VAMC CT: Open saphenous vein harvest
5/14/08
Equipment and Instruments:
Separate saphenous vein tray and mayo
Bulldogs
Antibiotic irrigation
Heparin flush
Methylene blue
Setup
Patient is prepped and chest is draped. Place roll (two gowns wrapped in a towel) under
thigh and folded towel under knee. The leg should be somewhat externally rotated.
Procedure:
1. Find the vein: anterior to the medial malleolus, a finger or two above the malleolus.
You can sometimes see an indentation where the vein is and can sometimes see the vein
higher in the leg. Make a 4 cm longitudinal incision, over where you think the vein is,
dissect down with the scissors (heavy or Metz) until you find the vein.
2. Expose the vein: You unzip the leg with scissors, following the vein. Control bleeding
with Bovie as you go. Use the heavy scissors to spread above the vein. Follow the vein
up the leg, spreading just enough to slide the scissors in. Cut the tissue above the vein
including skin with the heavy scissors; avoid making dog ears in the skin. Try to stay in
the plane right above the vein so the surface is well exposed. This layer is sometimes
called the “chicken wire”. Length: in general, you need a least one Metz-length per graft.
Bovie as you go, there will be lots of little skin bleeders and occasionally crossing veins
that need to be clipped, tied or cauterized.
-occasionally the vein splits in the leg and you should follow the bigger branch
-some attendings like you to make a “bridge” at the knee. You will need to tunnel
along the vein under the skin as you cross the crease of the knee. Make a new incision on
the other side of the knee where you think the vein is, dissect down and continue.
3. Identify and remove branches: use the mosquito to expose vein branches. Clip the
branch away from the vein, tie on the vein side using silk ties. With smaller branches, tie
closer to the saphenous. Be careful not to pucker the saphenous by tying too close, and
also not to create a big cul-de-sac in the branch by tying too far away from the saphenous.
Cut the branch near the clip.
4. Cannulate: expose the distal saphenous. Place a large silk tie around it as far distally as
you can, and tie it off. Raise the saphenous slightly with the mosquito, then cut halfway
through with the Metz to create your venotomy. Cannulate and inject heparinized saline
to expand the vein and help you find missed branches. You can use the bulldog to clamp
off the vein part way up the leg and help you expand it when injecting the saline.
5. Dissect the out the vein. Hold the vein in one hand, use the Metz in your other. Slide
the Metz under the vein, to one side of the vein, turn the Metz sideways, inspect the
tissue. If you can see through it, it is safe to cut. Watch how Mark does this and try to
copy him. Keep an eye open for missed branches and clip-tie-cut as you find them.
6. Some attendings want a blue racing stripe on the vein. Let the vein dangle, with
bulldog on the end, so it is not twisted. Lay it flat on the towel. Paint the top surface with
a single stripe using methylene blue, end to end.
7. Hand the vein off to the scrub nurse, it will be put into a cup of heparinized blood.
8. Irrigate the wound with antibiotic irrigation.
9. Close the wound with a running subdermal 2-0 vicryl followed by a running 3-0
monocryl. The subdermal enters just below the dermis and can go to the bottom of the
wound. Cover the incision with a non-stick dressing cut in half, then with an island
dressing. Wrap the leg from foot to top of incision with ACE bandage. The leg is then
covered with fresh half sheet.