Harvesting Saphenous

Vein
DR. TRI WISESA SOETISNA SP.B SP.BTKV(K), MARS
History
•The saphenous vein (SV) was used as a
bypass conduit first in the peripheral
circulation for the relief of claudication by
Kunlin in 1949
•Later in cardiac surgery for the correction of
anomalous origin of the left coronary artery
by Kollesov in 1966.

Jean Kunlin
Counduit of Choice
The goal of coronary artery bypass grafting (CABG) is complete revascularization of the area of
the myocardium with good viability
A durable conduit is vital for successful CABG.
There are a number of sites from which the conduit can be harvested, including the following:
•Saphenous vein
•Radial artery
•Left internal thoracic (mammary) artery (LITA)
•Right internal thoracic (mammary) artery (RITA)
•Right gastroepiploic artery
•Inferior epigastric artery
Counduit of Choice
The greater saphenous vein has been extensively used as a conduit
after internal mammary artery because :
• Easy to harvest
• Easy to handle
• An excellent inflow
• As coronary artery bypass grafting (CABG) conduits, the saphenous
veins have an 80-90% early patency rate, which decreases to 50% at 10
years.
Anatomy
Selection Length of the Vessel
Length of the vessel needed determined by the Surgeon from the
coronary angiogram and intra operation from location of blockage
and size of the heart
Positioning
•The supine position provides optimum
exposure for CABG
•Sterile soft linen should be place under the
thigh to provide good access during
procurement
•Legs should be slightly flexed and externally
rotated after prepping and draping to provide
good exposure of the saphenous vein and
femoral arteries for insertion of intra-aortic
balloon pump if necessary
•To determine the quality of vein quality we can
use palpation and ultrasoun
Landmarks
First constant anatomical landmark
•Arises anterior edge of the medial malleolus.
•It has a linearm course in the leg.
•It ascends vertically , posterior to the medial
border of the tibia and is accompanied by the
leg branch of the saphenous vein
Landmarks
Second constant anatomical landmark
At the knee, the long saphenous vein
travels posteriorly to the lateral femoral
condyle.
It then travels superficially over the medial
region of the thigh , remaining parallel to
the medial edge of the sartorius muscle
Two nerves structured accompany the
long saphenous vein :
1. The accessories nerve of the medial
saphenous nerve
2. Anterior branch of the medial
musculocutaneous nerve
Methods
•If the vein from the lower leg is to be
used, the initial skin incision is made
anterior to the medial malleolus
•If the upper portion of the vein will be
used, the initial skin incision is made in
the groin.
•An incision is made one-to-two
fingerbreadths from the femoral artery
pulse and the subcutaneous tissue is
dissected to expose the greater
saphenous vein
Methods
•The desired plane is accessed by blunt
dissection with scissors down to the
level of the vein
•Skin and subcutaneous fat are
undermined with scissors (or tunneling
with fingers if bridging), staying just
superficial to the vein and spreading
the tips of the scissors over the vein
Methods
•The incision alongside the knee joint is
subjected to cause strain and stretch in
several directions as the joint moves.
•This may give the patient significant
discomfort and interferes with
satisfactory healing.
•Therefore, the skin in this location is
usually left intact
Methods
•Creation of skin flaps should be avoided
•Care should be taken to preserve the saphenous
nerve
•The “no-touch” technique should be utilized. This
means handling the vein only by its adventitia with
atraumatic forceps, isolating the vein with vascular
band / tapes
Methods
•Remove the vein from its ‘bed’ by careful
dissection and division of its branches
•Tissue should be dissected around the vein
•All branches should be ligated.
•If bridging technique is used, ligate the branches
once the vein is explanted
Try to Avoid
Accidental Division of the Vein
•With the aid of scissors the skin incision is
extended over the index finger, which has
tunneled above and parallel to the saphenous
vein.
•This technique prevents accidental division of
a more superficially placed of the vein and
eliminates the development of unnecessary
dead spaces or redundant skin flaps
Intimal Injury
•The vein must never be pulled or stretched to
facilitate dissection
•The intimal layer is very delicate and may tear
•It will rise a formation of platelet aggregation
and possible subsequent early occlusion of the
graft
•This is more likely occur when multiple skin
incisions are made and the vein has to be
harvested from beneath the skin bridges
Nerve Injury
•The saphenous nerve runs along the greater
saphenous vein.
•Special care should be taken not to accidently
or divide it to avoid postoperative paresthesia
Preparing the Vein
•When adequate segment of vein is dissected
free, it is divided at each end and removed
•The vein stumps in the groin and the ankle are
securely ligated with 3/0 Ethibond tie
Over Distension to the Vein
•The vein graft should be gently distended
•Any excessive pressure can result intimal tear
and disruption
•Try to prevent the intraluminal pressure from
exceeding 150 mmHg
•Gently applying a squeezing technique from
proximal to distal end
Branch Stumps
•The branches should be ligated or clamped
approximately 1 mm from the vein wall to
minimize the presence of a stump, which may
predispose to thrombus formation and early
graft occlusion
•Any stump can easily be eliminated by
application of a fine metal clip behind the tie
parallel with the vein wall
Suturing the Vein Wall
•Sometimes, the wall of the vein at the site of the
avulsion of its branches requires suture closure
•This can be accomplished by taking longitudinal bites
of the vein wall with 7-0 or 8-0 Prolene when it is
being distended
•But the transverse suturing gives rise to localized
constriction
Prepairing the Vein for Distal
Anastomosis
Proximal Anastomosis
Wound Closure
•The leg wound is closed in layers with
absorbable sutures
•In the groin region or where the wound is
deep, an extra layer of closure is necessary
•The skin is close with fine absorbable suture
material with 3/0 cutting needle in a
subcuticular manner
Reference
Khonsari, S., Sintek, C.F. (2007). Cardiac surgery safeguards and pitfalls in operative technique
(4th ed.) Los Angeles, USA: Walters Kluwer Health/Lippincott Williams and Wilkins. Sabik, J.F.,
Lytle, B.W., Blackstone, E.H., Houghtaling, P.L.,
Cosgrove, D.M. (2005). Comparison of Saphenous Vein and Internal Thoracic Artery Graft
Patency by Coronary System. The Society of Thoracic Surgeons, 79:544 –51.
Treadwell, T. (2003). Diagnostic dilemma : Management of Saphenous Vein Harvest wound
complications following Coronary Artery Bypass grafting. Diagnostic Dilemma, 15(3), 83 – 91.