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Advantages of The Ultrasonic Harmonic Scalpel for Radial Artery Harvesting

Department of Cardiothoracic Surgery, Rabin Medical Center, Tel Aviv University, Tel Aviv, Israel

For reprint information contact: Georgios P Georghiou, MD Tel: 972 3 937 6701 Fax: 972 3 924 0762 Email: georgios{at}clalit.org.il, Department of Cardiothoracic Surgery, Rabin Medical Center, Beilinson Campus, Petah Tiqva 49100, Israel.

	ABSTRACT

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The aim of the study was to examine the safety and effectiveness of the Harmonic Scalpel^® for reducing spasm caused by thermal injury during radial artery harvesting. The study sample included 100 candidates undergoing coronary artery bypass grafting. In half the patients, radial artery harvesting was performed using the ultrasonic Harmonic Scalpel equipped with coagulating curved shears and a 14 cm scissor-grip handle and in the other half, hemostatic clips, scissors, and minimal electrocautery were employed. Comparison of outcome between the groups showed that radial artery harvesting with the Harmonic Scalpel was associated with a shorter harvesting time, lower frequency of spasm, larger internal diameter of the radial artery graft, and a significantly reduced need for clips to control bleeding than the standard method. In addition, there were no cases of hematoma or superficial wound infection in the arm, and no postoperative reduction in soft touch sensation or objective pin-prick sensation. In conclusion, the Harmonic Scalpel provides excellent control of bleeding without the need for potentially damaging electrocautery, and with a markedly decreased use of hemostatic clips. Harvesting time is also shorter. The minimized thermal injury decreases the rate of radial artery spasm. Further studies using additional objective measures are currently underway to confirm these findings.

	INTRODUCTION

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Use of the radial artery as an alternative conduit for coronary artery bypass grafting was introduced in 1973¹ but abandoned two years later because of severe diffuse narrowing in 35% of the grafts caused by spasm of the denervated artery.² Recently, interest in this method was renewed with the development of alpha-adrenergic blocking agents³ and modified surgical techniques which avoid skeletonization and excessive dilatation of the graft. The Harmonic Scalpel^® (Ethicon Endo-Surgery, Cincinnati, OH) is an ultrasonic surgical tool for cutting and coagulating tissues. It operates at a frequency of 55.5 KHz. Bleeding vessels are coapted by tamponading and then sealed with a denaturized protein coagulum. Electrocautery with the Harmonic Scalpel denatures the protein by transferring sufficient mechanical energy to the tissue to break the tertiary hydrogen bonds; high-frequency vibration of the tissue also generates heat from internal cellular friction.⁴ Since coagulation is uniform throughout the vessels, the reduction in power density characteristic of standard methods is avoided, and there is no bleeding from the vessel wall closest to the electrocautery blade.⁵ Having an ultrasonic Harmonic Scalpel available in our department, we began to use it for radial artery harvesting in cardiovascular procedures, on the assumption that it would lessen the arterial spasm. The aim of the present study was to report the results of this modified technique.

	PATIENTS AND METHODS

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The study sample consisted of 100 candidates for coronary artery bypass grafting with good flow to the palmar arch of the nondominant hand. Patients were randomly divided into two groups and matched for demographic characteristics. In 50 patients, the radial artery was harvested with the Harmonic Scalpel, and in 50, with hemostatic clips, scissors, and minimal electrocautery. A single surgeon (G.P.G.) removed the radial artery vessels for standardization of the technique.

The groups were compared for harvesting time (interval from skin incision to ligation of the proximal end of the artery), frequency of spasm (disappearance of visible and palpable pulsation, diameter of the radial artery graft, appearance of visible constriction of the radial artery graft, and color change from dark red to white), use of hemostatic clips, hematomas (requiring re-exploration of the arm), superficial wound infection (managed with local drainage and antibiotics), and objective neural sensation (as assessed by soft touch with cotton wool and pin prick).

The Allen test with pulse oximetry was used to assess the adequacy of the blood supply from the ulnar artery to the nondominant hand.⁶ None of the patients had a contraindication for radial artery harvest, defined as a delay in capillary refill exceeding 10 seconds. The entire arm was prepared circumferentially and positioned over an arm-board. An incision was made from the wrist (over the radial artery pulse) to the mid-antecubital fossa (over the brachial artery pulse). Unlike the diverse topography of the saphenous veins, the course of the radial artery is very constant and predictable. Only the skin incision was performed with a surgical blade. A Harmonic Scalpel with coagulating curved shears and 14 cm scissor-grip handle was used to cut the subcutaneous tissue and overlying fascia of the radial artery. After the antebrachialis fascia was incised, a self-retaining retractor was placed between the brachioradialis and flexor carpiradialis muscles in order to expose the entire length of the radial artery. The two satellite veins and the surrounding adipose tissue were left attached to the radial artery to preserve its blood supply as much as possible and to prevent spasm. The radial artery and the satellite vein side-branches along its entire length were coagulated with the coagulating shears of the ultrasonic scalpel. The shears were then used to free the medial side from the adjacent tissue and to apply minimal upward traction to the underside of the radial artery. Finally, the lateral side was dissected and the radial artery pedicle was ligated and divided at both ends. The radial artery graft was stored in a solution containing blood, normal saline, heparin and Regitine^® (phentolamine mesylate, 10 mg•dL^{– 1}).

