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Protocol: Vein Harvesting in the Operating Theater

Friday, January 29, 2016

When harvesting a vein graft, a few points are important to bear in mind:

  1. Patients have more complications from their leg wound than anything else after cardiac surgery. Make a good job of hemostasis and leg closure. Ensure there is no dead space and bury all knots.
  2. Commence your incision well clear of the medial malleolus as this area heals poorly. Usually the right leg is used but check with your seniors whether there is any reason for the other leg to be used, e.g., previous varicose vein surgery or peripheral vascular disease.
  3. After identifying the vein, advance about 11⁄2 inches at a time, following the vein up the medial aspect of the leg. Use Mayo scissors or a scalpel to incise in the line of the vein and at right angles to the skin, down onto the vein itself. Trying to advance too far at a time will result in you losing the line of the vein.
  4. Vein is usually harvested to just above the knee (2 vein grafts) or to the groin (> 3 vein grafts). One vein graft is approximately the length of a pair of McIndoe scissors.
  5. Once the incision has been made, go back and begin to dissect out the vein from its bed. Do this carefully. Identify each side branch and tie the vein side perfectly. Do not tie too close to the vein as this may lead to distortion. Ensure side branches are cut long enough to prevent ties coming off. Avoid the saphenous nerve. The end of the side branch is Liga-clipped. Remember the vein will be operating under arterial pressure - imperfect side branch ties may fall off, causing much wailing and gnashing of teeth amongst the surgical ITU staff post-operatively.
  6. When the vein has been completely dissected out, it will remain attached top and bottom only. Place a clip at the lower end and part incise the lower end of the vein to insert a plastic vein cannula. Tie this in.
  7. Test the vein. Some heparinized blood or saline is provided for this purpose. Identify any side branches or holes and fix them, e.g., Ligaclips or ties. Occasionally 7/0 Prolene may be necessary. Do not over-inflate the vein as this damages the endothelium and limits long term patency.
  8. After you are happy, place the vein in the bowl provided and ensure it is covered in blood or saline to prevent it drying out. Hand it carefully to the scrub nurse. If you drop it on the floor at this point there will be considerable unhappiness and you would be advised to consider Public Health Medicine as an alternative career.
  9. NOTE: Traumatic handling of the vein and overdistension during testing both influence the long term patency of the vein graft. Handle the vein carefully and gently.
  10. Close the leg carefully. Attention to technique, especially hemostasis, at this point, will significantly influence the rate of leg complications.
  11. Some consultants have preferences over the site of vein to be used or how it is harvested. The above notes are a generalization. Check with your team what is required before operating. 

This protocol is provided by the Freeman Hospital Regional Cardiothoracic Centre. 


Excellent protocol . In point No 5 - you may add : the distance of the tie on the branch from the parent vein should be the same as the size of the branch ie if the branch is 1mm wide - the tie should be 1 mm from the main vein, This prevents distortion (by too close a tie) or outpouching (from a tie too far off) .
No touch technique helps in avoiding push and pull of the vein graft. A vessel loop passed under the vein and held across a Kelly clamp will allow the vein to be gently placed on traction to facilitate branch ligation. This technique avoids intimal tears along branch entry points and facilitates easy harvest. Also to note, leaving a bridge across the knee joint helps in early pain-free ambulation of the patient.
Who takes vein using the open technique anymore? Almost all leg complications and the pain, are reduced using the endoscopic harvest approach. Great list of dos and donts- from 15 years ago!

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