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PAPAVERINE HYDRODISSECTION OF INTERNAL THORACIC ARTERY

Department of Cardiac Surgery, Prince Charles Hospital, Rode Road, Chermside, 4032, Australia

We read with great interest the article by Bahcivan and co-workers¹ regarding their experience with the use of papaverine for improving the flow in internal thoracic artery (ITA) as a conduit for coronary artery bypass surgery (CABG). The authors compared three different methods of using papaverine, which included injection into endothoracic fascia, into the pedicle of ITA following harvesting and direct intraluminal injection of the drug. The authors found that the harvesting time of the conduit was significantly shortened by injection of papaverine into endothoracic fascia. However, interestingly, there was no statistically significant difference in the flow of blood in three different groups prior to distal anastomosis with LITA graft. We would like to share our experience of this interesting topic with your readers and add few points.

We previously published our technique of "hydrodissection" of ITA² by injecting saline into the endothoracic tissue of the chest wall. We found that this method greatly facilitates the dissection of ITA. We would usually skeletonize the conduit and inject papaverine solution intraluminally following the division of the internal thoracic artery. It has been previously demonstrated that vasospasm is avoided and the graft flows are better in skeletonized ITAs as compared with pedicle ITAs following direct injection of papaverine into the graft³. By skeletonizing the ITA, a greater length of conduit is obtained and it also improves the technique of multiple sequential ITA grafts. We think that the technique of injecting saline or papaverine develops the plane of dissection of ITA. In our earlier experience with the injection of papaverine into endothoracic fascia, bleeding was an issue from small side branches and accompanying veins due to vasodilatory effect. We would recommend a liberal use of papaverine for dissection of this graft. This agent has been shown to relieve the most intractable of the spasms in native circulation and the ITA⁴. We would only avoid injecting papaverine intraluminally in elderly females with thin walled and fragile internal thoracic arteries.

We would like to congratulate the authors on this elaborate study.

References

1. Bahcivan M, Kolbakir F, Karamustafa H, Keceligil HT. Endothoracic papaverine application for internal thoracic artery harvest. Asian Cardiovasc Thorac Ann 2007;15:123–6.[Abstract/Free Full Text]

2. Saxena P, Mejia R, Tam R. Hydrodissection technique of harvesting left internal thoracic artery. Ann Thorac Surg 2005;80:355–6.[Abstract/Free Full Text]

3. Choi JB, Lee SY. Skeletonized and pedicle internal thoracic artery grafts: effects on free flow during bypass. Ann Thorac Surg 1996;61:909–13.[Abstract/Free Full Text]

4. Sanders L, Newman MAJ. Intractable post-operative internal thoracic artery spasm managed with angiographic intraluminal papaverine. J Thorac Cardiovasc Surg 2005;130:938–40.[Free Full Text]

This Article Extract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Pankaj Saxena Robert Tam Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Saxena, P. Articles by Tam, R. Search for Related Content PubMed PubMed Citation Articles by Saxena, P. Articles by Tam, R.