Skeletonized internal thoracic artery harvesting using the Harmonic Focus ultrasonic scalpel

Introduction

In coronary artery bypass grafting, using an internal thoracic artery graft (ITA) is standard (1), and skeletonized ITA harvesting using an ultrasonic scalpel is common (2-5). In skeletonized ITA harvesting, the hook-type Harmonic Synergy^® (HS) blade (Ethicon Endo-Surgery, Inc., Cincinnati, OH, USA) is conventionally used (6). However, the supply of this HS blade became unstable for a period of time. During the period, another harvesting technique was necessary. Herein, we present a new skeletonized ITA harvesting technique using the Harmonic Focus^TM+ (HF) ultrasonic scalpel (Ethicon Endo-Surgery, Inc.). We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1316/rc).

Preoperative preparations and requirements

The HF has a shear tip comprising a tissue pad and blade. The HF is connected to the device’s generator, the energy level of the HF is set at 3 of low-energy level and at 5 of high-energy level, and the tone change mode is canceled. When harvesting the ITA, a foot switch is usually used.

All procedures performed in this study were in accordance with the Ethics Committee of Nara Medical University (certification No. 3862) and with the Helsinki Declaration and its subsequent amendments. Publication of this article and accompanying images and video was waived from patient consent owing to the use of retrospective, anonymized data.

Step-by-step description

The ITA harvesting technique is shown in Video 1. After positioning the retractor, harvesting begins from 4th intercostal space towards the subclavian artery. The ITA is visualized under the endothoracic fascia by cutting and removing the mediastinal fat tissue. The endothoracic fascia and transverse muscle are then cut using electrocautery at the medial side of the ITA, followed by blunt dissection between the artery and fascia using the HF. The HF tip is used in closed-shear mode for blunt dissection of surrounding fat tissue (Figure 1A), and the tip is moved quickly. After identification of the ITA trunk and its accompanying vein, dissection between the artery and vein is performed using the HF blade in open-shear mode (Figure 1B). The open-shear mode is useful for precise lesion dissection. The branches of the ITA can easily be cut and sealed with the HF shear-tip (Figure 1C). The endothoracic fascia is also cut using the HF. Where the main trunk of the ITA is easily detected and there is distance from the thoracic wall, we can simultaneously cut the surrounding tissue and seal the branches using the shear tip of the HF. In treating a short branch, the active blade is used like HS. The tip of the active blade is placed on the branch at least 1 mm from the ITA trunk. The branch is then coagulated and cut ultrasonically. After harvesting the proximal ITA, distal harvesting is performed to the distal end of the ITA, close to the diaphragm. Vascular clips are rarely used in this harvesting procedure.

Figure 1 How to use the tip of the HF. (A) Closed-shear mode; (B) open-shear mode; (C) cutting and sealing the vessel branch. *, vessel branch. HF, Harmonic Focus^TM+.

Postoperative considerations and tasks

Thirty-one patients who underwent coronary artery bypass in our institute received an ITA graft harvested using the HF. The mean age was 70.8±10.8 (± standard deviation) years old, and 23 patients were male. In 4 patients, concomitant valve surgery was performed. In these patients, 31 left ITAs and two right ITAs were harvested. All ITAs’ harvests were performed by the first author. All ITAs were used as vascular grafts without injury, and no cases required a change to another harvesting technique. Each harvesting time is shown in Figure 2. After the harvesting technique was established, the harvesting time was 15–30 minutes except for the patients whose ITA was partially buried in bone or cartilage. The mean flow of ITA grafts after revascularization was 45.3±22.1 (mean ± standard deviation) mL/minute. There were no complications related to this harvesting technique and no hospital deaths.

Figure 2 Changes in graft harvesting time.

Tips and pearls

The vessel branch can be sealed and cut by clamping the branch between the tissue pad and blade of the HF tip (Figure 1C), omitting vascular clips. When using close-shear mode, the tone change mode has to be canceled; otherwise, the oscillation of the blade stops in a short time. In harvesting ITA, a foot switch is recommended because a hand switch is difficult to use. Close-shear mode should be used for <5 seconds at a time to avoid tissue pad damage caused by friction with the active blade.

Discussion

Skeletonized ITA harvesting was suggested to be more effective than other harvesting techniques in preventing sternal wound infections by preserving sternal blood flow (2). Furthermore, compared with other techniques, skeletonized harvesting allows more distal anastomosis and sequential grafting (3). Harmonic scalpels have been proposed for skeletonized harvesting of the ITA (4). Harmonic scalpels are associated with low rates of thermal damage, easy dissection of surrounding tissue, and clipless branch cutting and sealing (5). Previously, the hook-type HS scalpel has been used for skeletonized harvesting, but the HS supply temporarily became unstable. As a result, we adopted a new skeletonized ITA harvesting technique using the HF. The HF is easier and more certain in clipless cutting and sealing branches than the HS. Furthermore, after the ITA trunk is detected and freed from the thoracic wall, the HF allows easy cutting and simultaneous coagulation of both branches and surrounding tissue, even if the branches are not precisely detected in the surrounding tissue. Jung et al. (7) have also reported acceptable results from using another type of shear-tip harmonic scalpel with a long shaft for harvesting the ITA when performing minimally invasive coronary artery bypass. We consider the HF to be as useful as the HS in ITA harvesting. In practice, most cardiac surgeons prefer an HS and are more familiar with using this device. Furthermore, harvesting time using HF is longer and more costly. However, the HF is a good alternative for performing ITA harvesting when other devices are unavailable.

Although supply of the hook-type Harmonic scalpel has recovered, a lack of harvesting devices may occur in the future. Several options of the ITA harvesting technique should be prepared for such situations. We believe the harvesting technique presented here can be a useful option.

Conclusions

A skeletonized ITA can be harvested easily and safely using the HF ultrasonic scalpel.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1316/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1316/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1316/coif). M.H. received speakers fee for educational event from Johnson and Johnson K.K. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Ethics Committee of Nara Medical University (certification number: 3862) and with the Helsinki Declaration and its subsequent amendments. Publication of this article and accompanying images and video was waived from patient consent was waived owing to the use of retrospective, anonymized data.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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