Ann Thorac Surg 2000;69:295-297
© 2000 The Society of Thoracic Surgeons
How to Do It
Facile location of the saphenous vein during endoscopic vessel harvesting
Keith B. Allen, MDa,
Carl J. Shaar, PhDa
a Department of Cardiothoracic Surgery, St Vincent Hospital, Indiana Heart Institute, Indianapolis, Indiana, USA
Address reprint requests to Dr Allen, 8333 Naab Rd, Suite 300, Indianapolis, IN 46260
e-mail: cvsurgeon{at}iquest.net
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Abstract
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Endoscopic techniques are used more frequently to harvest the saphenous vein for cardiac and peripheral vascular procedures. To identify the saphenous vein through an initial small access incision can be difficult. We describe the use of a portable intraoperative ultrasound system to expeditiously identify the saphenous vein during endoscopic harvesting, particularly in obese patients.
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Introduction
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Venous conduit remains an essential component in most cardiac practices. With increased emphasis on minimally invasive techniques, endoscopic saphenectomy is being used more frequently because of improved patient satisfaction and decreased morbidity. Endoscopic saphenectomy has been shown to be associated with fewer wound complications than the traditional longitudinal method in both randomized [1] and nonrandomized [2–4] clinical trials.
Despite important patient benefits the learning curve associated with endoscopic vein harvesting has hindered its widespread acceptance. During traditional saphenous vein (SV) harvesting, initially locating the SV at the groin or ankle poses little difficulty. With the endoscopic technique, however, initially locating the SV above and below the knee can be time-consuming and frustrating even for experienced assistants. To circumvent this problem, transverse rather than linear incisions have been recommended to help locate the SV and prevent unnecessary skin flaps [2]. Unfortunately, even with a transverse skin incision, initially locating the SV can be difficult, particularly in obese patients.
We describe an intraoperative ultrasound system (Site Rite, Dymax Corp, Pittsburgh, PA) for the expeditious identification and evaluation of the SV. We propose that its use may decrease the overall learning curve associated with endoscopic saphenectomy, particularly when used in obese patients.
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Technique
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The Site Rite ultrasound system is a small, battery operated, portable unit consisting of a monitor and two ultrasound probes (Fig 1). A 9 MHz probe is used to evaluate superficial structures located less than 2 cm from the surface, whereas the 7.5 MHz probe is used to evaluate deeper structures located more than 2 cm from the surface. Probe selection for Site Rite scanning depends on whether the leg is normal (9 MHz probe) or obese (7.5 MHz probe). When scanning for the vein, it is important to use minimal pressure because veins are easily compressed and disappear on ultrasound when too much pressure is applied. Unlike arteries that visibly pulse and are not compressible, confirmation that the vein has been identified is done by ballottement of the vein with the probe to verify its collapse and expansion (Fig 2).
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Fig 1. The Site Rite ultrasound system is a small, battery operated, portable unit (US $11,000), which can be used to identify vascular structures.
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Fig 2. (A) Appearance of the greater saphenous vein in the mid-thigh with ultrasound. (B) Confirmation of the venous structure is with ballottement to partially compress the structure.
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The efficiency and accuracy of Site Rite to identify and characterize the greater SV before endoscopic saphenectomy were studied prospectively in 30 patients. Each patient underwent saphenectomy using an endoscopic vein harvesting (EVH) system (Ethicon EndoSurgery Inc, Cincinnati, OH). The technical aspects of EVH have been described previously [1, 2]. During anesthesia induction, patients’ legs were placed in a slightly frogged position and prepared and draped. Surgical assistants were asked to mark with an indelible marker where their initial skin incision would be made. The Site Rite ultrasound system was then used to identify the greater SV. An incision site based on ultrasound was marked and its location was compared with the previous mark made without ultrasound guidance. Assistants were also asked to record the time required to initially locate the vein beginning with the skin incision when the Site Rite was used. These times were compared with those recorded for 30 patients in whom the SV was located without use of the Site Rite ultrasound system. Patient demographics with respect to gender and degree of obesity were similar in both groups.
In 30 consecutive patients undergoing EVH, which included 18 patients who were obese (6 morbidly obese patients and 12 obese patients) and 12 patients whose body weight was in a normal range, the Site Rite system enabled assistants to quickly and easily identify the location of the SV. The Site Rite evaluation caused assistants to alter their initial incision location in 60% (18 of 30) of patients.
When the Site Rite system was used assistants took a mean 2.2 ± 1.4 min (range, 1 to 6 minutes) to initially locate and dissect out the SV compared with a mean of 4.1 ± 2.6 min (range, 1 to 12 minutes) in 30 demographically similar patients in whom ultrasonography was not used at all (p = 0.002). The Site Rite system improved SV location and dissection times in obese and morbidly obese patients but not in patients with normal body weight when compared with the traditional location technique (Table 1).
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Table 1. Comparison of Initial Saphenous Vein Dissection Time With Respect to Body Habitus With and Without Ultrasound Guidance
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Comment
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Although identifying the initial location of the SV during endoscopic saphenectomy represents a small portion of this technique, it does establish the tone that the harvest will take. This is particularly true during the early learning curve when assistants are not only trying to master the endoscopic technique but also are learning how to find the SV at mid-thigh and calf locations without the usual groin and ankle landmarks. Previously, we have not recommended using preoperative vein mapping because of patient inconvenience and additional cost. The Site Rite ultrasound system allowed even an experienced EVH assistant to more efficiently locate and initially dissect out the SV in obese patients.
Application of this technology is not confined to identifying the greater SV during EVH. The Site Rite system has been used for other procedures: as an epiaortic probe for identification of atheromatous debris within the ascending aorta; for locating peripheral and central vascular structures for cannulation in both children and adults; and for identification of a nonpulsatile femoral artery while patients are undergoing cardiopulmonary bypass for intraaortic balloon pump insertion [5].
Considering the benefits to the patient, endoscopic saphenectomy will likely become the standard of care. Continued modifications of endoscopic equipment and harvest techniques as described herein will make this transition easier for surgeons and assistants.
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References
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Allen K.B., Griffith G.L., Heimansohn D.A., et al. Endoscopic versus traditional saphenous vein harvesting. Ann Thorac Surg 1998;66:26-32.[Abstract/Free Full Text]
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Allen K.B., Shaar C.J. Endoscopic saphenous vein harvesting. Ann Thorac Surg 1997;64:265-266.[Abstract/Free Full Text]
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Davis Z., Jacobs H.Z., Zhang M., Thomas C., Castellanos Y. Endoscopic vein harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1988;116:228-235.[Abstract/Free Full Text]
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Lumsden A.B., Eavess F.F., III, Ofenloch J.C., Jordan W.D. Subcutaneous, video-assisted saphenous vein harvest. Cardiovasc Surg 1996;4:771-776.[Medline]
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Kanchuger M, Tissot M, Grossi E, Armstrong JM, Marschall K. Epiaortic ultrasonography is superior to biplane transesophageal echocardiography or surgical palpation in detecting ascending aortic atherosclerosis. Presented at the Sixteenth Annual Meeting of the Society for Cardiovascular Anesthesia, Montreal, Canada, April 23–27, 1994.
Accepted for publication July 29, 1999.
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Abstract
Introduction
