Ultrastructural Investigations of Arterial Bypass Conduits after the Use of Different Harvesting Techniques Using an Electron Microscope
Keywords:Arterial conduits, harmonic scalpel, endothelial pathology, scanning electron microscope.
Objectives: The aim of this study was to perform morphometric analysis of arterial conduits harvested by harmonic scalpel in coronary artery bypass grafting (CABG) patients.
Methods: From 100 CABG patients, 200 arterial conduits—100 radial arteries (RAs) and 100 left internal thoracic artery (LITAs)—were harvested. The patients had similar characteristics (mean age, sex ratio, comorbidities, etc.). We divided the patients into 2 groups according to harvesting technique. In group 1, a harmonic scalpel was used in 50 patients for harvesting arterial conduits (50 LITA and 50 RA). In group 2, conduits were harvested using low-voltage electrocautery. To prevent side effects of clipping, all conduits in both groups remained in perfused condition until anastomosis. A 10-mm length of conduit was cut for transmission electron microscopy investigation. We calculated duration of harvesting, blood flow changes, and histopathologic changes of the conduits according to a vessel scoring system.
Results: In the harmonic scalpel group, we detected pathologic findings—corruption of endothelial integrity, subendothelial damage, and endothelial pathology—in 5 specimens (10%) (3 LITA [6%] and 2 RA [4%]). In group 2, pathologic findings were detected in 16 conduits (32%; 11 LITA, 22%, and 5 RA, 10%). Endothelial dissection, subendothelial disarrangement, cellular separation due to intercellular edema, and subadventitial hematoma were the main pathologic changes in the classic harvesting method. There was a significant difference between the groups (P = .001). Harvesting time of LITA was nearly similar in both groups: 26.9 ± 11.1 min (range 25-38) in group 1 and 21.3 ± 8.6 min (range 21-25) in group 2 (P = .049). RA harvesting time was significantly shorter with the harmonic scalpel technique (20.3 ± 3.9 versus 27.6 ± 5.4 min, P = .022). The blood flow of the conduits was similar, with no statistical difference for the 2 arterial conduits (LITA, P = .76; RA, P = .55).
Conclusion: In the learning curve period, the use of a harmonic scalpel is time consuming and presents some difficulties during the harvesting of conduits. According to our study results, however, the harmonic scalpel technique may be useful because of decreased pathology, including spasm. In our opinion, graft occlusion or thrombus as a life-threatening condition and endothelial dysfunction may decrease with the use of this alternative harvesting technique.
Amaral JF. Comparison of the ultrasonically activated scalpel to electrosurgery and laser for laparoscopic surgery. Surg Endosc 1993;7:141-142.
Campeau L, Enjalbert M, Lesperance J, et al. Atherosclerosis and late closure of aortocoronary saphenous vein grafts: Sequential angiographic studies at 2 weeks, 1 year, 5 to 7 years, and 10 to 12 years after surgery. Circulation 1983;68:1-7.
Cooper G, Underwood M, Deverall P. Arterial and venous conduits for coronary artery bypass. A current review. Eur J Cardiothorac Surg 1996;10:129-140.
Dogan OF, Tatar I, Duman U, Yorgancioglu C, Demircin M, Aldur M, Celik HH, Boke E. Comparison of the pretreatment effects of mixed vasodilators (3-D solution) on radial and internal thoracic arteries by using a 3-dimensional (3D) anaglyph electron microscope technique. Heart Surg Forum 2006;9:643-649.
Dogan OF. Examination of the internal thoracic artery by transmission electron microscope in coronary artery bypass surgery patients. Turk J Thorac Cardiovasc Surg 2011;19:329-336.
Fukata Y, Horike K, Kano M. Histological study on the influences of an ultrasonic scalpel on skeletonized vessel wall. Ann Thorac Cardiovasc Surg 2002;8:291-297.
Higami T, Kozawa S, Asada T, et al. Skeletonisation and harvest of the internal thoracic artery with an ultrasonic scalpel. Ann Thorac Surg 2000;70:307-308.
Higami T, Maruo A, Yamashita T, Shida T, Ogawa K. Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel. J Thorac Cardiovasc Surg 2000;120:1142-1147.
Kinoshita T, Tawa M, Suzuki T, Aimi Y, Asai T, Okamura T. Endothelial dysfunction of internal thoracic artery graft in patients with chronic kidney disease. J Thorac Cardiovasc Surg 2017;153:317-324.
Lamm P, Juchem G, Weyrich P, Schütz A, Reichart B. The harmonic scalpel: optimizing the quality of mammary artery bypass grafts. Ann Thorac Surg 2000; 69:1833-1835.
Lehtola A, Verkkala K, Jarvinen A. Is electrocautery safe for internal mammary artery mobilisation? A study using scanning electron microscopy. Thorac Cardiovasc Surgeon 1989;37:55-57.
Lima Cañadas PP, Cañas AC, Orradre Romeo JL, Rubio Martínez CI, López Almodóvar LF, Calleja Hernández M. Endothelium histological integrity after skeletonized dissection of the left internal mammary artery with ultrasonic scalpel. Interact Cardiovasc Thorac Surg 2005;4:160-162.
Ohtsuka T, Wolf KR, Warnig P, Park SE. Thoracoscopic limited pericardial resection with an ultrasonic scalpel. Ann Thorac Surg 1998;65:855-856.
Onan B, Yeniterzi M, Onan IS, Ersoy B, Gonca S, Gelenli E, Solakoglu S, Bakir I. Effect of electrocautery on endothelial integrity of the internal thoracic artery: ultrastructural analysis with transmission electron microscopy. Tex Heart Inst J 2014;1;41:484-490.
Orejola WC, Villacin AB, Defilippi VJ, Mekhjian HA. Internal mammary artery harvesting using the harmonic scalpel. ASAIO J 2000;46:99-102.
Petry A, BelAiba RS, Weitnauer M, Görlach A. Inhibition of endothelial nitric oxide synthase increases capillary formation via Rac1-dependent induction of hypoxia-inducible factor-1α and plasminogen activator inhibitor-1. Thromb Haemost 2012;108:849-862.
Posacıoğlu H, Atay Y, Çetindağ B, et al. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.
Ronan WJ, Perry AL, Barner BH, et al. Radial artery harvest: Comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000;69:113-114.
Takao S, Shinchi H, Maemura K, Aikou T. Ultrasonically activated scalpel is an effective tool for cutting the pancreas in biliary-pancreatic surgery: experimental and clinical studies. J Hepatobiliary Pancreat Surg 2000;7:58-62.
Tanemoto K, Kanaoka Y, Murakami T, et al. Harmonic scalpel in coronary artery bypass surgery. J Cardiovasc Surg 1998;39:493-495.
Thatte HS, Khuri SF. The coronary artery bypass conduit: I. Intraoperative endothelial injury and its implication on graft patency. Ann Thorac Surg 2001;72:2245-2252.
Verrier ED, Boyle EM Jr. Endothelial cell injury in cardiovascular surgery. Ann Thorac Surg 1996;62:915–922.
Yoshikai M, Ito T, Kamohara K, Yunoki J. Endothelial integrity of ultrasonically skeletonized internal thoracic artery: Morphological analysis with scanning electron microscopy. Eur J Cardiothorac Surg 2004;25:208-211.
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