[HSF] AATS
Michael Firstenberg
msfirst at gmail.com
Sun May 18 14:26:58 EDT 2008
Ani -
Oh, I believe you on all aspects and I think this clearly illustrates
the complex balance of clinical (what is best for the patient),
educational (resident learning new techniques), economic($$$ -
disposables, OR time, resource utilization), administrative (all of
the other "stuff" we have to do beside being in the OR), cosmetic
(incisions), and of course political (what our institutions or
referring docs mandate). Can I harvest vein? Yes, but we have PAs -
some of whom have 20-30 years of OR experience - who can do it better
and faster that I - particularly in an emergency situation where my
addition (and yours!) needs to be focused elsewhere.
Obviously at the end of the day we have to do what we believe is best
for the patient - but "what is best" in Columbus may be different
than what is best in Japan, Florida, India and so on - even I am sure
there are differences between Mt Sinai and Columbus and Cornell.
-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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