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J Thorac Cardiovasc Surg 2007;134:1259-1265
© 2007 The American Association for Thoracic Surgery

Evolving Technology

Strategies to reduce intraluminal clot formation in endoscopically harvested saphenous veins

Emile N. Brown, BSa, Zachary N. Kon, BAa, Richard Tran, BSa, Nicholas S. Burris, BSa, Junyen Gu, MD, PhDa, Patrick Laird, BAa, Philip S. Brazio, BS, BAa, Seeta Kallam, MDa, Kimberly Schwartz, RNFA, MBAa, Lisa Bechtel, PA-Cb, Ashish Joshi, MD, MPHc, Shaosong Zhang, MD, PhDd, Robert S. Poston, MDa,*

a Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Md
b St Joseph Medical Center, Baltimore, Md
c University of Maryland Baltimore County, Department of Information Systems, Baltimore, Md
d LightLab Imaging, Inc, Westford, Mass.

Received for publication May 10, 2007; revisions received July 10, 2007; accepted for publication July 24, 2007.

* Address for reprints: Robert S. Poston, MD, Associate Professor of Surgery, University of Maryland School of Medicine, 22 S Greene St, Room N4W94, Baltimore, MD 21201. (Email: rposton{at}smail.umaryland.edu).

Objective: Residual clot strands within the excised saphenous vein are an increasingly recognized sequela of endoscopic vein harvest. We hypothesized that endoscopic visualization facilitated by sealed carbon dioxide insufflation causes stagnation of blood within the saphenous vein. In the absence of prior heparin administration, this stasis provokes clot formation.

Methods: Forty consecutive patients having coronary artery bypass grafting underwent endoscopic vein harvest using sealed (Guidant VasoView, n = 30; Guidant Corp, Minneapolis, Minn) or open (Datascope ClearGlide, n = 10; Datascope Corp, Montvale, NJ) carbon dioxide insufflation followed by ex vivo assessment of intraluminal saphenous vein clot via optical coherence tomography. In the sealed carbon dioxide insufflation groups, clot formation was compared with (preheparinized, n = 20) and without (control, n = 10) heparin administration before endoscopic vein harvest, either at a fixed dose or titrated to an activated clotting time greater than 300 seconds. Risk factors for clot formation were assessed.

Results: Residual saphenous vein clot was a universal finding in control veins (sealed carbon dioxide insufflation endoscopic vein harvest without preheparinization). At either dose used, heparin given before endoscopic vein harvest significantly decreased saphenous vein clot burden. A similar reduction in clot was observed when using open carbon dioxide insufflation endoscopic vein harvest without preheparinization. Intraoperative blood loss and blood product requirements were similar in all groups. Patient age and preoperative maximum amplitude of the thrombelastography tracing showed a linear correlation with saphenous vein clot volume.

Conclusion: By enabling the quantification of this issue as never before possible, optical coherence tomography screening revealed that intraluminal saphenous vein clot is frequently found after endoscopic vein harvest. Systemic heparinization before harvest or an open carbon dioxide endoscopic vein harvest system are benign changes in practice that can significantly lessen this complication.

Abbreviations and Acronyms CABG = coronary artery bypass grafting; EVH = endoscopic vein harvest; OCT = optical coherence tomography; SV = saphenous vein; SVG = saphenous vein graft; TEG = thromboelastography


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J. Thorac. Cardiovasc. Surg. 2007 134: 1265. [Extract] [Full Text] [PDF]



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