Minimally Invasive ITA Harvesting Using a Harmonic Hook Blade

This video shows internal thoracic artery (ITA) harvesting in a skeletal technique through left anterior thoracotomy access using an harmonic synergy combination hook blade. The use of the harmonic synergy hook blade has become very popular recently for the preparation of ITA after sternotomy, demonstrating a short learning curve for surgeons and very quick harvesting.

After performing the thoracotomy and positioning the retractor, the first step is to open the thoracic fascia lateral to the internal thoracic artery. The thoracic fascia can be easily opened using the blunt outer radius of the instrument, exposing internal thoracic artery. The instrument tip acts as a coaptive coagulator by converting ultrasonic waves into mechanical energy. The mechanical energy of the instrument enables the denaturation of proteins into a hemostatic clot capable of healing small vessels. The instrument is also equipped with an inner radius with a sharp hook for cutting, which is useful to separate vascular branches. On the instrument there are two buttons for coagulation, one of which is adjustable from one to five, while the other expresses the maximum power of the instrument. For ITA harvesting, a level of three out five is advisable, since it is enough for the preparation of whole arterial branches.

After opening the fascia, as can be seen in the accompanying video, proceed to detach the lower adventitial tissue to release the ITA and mobilize it.

The internal thoracic artery is widely defined as graft of choice for the left anterior descending coronary artery. Furthermore, its use as an “in situ” graft is valid in all different surgical approaches—on pump, off pump, or minimally invasive. Therefore, preserving the integrity of ITA during preparation is the main prerequisite for successful surgery. Its preparation requires precision and care, especially in the small surgical access for a left anterior thoracotomy, characterized by its limited visibility. Therefore, the possibility of using a single instrument and avoiding the use of metal clips to drop arterial branches is of considerable advantage.

In the case of bleeding from an arterial branch, once the mammary artery has been secured, it is possible to coagulate using the full power button to achieve hemostasis. In the case of a branch with larger caliber, a metal clip can be applied proximal to the internal thoracic artery to minimize the risk of bleeding in the case of partial coagulation. As can be seen in this case, the vessel can be fully coagulated with the hook blade.

A further advantage of the synergy blade system is that it coagulates at a lower temperature than the classic coagulator—around a temperature of 80°C, in contrast to the approximately 300°C of the classic electrocauter. As can be seen in the accompanying video, the division of the artery from the vein allows coagulation very close to the venous vessel without damaging it.

Lastly, two metal clips can be used as usual to divide the internal thoracic artery.

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