[HSF] AATS

Sun May 18 15:46:06 EDT 2008

HAL
MAYBE YOU NEED BETTER PA'S.

BUT MORE INTERESTING IS WHY YOU NEEDED TO BYPASS THE RCA?   WAS IT AN
AVR?  SOMETHING MORE SINISTER?

SORRY ABOUT ALL CAPS - BLAME MS-MOBILE

MICHAEL

On 5/18/08, hgrmd at aol.com <hgrmd at aol.com> wrote:
> Michael,
>   All I can tell you is that it's comforting to know I can harvest a vein
> quicker than any of my P.A.'s if feces is hitting the fan.  I recently did a
> double valve on an old lady.  Twice I couldn't get off pump due to RV
> failure.  I quickly grabbed and grafted a piece of vein to the RCA.  Problem
> resolved, she did great.  What if I had to cry and wait for the P.A. To save
> the day?
>
> Hal
> Sent from my Verizon Wireless BlackBerry
>
> -----Original Message-----
> From: Michael Firstenberg <msfirst at gmail.com>
>
> Date: Sun, 18 May 2008 13:26:58
> To:OpenHeart-L at lists.hsforum.com
> Subject: Re: [HSF] AATS
>
>
> 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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