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• W1976245515 abstract "In coronary artery bypass grafting, the target arteries for grafting can be buried in thick adipose tissue or myocardium, and exposure may be difficult. We used an ultrasonic surgical aspirator to expose buried coronary arteries. Fat tissue or myocardium covering coronary arteries was removed, and target arteries were exposed with little bleeding. No arrhythmia or coronary spastic event occurred during its application, and bypass grafting could be completed. In postoperative angiography, no deformity or shrinkage of coronary arteries was observed at the sites at which the ultrasonic aspirator was applied. In coronary artery bypass grafting, the target arteries for grafting can be buried in thick adipose tissue or myocardium, and exposure may be difficult. We used an ultrasonic surgical aspirator to expose buried coronary arteries. Fat tissue or myocardium covering coronary arteries was removed, and target arteries were exposed with little bleeding. No arrhythmia or coronary spastic event occurred during its application, and bypass grafting could be completed. In postoperative angiography, no deformity or shrinkage of coronary arteries was observed at the sites at which the ultrasonic aspirator was applied. Coronary arteries buried in thick subepicardial fat tissue or supraarterial myocardial bridges are occasionally encountered in coronary artery bypass grafting (CABG). In such cases, locating or exposing coronary arteries may be difficult because of possible bleeding from the surrounding tissue and inadvertent coronary artery injuries. Among several techniques to locate [1Larsson S. Nilsson F. A method for surgical exposure of intramyocardial coronary arteries for bypass grafting.Scand J Thor Cardiovasc Surg. 1988; 22: 47-49Crossref PubMed Scopus (2) Google Scholar] and expose [2Parachuri R.V. Chattuparambil B. Hasabettu P.K. et al.Marsupialization of intramyocardial left anterior descending artery: a novel approach for easy access during revascularization.Ann Thorac Surg. 2005; 80: 2390-2392Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar] buried coronary arteries, the use of ultrasonic surgical aspirators was reported in 1985 [3Mitsui T. Onizuka M. Ijima H. et al.Ultrasonic aspiration in coronary artery surgery.Ann Thorac Surg. 1985; 40: 199-200Abstract Full Text PDF PubMed Scopus (5) Google Scholar]. This device is generally called CUSA (Cavitron Ultrasonic Surgical Aspirator; Tyco Healthcare, Mansfield, MA). Because reports about this device for coronary exploration are very scarce [4Ghosh P.K. Coronary ostial reconstruction: technical issues.Ann Thorac Surg. 1991; 51: 673-675Abstract Full Text PDF PubMed Scopus (14) Google Scholar], the usefulness and long-term results of the application of ultrasonic aspirators on coronary arteries has yet to be clarified. Here we describe our technique and experience. The Sumisonic ME 2400 (Sumitomo Bakelite, Ltd, Tokyo, Japan) was used as an ultrasonic surgical aspirator with functioning values of amplitude (60%), suction (10 cm Hg), and irrigation (10 mL/min). A test was performed on subcutaneous tissue. Functioning values were readjusted to remove only adipose tissue and leave small vessels intact. It was then applied to the surface of the heart after severing the thin epicardial membrane with a knife. In off-pump CABG, an ultrasonic surgical aspirator was applied to a beating heart immobilized by a vacuum-type mechanical stabilizer. Subepicardial fat tissue and supraarterial myocardial bridges were then aspirated and removed. Most veins were left uninjured and were then clipped or electrocauterized with a low coagulation output. The nodule tip of the aspirator was controlled to gently and precisely touch fat or myocardium without pushing down onto the heart (Fig 1). In exploration, the coronary artery could be identified through a thin adipose or myocardial layer over the artery before exposure of its adventitia. At this point of identification of the coronary artery, application of the ultrasonic aspirator was withheld and the remaining thin layer was removed with a small rounded scalpel. In some cases, deeply buried coronary arteries were located and exposed by application of the aspirator from the distal superficial part of the artery to the proximal deep portion along the artery. We used an ultrasonic surgical aspirator to expose buried coronary arteries that could not be identified by inspection or palpation. Since 1997 we have used this device in 25 patients (21 men, 4 women, age range of 62–84 years) with CABG (ie, about 12% of total CABG cases). A retrospective study of these cases was approved by the institutional review board at our institute. There were 6 cases of intramyocardial coronary arteries and 19 cases of arteries buried deep in subepicardial fat tissue. The branches to which ultrasonic aspiration was applied were the left anterior descending (LAD) artery in 20 cases, obtuse marginal