Randomized comparison of HARVesting the Left Internal Thoracic Artery in a skeletonized versus pedicled technique: the HARVITA trial-study protocol

Latest research has indicated a potential adverse effect on graft patency rates and clinical outcomes with skeletonizing the left internal thoracic artery. We aim to provide a prospective, randomized, multicentre trial to compare skeletonized versus pedicled harvesting technique of left internal thoracic artery concerning graft patency rates and patient survival. A total of 1350 patients will be randomized to either skeletonized or pedicled harvesting technique and undergo surgical revascularization. Follow-up will be performed at 30 days, 1 year, 2 years and 5 years after surgery. The primary outcome will be death or left internal thoracic artery graft occlusion in coronary computed tomography angiography or invasive angiography within 2 years (+/- 3 months) after surgery. The secondary outcome will be major adverse cardiac events (composite outcome of all-cause death, myocardial infarction and repeated revascularization) within 1 year, 2 years and 5 years after surgery. The primary end point will be compared in the modified intention-to-treat population between the two treatment groups using Kaplan-Meier graphs, together with log-rank testing. Hereby, we present the study protocol of the first adequately powered prospective, randomized, multicentre trial which compares skeletonized and pedicled harvesting technique of left internal thoracic artery regarding graft patency rates and patient survival.

Clipless skeletonized internal mammary artery harvesting with harmonic technology

Since the introduction of the mammary artery harvesting procedure, electrocautery has been used as a standard method of care. However, mammary artery spasm, subadventitial haematoma and mammary artery damage due to clips dispositioning or high thermal energy injury have been recorded. To achieve a perfect mammary artery graft, we propose the usage of a high-frequency ultrasound device, usually recognized as a harmonic scalpel. It reduces thermal-related injuries, the use of clips and the risk of mammary artery spasm and/or dissection.

The radial artery: Open harvesting technique

The radial artery is an important conduit in coronary artery surgical revascularization due to its robust long-term clinical outcomes. The use of the radial artery has become popularized in recent times. Therefore it is essential for junior surgeons to master harvest techniques that are safe, reliable, and easy to replicate.

In patients undergoing coronary artery bypass grafting is semi-skeletonization superior to pedicled harvesting of the left internal mammary artery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, 'in patients undergoing coronary artery bypass grafting is semi-skeletonized harvesting superior to pedicled harvesting of the left internal mammary artery (LIMA) in terms of conduit length, flow, rate of sternal wound infections and post-operative bleeding?'. Altogether, 235 papers were found using the reported search, of which 5 represented the best evidence to answer the clinical question. Three studies were cohort studies and 2 were randomized controlled trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. One randomized controlled trial showed superiority with semi-skeletonized harvesting in terms of conduit length (P < 0.001), flow (P = 0.004) and diastolic filling (P = 0.005). Three studies included data on surgical wound infections/mediastinitis, all of which reported n = 0. One randomized controlled trial and 3 cohort studies reported that semi-skeletonized harvesting reduced postoperative bleeding. No studies reported a statistically significant difference in operative time. This review suggests that semi-skeletonized harvesting could possibly be associated with favourable outcomes when compared to pedicled harvesting with respect to graft length and flow, and lower postoperative bleeding, without increasing operative time; although there is insufficient data to compare sternal wound infections or long-term outcomes. In conclusion, the limited evidence base prevents robust informed decision-making when comparing both techniques.

Novel harvesting technique of no-touch saphenous vein graft using THUNDERBEAT

The no-touch technique of saphenous vein involves harvesting the vein as a pedicled graft and avoidance of direct contact with the vein or excessive high-pressure expansion. This technique provides long-term graft patency as that of internal mammary artery; however, the wound complications could be greater than conventional skeletonized technique. To solve the problem of leg wound trouble and to harvest the vein simpler, we have developed a novel harvesting technique using a newly developed energy device, THUNDERBEAT. This technique has the ability of efficacious tissue dissection, safer sealing of branches, and less wound complications without thermal damage to the graft. This strategy was successfully used in 35 patients.