Proximal first: a beneficial strategy for no-touch saphenous vein graft

Proximal first: a beneficial strategy for no-touch saphenous vein graft Abstract In the mid-1990s, a novel saphenous vein harvesting technique, in which the vein is harvested with its surrounding tissue without manual distention, was introduced. This no-touch technique provides an excellent long-term patency; however, graft twisting and kinking should be given attention. To fully bring out the benefit of the no-touch method while reducing the risk of twisting and kinking, we have modified the anastomosis strategy. Our simple modified strategy involved a proximal anastomosis prior to the distal anastomosis. This strategy was successfully used in 16 patients. Coronary artery bypass grafting, No-touch saphenous vein, Anastomosis strategy INTRODUCTION The novel no-touch method of the saphenous vein (SV) harvest developed by Dr Souza brought about a revolution in coronary artery bypass grafting (CABG). This technique preserves the adventitial vasa vasorum and is associated with an improved long-term patency [1]. However, the following drawbacks have also been noted. First, the incidence of leg wound complications in the early postoperative phase is higher than with the conventional SV harvest [2]. Second, intraoperative management against graft kinking and twisting is required. In Japan, more than 60% of CABGs are performed as off-pump CABGs (OPCABs) [3]. The original novel no-touch method is not suited for OPCAB for several reasons. To adjust the no-touch saphenous vein (NT-SV) technique to OPCAB and to bring out its benefit, we have modified the anastomosis process. TECHNIQUE We introduced the NT-SV harvest in July 2016. The SV was harvested from the lower leg through skipped incisions (Fig. 1). Before removing the SV from the vascular bed, the graft was marked by a dye to avoid twisting. The skin was closed after the insertion of a 12-Fr fluted silicone drain (SMART DRAIN; Redax SpA, Poggio Rusco, Italy) in the SV harvest site. The SV was cannulated and flushed gently using heparinized saline. Initially, we connected the SV to a cannula inserted into the femoral artery for predilation and checked for leakage from the branches. Anastomosis of insitu internal mammary artery was performed, followed by the distal anastomosis of the NT-SV. Finally, the proximal anastomosis was achieved. Figure 1: View largeDownload slide Postoperative view of the lower legs on the 10th postoperative day. The wounds healed well. Black dotted lines indicate skipped skin incisions, and black arrows indicate drain holes. Figure 1: View largeDownload slide Postoperative view of the lower legs on the 10th postoperative day. The wounds healed well. Black dotted lines indicate skipped skin incisions, and black arrows indicate drain holes. Recently, we employed a ‘proximal first’ strategy (Video 1). The SV was initially anastomosed to the ascending aorta using a HEARTSTRING device (MAQUET Holding B.V. & Co. KG, Rastatt, Germany) in accordance to our original technique [4]. After examining anastomosis for abundant flow, the distal end of the SV was clipped. Sufficient predilation was achieved, and inspection for leakage was done (Fig. 2). After anastomosis of the internal mammary artery was performed, the NT-SV was placed towards the target vessel, and the graft length was assessed. Matching the length was easy because the NT-SV was pressurized and fully inflated. The SV was incised, and pulsatile flow was obtained if there were no kinks or twists. Thus, detection of graft twisting or kinking was quite easy. Finally, distal anastomosis was performed. Video 1 The procedure of a ‘proximal first’ coronary artery bypass grafting. Sufficient blood flow obtained from the distal ends of the grafts, well-inflated veins without kinking and twisting and the process of the adjustment of the graft length are highlighted. Video 1 The procedure of a ‘proximal first’ coronary artery bypass grafting. Sufficient blood flow obtained from the distal ends of the grafts, well-inflated veins without kinking and twisting and the process of the adjustment of the graft length are highlighted. Close Figure 2: View largeDownload slide (A) Intraoperative view of the prepared no-touch saphenous vein (NT-SV) and bilateral internal mammary arteries (IMAs). The NT-SV was anastomosed