The Importance of Dissection for a Successful Endoscopic Vessel Harvesting (EVH) Procedure
Carlo Zingaro, MD, is a Senior Cardiac Surgeon at Ospedali Riuniti Di Ancona in Ancona, Italy, and has held this position since 2012. Prior to that, he completed his residency at the same institution. In addition to his surgical practice, Dr. Zingaro has been proctoring other healthcare providers in EVH for nearly 20 years. In 2002 he graduated with honors from Gabriele D’Annunzio University, in Chieti-Pescara, Italy, earning his degree in Medicine and Surgery. In 2008 Dr. Zingaro completed his Specialization in Cardiac Surgery at the same university – again graduating with honors. He is also a prolific researcher, having authored or co-authored nearly 40 peer-reviewed articles in numerous medical journals.
Chase Hungerford is a PC-C, who lives and works in the Los Angeles, CA, area. He earned a bachelor's degree in Kinesiology and Exercise Science from California State University of Long Beach and then went on to earn a Master of Physician Assistant Studies from the University of Southern California. Chase has worked in the cardiovascular operating room for more than 9 years and in that time he estimates that he has completed over 800 endoscopic harvesting procedures. He says that his time in the CVOR has provided a challenging and rewarding career with the opportunity to help support patients in some of the darkest moments of their lives. Chase advises beginning harvesters to not rush the dissection portion of the EVH process, as the time spent during dissection helps with the remainder of the procedure.
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In your opinion, why is dissection such an integral part of EVH?
Dr. Carlo Zingaro: "I think that a current section of the vein is essential to obtain a perfect tunnel in which to move freely for cutting the collaterals. The better the dissection is performed, the easier and faster the collateral cutting the phase will be."
Chase Hungerford: "My opinion, dissection is one of the key aspects of having successful endoscopic being harvesting. It sets you up for success in the latter half of the operation where you can fully see all of the branches and including large branches and their base where there might actually be smaller sub branches that you could tackle allowing for better cauterization and a drier tunnel."
What strategies do you utilize to ensure you create an optimal tunnel?
Dr. Carlo Zingaro: "I usually perform the dissection advancing with the tip of the cannula* in just two steps, one above the vein at first and one below the vein. During the first step I take tear to prepare well all the branches that I encounter in the 180° above the vein. With the second steps I prepare the remaining branches below the vein in order to correctly prepare the collateral. Easy enough doing gently tap tap with the tip of the cannula* in front and behind the branch, but is often useful aptly pressure with the left hand above the skin to divert the sophamous vein towards the tip of the dissector. You need to have a perfect control of the people of the cannula* to avoid creating false tunnels through the walls of the right tunnel. A tunnel with the integral walls, with the clean vein and branches, without fat and without three pieces of fat is a perfect tunnel."
*Cannula = VirtuoSaph Puls dissector
Chase Hungerford: "Creating an optimal tunnel with dissection is extremely important to have a successful outcome with endoscopic vein harvesting. One of the things I like to do is to #1 slow down and #2 really dissect out the branches to make sure that if it's a large branch, you're not going to be struggling with that large branch in the second part of the harvest. And you may find that that large branch actually branches down into some smaller ones, which is going to make it much easier to have success in cauterizing them and freeing branches."
If you could give one piece of advice to clinicians about dissection, what would it be and why?
Dr. Carlo Zingaro: "My advice is definitely to take care to perform a perfect section as accurate as possible, obtaining a tunnel as large as possible, as free from obstacle as as possible in order to perform a quick and easy collateral cutting phase. So take your time to have a perfect tunnel with the perfect dissection before moving on to the collateral scatting."
Chase Hungerford: "And one key piece of advice for newer harvesters starting out with endoscopic vein harvesting would be to keep your cone as close to that main vein as possible, but not into that vein. And to really slow down and take your time around branches kind of above and below on either side of them to fully dissect them out, making the second part of the harvesting operation much easier.""
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