliminated. The totally encountered incidence in this series was 27.7%, but clinical relevance was limited to 4 patients (7.8%), again comparable to other series.19 The clinically insignificant aspect of these paresthesias in most cases is also evidenced by the high patient satisfaction rate (87%).
During the study period, we did adapt a few technical aspects to decrease the incidence of paresthesia. We now always separate and visualize the RA and the SRN at the level of the wrist. At this level, we also divide the side branches under direct vision, and once we start the endoscopic dissection, we stay as close as possible to the RA. Adopting these small modifications reduced but unfortunately did not eliminate the occurrence of paresthesia.
The integrity of the conduit has not been altered, as demonstrated by the histologic findings of the conduit. This has also been demonstrated previously with light and electronic microscopy, indicating that one could dissect with the Harmonic Scalpel as close as 1 mm to the main trunk of the conduit without damaging the endothelium.6,8 Preservation of both satellite veins provides a safety barrier exceeding this critical distance.
This procedure certainly has a learning curve, as demonstrated by our initial harvesting times. Although we had experience with endoscopic vein harvesting and the use of the Harmonic Scalpel in open RA harvesting, we still needed about 15 cases before becoming comfortable with ERA and harvesting the conduit in an acceptable time interval. We therefore strongly recommend adequate experience with endoscopic vein harvesting and the Harmonic Scalpel before attempting ERA. In addition, the company recently has introduced a training model, which should also reduce the required harvesting time in vivo.
Cost may of course be an issue, because the procedure requires a video tower, an ultrasonic generator, a Harmonic Scalpel, and a dissector kit. Because our department performs a lot of video-assisted procedures, the video tower was available. The same applies for the generator, because our abdominal surgeons use this exclusively for all their laparoscopic procedures. The cost per patient of the Harmonic Scalpel and the kit may remain an issue, but we hope that increased experience will further diminish the paresthesia rate and therefore justify the use of this technique.
Although the technique is appealing, nothing is known about the long-term patency rates of endoscopically harvested RA. This is why we recently started to control predischarge patency rates with angiographic CT to establish a "baseline patency rate." Although the initial images and results are encouraging, numbers are still insufficient to draw any conclusions. However, angiographic CT allows us to control bypass conduit patency rates in a less invasive manner than coronary angiography, and we plan to repeat these at various intervals. This should allow a time-related comparison with literature data concerning patency rates of traditionally harvested RA.
Conclusions
Experience with endoscopic vein harvesting facilitates the learning curve associated with ERA. Once the technique has been mastered, ERA takes about 25 to 30 minutes. In our experience the technique provided ample patient satisfaction but did not totally eliminate the occurrence of SRN paresthesia. Future trials need to elucidate longer-term patency rates of conduits obtained by ERA.
|
Acknowledgments |
|---|
|
References |
|---|
|
TopAbstractMethodsResultsDiscussionReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  G. Bisleri and C. Muneretto Endoscopic radial artery harvesting MMCTS, January 1, 2009; 2009(0907): mmcts.2008.003780 - mmcts.2008.003780. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 B. Medalion, A. Tobar, Z. Yosibash, A. Stamler, E. Sharoni, E. Snir, E. Porat, and E. Hochhauser Vasoreactivity and histology of the radial artery: comparison of open versus endoscopic approaches Eur J Cardiothorac Surg, October 1, 2008; 34(4): 845 - 849. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Bleiziffer, I. Hettich, B. Eisenhauer, D. Ruzicka, B. Voss, R. Bauernschmitt, and R. Lange Neurologic sequelae of the donor arm after endoscopic versus conventional radial artery harvesting J. Thorac. Cardiovasc. Surg., September 1, 2008; 136(3): 681 - 687. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. Nishida, Y. Kikuchi, G. Watanabe, M. Takata, S. Ito, and K. Kawachi Endoscopic Radial Artery Harvesting: Patient Satisfaction and Complications Asian Cardiovasc Thorac Ann, February 1, 2008; 16(1): 43 - 46. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 V. Falk and F. W. Mohr Minimally Invasive Myocardial Revascularization Card. Surg. Adult, January 1, 2008; 3(2008): 697 - 710. [Full Text]
|
|
|
|
 |
|
 R. V. Newman, W. G. Lammle, and K. J. Matz Cost Effective Endoscopic Radial Artery Harvesting Ann. Thorac. Surg., July 1, 2006; 82(1): 353 - 354. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
O. Aziz, T. Athanasiou, and A. Darzi Minimally invasive conduit harvesting: a systematic review Eur J Cardiothorac Surg, March 1, 2006; 29(3): 324 - 333. [Full Text] [PDF]
|
|
|
|
|
|
O. M. Shapira, B. R. Eskenazi, E. Anter, L. Joseph, T. G. Christensen, C. T. Hunter, H. L. Lazar, J. A. Vita, R. J. Shemin, and J. F. Keaney Jr Endoscopic versus conventional radial artery harvest for coronary artery bypass grafting: Functional and histologic assessment of the conduit J. Thorac. Cardiovasc. Surg., February 1, 2006; 131(2): 388 - 394. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| ANN THORAC SURG | ASIAN CARDIOVASC THORAC ANN | EUR J CARDIOTHORAC SURG |
| J THORAC CARDIOVASC SURG | ICVTS | ALL CTSNet JOURNALS |