to the ascending aorta and predilated. (B) Intraoperative view of the NT-SVs anastomosed in a piggyback fashion and the left IMA. White and black arrows indicate NT-SVs and IMAs, respectively. Figure 2: View largeDownload slide (A) Intraoperative view of the prepared no-touch saphenous vein (NT-SV) and bilateral internal mammary arteries (IMAs). The NT-SV was anastomosed to the ascending aorta and predilated. (B) Intraoperative view of the NT-SVs anastomosed in a piggyback fashion and the left IMA. White and black arrows indicate NT-SVs and IMAs, respectively. COMMENTS Although the NT-SV technique provides an excellent long-term patency, it has some drawbacks. As the vein needs to be harvested together with the surrounding tissue, leg wound complications should be given attention. Furthermore, careful checking for graft twisting and kinking is necessary. Given that the SV itself is covered with fat tissue, detection of graft twisting is difficult. Recently, Kim et al. [5] demonstrated that wound complications were minimized by the insertion of a drainage tube and by harvesting the NT-SV through interrupted skin incisions instead of a continuous longitudinal incision. The incidence of surgical site complications has decreased with various modifications to the surgical technique. In our small series, the NT-SV was harvested from the lower leg through skipped incisions, and a drainage tube was inserted routinely for 2–3 days. No wound complications were observed. The problem of graft kinking and twisting is still not completely resolved. Our ‘proximal first’ strategy has the potential to solve this problem for the following reasons. First, confirming the quality of the proximal anastomosis is quite easy. Second, adequate predilation is achieved, and inspection for leakage is done during the procedure. Kim et al. [5] anastomosed the NT-SV to the internal mammary artery as a composite graft. They reported that the NT-SV was dilated by arterial pressure spontaneously [5]. Although their approach is different from ours, the same result was obtained. Third, graft length adjustment is also easy. Fourth, inspection for kinking or twisting is easily achieved. Fifth, this strategy can provide blood flow to the ischaemic territories as each anastomosis is done. This advantage facilitates OPCAB, especially for patients with severely unstable haemodynamics. The limitation of this method is that it can only be applied to beating-heart CABG. We have applied this technique for 6 months in 16 consecutive patients. The haemodynamics of all patients remained remarkably stable, and postoperative imaging showed patency of all grafts. Although we have manipulated the ascending aorta, careful assessment by epiaortic echo and the use of the HEARTSTRING device were effective. No cerebral infarction occurred. CONCLUSION In conclusion, our novel strategy involving a simple modification of the no-touch technique confers significant benefits for patients. ACKNOWLEDGEMENTS We thank Editage (www.editage.jp) for the English language editing. Conflict of interest: none declared. REFERENCES 1 Samano N , Geijer H , Liden M , Fremes S , Bodin L , Souza D. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: a randomized trial . J Thorac Cardiovasc Surg 2015 ; 150 : 880 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Verma S , Lovren F , Pan Y , Yanagawa B , Deb S , Karkhanis R et al. Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation: the PATENT saphenous vein graft study . Eur J Cardiothorac Surg 2014 ; 45 : 717 – 25 . Google Scholar CrossRef Search ADS PubMed 3 Masuda M , Okumura M , Doki Y , Endo S , Hirata Y , Kobayashi J et al. Thoracic and cardiovascular surgery in Japan during 2014: annual report by The Japanese Association for Thoracic Surgery . Gen Thorac Cardiovasc Surg 2016 ; 64 : 665 – 97 . Google Scholar CrossRef Search ADS PubMed 4 Hamasaki A , Uchida T , Sadahiro M. Simple and safe removal modification of the HEARTSTRING device . Eur J Cardiothorac Surg 2018 ; 53 : 282 – 3 . Google Scholar CrossRef Search ADS PubMed 5 Kim YH , Oh HC , Choi JW , Hwang HY , Kim KB. No-touch saphenous vein harvesting may improve further the patency of saphenous vein composite grafts: early outcomes and 1-year angiographic results . Ann Thorac Surg 2017 ; 103 : 1489 – 97 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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Abstract

