|Year : 2020 | Volume
| Issue : 1 | Page : 94-95
A novel technique of tunneled venous conduit retrieval for femoropopliteal artery bypass
George Varghese Kurien, Manoj P Nair, Lincoln Samuel, Nikhil Joe Jacob
Department of Cardiovascular and Thoracic Surgery, Aster Medcity, Kochi, Kerala, India
|Date of Submission||03-Jun-2019|
|Date of Decision||15-Jul-2019|
|Date of Acceptance||13-Oct-2019|
|Date of Web Publication||16-Mar-2020|
Dr. Lincoln Samuel
Department of Cardiovascular and Thoracic Surgery, Aster Medcity, Kochi, Kerala
Source of Support: None, Conflict of Interest: None
We would like to report a novel technique in the use of endoscopically retrieved reverse saphenous vein for femoropopliteal bypass grafting. A common mishap encountered while tunneling reversed saphenous vein is avulsion of side branches. At our center, we improvised and used an autoclaved Fogarty catheter case to tunnel the reversed saphenous vein. We found this technique to be safe, cheap, and reproducible even in a low-volume center.
Keywords: Endoscopic venous harvesting, peripheral vascular disease, saphenous vein
|How to cite this article:|
Kurien GV, Nair MP, Samuel L, Jacob NJ. A novel technique of tunneled venous conduit retrieval for femoropopliteal artery bypass. Indian J Vasc Endovasc Surg 2020;7:94-5
|How to cite this URL:|
Kurien GV, Nair MP, Samuel L, Jacob NJ. A novel technique of tunneled venous conduit retrieval for femoropopliteal artery bypass. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Apr 8];7:94-5. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/94/280665
| Introduction|| |
Reversed autogenous femoropopliteal venous bypass grafts have been employed at Saint Louis University Hospitals as early as 1966. Saphenous vein grafts are the gold standard conduit for lower-extremity bypass grafting. Endoscopic vein harvest (EVH) has been demonstrated to improve early morbidity when compared with conventional open-vein harvest (OVH) technique for infrainguinal bypass surgery. However, the conventional vein tunneling technique has its own technical complications. The aim of this article is to report a simple but unique technique to tunnel the vein graft without injury in the usage of reverse saphenous vein grafts in infrainguinal bypass surgeries.
| Case Report|| |
A 50-year-old male, laborer by occupation and chronic smoker, was admitted with a nonhealing ulcer of the anterior aspect of the tibia with an associated history of intermittent claudication and rest pain. Clinical evaluation was suggestive of a Rutherford Grade 2, category 4 peripheral arterial occlusive disease. Infrapopliteal peripheral pulsations were impalpable. Computed tomography aortogram revealed a completely occluded superficial femoral artery with a two-vessel runoff infra-popliteally. He was categorized as a TASC II TYPE D lesion for which infrapopliteal revascularization was planned. A femoropopliteal bypass using autologous reverse saphenous vein grafts, harvested by the endoscopic technique was undertaken after obtaining consent.
Endoscopic Reversed Saphenous Vein Harvest was performed with the disposable VASOVIEW 7 EVH System (Maquet Inc., Wayne, NJ, USA), using standard techniques. We introduced an autoclaved 5 French Fogarty's catheter case for threading across a tunnel [Figure 1] and [Figure 2]. A standard atrium tunneler set was used in the subsartorial muscular plane to create the tunnel. The catheter case was threaded along the tunneler. An ethisteel No. 6–75 cm (MNW-9494) straight tip was passed into the Fogarty cover. The end of the steel wire was made into a loop. The reversed end of the vein was attached to the loop, and the vein was railroaded along the whole length of the tunneler [Figure 3]. Once the vein reached the desired length for the distal anastomosis, the catheter case was removed. The proximal and distal anastomoses were done in standard fashion for femoropopliteal bypass.
On immediate postoperative follow-up, this patient had excellent wound healing and good peripheral perfusion. Color Doppler at 1-month and 6-month follow-up showed excellent flow across the conduit as opposed to patients who had received conventionally endscopically retrieved grafts.
| Discussion|| |
Minimally invasive vein harvesting techniques were initially introduced in 1994 and have been developed to reduce the wound morbidity associated with OVH. New-generation EVH systems have been developed to minimize endothelial cell damage secondary to “thermal spread” The harvested veins are tunneled by a technique described for prosthetic grafts. This entails the creation of a subsartorial tunnel. Following this, the RSVG is directly attached to the tunnel head and retrieved at the other end. While using this technique, vein avulsion and internal bleeding during retrieval are potential complications. Small intimal tears and stretching on the side branches while tunneling can lead to disastrous consequences. Sometimes, this may result in sacrificing the only autograft conduit available for the patient. This may result in the patient receiving a prosthetic graft with reported poor long-term patency.,,, The subcutaneous tunnel created by the endoscopic dissector can also be used. However, the subsartorial tunnel is superior in terms of anatomical lie and vein preservation. The use of a chest tube acting as a tunnel to minimize the vein damage during RSVG retrieval has been described.
Our center routinely uses EVH harvested RSVG for femoropopliteal bypass operations. We have quite commonly encountered the before-mentioned technical problems. These complications are not well described in literature owing to the recent widespread use of EVH. The use of a catheter case for tunneling the RSVG has never been reported in literature before. The procedure necessitates the use of a subsartorial tunnel. In addition to this, the use of a catheter case as described can reduce the risk of disastrous consequences. This convenient technique can minimize potential intimal damage, side branch avulsion, slipping of ligatures, internal bleeding, and conversion to open wound exploration.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to thank Mr. Bineesh Sukumaran, scrub nurse, for technical support in the operating room.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]