Mateo Marin-Cuartas, MD and Michael A. Borger, MD, PhD
University Department of Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
Essential Operative Steps
- Confirm lack of varicose veins and DVT
- Identify anatomical landmarks
- Incision starting at the level of the ankle and continuing proximal (upwards)
- Once the necessary length is freed from the connecting tissue, small branches are clipped
- The proximal end is ligated, and a cannula is affixed to the graft lumen
- The distal end is clamped
- Carefully run saline/cardioplegia through the cannula to identify remaining branches
- Achieve hemostasis and close the wound in layers
Potential Complications and Pitfalls
- Deep skin flaps during skin incision or insufficient/inaccurate wound closure can lead to wound healing disorders and
surgical site infection - Saphenous nerve injury can cause lower leg paresthesia and chronic neuropathic pain
- Inaccurate hemostasis or loosening of the saphenous vein stump ligature/clip are common causes of postoperative
bleeding - Hematoma formation or excessively tight circumferential leg wrapping with an elastic bandage can lead to a
compartment syndrome - Overdistention during graft flushing, excessive vein manipulation during harvesting, or graft storage in an inaccurate
storage solution frequently causes saphenous intimal damage, which reduces long-term graft patency - Clipping/ligating venous branches too close to the saphenous vein could narrow the graft´s lumen
- An excessively deep skin incision, uncareful dissection of surrounding connective tissue during graft harvesting, or
overlooking venous branches commonly causes graft damage (e.g. perforation)
Template Dictation
Preoperative Diagnosis: [INDICATION: Coronary artery bypass, coronary artery disease, coronary artery injury]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: [BLANK]
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT]. Preoperative cardiac
catheterization reveals [FINDINGS].
Description of the Procedure [Open Technique]: The patient was taken to the operating room and was placed on the operating
room table in the supine position. The patient’s lower extremity was prepared and draped in the usual sterile fashion.
The saphenous vein was externally identified at the ankle level, approximately 2 cm superior and lateral to the medial malleolus.
The skin incision was started at the ankle level and continued upwards to the knee, following the trajectory of the vein, and
taking special care not to create deep skin flaps. Once the vein was exposed, a combination of blunt and sharp dissection was
used to loosen the vein from the surrounding connective tissue without dividing the vein branches. Damage to the parallelly
running saphenous nerve was avoided. The vein was handled with a vessel loop to avoid intimal injury. Once the necessary
length of the vein was freed from the surrounding connective tissue, small branches were clipped, and bigger branches were
both ligated and clipped. This was done a few millimeters away from the vein lumen to avoid narrowing it. Once the branches
were divided and clipped, the vein’s distal end was clamped with a mosquito clamp. Before completely dividing the vein’s
distal end, a partial division (50% of the vein’s lumen) was made to insert a blunt venous cannula into the conduit´s lumen.
Once the cannula was inserted and fixed with a suture, the vein was fully divided at its distal end. The distal vein stump was
then ligated and clipped. The proximal end was clamped with a mosquito clamp and divided.
The graft was then assessed by flushing gently with cardioplegia/saline through the venous cannula. Any remaining branches
were clipped and divided. The vein was stored in an appropriate solution [Variable: saline, heparinized blood, cardioplegia,
or any commercially available graft preservation solution].
Rigorous hemostasis of the wound bed was obtained. The wound was closed in multiple layers, and a closed suction drain (12
or 14Fr) was inserted to prevent the postoperative formation of hematoma and seroma. The leg was circumferentially wrapped
with an elastic bandage, starting from the ankle and going upwards to the knee.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure
Table 1. Comparison of most common saphenous vein graft harvesting techniques
Figure 1: Open harvesting technique. The improved graft exposure allows faster harvesting with less surgical trauma to the
conduit.
Figure 2: Bridged harvesting technique. Several small incisions are performed on the lower leg to harvest the saphenous vein
graft (yellow arrows). Image courtesy of Dr. Alejandro Escobar (Medellin, Colombia)
Figure 3: Normal anatomical course of the great saphenous vein (blue dashed line). Medial malleolus (blue arrow), popliteal
fossa (yellow arrow), and patella (red arrow).
Video Tutorial: A video tutorial on how we routinely perform open saphenous vein graft harvesting at our institution
Sources
Marín-Cuartas M, Kang J, Davierwala PM, Misfeld M, Borger MA. Step-by-step harvesting of various grafts for coronary
artery bypass surgery. Multimed Man Cardiothorac Surg. 2021 Nov 12;2021.
