Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 94-95

A novel technique of tunneled venous conduit retrieval for femoropopliteal artery bypass


Department of Cardiovascular and Thoracic Surgery, Aster Medcity, Kochi, Kerala, India

Date of Submission03-Jun-2019
Date of Decision15-Jul-2019
Date of Acceptance13-Oct-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Lincoln Samuel
Department of Cardiovascular and Thoracic Surgery, Aster Medcity, Kochi, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_33_19

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  Abstract 


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 5];7:94-5. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/94/280665




  Introduction Top


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.[1] 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 Top


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.
Figure 1: Fogarty case being driven through subsartorial tunnel

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Figure 2: Fogarty case delivered out at femoral opening

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Figure 3: Retrieved saphenous vein at the top end of the Fogarty case

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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 Top


Minimally invasive vein harvesting techniques were initially introduced in 1994 and have been developed to reduce the wound morbidity associated with OVH.[2] 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.[3] 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.[1],[4],[5],[6] 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.[7]

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.

Acknowledgment

We would like to thank Mr. Bineesh Sukumaran, scrub nurse, for technical support in the operating room.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adale WA, Deweese JA, Scott WJ. Autogenous venous shunt grafts; Rationale and report of 31 for atherosclerosis. Surgery 1959;46:145-63.  Back to cited text no. 1
    
2.
Lumsden AB, Eaves FF 3rd, Ofenloch JC, Jordan WD. Subcutaneous, video-assisted saphenous vein harvest: Report of the first 30 cases. Cardiovasc Surg 1996;4:771-6.  Back to cited text no. 2
    
3.
Linton RR, Darling RC. Autogenous Saphenous Vein Bypass Grafts in Femoropopliteal Obliterative Disease. Surgery 1962;51:62.  Back to cited text no. 3
    
4.
Irvine WT, Kenyon JR, Stiles PJ. A study of the early results of 95 patients undergoing femoro-popliteal bypass graft. J Cardiovasc Surg (Torino) 1963;4:348-56.  Back to cited text no. 4
    
5.
Linton RR, Darling RC. Autogenous saphenous vein bypass grafts in femoropopliteal obliterative arterial disease. Surgery 1962;51:62-73.  Back to cited text no. 5
    
6.
Szilagyi DE, Smith RF, Elliott JP. Venous autografts in femoropopliteal arterioplasty. observations in the treatment of occlusive disease. Arch Surg 1964;89:113-25.  Back to cited text no. 6
    
7.
Goyal VD, Rana S, Sharma S, Kumar S. New technique for tunneling of reversed saphenous vein graft to prevent kinking and twisting during vascular bypass procedures. Indian J Thorac Cardiovasc Surg 2013;29:274.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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