CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 5, September/October 2022 AFRICA 243 Identifying the optimal monopolar electrocautery output power in pedicular internal thoracic artery harvesting: 20 or 40 watts? Emin Can Ata, Gözde Erkanli Şentürk, Halil Ibrahim Saygi, Mustafa Özer Ulukan, Murat Uğurlucan, Korhan Erkanli, Metin Onur Beyaz, Erkan Yildiz Abstract Background: Monopolar electrocautery is an important tool for harvesting the pedicular internal thoracic artery (ITA) in cardiac surgery. The different power outputs of cautery may affect graft integrity and long-term patency. This study aimed to identify the optimal threshold of electrocautery power for ITA harvest. Methods: This prospective study included 30 patients who underwent elective coronary artery bypass surgery at the Medipol Mega University Hospital. The ITA was harvested by monopolar electrocautery after a median sternotomy. The output of cautery was adjusted at 20 W in group A and 40 W in group B. Three to 4 cm of a distal ITA sample from each patient was examined under a light microscope by two independent pathologists. Results: The ITA harvest time was longer in group A (21.2 ± 7.5 vs 10.3 ± 8.1 min, p < 0.001) than in group B. ITA free flow was similar in the two groups (43.6 ± 48.7 vs 51.7 ± 45.0 ml/min, p = 0.762). Mild to moderate injury in the endothelial and sub-endothelial sample was more frequent in the lowcautery group (p = 0.0037). Conclusion: ITA endothelial integrity was found to be better preserved with 40W electrocautery. Moreover, 20W of monopolar electrocautery may not be safe in pedicular ITA harvesting. Keywords: coronary artery bypass, electrocautery, endothelial injury, internal thoracic artery Submitted 26/5/20, accepted 27/1/22 Published online 23/2/22 Cardiovasc J Afr 2022; 33: 243–247 www.cvja.co.za DOI: 10.5830/CVJA-2022-005 The internal thoracic artery (ITA) is the standard conduit for coronary artery bypass graft surgery (CABG) because of its long-term patency.1 Skeletonised ITA has been favoured for the last two decades due to lower sternal wound infection, longer graft length and better free flow, but long-term patency is not superior to pedicular ITA.2 Besides the excellent long-term patency, pedicular ITA is still preferable because it is faster to harvest in a more straightforward way. Pedicular ITA can be prepared with different techniques. Monopolar electrocautery (MEC) and a harmonic scalpel are the primary instruments that have been used for over four decades, and the harvested ITA has proven to produce excellent long-term results.3,4 The ITA can also be harvested with a surgical scalpel and scissors. Apart from different instruments, the output power of electrocautery and the number of metallic haemoclips for side branches may vary depending on the surgeon’s preference. In this study, we investigated the effect of two different cautery powers, 20 and 40W, on ITA free flow and endothelium to find out the safer and more practical technique. Methods This prospective study was carried out after the approval of the Istanbul Medipol University ethics committee (NO:10840098604.01.01-E.3643). Patient consent forms were obtained before CABG. The study included two groups with an equal number of patients. All the patients were operated on by the same surgical team. This study included 30 elective, isolated CABG patients operated on at Medipol Mega University Hospital between February and April 2019. Patients were randomly divided into two groups, and each group consisted of 15 patients. The mean age was 63.2 ± 8.6 (range 47–82 years). Female and male patients represented 36.7 and 63.3%, respectively. In the first group (group A), 20W of output power was used, and the output power was increased to 40W in the other group (group B) for ITA harvesting. The primary endpoint of the study included an assessment by a permanent histologist of the wall integrity of the endothelial layer of the ITA. The secondary endpoint was echocardiographic evaluation of all the patients, and angiographic evaluation of the patients with a damaged ITA 12 months after surgery. Due to possible pre-existing ITA pathology, patients with diffuse vascular disease, uncontrolled or untreated diabetes mellitus, thoracic deformity or trauma, and radiotherapy after left-sided mastectomy were excluded from the study. The ITA was harvested by two highly skilled surgeons in turn. In both groups, 2–3-cm-wide pedicular ITA was harvested from its subclavian origin to 2–3 cm beyond the musculophrenic Clinic of Cardiovascular Surgery, Haseki Education and Research Hospital, Istanbul, Turkey Emin Can Ata, MD, dr.enata@yahoo.com Department of Histology and Embryology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey Gözde Erkanli Şentürk, MD Halil Ibrahim Saygi, MD Department of Cardiovascular Surgery, Medipol Mega University Hospital, Istanbul, Turkey Mustafa Özer Ulukan, MD Murat Uğurlucan, MD Korhan Erkanli, MD Erkan Yildiz, MD Department of Cardiovascular Surgery, Tayfur Ata Sokmen Medical Faculty, Mustafa Kemal University, Hatay, Turkey Metin Onur Beyaz, MD
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