Abstract In the mid-1990s, a novel saphenous vein harvesting technique, in which the vein is harvested with its surrounding tissue without manual distention, was introduced. This no-touch technique provides an excellent long-term patency; however, graft twisting and kinking should be given attention. To fully bring out the benefit of the no-touch method while reducing the risk of twisting and kinking, we have modified the anastomosis strategy. Our simple modified strategy involved a proximal anastomosis prior to the distal anastomosis. This strategy was successfully used in 16 patients. Coronary artery bypass grafting, No-touch saphenous vein, Anastomosis strategy INTRODUCTION The novel no-touch method of the saphenous vein (SV) harvest developed by Dr Souza brought about a revolution in coronary artery bypass grafting (CABG). This technique preserves the adventitial vasa vasorum and is associated with an improved long-term patency [1]. However, the following drawbacks have also been noted. First, the incidence of leg wound complications in the early postoperative phase is higher than with the conventional SV harvest [2]. Second, intraoperative management against graft kinking and twisting is required. In Japan, more than 60% of CABGs are performed as off-pump CABGs (OPCABs) [3]. The original novel no-touch method is not suited for OPCAB for several reasons. To adjust the no-touch saphenous vein (NT-SV) technique to OPCAB and to bring out its benefit, we have modified the anastomosis process. TECHNIQUE We introduced the NT-SV harvest in July 2016. The SV was harvested from the lower leg through skipped incisions (Fig. 1). Before removing the SV from the vascular bed, the graft was marked by a dye to avoid twisting. The skin was closed after the insertion of a 12-Fr fluted silicone drain (SMART DRAIN; Redax SpA, Poggio Rusco, Italy) in the SV harvest site. The SV was cannulated and flushed gently using heparinized saline. Initially, we connected the SV to a cannula inserted into the femoral artery for predilation and checked for leakage from the branches. Anastomosis of insitu internal mammary artery was performed, followed by the distal anastomosis of the NT-SV. Finally, the proximal anastomosis was achieved. Figure 1: View largeDownload slide Postoperative view of the lower legs on the 10th postoperative day. The wounds healed well. Black dotted lines indicate skipped skin incisions, and black arrows indicate drain holes. Figure 1: View largeDownload slide Postoperative view of the lower legs on the 10th postoperative day. The wounds healed well. Black dotted lines indicate skipped skin incisions, and black arrows indicate drain holes. Recently, we employed a ‘proximal first’ strategy (Video 1). The SV was initially anastomosed to the ascending aorta using a HEARTSTRING device (MAQUET Holding B.V. & Co. KG, Rastatt, Germany) in accordance to our original technique [4]. After examining anastomosis for abundant flow, the distal end of the SV was clipped. Sufficient predilation was achieved, and inspection for leakage was done (Fig. 2). After anastomosis of the internal mammary artery was performed, the NT-SV was placed towards the target vessel, and the graft length was assessed. Matching the length was easy because the NT-SV was pressurized and fully inflated. The SV was incised, and pulsatile flow was obtained if there were no kinks or twists. Thus, detection of graft twisting or kinking was quite easy. Finally, distal anastomosis was performed. Video 1 The procedure of a ‘proximal first’ coronary artery bypass grafting. Sufficient blood flow obtained from the distal ends of the grafts, well-inflated veins without kinking and twisting and the process of the adjustment of the graft length are highlighted. Video 1 The procedure of a ‘proximal first’ coronary artery bypass grafting. Sufficient blood flow obtained from the distal ends of the grafts, well-inflated veins without kinking and twisting and the process of the adjustment of the graft length are highlighted. Close Figure 2: View largeDownload slide (A) Intraoperative view of the prepared no-touch saphenous vein (NT-SV) and bilateral internal mammary arteries (IMAs). The NT-SV was anastomosed to the ascending aorta and predilated. (B) Intraoperative view of the