In the second group, low-energy electrocautery (Valleylab, 390 kHz Int. 10s/30s, Valleylab Inc., Boulder, CO) was used to separate the radial artery from the subcutaneous tissue, muscle, and overlying fascia. The collateral branches were occluded by means of hemostatic clips (Premium Surgiclip, Auto Suture, Norwalk, CT) and divided with scissors. Electrocautery was avoided to prevent thermal injury to the artery and to ensure patency of the arterial grafts. In addition, no metallic probes or dilators were used in order to prevent intimal trauma. The radial artery graft was stored in a solution containing blood, normal saline, heparin and Regitine^® (10 mg•dL^{– 1}). Hemostasis was verified carefully before the arm incision was closed. The fascia antebrachialis was left open to prevent compartment syndrome. Dressings and elastic bandages were applied, and the arm was repositioned parallel to the patient’s body using an elbow pad. The arm and hand were re-examined before the patient was transferred from the operating room.

	RESULTS

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Radial artery harvesting with the Harmonic Scalpel was associated with shorter harvesting time, considerably wider internal diameter of the radial artery graft measured immediately before anastomosis, lower frequency of spasm, and use of significantly fewer clips to control bleeding than the standard method (Table 1). The markedly decreased need to use hemostatic clips for side branches led to less traumatic, more rapid, and spasm-free harvesting. In no patient did we need to place additional hemostatic clips on the radial artery after anastomosis. In addition, there were no cases of hematoma or superficial wound infection observed in the arm. In the second group, one patient required re-exploration of the arm for hemostasis and evacuation of a hematoma at termination of the operation. One patient had a superficial wound infection in the arm, which was managed successfully by local drainage and antibiotics. There were no abnormalities in soft touch sensation in either group. Five patients in group 2 had a minor reduction in pin-prick sensation in the thenar eminence region, which did not affect daily use of the hand.

	DISCUSSION

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Early thermal studies indicated that the heat generated in the tissue as a result of stress and friction is limited when a short period of energy is used. Electrocautery allows the surgeon very little control, as the tissue effect is almost instantaneous. The Harmonic Scalpel, however, ensures that the pressure applied to the tissues is held constant, so that the depth of heat penetration and lateral heat spread to the tissues is increased directly proportional with time. The Scalpel can also be used near hemostatic clips without any harmful effects to the vessel.⁵ These advantages provide for fast, safe, and spasm-free harvesting without the need for hemostatic clips for vessel side branches.

As a result, the Harmonic Scalpel has come into widespread use by cardiac surgeons.⁹ Our new cardiovascular technique with the Harmonic Scalpel makes radial artery harvesting easier and faster, with spasm-free arterial conduits. In addition, it appears to be associated with lower rates of superficial wound infection and hematoma of the arm, and lower rates of residual sensory symptoms. Harvesting without hemostatic clips also facilitates handling of the radial artery during anastomosis.

In conclusion, the ultrasonic technique appears to be a simple, safe, fast, and minimally invasive radial artery harvesting method. Prompted by these promising results, we are planning further long-term studies of the effect of our technique on graft patency and endothelial integrity using additional quantitative measures, including internal and external vessel diameter and vessel flow against zero resistance, in addition to laboratory tests of vasoreactivity and histological evaluation.

The authors thank Gloria Ginzach and Charlotte Sachs of the Editorial Board, Rabin Medical Center, Beilinson Campus, for their assistance.

	REFERENCES

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1. Carpentier A, Guermonprez JL, Deloche A, Frechette C, Dubost C. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111–21.[Medline]

2. Carpentier A. Discussion of: Geha AS, Krone RJ, McCormick JR, Baue AE. Selection of coronary bypass. Anatomic, physiological, and angiographic consideration of vein and mammary artery grafts. J Thorac Cardiovasc Surg 1975;70:429–30.

3. Locker C, Mohr R, Paz Y, Lev-Ran O, Herz I, Uretzky G, et al. Pretreatment with alpha-adrenergic blockers for prevention of radial artery spasm. Ann Thorac Surg 2002;74:S1368–70.[Abstract/Free Full Text]

4. Amaral JF. Ultrasonic dissection. Endosc Surg Allied Technol 1994; 2:181–5.[Medline]

5. Hambley R, Hebda PA, Abell E, Cohen BA, Jegasothy BV. Wound healing of skin incisions produced by ultrasonically vibrating knife, scalpel, electrosurgery, and carbon dioxide laser. J Dermatol Surg Oncol 1988;14:1213–7.[Medline]

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7. Acar C, Jebara VA, Portoghese M, Beyssen B, Pagny JY, Grare P, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652–60.[Abstract]

8. Chong WC, Ong PJ, Hayward CS, Collins P, Moat NE. Effects of radial artery harvesting on forearm function and blood flow. Ann Thorac Surg 2003;75:1171–4.[Abstract/Free Full Text]

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