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Enhanced Endoscopic Vein Harvesting Of The Great Saphenous Vein For Cabg Using Hydrodissection
Louis P. Perrault1, John F. Gallagher
2, Pamela M. Gallagher
3, Steven Escavarage
4, Kaitlin Masciello
5, Paul J. Gallagher
6, Victor Garcia
7, Dan Fusco
8.
1Montreal Heart Institute, Montreal, QC, Canada,
2Montreal Heart Institute Research Center, Montreal, QC, Canada,
3N/A, N/A, NY, USA,
4Hartford HealthCare Medical Group, Bridgeport, CT, USA,
5Hackensack Meridian Health, New York, NY, USA,
6N/A, Bayshore, NY, USA,
7New York Medical College, Valhalla, NY, USA,
8Hartford HealthCare Medical Group, Bri, CT, USA.
BACKGROUND: Coronary Artery Disease (CAD) is the primary cause of mortality in the United States and the third leading cause of death globally. While Coronary Artery Bypass Grafting (CABG) using the left internal mammary artery to the left anterior descending artery remains the gold standard with a 90% patency rate at 15 years, the great saphenous vein (GSV) harvested by endoscopic vein harvesting (EVH) is the second most common conduit despite its poor long-term patency due to vein graft failure (VGF). To address the limitations of EVH and the technically demanding "no touch" technique, we developed the Minimally Invasive No Touch (MINT) technique
METHODS: GSVs were harvested using three techniques: standard EVH, "no touch," and the MINT procedure. The MINT technique involves hydrodissection to gently harvest the GSV with minimal trauma. A Physician Assistant (PA) with experience in over 2,000 standard EVH procedures conducted the harvesting. The quality of the GSVs was evaluated by measuring endothelial nitric oxide synthase (eNOS) activity and nitric oxide (NO) bioavailability.
RESULTS: Preliminary studies revealed that GSVs harvested using the MINT procedure showed a 3.4-fold increase in NO generation compared to standard EVH and "no touch" samples. Moreover, histological staining of MINT-harvested veins uncovered a preserved endothelial cell layer and reduced clot formation.This indicates that MINT-harvested veins have a structurally and functionally intact endothelium, as evidenced by elevated eNOS activity and NO bioavailability.
CONCLUSIONS: The MINT technique effectively addresses the issues of VGF and excessive trauma associated with GSV harvesting in CABG. GSVs harvested using the MINT procedure demonstrate improved endothelial function, suggesting potential long-term patency benefits. Further studies are needed to fully understand the vascular benefits and clinical implications of the MINT technique for CABG procedures.
LEGEND: Figure 1. A) Representative still image of MINT-harvesting procedure showcasing the hydrodissected main trunk of greater saphenous vein (GSV)* and side branch**H: Hydrodissector. High-resolution scanning electron microscopy (SEM) images of
B) MINT,
C) Open No Touch, and
D) EVH-harvested GSVs at X1500 magnification. High-resolution photomicrographs of MINT SVG segments (Figure B) demonstrated an intact endothelial structure displaying the characteristic cobblestone pattern, devoid of any adherent thrombi. SEM of EVH samples (Figure D) showed an irregular endothelial surface. In contrast, SEM examination of the Open No Touch specimens (Figure C) reveal disrupted endothelial layers, manifesting as an irregular surface pattern, cellular edema, and the presence of red blood cells.
E-F) Endothelial Nitric Oxide Synthase (eNOS) activity assays conducted in human GSV segments from MINT, standard EVH with CO
2 and Open No Touch techniques (n=17, 7, and 24 respectively, 2-3 vessel rings/sample, triplicate measurements) (P ≤ 0.0001). On eNOS activity assays, MINT-harvested GSV segments (n=17) showed significantly greater preservation of eNOS activity compared to both the standard EVH (n=7) and Open No-Touch (n=24) groups (P ≤ 0.0001 for both comparisons). The significance of differences was assessed using the ordinary one-way analysis of variance (ANOVA), with Brown-Forsythe and Bartlett’s test.
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