NT-SVs anastomosed in a piggyback fashion and the left IMA. White and black arrows indicate NT-SVs and IMAs, respectively. Figure 2: View largeDownload slide (A) Intraoperative view of the prepared no-touch saphenous vein (NT-SV) and bilateral internal mammary arteries (IMAs). The NT-SV was anastomosed to the ascending aorta and predilated. (B) Intraoperative view of the NT-SVs anastomosed in a piggyback fashion and the left IMA. White and black arrows indicate NT-SVs and IMAs, respectively. COMMENTS Although the NT-SV technique provides an excellent long-term patency, it has some drawbacks. As the vein needs to be harvested together with the surrounding tissue, leg wound complications should be given attention. Furthermore, careful checking for graft twisting and kinking is necessary. Given that the SV itself is covered with fat tissue, detection of graft twisting is difficult. Recently, Kim et al. [5] demonstrated that wound complications were minimized by the insertion of a drainage tube and by harvesting the NT-SV through interrupted skin incisions instead of a continuous longitudinal incision. The incidence of surgical site complications has decreased with various modifications to the surgical technique. In our small series, the NT-SV was harvested from the lower leg through skipped incisions, and a drainage tube was inserted routinely for 2–3 days. No wound complications were observed. The problem of graft kinking and twisting is still not completely resolved. Our ‘proximal first’ strategy has the potential to solve this problem for the following reasons. First, confirming the quality of the proximal anastomosis is quite easy. Second, adequate predilation is achieved, and inspection for leakage is done during the procedure. Kim et al. [5] anastomosed the NT-SV to the internal mammary artery as a composite graft. They reported that the NT-SV was dilated by arterial pressure spontaneously [5]. Although their approach is different from ours, the same result was obtained. Third, graft length adjustment is also easy. Fourth, inspection for kinking or twisting is easily achieved. Fifth, this strategy can provide blood flow to the ischaemic territories as each anastomosis is done. This advantage facilitates OPCAB, especially for patients with severely unstable haemodynamics. The limitation of this method is that it can only be applied to beating-heart CABG. We have applied this technique for 6 months in 16 consecutive patients. The haemodynamics of all patients remained remarkably stable, and postoperative imaging showed patency of all grafts. Although we have manipulated the ascending aorta, careful assessment by epiaortic echo and the use of the HEARTSTRING device were effective. No cerebral infarction occurred. CONCLUSION In conclusion, our novel strategy involving a simple modification of the no-touch technique confers significant benefits for patients. ACKNOWLEDGEMENTS We thank Editage (www.editage.jp) for the English language editing. Conflict of interest: none declared. REFERENCES 1 Samano N , Geijer H , Liden M , Fremes S , Bodin L , Souza D. The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: a randomized trial . J Thorac Cardiovasc Surg 2015 ; 150 : 880 – 8 . Google Scholar CrossRef Search ADS PubMed 2 Verma S , Lovren F , Pan Y , Yanagawa B , Deb S , Karkhanis R et al. Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation: the PATENT saphenous vein graft study . Eur J Cardiothorac Surg 2014 ; 45 : 717 – 25 . Google Scholar CrossRef Search ADS PubMed 3 Masuda M , Okumura M , Doki Y , Endo S , Hirata Y , Kobayashi J et al. Thoracic and cardiovascular surgery in Japan during 2014: annual report by The Japanese Association for Thoracic Surgery . Gen Thorac Cardiovasc Surg 2016 ; 64 : 665 – 97 . Google Scholar CrossRef Search ADS PubMed 4 Hamasaki A , Uchida T , Sadahiro M. Simple and safe removal modification of the HEARTSTRING device . Eur J Cardiothorac Surg 2018 ; 53 : 282 – 3 . Google Scholar CrossRef Search ADS PubMed 5 Kim YH , Oh HC , Choi JW , Hwang HY , Kim KB. No-touch saphenous vein harvesting may improve further the patency of saphenous vein composite grafts: early outcomes and 1-year angiographic results . Ann Thorac Surg 2017 ; 103 : 1489 – 97 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Apr 27, 2018

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