Does radial artery harvest with a harmonic scalpel result in fewer complications than standard electrocautery methods
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a Department of Cardiothoracic Surgery, Wessex Cardiothoracic Centre, Southampton, UK
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether radial arterial harvest with a harmonic scalpel produced a lower incidence of complications or was superior to conventional harvest with the diathermy or scissors and clip techniques. Two hundred and forty-seven papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We identified 10 studies, 2/5 studies report faster harvesting with the harmonic scalpel, 6 studies report reduced requirement for surgical clips, 2 papers report less spasm, 2/4 studies reported less numbness, and 2 studies reported no electron microscopic differences. Three studies looked at angiography or flow, with one equivocal, one in favour of harmonic and one in favour of scissors and clips. We conclude that there is little convincing evidence in the literature to guide the decision to use a harmonic scalpel over electrocautery for radial artery harvest.
Key Words: Thoracic surgery; Harmonic scalpel; Radial artery; Coronary arterial bypass graft
1. Introduction
A best evidence topic was constructed according to the structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You have been approached by a representative of a company who is promoting their harmonic scalpel. They tell you that their scalpel is quicker and safer than the diathermy technique and that it causes less arterial spasm. The representative gives you several brochures to back this up with some references in small type at the bottom of the page. You are keen to try this ultrasonic scalpel but you discover that it is more expensive than your usual technique so you decide to look up the clinical evidence for a benefit for harmonic scalpels before committing to a trial of this new device.
3. Three-part question
In [patients undergoing radial artery harvest for CABG] is the [harmonic scalpel] superior to standard harvesting techniques in terms of [reducing complications].
4. Search strategy
Medline 1990 to Oct 2005 using the OVID interface. [exp radial artery/ OR radial.mp] AND [Harmonic.mp OR ultrasonic$.mp] Humans (Limit).
5. Search outcome
Using the above search 247 papers were identified of which 10 represented the best evidence to answer the question (Table 1).
6. Discussion
Radial artery harvest using the harmonic scalpel is a relatively new technique, with the first reports appearing in 1998 [2]. We found 5 randomized studies and 5 cohort studies or series that assessed its benefit against electrocautery, scissors and clips.
Mitsumasa Hata [3] harvested 90 radial arteries, randomizing to either electrocautery, harmonic scalpel or scissors and clips techniques. He found that 30% of harmonic patients reported hand numbness compared to none of the scissors and clip patients. In addition he performed angiography at 1 and 12 months and interosseous artery recovery and connection to the palmar arch was present in 87% of scissors and clips patients compared to only 37% of harmonic patients. This difference disappeared at 12 months.
Georgios Georghiou [4] harvested 100 radial arteries, randomizing to either harmonic scalpel with curved coagulating shears, or electrocautery scissors and clips. He took an average of 37 min with electrocautery compared to only 20 min with the harmonic scalpel. In addition, he reported a 20% spasm rate on inspection with the former technique but none in the harmonic group and larger internal vessel diameter and lower complications with the harmonic scalpel. No statistical tests were performed to assess the significance of the results and no assessment of graft flow after anastomosis were performed.
Moon et al. [5] contacted 602 patients by phone or post who had had their radial artery harvested with either a standard technique or using a harmonic scalpel. They found no differences in neurological or all types of complication between the two groups, although 9% of patients in both groups suffered long term neurological complications in terms of weakness or numbness.
Andreas Rukosujew [6] harvested 40 radial arteries in four combinations of scissors and clips versus harmonic scalpel and pedicle and skeletonized techniques. There was no difference in the time taken to harvest the radial artery or the Doppler flow of the anastomosed vessels. He also performed electron microscopy of samples of the radial artery. The lowest level of damage was found in pedicled arteries using the harmonic scalpel, but skeletonizing with the harmonic was associated with a high level of damage.
Mustafa Cikirikcioglu [7] took the discarded ends of 14 radial arteries that were harvested using either the scissors and clips technique or the harmonic scalpel method. They were then placed in an organ bath and subjected to a series of vasoconstrictors and vasodilators. There were no significant differences found. The samples were also examined by electron microscopy and no differences were found.
Wright et al. [8] randomized 51 patients to harmonic scalpel or ‘cold-steel’ scalpel techniques. There was no difference in the time taken to harvest the vessel, the quality of the graft or the need for repeat angiography at 3 months.
Bhan et al. [9] used the harmonic scalpel to harvest all arterial conduits including the LIMA in 80 patients, and compared this to a retrospective cohort. They could not assess the speed of harvest but found that 7 patients had hand-numbness with electrocautery, compared to none in the harmonic group.
Ronan et al. [10] presented a study that was most in favor of the harmonic scalpel. It was a non-randomized study that compared the harvesting of 21 radials using electrocautery with 41 patients with the harmonic scalpel. While the harvest time was no different, there was a doubling in the in-situ free flow, a near doubling in the free flow after proximal anastomosis and an increase in the free flow after papaverine.
Posacioglu et al. [11] harvested 10 radial arteries using electrocautery and compared this technique to 10 patients who had harvesting with the harmonic scalpel. They found that harvesting took an average of 36 min compared to 20 min with the harmonic scalpel, and 2 patients in the standard group suffered arterial spasm. No statistical tests were used in this paper.
In summary: of 5 studies reporting time to harvest, three report no difference and two report that the harmonic scalpel is quicker. Six studies reported the marked reduction in the number of clips used with the harmonic scalpel. Two papers reported a small benefit in reducing spasm. Two studies looked at the artery electron microscopically but no significant differences were seen. Two studies reported less numbness and two studies no difference in numbness post-operatively. Three studies looked at the results angiographically or by flow assessment, one study showed no difference, one study reported harmonic superiority, and one study reported that scissors and clips were superior. All studies were small and either used a single surgeon or a very small number of surgeons to harvest the radial artery. Highly subjective outcome measures to assess numbness and spasm were employed, together with poor or absent blinding of assessors.
7. Clinical bottom line
From 10 identified studies, 2/5 studies report faster harvesting, 6 studies report reduced requirement for surgical clips, 2 papers report less spasm, 2/4 studies reported less numbness, and 2 studies reported no microscopic differences. Three studies looked at angiography or flow, with one equivocal, one in favor of harmonic and one in favor of scissors and clips. We conclude that there is little convincing evidence in the literature to guide the decision to use a harmonic scalpel over electrocautery for radial artery harvest.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003; 2:405–409.
Isomura T, Suma H, Sato T, Horii T. Use of Harmonic Scalpel for harvesting arterial conduits in coronary artery bypass. Euro J Cardiothoracic Surg 1998; 14:101–103.
Hata M, Shiono M, Sezai A, Iida M, Saitoh A, Hattori T, Wakui S, Soeda M, Negishi N, Sezai Y. Determining the best procedure for radial artery harvest: prospective randomized trial for early postharvest complications. J Thorac Cardiovasc Surg 2005; 129:4885–889.
Georghiou GP, Stamler A, Berman M, Sharoni E, Vidne BA, Sahar G. Advantages of the ultrasonic harmonic scalpel for radial artery harvesting. Asian Cardiovasc & Thorac Ann 2005; 13:158–60.
Moon MR, Barner HB, Bailey MS, Lawton JS, Moazami N, Pasque MK, Damiano RJ Jr. Long-term neurologic hand complications after radial artery harvesting using conventional cold and harmonic scalpel techniques. Ann Thorac Surg 2004; 78:2535–538.
Rukosujew A, Reichelt R, Fabricius AM, Drees G, Tjan TD, Rothenburger M, Hoffmeier A, Scheld HH, Schmid C. Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel. Ann Thorac Surg 2004; 77:1120–125.
Cikirikcioglu M, Yasa M, Kerry Z, Posacioglu H, Boga M, Yagdi T, Topcuoglu N, Buket S, Hamulu A. 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; 122:3624–626.
Wright CB, Barner HB, Gao A, Obial R, Bandy B, Perry L, Ronan J, Kelly CR. The advantages of the Harmonic Scalpel for the harvesting of radial arteries for coronary artery bypass. Heart Surg Forum 2001; 4:3226–229.
Bhan A, Choudhary SK, Saikia M, Sharma R, Venugopal P. Harmonic Scalpel: initial experience. Asian Cardiovasc & Thorac Ann 2001; 9:3–6.
Ronan JW, Perry LA, Barner HB, Sundt TM III. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000; 69:1113–114.
Psacioglu H, Atay Y, Cetindag B, Saribulbul O, Buket S, Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998; 65:4984–985.(Anish Patel, Sanjay Asopa)
b Department of Cardiothoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether radial arterial harvest with a harmonic scalpel produced a lower incidence of complications or was superior to conventional harvest with the diathermy or scissors and clip techniques. Two hundred and forty-seven papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses were tabulated. We identified 10 studies, 2/5 studies report faster harvesting with the harmonic scalpel, 6 studies report reduced requirement for surgical clips, 2 papers report less spasm, 2/4 studies reported less numbness, and 2 studies reported no electron microscopic differences. Three studies looked at angiography or flow, with one equivocal, one in favour of harmonic and one in favour of scissors and clips. We conclude that there is little convincing evidence in the literature to guide the decision to use a harmonic scalpel over electrocautery for radial artery harvest.
Key Words: Thoracic surgery; Harmonic scalpel; Radial artery; Coronary arterial bypass graft
1. Introduction
A best evidence topic was constructed according to the structured protocol. This protocol is fully described in the ICVTS [1].
2. Clinical scenario
You have been approached by a representative of a company who is promoting their harmonic scalpel. They tell you that their scalpel is quicker and safer than the diathermy technique and that it causes less arterial spasm. The representative gives you several brochures to back this up with some references in small type at the bottom of the page. You are keen to try this ultrasonic scalpel but you discover that it is more expensive than your usual technique so you decide to look up the clinical evidence for a benefit for harmonic scalpels before committing to a trial of this new device.
3. Three-part question
In [patients undergoing radial artery harvest for CABG] is the [harmonic scalpel] superior to standard harvesting techniques in terms of [reducing complications].
4. Search strategy
Medline 1990 to Oct 2005 using the OVID interface. [exp radial artery/ OR radial.mp] AND [Harmonic.mp OR ultrasonic$.mp] Humans (Limit).
5. Search outcome
Using the above search 247 papers were identified of which 10 represented the best evidence to answer the question (Table 1).
6. Discussion
Radial artery harvest using the harmonic scalpel is a relatively new technique, with the first reports appearing in 1998 [2]. We found 5 randomized studies and 5 cohort studies or series that assessed its benefit against electrocautery, scissors and clips.
Mitsumasa Hata [3] harvested 90 radial arteries, randomizing to either electrocautery, harmonic scalpel or scissors and clips techniques. He found that 30% of harmonic patients reported hand numbness compared to none of the scissors and clip patients. In addition he performed angiography at 1 and 12 months and interosseous artery recovery and connection to the palmar arch was present in 87% of scissors and clips patients compared to only 37% of harmonic patients. This difference disappeared at 12 months.
Georgios Georghiou [4] harvested 100 radial arteries, randomizing to either harmonic scalpel with curved coagulating shears, or electrocautery scissors and clips. He took an average of 37 min with electrocautery compared to only 20 min with the harmonic scalpel. In addition, he reported a 20% spasm rate on inspection with the former technique but none in the harmonic group and larger internal vessel diameter and lower complications with the harmonic scalpel. No statistical tests were performed to assess the significance of the results and no assessment of graft flow after anastomosis were performed.
Moon et al. [5] contacted 602 patients by phone or post who had had their radial artery harvested with either a standard technique or using a harmonic scalpel. They found no differences in neurological or all types of complication between the two groups, although 9% of patients in both groups suffered long term neurological complications in terms of weakness or numbness.
Andreas Rukosujew [6] harvested 40 radial arteries in four combinations of scissors and clips versus harmonic scalpel and pedicle and skeletonized techniques. There was no difference in the time taken to harvest the radial artery or the Doppler flow of the anastomosed vessels. He also performed electron microscopy of samples of the radial artery. The lowest level of damage was found in pedicled arteries using the harmonic scalpel, but skeletonizing with the harmonic was associated with a high level of damage.
Mustafa Cikirikcioglu [7] took the discarded ends of 14 radial arteries that were harvested using either the scissors and clips technique or the harmonic scalpel method. They were then placed in an organ bath and subjected to a series of vasoconstrictors and vasodilators. There were no significant differences found. The samples were also examined by electron microscopy and no differences were found.
Wright et al. [8] randomized 51 patients to harmonic scalpel or ‘cold-steel’ scalpel techniques. There was no difference in the time taken to harvest the vessel, the quality of the graft or the need for repeat angiography at 3 months.
