Navigating Challenging Endoscopic Vessel Harvesting Cases

Can you describe a challenging EVH case you’ve encountered and what strategies you implemented to overcome the difficulties?

Adam Wiesenthal: "Challenging EVH case that I recently came across was a double system with large bilateral varicosities. For this case, initially we had bilateral vein mapping which gave us an idea into what we've been encountering and intra OP we did a bilateral ultrasound to give a better road map of branches and where the double system is as well as diameters of each vein. The conical tip of the dissector was very helpful. We were able to isolate large branches and the open gas system grave great visualization for both systems at the same time and when it came to harvesting the V-cutter and spot cautery were very helpful and give a great result for our vein removal."

Majed Tolah:Majed Tolah: "The most difficult cases what we are facing is the patients with varicose veins. Especially in these patients who had stripping before in another leg or the same leg, the conduit choices will be minimized in these situations. The saphenous veins mostly are not only tortuous but also fragile. That's means it will be more tricky to dissect and harvest without damaging it. The enlarged branches in these situations plus the regular pathway which will make it more complex in such cases.

I talk as small key points: First, just keep in mind that's how important this vein for the patients and try to to be professional in your way and give the patient the best of what he deserves. Second, careful dissection. During the procedure, try to be gentle as much as you can and dissecting the small branches first, avoid any excessive pulling or tension, especially in the big branches or the fragile areas. Then one of the most difficult points is managing the branches, managing branches, especially the dilated one or enlarged. Just try to prevent the unnecessary stress in the main conduit. And for my points for my view, I will try to harvest these big branches at the beginning to make sure that this will be no bloody area to complete the harvesting.

Finally, and the most importantly in my mind, keeping my team updated throughout the case, if you're facing any difficulties with the veins facing a small area, it's not graftable or a big huge dilated veins, just communicate with the team with no don't hesitate. You may switch to another alternative conduit like rima or radial arteries."

What lessons or key takeaways from that challenging experience have influenced your approach to future EVH procedures?

Adam Wiesenthal: " So lessons from that EVH experience have taught me to routinely and personally perform an ultrasound in the operating room, evaluate bilateral lower extremities to get a better road map of what you'll encounter close communication with the surgeon is paramount. It allows the two of you to plan the case more efficiently and also to take the time and carefully isolate large branches and use the V-cutter and spot cautery rate when necessary. "

Majed Tolah: "In that case really enforced me to plan and to see how important is the plan and adaptability. The preoperative mapping gives you a road map and how to prepare myself to what you can do, and you will not expect. A small trick could help a lot. Mark the vein and the branches over the skin you're using ultrasound preoperatively, it will assist you or guiding you during harvesting. It's with that's especially for the beginners will help a lot. An additional way is, learn how to be a systematic just be systematic. Especially during the difficult cases, obese patients or fragile varicose veins or also a too skinny patient.

Another key take away as well is how important is to be flexible. Sometimes you need to adjust your approach and just your manoeuvre and standing, moving and just be flexible in these situations.

And the last but not least, react fast and communicate with your team quickly. Sometimes you have to do a consensus decision just once you are facing difficult cases or difficult veins during your approach contact with your team and to seek for an alternative conduits or an alternative methods as in some cases, you have to go with the anesthesis as a T or Y graft."

What advice would you give to other clinicians on handling complex cases and maintaining composure under pressure during EVH?

Adam Wiesenthal: " Like I stated before, ultrasounding the leg and making sure that you have a road map in your mind is really important. Having great communication with their surgeon is very important. Also knowing where your instruments and chords are at all times on your mayostand. Staying organized is really paramount. You want to make sure that you're not looking for anything if there's an issue. Another strategy that I like to use is marking the skin with a skin marker at large branches so that I have an idea on where I may need to go back and spot photorize if needed. And then planning on knowing your resources. Typically having another harvester in the hospital or maybe in a room next door or somebody who can come in and give you advice is really helpful, especially for the first few years of harvesting advice."

Majed Tolah: "Plan ahead before you start. I prefer to preoperatively visit the patient, see his conduits, veins or radius and do a mapping before. That would help you. It will help you a lot to be flexible. There is no two cases similar, so you may need to adopt your technique to your manoeuvre and you're standing, you're moving and so on. The third things, the third advice, keep calm and focus the pressure. The pressure is part of your job. Just take it seriously, be calm and avoid. Clean your mind, clear your mind and avoid some mistakes communications, just talk with the team.

A good team, a good supportive team, cooperating will help you a lot to avoid this or to get out of these situations. Learn from every single case. Every single case you may face might be difficult. Whatever you moved on, how you did, how is, how was your approach? Just learn it and keep in your mind it will improve you in the future.

At the end of the day, the complex cases are always going to be a part of your job. Whatever what matter do you have facing individually? Just prepare yourself, be patient and adopt yourself and communicate with the team to make the difficulties easier. And good luck."