Nickum, Christopher W. MPAS, PA-C*; Dullum, Mercedes KC. MD*; Boyd, W Douglas MD*; Gray, Dana R. PA-C†
*Section of Cardiothoracic Surgery, Cleveland Clinic Florida; and †Northwest Surgical Associates, Portland, OR.
Address correspondence and reprint requests to Christopher W. Nickum, 2950 Cleveland Clinic Boulevard, Weston, FL 33331; e-mail: firstname.lastname@example.org.
Endoscopic vessel harvesting has become a widely used modality for harvesting venous and arterial conduits for coronary artery bypass grafting. Specifically, it has been used to harvest the greater saphenous vein, internal thoracic artery, and the radial artery. A case of endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting is reported.
Reoperations for coronary artery bypass grafting (CABG) are being seen with increasing frequency.1 This subset of patients can often present with limited conduit availability secondary to previous greater saphenous vein (GSV) harvesting, internal thoracic artery harvesting, and/or radial artery harvesting. The lesser saphenous vein (LSV) has been described as an alternative conduit choice for CABG,2,3 but its historical use has been limited for a myriad of reasons including difficulty in its harvest and reduced vessel size.
Endoscopic vessel harvesting (EVH) techniques associated with CABG have been well described since Allen and Shaar's initial description in 1996.4 The benefits are also well described and include decreased wound infection, decreased pain, and better cosmesis.5,6 We performed an endoscopic harvest of the LSV for CABG and herein describe its process.
A 69-year-old man presented to our service for assessment for redo CABG. The patient had undergone CABG 14 years ago, at which time the left internal thoracic artery and bilateral GSVs were harvested. Although a modified Allen's test using plethysmography revealed bilateral ulnar artery dominance, the patient's history of noninsulin-dependant diabetes and peripheral vascular disease prompted further evaluation of the patient's radial arteries via ultrasonography. Evaluation revealed significant and diffuse calcifications throughout both radial arteries, rendering them unusable as coronary grafts. It was decided not to use the right internal thoracic artery given the patient's reduced pulmonary capacity in conjunction with his obesity, diabetes, and prior sternal complications with his previous surgery. The right and left lesser saphenous veins were then evaluated via ultrasonography and were both found to be patent with mean diameters of 1.9 mm and 2.9 mm, respectively.
After anesthesia induction and placement of appropriate monitoring lines, the patient was placed in the prone position, exposing the dorsal aspect of both legs. A pillow was placed beneath the lower legs to avoid contact between the toes and the operating table. Additionally, the right foot was dorsiflexed to lower the height of the calcaneus, thereby helping to prevent the endoscope from abutting the calcaneus during the harvest. The patient's legs were then prepped circumferentially and draped in sterile fashion from the upper thighs to the ankles, excluding the buttocks and feet (Fig. 1).
A 3-cm longitudinal incision was made approximately 14 cm cephalad from the calcaneus over the Achilles tendon. With blunt and local sharp dissection, the right lesser saphenous vein was isolated creating lateral and medial planes for insertion of the bipolar cauterization device. Using standard endoscopic vein harvesting equipment consisting of a 30-degree/5-mm endoscope (Karl-Storz, Tuttlingen, Germany), subcutaneous Optical Dissector, Ultra-Retractor, pig-tail Vessel Dissector, and Clearglide bipolar cauterization device (CardioVations, Sommerville, NJ), an anterior dissection was initially performed with the Optical Dissector. Next, the Ultra Retractor was inserted and in consideration of the fragility of the LSV, the bipolar cauterization device was used to divide the subcutaneous tissue 0.5 cm lateral and medial to the vein thus harvesting the vein in pedicle format. Using the bipolar cauterization device, posterior dissection was then completed through a gentle sweeping motion, thereby releasing the vein from much of the posterior tissue. With the jaws of the bipolar cauterization device in a “Y” position, the device was then inserted posterior to the vein and advanced cephalad. As the bipolar cauterization device encountered adhering tissue and tributaries, the jaws were then closed and tissue cauterized and divided. A 1.8-cm “helper” incision was made approximately 5 cm from the proximal stump to facilitate the most distal portion of the harvest. At the completion of the dissection, the pig-tail Vessel Dissector was then advanced proximally and distally along the course of the vein to identify residual adhering tissue and tributaries. The vein was then ligated distally with a nonabsorbable suture and divided. An 18-inch Ethicon PDS Endoloop (CardioVations) was advanced to the most proximal portion of the dissection and deployed, ligating the vein proximally. The vein was then divided distal to the Endoloop knot, using the blade of the bipolar cauterization device, and subsequently removed from the leg.
The measured length of the LSV was 23 cm (Fig. 2) and was harvested in 39 minutes. The vein was anastomosed to the left anterior descending artery with excellent intraoperative flow characteristics. Transit time flow measurements7 via Butterfly Flowmeter (Medi-Stim, Oslo, Norway) demonstrated flow rates of 38-mL/min with a maximum rate of 84 mL/min, 78% of which was diastolic flow (Fig. 3).
The endoscopic approach for harvesting the LSV is a viable and safe way to atraumatically harvest a venous conduit for CABG. There are 3 considerations, however, that are worthy of discussion. First, our approach involved placing the patient in the prone position and at the completion of the harvest, returning the patient to the supine position for re-prep and draping before sternotomy. Lack of access to the chest may pose safety issues in those patients who are experiencing hemodynamic lability and thus a modified approach to patient positioning would be necessary in those instances. Second, the LSV is an anatomically superficial vessel. As such, we found the anterior space in the proximal portion of the surgical tunnel to be somewhat limiting. Subsequently, a 1.8-cm helper incision approximately 5 cm distal to the proximal stump was required to facilitate an easier and safer harvest of the proximal portion of the vein. Third, despite efforts to minimize the height of the calcaneus, we found the endoscope did abut the calcaneus, making the initial portion of the harvest more laborious. A potential solution would be to make the initial incision in the mid-zone of the gastrocnemius muscle. After the initial cephalad dissection is complete, the endoscope could be reversed, enabling a caudal dissection for the distal portion of the vein. This would avoid the need for a helper incision and avoid contact between the endoscope and the calcaneus during the initial dissection.
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5. Bonde P, Graham AN, MacGowan SW. Endoscopic vein harvest: advantages and limitations. Ann Thorac Surg.
6. Marty B, von Segesser LK, Tozzi P, et al. Benefits of endoscopic vein harvesting. World J Surg.
7. D’Ancona G, Karamanoukian HL, Ricci M, et al. Graft revision after transit time flow measurement in off-pump coronary artery bypass grafting. Eur J Cardiothorac Surg.
© 2005 Lippincott Williams & Wilkins, Inc.