Superior Vena Cava Bypass Using Spiral Vein Graft - Ministernotomy Technique

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Primary Incision and Exposure
A 10 centimeter incision is made in the midline over the upper one-half of the sternum. The incision is deepened to the sternum. The sternum is divided transversely in the third intercostal space, and vertically to that point. A small retractor is used to seperate the sternal edges.
	The innominate vein is separated completely from surrounding tissues and controlled with a vessel loop.
The pericardium is opened to allow access to the right atrial appendage. The distance between the innominate vein and the right atrial appendage is measured. It is quite short in this case, measuring only 4 centimeters.
Saphenous Vein Harvest and Creation of Spiral Graft
	The saphenous vein is harvested from the left leg. The length of vein required for a graft of the same size as the innominate vein is related to the ratio of the diameter of the graft desired and the average diameter of the saphenous vein. If the diameter of the graft was to be 15 mm and the diameter of the saphenous vein is 5 mm, 3 times the length of saphenous vein will be required. In this case, that would be 12 cm of saphenous vein.
The saphenous vein is incised longitudinally throughout its length.
	A thoracostomy tube with a diameter approximating that of the innominate vein serves as a stent on which the spiral vein graft will be constructed. The vein graft is wrapped around the stent and secured with a 7-0 polypropylene suture. The graft is rolled onto the stent in spiral fashion, keeping a good tension on the vein graft.
The edges of the vein graft are sewn together using 7-0 polypropylene suture for the length of the vein. Optical magnification is to assure accuracy of the suture line. About 20 to 30 minutes are required to complete this long suture line. Of the several advantages of the composite spiral vein graft, the ability to construct a tubular graft from autogenous tissue with living endothelium of any desired diameter and length stands out as significant.
Implantation of Spiral Vein Graft
The innominate vein is occluded with a soft jaw clamp. The innominate vein is then divided. The distal end of the innominate vein, containing clot, is oversewn.
	An end-to-end anastomosis of the spiral vein graft to the innominate vein is constructed using 7-0 polypropylene suture. This anastomosis should be completely accurate. A straight on end-to-end anastomosis is preferred, rather than an end-to-side anastomosis, so that there is obligatory flow into the graft.
The vein graft is brought into approximation with the right atrial appendage. The appendage is isolated by vascular clamp. The tip of the appendage is excised. Trabeculations within the appendage are completely removed. A beveled end-to-end anastomosis of the graft to the atrial appendage is constructed using 5-0 polypropylene suture.
	The occlusion clamp is removed from the atrial appendage to backfill the graft. This shows the graft after removal of the proximal occlusion clamp.

Publication Date: 20-Apr-2005
Last Modified: 20-Apr-2005