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Page 12 of 22 Royse et al. Vessel Plus 2020;4:5 I http://dx.doi.org/10.20517/2574-1209.2019.34

plane (within the fascia surrounding the neurovascular bundle), dissect the tissues with low power electro-
cautery, divide the branches between two small metal clips with electro-cautery and retain the satellite
veins. Alternatively, use of scissors or an ultrasonic scalpel is also very safe. Topical and intraluminal 1%
papaverine is used.
(3) Harvest of the RA is faster than for IMA and similar to or faster than SVG.
(4) RA is less prone to intraoperative spasm requiring topical therapy than IMA.
(5) For more than two decades, our institution has liberally used intermittent and/or continuous
intravenous vasoconstrictors to maintain physiological blood pressure (usually > 100 mmHg systolic) in
order to maintain end organ perfusion (including cardiac graft perfusion). In the case of these authors,
since 2008, 100% of all cardiac operations have had a low dose of norepinephrine commence at the start
of the anaesthetic and continued throughout the operation and into the ICU period - sometimes for
days. In the case of a severe systemic inflammatory response syndrome, the infusion may be substantially
increased even to 50 µg/min. We have not observed RA spasm clinically, and, rarely when a patient
undergoes perioperative angiography, we have not documented RA spasm. We do not use intraoperative
calcium channel blocking agents and there is a highly variable use of these agents postoperatively with poor
compliance on follow up. We therefore advocate that surgeons using RA for the first time or infrequent
users of RA should not vary their intraoperative or postoperative management from their usual practice
and not make any adjustments to their usual blood pressure guidelines or to the drugs that they normally
use.
(6) RA is longer than IMA.
(7) RA is larger and more robust, making anastomosis construction easier than for IMA.
(8) RA is less prone to kinking than SVG.

Cognitive dissonance
Leon Festinger was a New York born social psychologist, who published the Theory of Cognitive
Dissonance [90,91] . This wide-ranging theory has some applicability to cardiac surgery.

Consider: Example from the theory: a smoker, who knows that smoking is harmful and that he should stop,
continues to smoke. Why?

The theory explains that the desire to smoke conflicts with the desire to be healthy, resulting in internal
psychological tension (dissonance) and they will take steps to try and reduce this tension. For example,
they may rationalise their behaviour, excuse it, blame others, deny it, etc. However, a further facet of the
theory is that, if another person were to try and persuade them to stop smoking, or even blame them
for smoking, then they will vigorously defend their right/desire/intent to keep smoking. That is, the help
offered is frequently seen as more threatening to their sense of self than is their own internal conflict on the
same subject.

Example from cardiac surgery: a cardiac surgeon, who believes that SVG will ultimately fail and would
prefer to use more arterial grafts but continues to use SVG.

THE HOW: PRACTICAL STEPS TO BECOME A ROUTINE TAR SURGEON
Keys to success
1. It is relatively easy and safe to become a “mostly” TAR surgeon.
2. Stage the introduction of more complex techniques and become comfortable with them before
proceeding.