title: Histologic and physiologic evaluation of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel.
abstract: OBJECTIVE
  The safety and reliability of a method of skeletonized internal thoracic artery harvesting with an ultrasonic scalpel (Harmonic Scalpel; Ethicon Endo-Surgery, CVG, Cincinnati, Ohio) were evaluated.
  
  
  METHODS
  The mural branches of the internal thoracic artery were cut by means of 3 methods, differentiated by distance from the site of application of the Harmonic Scalpel blade to the internal thoracic artery. A total of 15 branches were cut from the internal thoracic artery at (0 mm) the origin (group I) or at 1 mm (group II) or 2 mm (group III) distal to the origin. Tissue preparations were examined for successful vessel closure and severity of tissue damage. The length of stump (L) and the length of tissue damage from the stump (D) were determined by a computer image analysis system, and pressure testing was performed to evaluate the physical strength of vessel closure.
  
  
  RESULTS
  In group I, 8 of the 15 branches exhibited discontinuity of the vascular wall structure, probably because of insufficient sealing of the divided section, and 12 of the 15 branches exhibited tissue denaturation on the internal thoracic artery wall adjacent to areas of origin, which was probably caused by the heat transferred from the branches during the process of coagulation. In groups II and III, continuity of wall structure of stumps suggestive of stable closure of branches was confirmed. The lengths of tissue damage from the stump (D) were 0.96, 0.58, and 0.63 mm in groups I, II, and III, respectively, and the lengths of intact area (L - D) in the corresponding groups were -0.78, 0.61, and 1.51 mm. The negative figure in group I indicates the presence of tissue damage in the internal thoracic artery itself. By contrast, in groups II and III the internal thoracic arteries were intact, with a safety margin of greater than 0.5 mm. On physiologic evaluation of vessel closure, 2 of the 24 (8.3%) branches burst under a pressure lower than 350 mm Hg because of insufficient vessel coagulation, but the remaining 22 branches (91.7%) remained intact under pressures up to 350 mm Hg.
  
  
  CONCLUSIONS
  The internal thoracic artery skeletonization method with an ultrasonic scalpel (Harmonic Scalpel: output level 2) appears to be a safe and reliable method of skeletonized internal thoracic artery harvesting when branches are sectioned at least 1 mm distal to their origin at a sufficiently slow speed.
authors.affiliation: Division of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, Japan. thigami@hbhc.hiabcd.go.jp
authors.forename: T
authors.initials: T
authors.lastname: Higami
authors.forename: A
authors.initials: A
authors.lastname: Maruo
authors.forename: T
authors.initials: T
authors.lastname: Yamashita
authors.forename: T
authors.initials: T
authors.lastname: Shida
authors.forename: K
authors.initials: K
authors.lastname: Ogawa
mesh_terms: D000818:Animals; D001026:Coronary Artery Bypass / Q000379:methods; D004210:Dissection / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*; D007091:Image Processing, Computer-Assisted; D008323:Mammary Arteries / Q000293:injuries / Q000502:physiology / Q000637:transplantation* / Q000648:ultrastructure; D012449:Safety; D013552:Swine; D013718:Tensile Strength; D020858:Tissue and Organ Harvesting / Q000009:adverse effects / Q000379:methods*; D014463:Ultrasonography / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods*