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

BackgroundElectrosurgery 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.MethodsIn 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.ResultsHistological 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%.ConclusionHistologically, 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 registrationNCT03510026, registered 4th April 2018 (retrospectively registered).

PlasmaBlade-assisted surgical septal myectomy: technique and our experience

“…The use of the PlasmaBlade in cardiac surgery is very limited. A recent study published on PlasmaBlade-assisted internal mammary artery harvesting showed non-inferiority of the PlasmaBlade compared to conventional electrocautery when considering the 6-month patency of the internal mammary arteries ( 7 ). Another recently published trial on the safety of using the PlasmaBlade for pocket preparation for ICD device insertion or generator change in patients on anticoagulation has shown significantly reduced adverse events compared to standard electrocautery.…”

“…Plasma is an electrically conductive cloud created when the energy contacts tissue. The “plasma” allows the radiofrequency energy to cross the tissue at a much lower overall power level, resulting in lower operating temperatures and less thermal damage ( 7 ). The PlasmaBlade operates at 40–100°C, while the blade tip stays near body temperature.…”

“…Therefore, underlying tissue damage is limited. Studies reporting the use of the PlasmaBlade during internal mammary artery harvesting or ocular surgeries have found the area of collateral damage to be only 2–10 μm with the PlasmaBlade compared to 100–400 μm with electrosurgery ( 7 , 8 ).…”

Comparative healing of swine skin following incisions with different surgical devices

“…The PB is a relatively new electrosurgical technology developed to achieve cutting and coagulation effects with a relatively low operating temperature, which reduces thermal damage (6,25). It applies high-frequency RF pulses to generate electrical plasma along the edge of the electrode (26).…”

Impact of target coronary artery stenosis severity measured by instantaneous wave-free ratio on to bypassed graft patency

“…The internal mammary artery endothelium possesses a number of properties that make it resistant to the development of atherosclerosis [25]. Current data recommend skeletonised internal mammary artery harvesting for revascularisation, with low thermal damage providing an improved endothelial layer and better integrity of the vessel wall [26]. IMA graft failure most commonly results from damage during mobilisation or harvesting, spasm, inflammation or suboptimal target vessel anastomosis [22].…”