[HSF] AATS

Michael Firstenberg msfirst at gmail.com
Sun May 18 14:31:08 EDT 2008 

.... another thing - knowing your Boss (who recently gave an  
excellent presentation at our Institution) - if YOU were completely  
convinced that in YOUR practice open vein was better, I am sure he  
would let you do it.

... of course to use Tea-logic - we are all assuming open vein is  
less barbaric than endo.  I think the key is that all tissue must be  
treated with the tender loving care that it deserves considering the  
vital role it has.

on a side note - how many of use full or partial heparin prior to  
harvesting vein.  I will wait until the vein is out prior to heparin  
(I hate leg hematomas) but I know some people who give 5000u prior to  
starting endo-harvest.

-michael



On May 18, 2008, at 1:08 PM, Ani Anyanwu wrote:

> So, for your > next couple of hundred CABGs - you harvest the vein  
> with an open > technique while your resident opens the chest, takes  
> down the IMA, > and cannulates
>> -michael
>
> Michael
>
> Believe it or not this scenario was quite commonplace in London  
> where I trained - the consultant or senior trainee would often  
> harvest the vein to give the junior trainee or resident an  
> opportunity to do the sternotomy, harvest IMA and cannulate. I have  
> even done that twice or thrice in US to give my PA a chance to open  
> and take the IMA too. A tragedy of US training today is lack of  
> exposure to non-IMA conduit harvest. In my period of training in UK  
> I procured over 700 veins (LSC, SSV, arm vein) and almost 300  
> radial arteries - the similar number over the last 3 years for our  
> chief resident who will be an attending shortly  is zero for each.  
> One of my co-attendings was in an emergency situation few weeks ago  
> and needed vein emergently - the track fellow obviously would not  
> know surgeons ever take vein and yells for a physician assistant in  
> the same way you would call for a cardiologist if you wanted a cath.
>
> Well to answer you no I would not take vein open for next two  
> hundred cases - I think my cardiologists would rather prefer no  
> scar on the leg at all and I try as much as possible to avoid using  
> vein. I use bilateral IMAs liberally in patients of all age  
> groups.  It is difficult though on an institutional level where  
> 'every' vein is taken endoscopically to do them open, even if I  
> wanted to, but I will probably consider that more if I am for  
> whatever reason using veins in patients other than the very elderly.
>
> I agree with Hal that endoharvest has all but eliminated leg wound  
> complications and saved huge amount of money (from treatment of leg  
> infections and avoiding prolonged hospilazation) but the question  
> is at what cost.
>
>
> Ani
>
>
>
>
>
>> From: msfirst at gmail.com> Subject: Re: [HSF] AATS> Date: Sun, 18  
>> May 2008 12:37:39 -0400> To: OpenHeart-L at lists.hsforum.com> CC: >  
>> > Ani,> > OK - I am convinced that this might be a good idea. So,  
>> for your > next couple of hundred CABGs - you harvest the vein  
>> with an open > technique while your resident opens the chest,  
>> takes down the IMA, > and cannulates (I am sure your PAs, as  
>> highly paid and overworked > they are could use a coffee break  
>> during this time period) - then let > us know. I am sure the  
>> patients and referring Cardiologists will > love their long leg  
>> scars.> > -michael> > > > On May 18, 2008, at 12:20 PM, Ani  
>> Anyanwu 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> >>>> > >> >>>> >>>>  
>> >>> **************Wondering what's for Dinner Tonight? > >> Get  
>> new twists on> >>> family> >>> favorites at AOL Food.> >>> > >>  
>> (http://food.aol.com/dinner-tonight?NCID=aolfod00030000000001)> >  
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