[HSF] AATS

Sun May 18 14:16:03 EDT 2008

So our results (EBM) at times might be more about the actions of us doctors than the reactions of the patients. Hummm..
tea

----- Original Message ----
From: Ani Anyanwu <anianyanwu at hotmail.com>
To: openheart-l at lists.hsforum.com
Sent: Sunday, May 18, 2008 11:20:06 AM
Subject: RE: [HSF] AATS

> 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)> >>> _______________________________________________> >>> OpenHeart-L mailing list> >>>> >>> Send postings to:> >>> OpenHeart-L at lists.hsforum.com> >>>> >>> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >>> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>>> >>> All messages transmitted by the OpenHeart-L are subject to the policies> >>> and> >>> disclaimers posted at:> >>> http://www.hsforum.com/listdisclaim> >>> -----------------------------------------> >>>> >>> _______________________________________________> >> OpenHeart-L mailing list> >>> >> Send postings to:> >> OpenHeart-L at lists.hsforum.com> >>> >> To UNSUBSCRIBE, to CHANGE email address, or to view archives:> >> http://mmp.cjp.com/mailman/listinfo/openheart-l> >>> >> All messages transmitted by the OpenHeart-L are subject to the
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