The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 1 , Pages 239-241, January 2010

Saphenous vein harvest with the Mayo extraluminal dissector: Is endothelial function preserved?

  • Michael R. Dashwood, PhD

      Affiliations

    • Department of Clinical Biochemistry, Royal Free and University College Medical School, London, United Kingdom
    • ,
  • Stephen Fremes, MD, MSc

      Affiliations

    • Divisions of Cardiac and Vascular Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
    • ,
  • Domingos S.R. Souza, MD, PhD

      Affiliations

    • Department of Cardiothoracic Surgery and Anesthesiology, Örebro University Hospital, Örebro, Sweden

Article Outline

CTSNet classification: 8, 23, 38

 

To the Editor:

The recent brief communication in this Journal by Narayan and associates1 describes potential benefits of using the Mayo extraluminal dissector to harvest the saphenous vein in patients undergoing coronary artery bypass grafting (CABG). Biochemical studies suggest that endothelial function is preserved. Inasmuch as there is no difference in baseline characteristics or cyclic guanosine monophosphate production between conventional harvesting and veins prepared with the Mayo vein stripper, the authors consider “the use of this underused surgical aid…a very attractive option.” In the same issue we provide histologic evidence that saphenous veins harvested using a “no-touch” technique retain a normal structure, an intact endothelium, and preserved endothelial nitric oxide synthase (eNOS) and NOS activity,2 factors contributing to improved patency in patients undergoing CABG.3

The Mayo vein stripper, introduced as an alternative means of harvesting the saphenous vein, has been the subject of numerous publications. A recent review describes potential benefits of endoscopic harvesting, including improved wound healing and cosmetic outcome and reduced infection. The authors cite functional studies showing no difference in vasoreactivity between conventional and endoscopically prepared veins, stating macroscopic comparison of these conduits to be only “fair.” However, a recently published secondary analysis from the PREVENT IV investigators strongly suggests that vein graft patency is inferior and late cardiac events increased with endoscopic compared with conventionally harvested saphenous veins.4, 5

Although many studies focus on the preserved luminal endothelium of endoscopically prepared veins, the effect of the Mayo stripper on the outer layers of the veins is generally neglected. In a recent study on 200 patients, significant endothelial denudation and reduced eNOS immunostaining of medial and adventitial vasa vasorum were reported in conventionally prepared saphenous veins compared with those harvested using the Mayo stripper.6 There is evidence that many perivascular structures that are damaged or removed when vein is harvested by conventional techniques affect graft performance (Figure 1). For example, the outermost vessel layer, the adventitia, contains the vasa vasorum, microvessels providing oxygen and nutrients to the vessel wall. In addition, the perivascular fat surrounding various blood vessels is a potential source of vasodilators or anticontractile factors (adipocyte-derived relaxing factors), one of which is nitric oxide.7 The main benefits of using the Mayo stripper for saphenous vein harvesting in patients undergoing CABG are reduced wound infection and improved wound healing and appearance, yet there is no compelling evidence that this method results in an improved graft patency. In our opinion, the outermost layers of the saphenous vein play a crucial role in the improved performance of the “no-touch” technique. These layers not only provide mechanical support to the vein once subjected to arterial hemodynamics2 but also contain the vasa vasorum, eNOS, messenger RNA, and protein and possesses NOS activity.2, 7 “No-touch” vein harvesting provides long-term patency comparable with the left internal thoracic artery,3 has been adopted by a number of other centers, and is to be investigated in a forthcoming multicenter trial. We believe that future efforts are now required to improve wound healing and attain better cosmesis in patients in whom the saphenous vein is harvested by the “no-touch” technique.

  • View full-size image.
  • Figure 1 

    Histology of saphenous veins in patients undergoing CABG. Transverse sections of saphenous vein harvested using the Mayo stripper (A), conventional preparation (B), and by the “no-touch” technique (C). The adventitia is damaged or removed using conventional methods and the Mayo stripper, whereas this layer remains intact using the “no-touch” technique (C). Also, the “no-touch” vein is surrounded by a cushion of fat (black staining). The arrows indicate the external elastic lamina, the media/adventitia border. Scale bar = 0.5 mm. (Part A was modified from Nowicki M, Buczkowski P, Miskowiak B, Konwerska B, Ostalsk-Nowiska D, Dyszkiewicz W. Immunocytochemical Study on Endothelial Integrity of Saphenous Vein Grafts Harvested by Minimally Invasive Surgery with the Use of Vascular Mayo Strippers. A Randomized Controlled Trial. Eur J Vasc Endovasc Surg. 2004;27:244-50. Published with permission.)

Back to Article Outline

References 

  1. Narayan P, Yeatman M, Caputo M, Capoun R, Cuilli F, Jeremy JY, et al. Saphenous vein harvest with the Mayo extraluminal disector: is endotelial function preserved?. J Thorac Cardiovasc Surg. 2009;138:508–510
  2. Dashwood MR, Savage K, Tsui JC, Dooley A, Shaw SG, Alfonso MS, et al. Retaining perivascular tissue of human saphenous vein grafts protects against surgical and distension-induced damage and preserves endothelial nitric oxide synthase and nitric oxide synthase activity. J Thorac Cardiovasc Surg. 2009;138:334–340
  3. Souza DSR, Johansson B, Bojö L, Karlsson R, Häkan G, Filbey D, et al. Harvesting the saphenous vein with surrounding tissue for CABG provides long-term patency comparable to the left internal thoracic artery: results of a randomized longitudinal trial. J Thorac Cardiovasc Surg. 2006;132:373–378
  4. Aziz A, Athanasiou T, Darzi A. Minimally invasive conduit harvesting: a systematic review. Eur J Cardiothorac Surg. 2006;29:324–333
  5. Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med. 2009;361:235–244
  6. Nowicki M, Buczkowski P, Miskowiak B, Konwerska B, Ostalsk-Nowiska D, Dyszkiewicz W. Immunocytochemical study on endothelial integrity of saphenous vein grafts harvested by minimally invasive surgery with the use of vascular Mayo strippers. A randomized controlled trial. Eur J Vasc Endovasc Surg. 2004;27:244–250
  7. Dashwood MR, Dooley A, Shi-Wen X, Abraham DJ, Souza DS. Does periadventitial fat-derived nitric oxide play a role in improved saphenous vein graft patency in patients undergoing coronary artery bypass surgery?. J Vasc Res. 2007;44:175–181

PII: S0022-5223(09)01252-5

doi:10.1016/j.jtcvs.2009.08.054

Refers to article:

  • Saphenous vein harvest with the Mayo extraluminal dissector: Is endothelial function preserved? , 01 September 2008

    Pradeep Narayan, Mark Yeatman, Massimo Caputo, Radek Capoun, Franco Ciulli, Jamie Y. Jeremy, Gianni D. Angelini
    The Journal of Thoracic and Cardiovascular Surgery August 2009 (Vol. 138, Issue 2, Pages 508-510)

The Journal of Thoracic and Cardiovascular Surgery
Volume 139, Issue 1 , Pages 239-241, January 2010

Article Tools

* Image Usage & Resolution