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Endoscopic Closed Tunnel Conduit Harvesting: Tips, Tricks and Traps 101
West retractor
Radial artery
Fig. 8 Illustrates the initial exposure of the radial artery in the wrist
Fig. 9 Illustrates the isolated radial artery before harvesting
Vesiloop
Radial artery
102 B. Krishnamoorthy and J. Blackmore
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Dissecng cone
Radial artery
Fig. 10 Illustrates the tunnel in the hand and the endoscopic dissection tip
Allen’s Test is again performed to ensure adequate hand perfusion by the ulnar artery. The
bulldog clamp is then removed, and additional
dissection of the RA pedicle and anterior fascia is
performed as far proximal as possible to allow
for safe entry of the endoscopic harvesting
device. Exsanguinate the arm with an Esmark
bandage and inflate the tourniquet.
The endoscopic harvesting device is then
introduced into the incision (Fig. 10) in between
the RA pedicle and the anterior fascia. Dissection
is performed initially by an anterior pass following along the vena comitantes on either side.
An additional posterior pass is then performed to
identify any branches and connective tissue on
the posterior aspect of the pedicle. During these
dissection passes, it is important to glance away
from the monitor down to the surgical field on
occasion to assess the progress up the arm. The
length of the RA is shorter than what a harvester
will be accustomed to with the SV, therefore the
proximal limit of dissection may be reached
sooner than anticipated. The RA harvest differs
from that of the SV in that the entirety of the
harvesting device will not be needed to reach the
endpoint. As the proximal limit of dissection is
approached, there will be an increase in adipose
tissue (Fig. 11) on and around the radial pedicle.
Take caution when approaching branches for
dissection as they are much more fragile than
those of the SV (Fig. 12).
Cauterization:
Blunt tissue dissection is followed by the cauterization step. Introduce the device into the
trocar, but do not proceed all the way into the
tunnel. This pause allows you to evaluate the
tunnel directly in front of the trocar. At this point,
you can advance the cautery sheers to ligate any
branches that would impede progression of the
device and to also begin the anterior fasciotomy
(Fig. 13). Continue the anterior fasciotomy
approximately 1/3 the distance up the forearm,
following the tendon of the brachioradialis
muscle. Conclude the fasciotomy as the tendon
crosses to the opposite side of the tunnel. Cauterize each branch as they are encountered to
avoid avulsion injury. Branches of the RA are
extremely small and fragile making them susceptible to avulsion. When the proximal limit of
dissection has been reached, retrace the length of
the pedicle to ensure that all branches and connective tissue have been ligated.
The harvesting device is then inserted the
length of the tunnel to the proximal limit of
dissection. Palpate the distal end of the device
while watching the monitor to determine the
desired ligation point. Using an #11 scalpel,
Endoscopic Closed Tunnel Conduit Harvesting: Tips, Tricks and Traps 103
Branch
Fig. 11 Illustrates the clear hand tunnel and branches of the radial artery
Fig. 12 Illustrates the dissected radial artery within the tunnel in the hand
puncture the skin down to the distal tunnel,
carefully observing the tip of the blade to avoid
injury to the pedicle. Insert a tonsil hemostat
through the incision site and open the tips to
stretch open the anterior fascia. When clamping
the pedicle, consider the depth of the tunnel that
it will need to be pulled through. This depth
should coincide with an equal length on the
Dissected Radial
artery
104 B. Krishnamoorthy and J. Blackmore
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Hemopro probe
Fascia
Radial artery
Fig. 13 Illustrates the anterior fasciotomy
proximal side of the clamp to avoid tension. With
the pedicle clamped, remove the hemostat from
the tunnel. Divide the pedicle under direct vision
and ligate the proximal stump with a stick-tie
using a 2–0 silk suture.
Conduit Preparation:
When the pedicle has been completely remo ved
from the tunnel, deflate the tourniquet, if using.
At this point, the distal end remains intact and
blood flow should be observed from the proximal, ligated end. Place a soft bulldog on the
ligated end and irrigate the pedicle with
Papaverine (Fig. 14). Using a small clip applier,
inspect the pedicle for branches and clip as they
are encountered. A large clip can be applied to
the connective tissue to denote the proximal end
of the conduit to aid in maintaining orientation.
Clamp the distal end of the radial pedicle with a
right-angle hemostat and ligate with a scalpel.
The distal RA stump is then tied off with a silk
tie. Engage the proximal end of the RA and flush
with vessel solution. The pedicle is then placed
in a specimen cup with vessel solution and stored
in a warmer at 37 °C (98°F). The wrist inci sion is
closed in usual fashion. The stab-and-grab incision is closed with a single figure-of-eight subcutaneous stitch using a 3–0 Vicryl (Fig. 15).
Cover each incision with appropriate bandages.
The arm is wrapped with a Kerlex dressing followed by an ACE wrap. A continuous pulse
oximeter is placed on the thumb to verify adequate perfusion. The wraps are removed on POD
1 to inspect for hematoma formation and baseline
strength and sensation of the hand and arm.
