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Asian Cardiovasc Thorac Ann 2006;14:89-90
© 2006 Asia Publishing EXchange Ltd

LETTER TO EDITOR

HARMONIC SCALPEL HAS ACUTE BENEFICIAL EFFECTS DURING RADIAL ARTERY HARVESTING

Mustafa Cikirikcioglu, MD, Hakan Posacioglu, MD

Department of Cardiovascular Surgery, University Hospital of Geneva, Switzerland
Department of Cardiovascular Surgery, Ege University, Izmir, Turkey

We read the manuscript of Georghiou et al named "Advantages of the ultrasonic Harmonic Scalpel for radial artery harvesting" with interest (Asian Cardiovasc Thorac Ann 2005;13:58–60[Abstract/Free Full Text]). They examined the safety and effectiveness of Harmonic Scalpel during radial artery harvesting and compared it with classic electrocautery technique. As a conclusion, they found shorter harvesting time and less radial artery spasm for Harmonic Scalpel group.

Harmonic Scalpel is an ultrasonic surgical instrument for cutting and coagulating tissues. It has been offered at the beginning for endoscopic surgical procedures because the working mechanism is totally different from electrocautery. Harmonic Scalpel can provide simultaneous incision and coagulation by transfer of mechanical and thermal energy to tissues but it does not produce any smoke whilst working.

The usage of Harmonic Scalpel is not a new technique for radial artery harvesting as explained by authors in the discussion. It was firstly proposed for radial artery harvesting by our institute (University Hospital of Ege) in 1998.1 In this technical report and comparison study, we have found shorter harvesting time, less spasm and less hemostatic clip usage with Harmonic Scalpel compared to electrocautery. Shortly after this publication, other groups have reported their results for radial artery and other graft preparations.

Although it has been documented by qualitative and quantitative studies that Harmonic Scalpel produces less radial artery spasm compared with classic electrocautery and clip technique, the mechanism of vasodilatation promoted by ultrasonic systems is not clear.1–2 Ronan et al compared traditional techniques with Harmonic Scalpel and found significantly better free blood flow in vessels dissected with ultrasonic device. Although demonstrated by Chokshi that endothelium dependent relaxation is responsible for the vasodilatation after ultrasonic manipulations, Fischell noted in the same model that endothelium-independent (smooth muscle mediated) mechanisms are more dominant.3 Maruo et al recently reported a well constructed study about ultrasonic vasodilatation mechanisms produced by Harmonic Scalpel.3 They observed that endothelium dependent release of nitric oxyde and prostacyclin by ultrasonic stimulation is more responsable to prevent vasospasm. A small, but consequential endothelium independent component also exists. A direct effect of ultrasonic energy on the smooth muscle contractile protein complexes may provide an alternative explanation for the endothelium independent vasodilatation component. Ultrasonic waves are known to be reversibly disrupting actin-actin bounds and lead to actin filament fragmentation.3 Therefore, it is worthwhile to check vascular smooth muscle changes with transmission electron microscopy for the following studies.

It is well documented that radial artery harvesting is fast, safe and produces less spasm compared with classic technique. Besides these acute beneficial effects, other points of interest are endothelial integrity and vascular vasomotor properties following Harmonic Scalpel harvesting as planned by authors. We compared radial artery endothelial integrity with scanning electron microscopy and endothelial properties with vascular reactivity test in an organ bath.4 The rings harvested with two different techniques (Harmonic Scalpel versus electrocautery) showed similar responses to vasoconstrictor and vasodilatator agonists and no morphologic differences were found in the appearance of endothelial cells. The cross sectional effect of Harmonic Scalpel has been evaluated by Fukata et al with in vitro and in vivo models also.5 They concluded that dissection of radial and internal thoracic arteries with Harmonic Scalpel is safe and even a single slide touch to the vessel itself was found to be harmless, so that thermal trauma did not reach the endothelium and was limited to the depth of the connective tissue of tunica externa.

Although it is published recently, the study of Georghiou et al did not include basic mechanisms and references. Thus, we wanted to share our remarks and give basic and updated references about this field.

REFERENCES:

  1. Posacioglu H, Atay Y, Cetindag B, Saribulbul O, Buket S, Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984–5.[Abstract/Free Full Text]

  2. Ronan JW, Perry LA, Barner HB, Sundt TM. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000; 69:113–4.[Abstract/Free Full Text]

  3. Maruo A, Hamner CE, Rodrigues AJ, Higami T, Greenleaf JF, Schaff HV. Nitric oxide and prostacyclin in ultrasonic vasodilatation of the canine internal mammary artery. Ann Thorac Surg 2004;77:126–32.[Abstract/Free Full Text]

  4. Cikirikcioglu M, Yasa M, Kerry Z, Posacioglu H, Boga M, Yagdi T, et al. The effects of the Harmonic Scalpel on the vasoreactivity and endothelial integrity of the radial artery: a comparison of two different techniques. J Thorac Cardiovasc Surg 2001;122:624–6.[Free Full Text]

  5. Fukata Y, Horike K, Kano M. Histological study on the influences of an ultrasonic scalpel on skeletonized vessel wall. Ann Thorac Cardiovasc Surg 2002;8:291–7.[Medline]





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