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In This Article

  • Summary
  • Abstract
  • Introduction
  • Protocol
  • Representative Results
  • Discussion
  • Acknowledgements
  • Materials
  • References
  • Reprints and Permissions

Summary

Presented here is a protocol for antegrade endoscopic vein harvesting from the lower leg, which can safely be introduced in routine coronary artery bypass grafting. Vein grafts present excellent graft quality following this standardized protocol with positioning of the legs, minimally invasive access to the vein, and antegrade endoscopic vein harvesting.

Abstract

Antegrade endoscopic harvesting of autografts for bypass grafting may be an optimal strategy addressing excellent graft quality and reduced post-operative wound complications. This standardized protocol for antegrade endoscopic vein harvesting (EVH) from the lower leg has the potential to be introduced to routine coronary artery bypass grafting (CABG). Patients undergoing CABG surgery are positioned on a surgical table with two additional foam rollers below the extended legs, enabling antegrade EVH from the lower leg. Following minimally invasive surgical access through a bridging vein harvest technique, an endoscopic optical dissector is inserted antegrade into the wound. The main vessel and side branches are dissected under continuous optical control of vein quality status and the working channel. After, an endoscopic optical retractor is inserted with an internal bipolar electrocoagulation device for precise, safe, and tissue-protective interruption of side branches. After release of the vein, the vessel is cut off at the proximal and distal ends under optical control, retrieved from the wound, then cannulated and flushed with heparinized saline. Finally, all side branches of the vein graft are double-clipped. Vascular histology is analyzed in a randomized selection of vein samples. After applying this standardized EVH protocol, the learning curve was shown to be steep, and graft quality was sufficient for coronary artery bypass grafting in every case. There was no conversion to surgical harvesting and low risks for tissue damage and bleeding. Leg positioning and synergizing EVH with bridging vein harvesting improved procedural success and vein graft quality. In our hands, antegrade EVH from the lower leg was feasible, demonstrating straightforward graft dissection as well as adequate macroscopic and microscopic graft quality with preserved endothelial integrity. In conclusion, the introduced technique is safe, shows excellent vein autograft quality, and illustrates feasibility for elective and urgent isolated CABG and combined CABG scenarios.

Introduction

Open atraumatic "low-touch" and "no-touch" techniques have been developed over the years for harvesting saphenous veins in coronary artery bypass graft (CABG) surgery or peripheral bypass grafting, producing grafts with excellent endothelial integrity and long-term patency. However, wound complications remain a major problem when using the open technique, especially in obese, diabetic, and chronic venous insufficiency patients1,2,3,4. The question arises of how physicians can harvest the saphenous vein with optimal graft qual....

Protocol

The study conforms to the Declaration of Helsinki. The protocol follows the guidelines of an independent institutional ethics committee, and human biomaterials were obtained after informed written consent (ethics committee approval: A 2018-0037).

1. Positioning of the legs

NOTE: Patient inclusion criteria included a history of coronary artery disease with elective/urgent indication for CABG surgery and the need for harvesting of at least one venous bypass graft for co.......

Representative Results

A steep learning curve was demonstrated for an experienced cardiac surgeon performing antegrade EVH of the great saphenous vein from the lower leg (Figure 4). There were no conversions to surgical harvesting. However, there were four cases of vein injury in the beginning of the learning curve. In three of the four cases, major injuries occurred at the distal portion of the vein because of an inadequately narrow working channel when the surgeon isolated the vein above the tibial metaphysis. D.......

Discussion

It should be stated that we prefer complete arterial coronary revascularization in our department. There is rising evidence that CABG using bilateral internal mammary artery (IMA) grafts can significantly improve long-term survival of patients14,15,16,17. However, there are valid reasons for a "single IMA plus vein grafts" strategy, especially in patients at advanced ages, patients with.......

Acknowledgements

We thank the entire surgical staff for excellent technical assistance.

....

Materials

NameCompanyCatalog NumberComments
disposable scalpel (size 11, Präzisa Plus)Dahlhausen, Germanya
small curved smooth (anatomical) clamps B. Braun Aesculap, Germanyb
toothed (surgical) forcepsB. Braun Aesculap, Germanyc
surgical scissors B. Braun Aesculap, Germanyd
holder for scalpel blade (size 10)B. Braun Aesculap, Germanye
fine smoth (anatomical) forcepB. Braun Aesculap, Germanyf
sponge-holding clampB. Braun Aesculap, Germanyg
clipping deviceFumedica, Switzerlandh
18 Gauge cannula (Sterican)B. Braun, Germanyi
light handleSimeon Medical, Germanyj
needle holderB. Braun Aesculap, Germanyk
tissue retractorB. Braun Aesculap, Germanyl
Redon needleB. Braun Aesculap, Germanym
adhesive hook and loop fastenerMölnlycke, Germanyn
extended length endoscope Karl Storz, Germanyo
optical cableKarl Storz, Germanyp
transparent drap camera coverECOLAB Healthcare, Germanyq
connection cable for electrocauterisationMaquet, Getinge Group, Germany r
gas insufflation setDahlhausen, Germanys
Fred Anti-Fog Solution Medtronic, USAt
bipolar electrocoagulation device Maquet, Getinge Group, Germany u
monitor (WideView)Karl Storz, Germanyv
light source (xenon 300)Karl Storz, Germanyw
gas insufflation controller (Endoflator)Karl Storz, Germanyx
half-cylindrical foam rollerAlmatros, Gebr. Albrecht KG, Germanyy
full-cylindrical foam rollerAlmatros, Gebr. Albrecht KG, Germanyz
bulldog clampB. Braun Aesculap, Germanyaa
flexible vessel cannulaMedtronic, USAab
vessel loop (Mediloops)Dispomedica, Germanyac
Heparin-Natrium (5000 U) in 200ml salineB. Braun, Germanyad
Langenbeck hooksB. Braun Aesculap, Germanyae
sutures (polygalctin 910, Vicryl 2-0, 4-0; poly ethylene terephthalate, Ethibond 2-0)Ethicon, Johnson & Johnson, USAaf
Endoscopic vessel harvesting system, Vasoview Hemopro IIMaquet, Getinge Group, Germany ag
Octenidindihydrochloride, OctenidermSchuelke & Mayr GmbH, Germany

References

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