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Skeletonized internal thoracic artery harvesting: a low thermal damage electrosurgical device provides improved endothelial layer and tendency to better integrity of the vessel wall compared to conventional electrosurgery.

ABSTRACT: BACKGROUND:Electrosurgery is fundamental to the precise, fast and bloodless preparation of internal thoracic artery grafts in cardiac surgery. The PEAK PlasmaBlade is a monopolar electrosurgical device that uses pulsed radiofrequency energy to generate a plasma-mediated discharge along an insulated electrode, creating a cutting edge while the blade stays near body temperature. The aim of this study is to compare the histological samples, cardiac computed-tomography of graft patency, and clinical outcomes of patients after off-pump coronary artery bypass grafting with preparation of the internal thoracic arteries by a conventional electrosurgical device and the PlasmaBlade. METHODS:In twenty subjects one internal thoracic artery was prepared with PlasmaBlade and the other artery with a conventional electrosurgical device. Histological samples were evaluated for three factors for potential graft failure: endothelial damage, integrity of the vessel wall and adventitial hemorrhage. Five samples per artery were evaluated by a novel scoring method based on the exposed circumference of the histological sample ("0": 0%, "1": 1-25%, "2": 26-50%, "3": 51-75%, "4": ?76% of the circumference). The Wilcoxon signed ranks test for mean scores within subjects was performed. Six-month-follow up by cardiac computed tomography for evaluation of graft patency was completed in 16 patients. RESULTS:Histological results demonstrated significantly less endothelial damage after PlasmaBlade (83% vs 60%, absolute: 75/90 vs. 53/89 samples with score "0-1", p =?0.04). PlasmaBlade samples demonstrated a tendency to better wall integrity (72% vs. 54%, absolute: 64/89 vs. 47/87 samples with score "0-1", p =?0.32). There were no differences in endothelial bleeding (PlasmaBlade 46% vs. electrosurgery 53%, absolute: 41/88 vs. 48/90 samples with score "0-1", p =?0.63). Computed tomography confirmed non-inferiority of the PlasmaBlade to conventional electrosurgery with a patency rate of 94%. CONCLUSION:Histologically, internal thoracic arteries harvested with PlasmaBlade demonstrate a more intact endothelial layer and a tendency to better wall integrity. Computed tomography of graft patency speaks for non-inferiority to conventional electrosurgery. PlasmaBlade may be preferable to conventional electrosurgery, if further follow-up confirms patency of internal thoracic arteries. TRIAL REGISTRATION:NCT03510026 , registered 4th April 2018 (retrospectively registered).

SUBMITTER: Zientara A

PROVIDER: S-EPMC6180394 | biostudies-literature | 2018 Oct

REPOSITORIES: biostudies-literature

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Skeletonized internal thoracic artery harvesting: a low thermal damage electrosurgical device provides improved endothelial layer and tendency to better integrity of the vessel wall compared to conventional electrosurgery.

Zientara Alicja A Komminoth Paul P Seifert Burkhardt B Odavic Dragan D Dzemali Omer O Häussler Achim A Genoni Michele M

Journal of cardiothoracic surgery 20181011 1

<h4>Background</h4>Electrosurgery is fundamental to the precise, fast and bloodless preparation of internal thoracic artery grafts in cardiac surgery. The PEAK PlasmaBlade is a monopolar electrosurgical device that uses pulsed radiofrequency energy to generate a plasma-mediated discharge along an insulated electrode, creating a cutting edge while the blade stays near body temperature. The aim of this study is to compare the histological samples, cardiac computed-tomography of graft patency, and ...[more]

PMID: 30305183

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Project description:ImportanceRecent evidence has suggested that skeletonization of the internal thoracic artery (ITA) is associated with worse clinical outcomes in patients undergoing coronary artery bypass surgery (CABG).ObjectiveTo compare the long-term clinical outcomes of skeletonized and pedicled ITA for CABG.Design, setting, and participantsThe Arterial Revascularization Trial (ART) was a 2-group, multicenter trial comparing the use of a bilateral ITA vs a single ITA for CABG at 10 years. Patients in the ART trial were stratified by ITA harvesting technique: skeletonized vs pedicled. Data were collected from June 2004 to December 2017, and data were analyzed from June to July 2021.InterventionsIn this analysis, the 10-year clinical outcomes were compared between patients who received skeletonized vs pedicled ITAs.Main outcomes and measuresThe primary outcome was all-cause mortality. The secondary outcomes were a composite of major adverse cardiac events (MACE) including all-cause mortality, myocardial infarction, and repeated revascularization and a composite including MACE and sternal wound complication (SWC). Cox regression and propensity score matching were used.ResultsOf 2161 included patients, 295 (13.7%) were female, and the median (interquartile range) age was 65.0 (58.0-70.0) years. At 10 years, the risk of all-cause mortality was not significantly different between the pedicled and skeletonized groups (hazard ratio [HR], 1.12; 95% CI, 0.92-1.36; P = .27). However, the long-term risks of the secondary outcomes were significantly higher in the skeletonized group compared with the pedicled group (MACE: HR, 1.25; 95% CI, 1.06-1.47; P = .01; MACE and SWC: HR, 1.22; 95% CI, 1.05-1.43; P = .01). The difference was not seen when considering only patients operated on by surgeons who enrolled 51 patients or more in the trial (MACE: HR, 1.07; 95% CI, 0.82-1.39; P = .62; MACE and SWC: HR, 1.04; 95% CI, 0.80-1.34; P = .78).Conclusions and relevanceWhile the long-term survival of patients was not different between groups, the rate of adverse cardiovascular events was consistently higher in the skeletonized group and the difference was associated with surgeon-related factors. Further evidence on the outcome of skeletonized ITA is needed.

