Achieving Optimal Conduit Quality with the VirtuoSaph Plus EVH System
Dr. Moritz Immohr is a cardiac surgery resident in the Department of Thoracic and Cardiovascular Surgery at the West German Heart and Vascular Center at Essen University Hospital. He completed his medical degree in 2018 and was trained at the University Hospitals of Düsseldorf and Aachen, and then at the TEDA International Cardiovascular Hospital in Tianjin, China. Dr. Moritz has been practicing EVH since 2019 and has successfully completed approximately 250 cases. He is fascinated by minimally invasive cardiac surgery and is constantly developing his technique to achieve the best possible results for patients.
Dr. Nelson Lee is a thoracic cardiovascular surgeon at the Philippines Heart Centre and also practices at private hospitals. He is the Head of the Operating Room Management Committee at the Philippines Heart Centre, where he is also a staff member of the Division of Thoracic Cardiovascular Surgery. Dr. Lee graduated from the University of Santo Tomas College of Medicine in 1990 and then went on to train further at the Philippines Heart Center. He finds cardiovascular surgery fascinating because he sees it as an opportunity to give critically ill patients a new chance at life. Dr. Lee began practicing EVH in 2010 and since then has successfully completed thousands of cases. He is particularly proud of the work he’s done with obese patients, noting that he has successfully harvested veins and reduced the incidence of complications, with better wound management for this patient group.
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What are the key characteristics of an optimal vein/arterial graft for bypass surgery?
Nelson Lee: "Personally for me, the key characteristics of an optimal vein or arterial graft is that they should have it should be of adequate size. For me for pain, it should be around 3 to 4mm and I determined this through preoperative ultrasound scanning of the patients. And then for arterial graft, it should be around this size also between 2 to 3mm of radial artery and it should be free of classification when we do the ultrasound scanning."
Moritz Immohr: "I think the most advantage of bypass surgery for example compared to PCI is long term patency. When you take out any graft or make graft harvesting, the first goal should be to achieve long term patency of the graft. For this is the quality of the graft.
The most important thing and one thing to achieve this good quality of grafts is that you preserve the intima integrity of the graft. For this you should avoid to cut any holes in the graft that you have terminal damage, that you have tension or that you dilatate the vein with or the arterial with strong pressure. And of course it's also important that the diameter of the graft fits the coronary system. So if you have for example, very large graft for very small coronary artery, then you will have very slow flow phenomena and this may lead to thrombotic events that can occur free of fast closure of the of the graft. And of course, it's also important that you have the right length of the graph. For example, if it's too short, then you'd also have tension on the graph which can lead to failure. And last but not least, and talking about minimal as of graft harvesting, it's also important that you have minimized the damage at the harvesting site that you have no extra morbidity for the patient during the due to the harvesting procedure."
How does the VirtuoSaph Plus EVH System support you in harvesting an optimal bypass graft?
Nelson Lee: "The VirtuoSaph Plus EVH system I think is a very good tool and instrument for us to have a very good quality of vein. When I compare previously when I do open surgeries with open technique, I find it daunting to have a very large wound. So with EVH it's quite easy. Our best thing when you get used to it will only take will only take me around 30 minutes as compared to open harvesting where sometimes it will take it will take you around one hour, 1 1/2 hour to paint to harvest the entire leg. So using the EVH system makes it quite easy and straightforward."
Moritz Immohr:"I think one of the main problems to achieve an optimal harvest graft is that you damage the vein. And in order to not damage the vein, it's really important to have a good visualization of the graft during the whole harvesting process. The ViertuoSpah Plus EVH system has a really good application for the CO2. The carbon dioxide is released at the tip of the system and both the dissector as well as the harvester itself. You always get the CO2 right there where you're doing the process. It helps you to visualize the graphs that you do not damage it where because you can't see the graph itself.
The v-keeper system helps you to safely take the graft in the working channel and that you do not miss any of the side branches. And also with the cautery it's you have a fixed distance between the beekeeper and the coagulation. You have really long ends of the side branches when you counter them. You are reducing thermal damage to the side branches and of course also to the graft itself, which is quite important for the long term pay to see and also for the integrity of the grafts. I think all together helps you to visualize the graph that you do not damage is and that you safely or securely cut off the side branches and do not miss anything. I think that's the main advances of the system."
During the learning phase of EVH, what is your advice to avoid common mistakes that may impact conduit quality??
Nelson Lee: "I'm sharing the first few cases that I did EVH make the common mistakes that I did before and what a young surgeon would want to avoid is try to avoid avulsing some of the tributaries that you encounter during dissection. So very important is how we dissect the vein. So previously I would do extensive dissection, but now I have learned that by just doing an anterior and posterior dissection, that should be enough. And you should progress in small, small steps or small minimal advancement at first and let the let the pressure of the gas, the carbon dioxide gas does some of the dissection for you. That's one. Avoid too much dissection.
Number two is to avoid applying too much energy on this tributary because the energy would tend to travel towards the main vein graft and that would create damage to the intima and probably would lead into early occlusion later on of the shop in this brain graft.
But those are the two most important things that I learned during the early pace of my learning doing EVH."
Moritz Immohr: "I would advise everyone in the learning phase, first of all, to look at the right or proper marking of the vein and before you start the procedure. You should, before you start the procedure, you should first look for the vein, mark it with the pen, for example, that afterwards you really know where the vein is and where to look at the vein. When you have this feature started, you already started with good or confident feeling because you will find the vein or though you're using just such a small incision.
Then it's very, very important in my opinion that you take your time. It's not good to hurry, especially within the first cases because if you hurry you will hurt the vein or the arterial graft definitely. So take your time, especially with the dissecting part, because during dissection you can look at all the side branches, take them clear that you can see them. And after this, this second procedure will be quite easy. But without good dissecting and with your tail hurry the dissecting part, you have very bad visualization of the side branches afterwards. You cannot correct this. So when you're new to EVH area, you should take a time dissecting very slowly, very carefully. Look in all the side branches. And if you're done with that, you will take the second part with the counter and it will be very easy and very fast without hurting the vein.
And last but not least, I think it's also important to recap your procedure afterwards. So if the graft is taking out and prepared for bypass surgery, you can look at the graft together with the other surgeon, see is there any damage. Then you can ask yourself why this kind of damage is there and just recap the procedure, what could be better the next time?
So that will help to improve one time after another."
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