Upload
dr-ashish-gaur
View
503
Download
1
Tags:
Embed Size (px)
Citation preview
Minimally Invasive Minimally Invasive Radial Artery HarvestRadial Artery Harvest
Ashish GaurAshish GaurB.S (BITS),M.D (AM), PG. Dip PPHCB.S (BITS),M.D (AM), PG. Dip PPHC
Senior Surgical Assistant Senior Surgical Assistant Kokilaben Dhirubhai Ambani hospitalKokilaben Dhirubhai Ambani hospital
MumbaiMumbai
History Of Radial Artery As History Of Radial Artery As ConduitConduit
Professor Alain Carpentier is credited with introducing the radial Professor Alain Carpentier is credited with introducing the radial artery (RA) as an alternative conduit for CABG.artery (RA) as an alternative conduit for CABG.
Initial results with the RA were unfavorable, leading Carpentier Initial results with the RA were unfavorable, leading Carpentier and others to abandon its use.and others to abandon its use.
Subsequently, several RA grafts were empirically observed to be Subsequently, several RA grafts were empirically observed to be patent at follow-up coronary angiography, leading to the concept’s patent at follow-up coronary angiography, leading to the concept’s reintroduction in the late 1980s .reintroduction in the late 1980s .
Radial Artery Versus Saphenous Vein Patency (RSVP) trial Radial Artery Versus Saphenous Vein Patency (RSVP) trial compared 5-year graft patency for RA versus SVG when placed to compared 5-year graft patency for RA versus SVG when placed to circumflex coronary artery branches that were at least 70% circumflex coronary artery branches that were at least 70% stenotic .These data demonstrated a significantly improved stenotic .These data demonstrated a significantly improved patency for RA grafts (98.3%) relative to SVG grafts (86.4%) .patency for RA grafts (98.3%) relative to SVG grafts (86.4%) .
So Why Was Radial Artery So Why Was Radial Artery AbandonedAbandoned
The occlusion was most likely caused by trauma to the vessel associated The occlusion was most likely caused by trauma to the vessel associated with harvesting techniques, such as mechanical dilation with metal with harvesting techniques, such as mechanical dilation with metal dilators, and forced hydrostatic dilation. dilators, and forced hydrostatic dilation.
Harvesting Tech---Too Much handling.Harvesting Tech---Too Much handling.
Spasms.Spasms.
Surgical AnatomySurgical Anatomy
Criteria To Use Criteria To Use >70% Block in coronary artery.>70% Block in coronary artery.
Arterial conduit.Arterial conduit.
Negative Allen's TestNegative Allen's Test
Negative Modified Allen Test.Negative Modified Allen Test.
No structural deformity.No structural deformity.
Multiple GraftsMultiple Grafts
Non Dominant hand.Non Dominant hand.
No arterial line.No arterial line.
Allen”s TestAllen”s Test
Compression over radial.Compression over radial.
MAT vs DopplerMAT vs Doppler Visualization of saturation trace over monitor over compressed radial Visualization of saturation trace over monitor over compressed radial
artery.artery.
When MAT was compared with Doppler ultrasonography of the thumb When MAT was compared with Doppler ultrasonography of the thumb artery, MAT was noted to have a sensitivity of 100% and specificity of 97% artery, MAT was noted to have a sensitivity of 100% and specificity of 97% for thumb ischemia.for thumb ischemia.
Ruengsakulrach P, Brooks M, Hare D, Gordon I, Buxton B. Ruengsakulrach P, Brooks M, Hare D, Gordon I, Buxton B. Preoperative assessment of hand circulation by means of Doppler Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen’s test. J Thorac ultrasonography and the modified Allen’s test. J Thorac
Cardiovascular Surge 2001; 121: 526-31Cardiovascular Surge 2001; 121: 526-31..
TechniqueTechnique Incision parallels the medial edge of the brachioradialis muscle .Incision parallels the medial edge of the brachioradialis muscle . Skin and subcutaneous tissue are incised down to the fascia overlying Skin and subcutaneous tissue are incised down to the fascia overlying
the flexor Carpi radialis muscle .the flexor Carpi radialis muscle . Fascial sheath that overlies the superficial muscles of the volar Fascial sheath that overlies the superficial muscles of the volar
forearm is divided between the brachioradialis muscle and the flexor forearm is divided between the brachioradialis muscle and the flexor Carpi radialis. Carpi radialis.
The lateral cutaneous nerve of the forearm usually overlies the The lateral cutaneous nerve of the forearm usually overlies the brachioradialis in the same plane as the fascial sheath. Care is taken brachioradialis in the same plane as the fascial sheath. Care is taken to prevent injury to this nerve: this is accomplished by displacing it to prevent injury to this nerve: this is accomplished by displacing it laterally .laterally .
Careful retraction of the brachioradialis and flexor Carpi radialis Careful retraction of the brachioradialis and flexor Carpi radialis muscles, 1st laterally and then medially, is performed with a self-muscles, 1st laterally and then medially, is performed with a self-retaining retractor retaining retractor
This maneuver reveals the entire course of the radial artery from the This maneuver reveals the entire course of the radial artery from the biceps tendon to the radial styloid .biceps tendon to the radial styloid .
The radial artery pedicle is gently mobilized to lift it from its muscular The radial artery pedicle is gently mobilized to lift it from its muscular bed. As the pedicle is lifted, the side branches of the radial artery are bed. As the pedicle is lifted, the side branches of the radial artery are exposed. Careful, gentle, and progressively upward traction of the exposed. Careful, gentle, and progressively upward traction of the pedicle is performed. The side branches are then isolated and either pedicle is performed. The side branches are then isolated and either clipped or ligated with the harmonic scalpelclipped or ligated with the harmonic scalpel..
