HOW TO DO IT
The Lesser Saphenous Vein A n Alternative Graft for Coronary Revascularization Ivan K. Crosby, F.R.C.S., and Joseph M. Craver, M.D.
ABSTRACT In patients with surgically removed or varicose greater saphenous veins and atherosclerotic or small internal mammary arteries, or in patients requiring three or more coronary bypasses, the lesser saphenous vein can be considered for aortocoronary revascularization procedures. Its suitability can be demonstrated preoperatively by careful clinical examination and by venography. This report describes the successful use of the lesser saphenous vein in 3 patients, with long-term follow-up.
A
lthough the greater saphenous vein is most commonly used in coronary revascularization procedures, alternative autogenous tissue conduits include the internal mammary artery, the radial artery, the splenic artery, and the cephalic vein [ l , 2, 41. When the greater saphenous veins are absent or grossly diseased, when the internal mammary arteries are small or atherosclerotic, and when the cephalic veins are thrombosed secondary to multiple venipunctures, it is sometimes difficult to acquire enough length of autogenous bypass material for a triple-vessel revascularization.The radial artery is less satisfactory in terms of its low patency rate (approximately 50%)because of severe subintimal hyperplasia [3], and rather than harvest homograft or xenograft conduits, surgeons could consider the suitability of the lesser saphenous veins. This report describes the evaluation of the lesser saphenous vein and its clinical use in coronary revascularization procedures.
Method Preoperative documentation of the presence of suitable lesser saphenous veins is important. This can be achieved by one of two techniques: in the nonobese, upright individual, the application of a venous tourniquetjust below the knee will cause the lesser saphenous vein to become distended and clinically obvious; when From the Division of Thoracic and Cardiovascular Surgery, University of Virginia Medical Center, Charlottesville, Va. Accepted for publication April 5, 1975. Address reprint requests to Dr. Crosby, Box 181, Department of Surgery, University of Virginia Hospital, Charlottesville, Va. 22901.
VOL. 20, NO. 6, DECEMBER, 1975
703
CROSBY AND CRAVER clinical examination fails to demonstrate a suitable lesser saphenous vein, venography performed by injection of contrast dye into the dorsal metatarsal arch will outline the presence of the lesser saphenous vein (Figure, A, B). In the operating room the anesthetized patient is turned into the prone position, and through separate skin incisions the lesser saphenous vein is harvested from the posterior to the lateral malleolus up to the popliteal fossa. This provides a vascular autogenous bypass approximately 35 cm in length and of a uniform internal diameter (4 to 5 mm) suitable for two coronary grafts (Figure, C). A similar length of vein can usually be harvested from the other leg. When these skin incisions are closed, the patient is turned to the supine position and redraped in preparation for his median sternotomy and coronary revascularization procedure.
(A)Preoperative venogram shows the lesser saphenous vein entering the poplitealfossa and joining the popliteal vein just above the level of the knee joint. ( B ) Venogram demonstrates absence of the greater saphenous system but a patent lesser saphenous systemfrom the ankle up to the kneejoint. (C) The vein from one leg is of adequate lengthf o r two aortocoronarygrafts and makes a satkfactory conduit in terms of internal diameter.
704
THE ANNALS OF THORACIC SURGERY
HOW TO DO IT:
Lesser Saphenous Vein as Coronary Graft
Results T h e lesser saphenous vein has been used in 3 patients, all of whom had absent greater saphenous veins due to surgical stripping and all of whom required multiple-vessel revascularization. In the first patient, clinical examination did not reveal satisfactory lesser saphenous veins; bilateral venograms showed the lesser saphenous vein in one leg to be suitable for two grafts and in the other leg to be unsuitable for such use. This patient underwent insertion of a left internal mammary graft and a double lesser saphenous vein graft. T h e second patient had clinically obvious lesser saphenous veins bilaterally and underwent a quadruple coronary bypass procedure. Five months after operation, due to persistent arrhythmias, coronary arteriograms were performed revealing all four grafts to be patent and of normal appearance; however, the patient died of an arrhythmia one week later. T h e third patient had clinically detectable lesser saphenous veins and underwent a triple-vessel revascularization using the lesser saphenous system bilaterally. Both this individual and the first patient are symptom free and have resumed full physical activity. Despite the presence of some chronic venous insufficiency, in all patients the surgical incisions on the posterior aspect of the lower leg healed normally prior to hospital discharge.
Comment T h e lesser saphenous vein is of optimal length and diameter for coronary revascularization procedures. Its presence can be demonstrated clinically or radiologically before operation, and it may even prove suitable for use in femoropopliteal grafts should the greater saphenous vein not be available. Its long-term patency rate is unknown at this time, but one presumes that it will approximate the long-term patency of the greater saphenous vein.
References 1. Adam, M., Mitchel, B. F., Lambert,'C.J., and Geisler, G. F. Long-term results in aorta-to-coronary artery bypass vein grafts. Ann Thorac Surg 14: 1 , 1972. 2. Brody, W. R., Kosek, J. C., and Angell, W. W. Changes in vein grafts following aorto-coronary bypass induced by pressure and ischemia. J Thorac Cardiovasc Surg 64:847, 1972. 3. Curtis, J. J., Stoney, W. S., Alford, W. C., Jr., Burrus, G. R., and Thomas, C. S., Jr. Intimal hyperplasia: A cause of radial artery aortocoronary bypass graft failure. P 628, this issue. 4. Edwards, W. S., Blakeley, W. R., and Lewis, C . E. Technique of coronary bypass with autogenous arteries. J Thorac Cardiovasc Surg 65272, 1973.