Bhan et al. [9] used the harmonic scalpel to harvest all arterial conduits including the LIMA in 80 patients, and compared this to a retrospective cohort. They could not assess the speed of harvest but found that 7 patients had hand-numbness with electrocautery, compared to none in the harmonic group.
Ronan et al. [10] presented a study that was most in favor of the harmonic scalpel. It was a non-randomized study that compared the harvesting of 21 radials using electrocautery with 41 patients with the harmonic scalpel. While the harvest time was no different, there was a doubling in the in-situ free flow, a near doubling in the free flow after proximal anastomosis and an increase in the free flow after papaverine.
Posacioglu et al. [11] harvested 10 radial arteries using electrocautery and compared this technique to 10 patients who had harvesting with the harmonic scalpel. They found that harvesting took an average of 36 min compared to 20 min with the harmonic scalpel, and 2 patients in the standard group suffered arterial spasm. No statistical tests were used in this paper.
In summary: of 5 studies reporting time to harvest, three report no difference and two report that the harmonic scalpel is quicker. Six studies reported the marked reduction in the number of clips used with the harmonic scalpel. Two papers reported a small benefit in reducing spasm. Two studies looked at the artery electron microscopically but no significant differences were seen. Two studies reported less numbness and two studies no difference in numbness post-operatively. Three studies looked at the results angiographically or by flow assessment, one study showed no difference, one study reported harmonic superiority, and one study reported that scissors and clips were superior. All studies were small and either used a single surgeon or a very small number of surgeons to harvest the radial artery. Highly subjective outcome measures to assess numbness and spasm were employed, together with poor or absent blinding of assessors.
7. Clinical bottom line
From 10 identified studies, 2/5 studies report faster harvesting, 6 studies report reduced requirement for surgical clips, 2 papers report less spasm, 2/4 studies reported less numbness, and 2 studies reported no microscopic differences. Three studies looked at angiography or flow, with one equivocal, one in favor of harmonic and one in favor of scissors and clips. We conclude that there is little convincing evidence in the literature to guide the decision to use a harmonic scalpel over electrocautery for radial artery harvest.
References
Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003; 2:405–409.
Isomura T, Suma H, Sato T, Horii T. Use of Harmonic Scalpel for harvesting arterial conduits in coronary artery bypass. Euro J Cardiothoracic Surg 1998; 14:101–103.
Hata M, Shiono M, Sezai A, Iida M, Saitoh A, Hattori T, Wakui S, Soeda M, Negishi N, Sezai Y. Determining the best procedure for radial artery harvest: prospective randomized trial for early postharvest complications. J Thorac Cardiovasc Surg 2005; 129:4885–889.
Georghiou GP, Stamler A, Berman M, Sharoni E, Vidne BA, Sahar G. Advantages of the ultrasonic harmonic scalpel for radial artery harvesting. Asian Cardiovasc & Thorac Ann 2005; 13:158–60.
Moon MR, Barner HB, Bailey MS, Lawton JS, Moazami N, Pasque MK, Damiano RJ Jr. Long-term neurologic hand complications after radial artery harvesting using conventional cold and harmonic scalpel techniques. Ann Thorac Surg 2004; 78:2535–538.
Rukosujew A, Reichelt R, Fabricius AM, Drees G, Tjan TD, Rothenburger M, Hoffmeier A, Scheld HH, Schmid C. Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel. Ann Thorac Surg 2004; 77:1120–125.
Cikirikcioglu M, Yasa M, Kerry Z, Posacioglu H, Boga M, Yagdi T, Topcuoglu N, Buket S, Hamulu A. 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; 122:3624–626.
Wright CB, Barner HB, Gao A, Obial R, Bandy B, Perry L, Ronan J, Kelly CR. The advantages of the Harmonic Scalpel for the harvesting of radial arteries for coronary artery bypass. Heart Surg Forum 2001; 4:3226–229.
Bhan A, Choudhary SK, Saikia M, Sharma R, Venugopal P. Harmonic Scalpel: initial experience. Asian Cardiovasc & Thorac Ann 2001; 9:3–6.
Ronan JW, Perry LA, Barner HB, Sundt TM III. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000; 69:1113–114.
Psacioglu H, Atay Y, Cetindag B, Saribulbul O, Buket S, Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998; 65:4984–985.(Anish Patel, Sanjay Asopa)