Synergizing Antegrade Endoscopic with Bridging Vein Harvesting for Improvement of Great Saphenous Vein Graft Quality from the Lower Leg

Our protocol for antegrade endoscopic vein harvesting might be the optimum strategy for addressing excellent vein graft quality and wound healing and routine coronary artery bypass surgery. Synergizeing antegrade endoscopic with bridging vein harvesting techniques enables minimally invasive and tissue protective isolation of high quality vein grafts from the lower leg in elective and urgent cases. Before beginning the procedure, place the instrumental setup for endoscopic vein harvesting near the end of the table and place one 60 centimeter long, 12 centimeter diameter foam rollers under the patient's extended legs below the achilles tendons.

Then place one half cylindrical foam roller just above the knee on the side of the graft to avoid overstretched knees and common perineal nerve lesions. To obtain minimally invasive access to the grade saphenous vein, first use institution standard disinfection procedures, octenadine hydrochloride, and a standard sterile covering to achieve aseptic surgical conditions. Next, starting at approximately one index finger above the imagined ankle joint, and proceeding upward parallel to the medial margin of the tibia bone, use a curved number 10 scalpel to make a one point five to two centimeter longitudinal skin incision in the lower leg.

Then, starting from the skin incision, use a vessel loop dissecting scissors, a small soft tissue retractor, and a langem beck hook to isolate the vessel four centimeters in each direction by applying the standard bridging vein harvesting technique. Take care to avoid harvesting varicose veins. And to make sure one small finger can easily access the working channel.

Before beginning the procedure, connect an extended length endoscope to an optical camera and connect a dissection tip from the endoscopic vessel harvesting system to assemble the optical dissector. Hydrate the optical dissector with saline containing heparin and place a hydrated inflatable blocker balloon over the optical dissector. Then gently insert the optical dissector antegrade and the inflatable blocker balloon into the wound under permanent optical control of the vein.

Block the inflatable blocker balloon with 10 milliliters of room air and flood the working channel with carbon dioxide. Confirm that the working channel is extended by the gas pressure and move the dissector antegrade until the imagined proximal medial end of the tibial diaphysis is reached. Gently move the optical dissector above and below the main vessel to isolate the vessel from the majority of the subcutaneous tissue until a clear identification of the side branches is obtained.

Take care to preserve the integrity of the peri vascular tissue as much as possible for both graft injury prevention and maximum reduction of mechanisms within the working channel. Then selectively dissect the side branches with one side of the vein preserving the peri vascular tissue as far as possible, before dissecting the other side. Next, remove the optical dissector from the wound and disconnect the dissection tip.

Adapt the blocker ballon for the optical retractor and block the working channel with a five milliliter syringe. To assemble the optical retractor, connect the extended length endoscope to the retractor device from the endoscopic vessel harvesting system. Then apply anti-fog fluid to the tip of the endoscope and hydrate the optical retractor with saline supplemented with heparin, before antegrade insertion through the blocked balloon.

When the retractor is ready, advance the device antegrade to the end of the working channel. Use the retractor to selectively interrupt the side branches with the bipolar electro coagulation device in a retrograde fashion to release the vein from the surrounding subcutaneous tissue. Flush the lens of the optical camera with heparinized saline if its vision becomes disturbed.

When the saphenous vein has been fully isolated, use a number 11 scalpel to execute a stab incision in the skin at the distal end of the dissected vein. Insert a smooth anatomical clamp through the incision. Clamp the vein under optical control with the optical retractor and gently retrieve the vein through the stab incision.

Cut off the vein proximally before gently removing the optical retractor through the blocked balloon while simultaneously relieving the distal portion of the vein. Deflate the blocker balloon and remove it from the wound. Then switch off the carbon dioxide.

To finish the bridging vein harvesting, execute a stab incision in the skin with a sharp number 11 scalpel at the proximal end of the isolated vein approximately three centimeters above the imagined ankle joint. Insert an anatomical clamp through the stab incision, retrieve the vein through the skin incision under digital and optical control while avoiding injury to the saphenous nerve and clamp the vein under direct vision. Then cut off the vein distally before gently relieving the entire vein graft through the initial minimally invasive surgical access site and cannulating the proximal end with a three milometer flexible vessel canula.

Before closing the wound, use a 10 milliliter syringe to gently flush the released venous graft with saline supplemented with heparin, alternating with double clipping of all of the side branches. Store the vein graft in a saline, heparin soaked compress at room temperature. Then use 2-O and 4-O polyglactin 910 sutures respectively to execute subcutaneous and intracutaneous wound closures at the minimally invasive access site.

Shown here is the utilized vein graft after completion of the subsequent coronary artery bypass surgery. These data demonstrate the steep learning curve that was required for an experienced cardiac surgeon to successfully perform antegrade endoscopic vein harvest of the great saphenous vein from the lower leg of 28 patients. The graph illustrates the immediate dynamic reduction in time expenditure, starting from the insertion of the optical dissector, until the termination of the vein graft retrieval.

These randomized blind microscopic analyses reveal an intact vascular morphology and a completely preserved endothelioid integrity for all of the analyzed vein samples after antegrade endoscopic vein harvest. It is most important to remember three essentials. The positioning of the legs, the directional bridging vein harvesting at the exerside, and the tissue protective antegrade endoscopic vein harvesting.

Our protocol could help both cardiac and vascular surgeons to develop their own optimal strategy for high quality vein graft isolation in elective and urgent cases. This step by step video should help you to prepare high quality vein by endoscopic vein harvesting.