branches in 6 cases, and right coronary arteries in 3 cases. Seven cases were on-pump CABG, and 18 cases were off-pump CABG. All coronary arteries were exposed with less bleeding, and bypass grafting could be conducted without arterial injury. Arrhythmias or coronary spastic episodes did not occur. The only complication was a small right ventricular perforation in a case of intramyocardial LAD dissection. The graft patency of ultrasonic surgical aspiration applied to coronary arteries was 96% in early postoperative coronary angiography performed in 22 cases. Graft occlusion occurred in a case of chronic total occlusion of the LAD with a fragile arterial wall probably caused by a technical problem in anastomosis unrelated to CUSA use. Early postoperative angiography showed no deformity in coronary arteries that underwent CUSA. In 6 patients, repeated coronary angiography was performed more than 3 years and up to 11 years after CAGB for follow-up of coronary artery disease or examination before other major operations. In these follow-up angiograms, no deformity or calcification was observed in the coronary arteries to which CUSA was applied (Fig 2). Ultrasonic surgical aspirators are used in cardiac procedures to remove the hard calcified plaques in valves or the aorta [5Baumgartner F.J. Pandya A. Omari B.O. et al.Ultrasonic debridement of mitral calcification.J Card Surg. 1997; 12: 240-242Crossref PubMed Scopus (19) Google Scholar, 6Takami Y. Tajima K. Terazawa S. Okada N. Fujii K. Sakai Y. Safer aortic crossclamping during short-term moderate hypothermic circulatory arrest for cardiac surgery in patients with a bad ascending aorta.J Thorac Cardiaovasc Surg. 2009; 137: 875-880Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar]. They can be modified to remove the soft tissue in the brain or liver [7Young W. Cohen A.R. Hunt C.D. Ransohoff J. Acute physiological effects of ultrasonic vibrations on nervous tissue.Nerurosurgery. 1981; 8: 689-694Crossref PubMed Scopus (47) Google Scholar, 8Farid H. O'Connell T. Hepatic resections: changing mortality and morbidity.Am Surg. 1994; 60: 748-752PubMed Google Scholar]. The nodule tip of the hand piece vibrates rapidly, thereby crushing soft tissues (eg, fat, muscle) and removes them by irrigation and aspiration through the nodule lumen. Bleeding from the dissected fat tissue or myocardial surface may make bypass grafting difficult in cases of buried coronary arteries, particularly in off-pump CABG. Ultrasonic surgical aspirators do not injure fibrous tissue, thereby leaving small vessels intact and facilitating dissection with less bleeding [8Farid H. O'Connell T. Hepatic resections: changing mortality and morbidity.Am Surg. 1994; 60: 748-752PubMed Google Scholar]. They appear useful for obtaining a less sanguineous grafting site because most small veins do not bleed and are clipped or electrocauterized. The effect of ultrasonic aspiration takes place only on the tissue in contact with the nodule tip. Since vertical excursion of the nodule tip in vibration is very small (about 150–355 µm), the crushing effect is very superficial [7Young W. Cohen A.R. Hunt C.D. Ransohoff J. Acute physiological effects of ultrasonic vibrations on nervous tissue.Nerurosurgery. 1981; 8: 689-694Crossref PubMed Scopus (47) Google Scholar]. Therefore injury to the coronary artery or spastic events are avoided if the nodule tip is applied precisely and then withheld at the point of identification of the artery through the thin adipose or myocardial layer over the artery. Although the use of ultrasonic aspirators for coronary exploration was reported more than 25 years ago [3Mitsui T. Onizuka M. Ijima H. et al.Ultrasonic aspiration in coronary artery surgery.Ann Thorac Surg. 1985; 40: 199-200Abstract Full Text PDF PubMed Scopus (5) Google Scholar], reports dealing with its clinical use are scarce [4Ghosh P.K. Coronary ostial reconstruction: technical issues.Ann Thorac Surg. 1991; 51: 673-675Abstract Full Text PDF PubMed Scopus (14) Google Scholar]. Its use for coronary exploration does not seem to have prevailed, probably because of fear of possible coronary damage or chronic deleterious effects on the coronary arteries to which it was applied. In our experience, however, injury to the coronary artery or spastic episodes were not encountered. Furthermore, deformity to indicate arteriosclerosis or calcification was not observed in the arteries to which CUSA was applied, even on repeated coronary angiograms years after the procedure. These results appear to indicate the usefulness and safety of ultrasonic surgical aspirators to expose buried coronary arteries in CABG. This study was supported in part by a grant-in-aid from the Osaka Foundation for the Prevention of Cancer and Cardiovascular Diseases ." @default.
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• W1976245515 title "Use of an Ultrasonic Surgical Aspirator to Expose Buried Coronary Arteries" @default.
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