VOL. 20, NO. 6, DECEMBER, 1975
705
The Lesser Saphenous Vein A n Alternative Graft for Coronary Revascularization Ivan K. Crosby, F.R.C.S., and Joseph M. Craver, M.D.
ABSTRACT In patients with surgically removed or varicose greater saphenous veins and atherosclerotic or small internal mammary arteries, or in patients requiring three or more coronary bypasses, the lesser saphenous vein can be considered for aortocoronary revascularization procedures. Its suitability can be demonstrated preoperatively by careful clinical examination and by venography. This report describes the successful use of the lesser saphenous vein in 3 patients, with long-term follow-up.
A
lthough the greater saphenous vein is most commonly used in coronary revascularization procedures, alternative autogenous tissue conduits include the internal mammary artery, the radial artery, the splenic artery, and the cephalic vein [ l , 2, 41. When the greater saphenous veins are absent or grossly diseased, when the internal mammary arteries are small or atherosclerotic, and when the cephalic veins are thrombosed secondary to multiple venipunctures, it is sometimes difficult to acquire enough length of autogenous bypass material for a triple-vessel revascularization.The radial artery is less satisfactory in terms of its low patency rate (approximately 50%)because of severe subintimal hyperplasia [3], and rather than harvest homograft or xenograft conduits, surgeons could consider the suitability of the lesser saphenous veins. This report describes the evaluation of the lesser saphenous vein and its clinical use in coronary revascularization procedures.
Method Preoperative documentation of the presence of suitable lesser saphenous veins is important. This can be achieved by one of two techniques: in the nonobese, upright individual, the application of a venous tourniquetjust below the knee will cause the lesser saphenous vein to become distended and clinically obvious; when From the Division of Thoracic and Cardiovascular Surgery, University of Virginia Medical Center, Charlottesville, Va. Accepted for publication April 5, 1975. Address reprint requests to Dr. Crosby, Box 181, Department of Surgery, University of Virginia Hospital, Charlottesville, Va. 22901.
VOL. 20, NO. 6, DECEMBER, 1975
703
CROSBY AND CRAVER clinical examination fails to demonstrate a suitable lesser saphenous vein, venography performed by injection of contrast dye into the dorsal metatarsal arch will outline the presence of the lesser saphenous vein (Figure, A, B). In the operating room the anesthetized patient is turned into the prone position, and through separate skin incisions the lesser saphenous vein is harvested from the posterior to the lateral malleolus up to the popliteal fossa. This provides a vascular autogenous bypass approximately 35 cm in length and of a uniform internal diameter (4 to 5 mm) suitable for two coronary grafts (Figure, C). A similar length of vein can usually be harvested from the other leg. When these skin incisions are closed, the patient is turned to the supine position and redraped in preparation for his median sternotomy and coronary revascularization procedure.
(A)Preoperative venogram shows the lesser saphenous vein entering the poplitealfossa and joining the popliteal vein just above the level of the knee joint. ( B ) Venogram demonstrates absence of the greater saphenous system but a patent lesser saphenous systemfrom the ankle up to the kneejoint. (C) The vein from one leg is of adequate lengthf o r two aortocoronarygrafts and makes a satkfactory conduit in terms of internal diameter.
704
THE ANNALS OF THORACIC SURGERY
HOW TO DO IT:
Lesser Saphenous Vein as Coronary Graft
Results T h e lesser saphenous vein has been used in 3 patients, all of whom had absent greater saphenous veins due to surgical stripping and all of whom required multiple-vessel revascularization. In the first patient, clinical examination did not reveal satisfactory lesser saphenous veins; bilateral venograms showed the lesser saphenous vein in one leg to be suitable for two grafts and in the other leg to be unsuitable for such use. This patient underwent insertion of a left internal mammary graft and a double lesser saphenous vein graft. T h e second patient had clinically obvious lesser saphenous veins bilaterally and underwent a quadruple coronary bypass procedure. Five months after operation, due to persistent arrhythmias, coronary arteriograms were performed revealing all four grafts to be patent and of normal appearance; however, the patient died of an arrhythmia one week later. T h e third patient had clinically detectable lesser saphenous veins and underwent a triple-vessel revascularization using the lesser saphenous system bilaterally. Both this individual and the first patient are symptom free and have resumed full physical activity. Despite the presence of some chronic venous insufficiency, in all patients the surgical incisions on the posterior aspect of the lower leg healed normally prior to hospital discharge.
Comment T h e lesser saphenous vein is of optimal length and diameter for coronary revascularization procedures. Its presence can be demonstrated clinically or radiologically before operation, and it may even prove suitable for use in femoropopliteal grafts should the greater saphenous vein not be available. Its long-term patency rate is unknown at this time, but one presumes that it will approximate the long-term patency of the greater saphenous vein.
References 1. Adam, M., Mitchel, B. F., Lambert,'C.J., and Geisler, G. F. Long-term results in aorta-to-coronary artery bypass vein grafts. Ann Thorac Surg 14: 1 , 1972. 2. Brody, W. R., Kosek, J. C., and Angell, W. W. Changes in vein grafts following aorto-coronary bypass induced by pressure and ischemia. J Thorac Cardiovasc Surg 64:847, 1972. 3. Curtis, J. J., Stoney, W. S., Alford, W. C., Jr., Burrus, G. R., and Thomas, C. S., Jr. Intimal hyperplasia: A cause of radial artery aortocoronary bypass graft failure. P 628, this issue. 4. Edwards, W. S., Blakeley, W. R., and Lewis, C . E. Technique of coronary bypass with autogenous arteries. J Thorac Cardiovasc Surg 65272, 1973.
VOL. 20, NO. 6, DECEMBER, 1975
705
