Endoscopic harvest of the radial artery

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In the endoscopic removal of the radial artery (forearm artery), short ERAH (derived from endoscopic radial artery harvesting), is minimally invasive method of obtaining replacement vessels in the coronary bypass -Surgeries.

With over 70,000 operations per year in Germany, bypass operations are routine operations and are the most common operations on the heart. The blood flow to the heart muscle is restored by creating a bypass circuit to bridge a narrow point (stenosis) in the coronary arteries. As a rule, the radial artery (radial artery), the internal mammaria artery (chest wall artery) or the great saphenous vein (leg vein) are used as bypass vessels.

A conventional method of graft extraction is the open removal of the vessels. This requires an incision of about 25 cm in order to gain either the great saphenous vein in the leg or the radial artery in the arm with scissors and clipping instruments. See also coronary artery bypass . This not only results in a long, unsightly scar and postoperative restriction of movement, but above all the risk of sensitivity and wound healing disorders (19% and 4% when using the radial artery and 61% and 20–30% when using the Great saphenous vein). The likelihood of wound healing disorders is particularly increased in patients with diabetes mellitus .

Minimally invasive surgery can reduce the risk of the above complications. For example, only an incision of approx. 2-3 cm at the level of the wrist is required to remove the radial artery . In order to free the artery from the surrounding tissue, either endoscopic clip applicators and scissors are used or, increasingly, thermofusion systems are used. In thermofusion procedures, the lateral vascular branches of the artery are sealed with heat.

Temperatures of around 60 ° C are sufficient for hemostasis using hyperthermia. As a rule, however, due to the function of the various thermofusion systems, temperatures of several hundred degrees are developed in the tissue, but this should be avoided when a vessel is removed. However, the temperature expansion in the tissue cannot always or with all techniques be controlled.

Current processes and technologies

The technologies used so far - bipolar current or ultrasound-operated forceps - require tissue to develop the appropriate heat. This means that the thermal expansion in tissue can hardly be controlled. This means that the fabric can heat up to over 50 ° C at a distance of up to 5 mm. Protein denatures at this temperature with the consequence that, for example, nerves in this area can be damaged.

A new type of technology is increasingly being used to seal and mobilize the vessels, the so-called "tissue welding" process. The results were presented at the Boston Congress of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS). This technique helps to avoid the otherwise inevitable thermal damage to the surrounding tissue and structures. The required heat is applied selectively to the tissue by a direct current operated heating element, so that the radiation in the tissue can be controlled.

The mode of action of the technologies used for thermofusion systems viewed in isolation


Bipolar HF technology:

With bipolar HF technology, a high-frequency electron current, driven by several thousand volts , flows through tissue that is compressed between forceps. Due to the frictional resistance of the flowing electrons with the electrons of the atoms in the cells, the cell fluid is heated and the collagenous structures fuse. Hemostasis is thus achieved. Then the tissue bridge is cut with scissors.

Example instrument: Ligasure from Covidien


Ultrasonic method:

The fabric is pressed between two branches , whereby one branch is immobile and the opposite moves back and forth across the fabric at a frequency of 55,000 Hz . The resulting frictional heat welds the collagen structures together. In addition, the movement supports the severing of the tissue (cutting).

Example product: Ultracision from Ethicon


Tissue welding technology:

The tissue is compressed between two grippers. A heating element operated with direct current is located in one of the grippers, which supplies the necessary heat to the tissue in a controlled manner. No heat is produced in the tissue itself. The collagen structures are fused and the tissue structure is interrupted by dehydration, i.e. cut. Water vapor is created. The moment the tissue is severed, no temperature is transferred to the surrounding tissue. Thus the expansion of the temperature can be controlled. In addition, the branches are equipped with a thermal insulation layer. Since the space available often does not allow a corresponding safety distance for a minimally invasive extraction of an artery or vein, the avoidance of heat radiation, as is the case with this new technology, makes the extraction much safer.

Example product: MiFusion (formerly Starion) from Microline

Web links

Individual evidence

  1. ↑ Coronary bypass surgery - uksh.de
  2. ↑ List, description and frequency of possible complications of the conventional, open method of harvesting the radial artery. From page 41 by Zirngast, Birgit: "The radial artery in coronary surgery". Dissertation, Medical University of Graz, October 2008
  3. ↑ Why wound healing is impaired in diabetes. Diabetes information service of the Helmholtz Center Munich, status October 18, 2016 (accessed June 26, 2018)
  4. ↑ Exemplary description of harvesting with clip applicator, however removal of the saphenous vein (same procedure as the radial artery). Gillrat, Guido: "Endoscopic harvesting of the great saphenous vein in coronary bypass surgery", dissertation at the Medical Faculty of the Ludwig Maximilians University of Munich, 2004 (PDF file)
  5. ↑ Endoscopic removal of the radial artery - dgch-onlinekongress.de  ( page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. (PDF file)@1@ 2Template: Toter Link / www.dgch-onlinekongress.de  
  6. ↑ Background information on hemostasis using hyperthermia (PDF file)
  7. ↑ Congress lecture "Minimal trauma radial artery harvesting using a new reusable endoscopic retractor and tissue welding technology"
  8. ↑ Background information on the technology ( Memento of the original from July 1, 2014 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF file) @1@ 2Template: Webachiv / IABot / www.klsmartin.com
  9. ↑ Manufacturer information Ligasure from Covidien
  10. ↑ Ultrasound method, see in "Surgical Cutting Techniques I" ( Memento of the original from April 2, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.  @1@ 2Template: Webachiv / IABot / www.uke.de
  11. ↑ Manufacturer information Ultracision from Ethicon
  12. ↑ Description of the function of Ultracision
  13. ↑ How Tissue Welding works ( Memento of the original from June 8, 2015 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. (PDF file)  @1@ 2Template: Webachiv / IABot / www.endotrust.de
  14. ↑ Manufacturer information MiFusion from Microline
  15. ↑ Product description in German ( Memento of the original from April 2, 2015 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice.  @1@ 2Template: Webachiv / IABot / www.endotrust.de