Body Habitus Considerations:
The body habitus of the patient can provide
additional variables that further complicate the
procedure. Thin patients generally provide harvesting advantages as the initial dissection to the
RA is simplified, the tunnel is easily maintained,
and the depth of which the RA pedicle needs to
traverse for ligation is minimal. Obese and
muscular patients, however, provide certain
procedural difficulties. A wrist with excess adipose tissue causes the initial dissection down to
the RA to become challenging. If using a closed-
Endoscopic Closed Tunnel Conduit Harvesting: Tips, Tricks and Traps 105
Radial artery
Fig. 14 Illustrates the harvested radial artery with bulldog clip
Fig. 15 Illustrates the closed arm after radial artery harvesting
106 B. Krishnamoorthy and J. Blackmore
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Video 3 Endoscopic radial artery harvest (▶ https://doi.org/10.1007/000-a7e)
CO2tunnel, an obese arm can cause the tunnel to
collapse. In addition to collapsing the tunnel, the
main disadvantage that a muscular arm produces
is that of the depth which the radial pedicle must
be retrieved for the stab-and-grab ligation
(Video 3).
General Concepts:
A harvester should be experienced and proficient
with endoscopic saphenous vein harvesting
before attempting an endoscopic radial artery
harvest. The branches of the RA are prone to
avulsion and the risk of vasospasm is high due to
vessel manipulation. Harvesters should have
completed 50–75 endoscopic SV harvests independently prior to pursuing ERAH. If possible,
formal training in a cadaver lab should be
obtained prior to attempting in the operating
room. In our experience, the non-dominant
hand should be the first choice, but the dominant hand does not need to be avoided if that
RA proves to be the best conduit for harvesting. Internal evaluation of the patient’s grip
strength 3 months after surgery has shown no
loss of strength from the donor arm.
5 Conclusion
Evidence continues to suggest the RA provides
superior patency rates compa red to the SV and
comparable patency rates to the RITA. There is
less risk associated with using the RA compared
to the RITA. For these reasons, the RA should be
the second choice for coronary revascularization
conduit, following the LITA. ERAH has been
proven to be a safe surgical technique with no
effects on graft patency or mortality [30]. Compared to open harvesting, ERAH results in
improved cosmesis, less pain, and fewer neurologic complications [31, 32].
Endoscopic Closed Tunnel Conduit Harvesting: Tips, Tricks and Traps 107
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Endoscopic Vein Harvest Using
®
an Open System (Terumo
Donna Croft, Steven Power,
and Louise Parry
)
Abstract
The advent of endoscopic vein harvesting
(EVH) has allowed operators to harvest the
long saphenous vein (LSV) through small
incisions. This has translated into a reduction
in leg wound infections, pain, hospital length
of stay and recent studies demonstrate it to be
equal to open vein harvesting (OVH) with
regards to long term vein graft patency.
Within our institution, EVH is routinely
performed by a Surgical Care Practitioner
(SCP) for most patients undergoing coronary
artery bypass grafts (CABG). The EVH
system routinely used at our institution is the
Terumo
sel Harvesting System. The learning curve for
EVH is steep and although we have encountered many traps along the way, we have
Supplementary Information The online version
contains supplementary material available at
https://doi.org/10.1007/978-3-031-21104-1_7. The
videos can be accessed individually by clicking the
DOI link in the accompanying figure caption or by
scanning this link with the SN More Media App.
D. Croft (&) S. Power L. Parry
Lancashire Cardiac Centre, Blackpool Teaching
Hospitals NHS Foundation Trust, Blackpool, UK
e-mail: donna.croft2@nhs.net
®
Virtuosaph®Plus Endoscopic Ves-
developed some tips and tricks that we would
like to share with you within this chapter.
Drawing on our experiences at Blackpool this
chapter will walk the operator through the
steps required to ensure successful EVH for
patients undergoing CABG. It will begin with
the preoperative assessment of patients for
EVH, followed by the procedure. This is
broken down into two parts; the dissection and
the harvest, followed by postoperative
complications.
Keywords
Endoscopic vein harvestingEVHTerumo
Long saphenous veinCoronary artery
bypass surgery
CABG
1 Introduction
Use of an Endoscopic Vein Harvest (EVH)
technique, when harvesting the Long Saphenous
Vein (LSV) for Coronary Artery Bypass Graft
Surgery (CABG), has been shown to reduce leg
wound complications when compared to open
vein harvesting, with no significant difference in
the rate of major adverse cardiac events [1].
The EVH programme was initiated at Black-
pool Teaching Hospitals NHS Foundation Trust
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
J. Zacharias (ed.), Endoscopic Cardiac Surgery,
https://doi.org/10.1007/978-3-031-21104-1_7
109
110 D. Croft et al.
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in 2007 and has become the standard practice for
all patients undergoing CABG. Currently,
approximately 75% of patients undergoing
CABG surgery at the trust receive EVH using the
Terumo™ EVH system.
2 Pre-operative Considerations
2.1 Equipment Preparation
Prior to undertaking your first EVH procedure, it
is important to ensure you have all the equipment
available, that it is working and that all the
equipment is compatible with each other.
The following equipment is essential (Fig. 1):
Non-disposable
• Video stack system and camera.
• CO
insufflation system.
2
• A compatible light lead.
• A compatible generator (See Table 1).
• Terumo™ Endoscope (MCENDO550).
Disposable
• Virtuosaph
®
Plus Endoscopic Vein Harvest-
ing System.
• Camera cover.
• CO
insufflation tubing.
2
2.2 Orientation to the Terumo
System (See Video 1)
See Fig. 2
Fig. 1 EVH equipment
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