[HSF] AATS

Sun May 18 23:00:26 EDT 2008

As a vascular surgeon trainee I saw a group of Japanese vascular surgeons
harvesting the vein when they visited our hospital where I trained.. The
respect they gave to it was impressive and worth emulating.
Prasanna

On Sun, May 18, 2008 at 9:50 PM, Ani Anyanwu <anianyanwu at hotmail.com> wrote:

> > There are studies showing that harvesting the veins with surrounding
> fascia> and fat results in a very high patency comparable to arteries.
>
> One such study was published recently by souza and colleagues from sweden
> (JTCVS 2006;132:463 Harvesting the saphenous vein with surrounding tissue
> for CABG provides long-term graft patency comparable to the left internal
> thoracic artery: Results of a randomized longitudinal trial). As far back as
> 1993 they randomized 156 patients to 3 methods of vein harvest. At eight
> year angiography they found a patency rate of 76% for conventional harvest
> vs 90% for no touch harvest. I have cut out an excerpt that shows what their
> non-touch technique involved:
>
> "...The SV was exposed by a longitudinal incision and all visible side
> branches ligated. The vein was then isolated together with a pedicle of
> surrounding tissue (Figure E1, b) and left in situ until extracorporeal
> circulation was started to allow continuous heparinized blood perfusion.
> After removal, the vein was stored in blood obtained from the aortic cannula
> before cooling. To check for leakage from the distal anastomosis, the
> proximal end of the graft was briefly connected to the arterial cannula.
> Accordingly, the graft was neither flushed nor distended manually..."
>
> Also important in both this study and buxton's study is that the senior
> (attending) surgeon harvested the vein while the assistant opened the chest
> and harvested the IMA - that is the level of importance they attach to the
> harvest of the vein.
>
> The important lesson I think from Buxton's AATS paper is that if you treat
> the vein as you do an artery (have it procured by a senior member of the
> team, procure it open, do not touch the vein during procurement, do not
> distend the vein, do not flush with saline, do not divide it unless conduit
> is heparinized) then the early and mid-term results would be as good as an
> arterial graft. However, if the veins are generally harvested by a junior
> surgeon, or with an endoscope, dilated with saline, pulled and manipulated
> during harvest etc then one cannot reproduce the results seen by buxton and
> the one year patency will be closer to 70% than 90%.
>
> There are two solutions. One is what gustavo suggests - treat the vein
> exactly as you would a right mammary graft. This is admittedly impractical
> in a lot of settings but is achievable. Second solution is avoid veins as
> much as one can as most surgeons will always treat an arterial graft as an
> arterial graft but will find it difficult to accord the vein the same
> respect.
>
> Ani
>
>
>
>
> > Date: Sun, 18 May 2008 18:56:08 +0530> From: prasannasimha at gmail.com>
> To: OpenHeart-L at lists.hsforum.com> Subject: Re: [HSF] AATS> CC: > > There
> are studies showing that harvesting the veins with surrounding fascia> and
> fat results in a very high patency comparable to arteries. Maybe that is>
> worth considering rather than aesthetic clearing of veins.> > On Sun, May
> 18, 2008 at 6:29 PM, gustavo abuin <gabuin at intramed.net> wrote:> > > If we
> harvest a saphenous vein like a mammary artery and we select a> > segment of
> vein without any valve and anastomose it to the LAD, we will> > very
> surprised about its patency.> > I don`t dilate the right mammary artery
> after cut it to anastomose with the> > left.> > So.> > Why do I let my
> assistance dilate "gently" any piece of saphenous vein ?> > Why do I dilate
> ""gently""(?) any piece of saphenous vein?> > Why do I directly "imagine"
> that a saphenous vein is a delicate graft to be> > treated in a similar
> fashion like the right mammary free graft?> > I will treat veins like a
> delicate and unique conduit from next monday.> > I will send you the results
> on 2018 (maybe)> > gustavo.> >> > ----- Original Message ----- From:
> "Michael Firstenberg" <> > msfirst at gmail.com>> > To: <
> OpenHeart-L at lists.hsforum.com>> > Sent: Saturday, May 17, 2008 10:58 PM> >
> Subject: Re: [HSF] AATS> >> >> > I am sure that the brutal way in which
> tissue is handled - be it vein,> >> radial, or even IMA can have a huge
> potential impact on long term> >> patencies> >> - against something probably
> impossible to prove but something that makes> >> sense. We must continue to
> search for why veins dont work as well as IMAs> >> (I in fact have an active
> research project in this area, but can not get> >> funding - hmmmm why?
> probably no expensive disposable or lifelong> >> medications involved). But
> if we put a vein to a crappy diffusely> >> diseases> >> target - then of
> course it will go down. May be part of it is that we are> >> bypass sicker
> and sicker patients with crappier and crappier targets. As> >> I> >> am sure
> our international colleagues can attest to CAD is different in> >> different
> part of the world and to categorically compare the results in> >> one> >>
> society to another may be a little misleading.> >>> >> -michael> >>> >> On
> Sat, May 17, 2008 at 6:24 PM, <Hgrmd at aol.com> wrote:> >>> >> Ani,> >>> For
> such an analytical fellow, I'm surprised at the conclusions you've> >>>
> drawn about endoscopically harvested veins. As far as I know, there's> >>>
> never> >>> been a head to head study comparing open versus closed harvesting
> of the> >>> veins> >>> in regards to patency. I have the clinical experience
> of having done> >>> CABG's> >>> for at least 10 to 12 years of open veins
> and around 6-8 years of> >>> endoveins.> >>> I certainly haven't perceived a
> difference in patency. In other words,> >>> I> >>> can't tell that a lot
> more cases are coming to cath with closed grafts> >>> as> >>> compared to
> open harvested veins. Indeed, there may be a difference,> >>> but> >>> it
> has> >>> been imperceptible to us.> >>> Our P.A.'s are extremely skilled at
> rapidly delivering an endoscopic> >>> vein> >>> through a 2 cm stab wound
> (usually no incision in groin at all) that> >>> rarely> >>> has avulsed
> branches requiring repair with 7-0. Quite frankly, I can't> >>> tell> >>>
> the difference in appearance between open and closed harvested veins.> >>>
> Your> >>> point about dilating with blood and papaverine is well taken.
> That> >>> preparation> >>> may be less stressful to the vein's endothelium.
> However, in the end,> >>> no> >>> matter how you prep them, the veins die no
> matter what you do to them.> >>> That's> >>> why it is imperative that we
> spend more time harvesting arterial> >>> conduits> >>> and> >>> not letting
> concerns about time supervene.> >>>> >>> Hal> >>>> >>>> >>>> >>>
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> -----------------------------------------> >> > > > -- > Prasanna Simha M>
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-- 
Prasanna Simha M