Project description:ImportanceThe relative safety and patency of skeletonized vs pedicled internal mammary artery grafts in patients undergoing coronary artery bypass graft (CABG) surgery are unknown.ObjectiveTo investigate the association of skeletonized vs pedicled harvesting with internal mammary artery graft patency and clinical outcomes 1 year after CABG surgery.Design, setting, and participantsThis study was a post hoc analysis of the multicenter, randomized, double-blind, placebo-controlled Cardiovascular Outcomes for People Using Anticoagulation Strategies (COMPASS) clinical trial, which enrolled 27 395 patients from 602 centers in 33 countries from March 2013 through May 2016. Eligibility criteria for the trial included CABG surgery for coronary artery disease with at least 2 grafts implanted and an estimated glomerular filtration rate of at least 30 mL/min. A total of 1002 of 1448 patients were randomized to the CABG arm of the COMPASS trial and underwent skeletonized (282 [28.1%]) or pedicled (720 [71.9%]) internal mammary artery harvesting. The patients had evaluable angiography results 1 year after surgery. Data were analyzed from October 11, 2019, to May 14, 2020.InterventionsPatients underwent graft harvesting with either the pedicled technique or skeletonized technique.Main outcomes and measuresThe primary outcome was graft occlusion 1 year after CABG surgery, as assessed by computed tomography angiography.ResultsA total of 1002 patients underwent skeletonized (282 [28.1%]; mean [SD] age, 65.9 [8.1] years; 229 men [81.2%]; 194 White patients [68.8%]) or pedicled (720 [71.9%]; mean [SD] age, 64.8 [7.6] years; 603 men [83.8%]; 455 White patients [63.2%]) internal mammary artery harvesting. Rates of internal mammary artery graft occlusion 1 year after CABG surgery were higher in the skeletonized group than in the pedicled group (33 of 344 [9.6%] vs 30 of 764 [3.9%]; graft-level adjusted odds ratio, 2.41; 95% CI, 1.39-4.20; P = .002), including the left internal mammary artery to left anterior descending artery (21 of 289 [7.3%] vs 25 of 725 [3.4%]; graft-level adjusted odds ratio, 2.10; 95% CI, 1.14-3.88, P = .02). After a mean follow-up of 23 months, skeletonized graft harvesting was also associated with a higher rate of major adverse cardiovascular events (20 [7.1%] vs 15 [2.1%]; adjusted hazard ratio, 3.19; 95% CI, 1.53-6.67; P = .002) and repeated revascularization (14 [5.0%] vs 10 [1.4%]; adjusted hazard ratio, 2.75; 95% CI, 1.10-6.88; P = .03).Conclusions and relevanceThis post hoc analysis of the COMPASS randomized clinical trial found that harvesting of the internal mammary artery during CABG surgery using a skeletonized technique was associated with a higher rate of graft occlusion and worse clinical outcomes than the traditional pedicled technique. Future randomized clinical trials are needed to establish the safety and patency of the skeletonized technique.Trial registrationClinicalTrials.gov Identifier: NCT01776424.

Project description:Knowledge of the lung vessel morphology in healthy subjects is necessary to improve our understanding about the functional network of the lung and to recognize pathologic deviations beyond the normal inter-subject variation. Established values of normal lung morphology have been derived from necropsy material of only very few subjects. In order to determine morphologic readouts from a large number of healthy subjects, computed tomography pulmonary angiography (CTPA) datasets, negative for pulmonary embolism, and other thoracic pathologies, were analyzed using a fully-automatic, in-house developed artery/vein separation algorithm. The number, volume, and tortuosity of the vessels in a diameter range between 2 and 10 mm were determined. Visual inspection of all datasets was used to exclude subjects with poor image quality or inadequate artery/vein separation from the analysis. Validation of the algorithm was performed manually by a radiologist on randomly selected subjects. In 123 subjects (men/women: 55/68), aged 59 ± 17 years, the median overlap between visual inspection and fully-automatic segmentation was 94.6% (69.2-99.9%). The median number of vessel segments in the ranges of 8-10, 6-8, 4-6, and 2-4 mm diameter was 9, 34, 134, and 797, respectively. Number of vessel segments divided by the subject's lung volume was 206 vessels/L with arteries and veins contributing almost equally. In women this vessel density was about 15% higher than in men. Median arterial and venous volumes were 1.52 and 1.54% of the lung volume, respectively. Tortuosity was best described with the sum-of-angles metric and was 142.1 rad/m (138.3-144.5 rad/m). In conclusion, our fully-automatic artery/vein separation algorithm provided reliable measures of pulmonary arteries and veins with respect to age and gender. There was a large variation between subjects in all readouts. No relevant dependence on age, gender, or vessel type was observed. These data may provide reference values for morphometric analysis of lung vessels.

Dataset Information

Skeletonized internal thoracic artery harvesting: a low thermal damage electrosurgical device provides improved endothelial layer and tendency to better integrity of the vessel wall compared to conventional electrosurgery.

Publications

Skeletonized internal thoracic artery harvesting: a low thermal damage electrosurgical device provides improved endothelial layer and tendency to better integrity of the vessel wall compared to conventional electrosurgery.

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