Minimally InvasiveMinimally Invasive Small CutsSmall Cuts
2 cms each2 cms each
Bridge in middle.Bridge in middle.
Minimal Diathermy (setting 15 Coag)Minimal Diathermy (setting 15 Coag)
Use Scissors. (For dissection).Use Scissors. (For dissection).
Warm Papaverine Spray and warm papaverine dipped gauze.Warm Papaverine Spray and warm papaverine dipped gauze.
Minimal handelling.Minimal handelling.
DissectionDissection
ClosureClosure Good Homeostasis.Good Homeostasis.
Washing with normal saline.Washing with normal saline.
Undyed number 1 vicrylUndyed number 1 vicryl
Drain –Romovac.Drain –Romovac.
MonocrylMonocryl
Crape Bandage for 4 days Crape Bandage for 4 days
InstrumentationInstrumentation Long tip Diathermy,Long tip Diathermy,
Roller under mid arm.Roller under mid arm.
Light.Light.
Retractor -- Cats Paw and Mastoid.Retractor -- Cats Paw and Mastoid.
Surgical Loupes.Surgical Loupes.
Spasm-Is that a worry?Spasm-Is that a worry? Initial Reason for abandoning radial artery was spasm related to handling and Initial Reason for abandoning radial artery was spasm related to handling and
dilatation.dilatation.
Vasoconstriction related to adventitia over radial artery.Vasoconstriction related to adventitia over radial artery.
This tendency to spasm, occurring in 5 to 10% of the patients, has been correlated This tendency to spasm, occurring in 5 to 10% of the patients, has been correlated to a significant proportion of early RA graft failures. It is generally accepted that the to a significant proportion of early RA graft failures. It is generally accepted that the adventitia provides structural support to the vessel. Although, in the last decade, adventitia provides structural support to the vessel. Although, in the last decade, several studies have indicated that the adventitia also has an active role in several studies have indicated that the adventitia also has an active role in vasomotor tone. vasomotor tone.
Limb arteries such as the RA are known to be more prone to spasm than somatic Limb arteries such as the RA are known to be more prone to spasm than somatic (IMA) or splanchnic arteries .(IMA) or splanchnic arteries .
Vasodilatation of the harvested RA should begin intraoperatively by exposing the Vasodilatation of the harvested RA should begin intraoperatively by exposing the conduit to papaverine or verapamil /nitroglycerin.conduit to papaverine or verapamil /nitroglycerin.
Strictly Strictly NO DILATATION.NO DILATATION.
Spasm intraopeartively-Can cause graft failure, slow flow and hemodynamic Spasm intraopeartively-Can cause graft failure, slow flow and hemodynamic instability.instability.
Post Op-String sign in angio.Post Op-String sign in angio.
Spasm-How to deal?Spasm-How to deal? Adventitial Dissection of the Radial Artery Graft:Adventitial Dissection of the Radial Artery Graft:
The adventitial dissected RA is less susceptible to vasoconstriction and The adventitial dissected RA is less susceptible to vasoconstriction and more prone to vasorelaxation more prone to vasorelaxation ex vivoex vivo. Therefore, we recommend to . Therefore, we recommend to perform adventitial dissection of the RA graft to reduce vasospasm for perform adventitial dissection of the RA graft to reduce vasospasm for arterial revascularization in CABG arterial revascularization in CABG ..
Minimal Handling.Minimal Handling.
Warm papaverine spray.Warm papaverine spray.
DissectionDissection
Endoscopic Endoscopic Latest Trend in India.Latest Trend in India. Successful,aesthetic,cosmetic.Successful,aesthetic,cosmetic. Needs TrainingNeeds Training CostCost
Patency rates are similar regardless of method of Patency rates are similar regardless of method of
harvestingharvesting Bleiziffer S, Hettich I, Eisenhauer B, et al. Patency rates of Bleiziffer S, Hettich I, Eisenhauer B, et al. Patency rates of
endoscopically harvested radial arteries one year after coronary endoscopically harvested radial arteries one year after coronary artery bypass grafting. J Thorac Cardiovascular Surg 2007; 134: artery bypass grafting. J Thorac Cardiovascular Surg 2007; 134: 649-56649-56..
Should Graduate-First step is minimally invasive.Should Graduate-First step is minimally invasive.
Endoscopic Vs MinimalEndoscopic Vs Minimal Cost effective.Cost effective.
Better quality.Better quality.
Minimal Handling.Minimal Handling.
No instrumentation.No instrumentation.
Small cuts contract 6 months post op.Small cuts contract 6 months post op.
Practically no visible scar.Practically no visible scar.
Learning curveLearning curve Initially make 3 cuts. Initially make 3 cuts.
Dissect between 2 bridges.Dissect between 2 bridges.
Decrease length of those cuts and use long tip diathermy.Decrease length of those cuts and use long tip diathermy.
Graduate to 2 cuts with long incision.Graduate to 2 cuts with long incision.
Graduate to small incision.Graduate to small incision.
Can try horizontal 2 incisions (Very difficult).Can try horizontal 2 incisions (Very difficult).
Remember No surgery should be performed at the cost of Remember No surgery should be performed at the cost of the safety of conduitthe safety of conduit
ResultResult Harvested =Near about 2000 radialsHarvested =Near about 2000 radials
90% Arterial Conduits in our setup90% Arterial Conduits in our setup
OF 90%- 85 % Radial Artery.OF 90%- 85 % Radial Artery.
Infection=0%Infection=0%
Ecchymosis =1%.Ecchymosis =1%.
Resuturing =0%Resuturing =0%
Vasomotor Deficit=0%Vasomotor Deficit=0%
Vascular Injury=0%Vascular Injury=0%
Can be a Surgical assistant”s Can be a Surgical assistant”s forteforte
ThanksThanks