Terumo Cardiovascular Group

Team Communication Can Optimize Conduit Quality

The importance of communication between clinicians during a cardiac surgery case cannot be overstated. Good conduit quality is a direct outcome of clear and consistent decisions made after deliberate discussions between the clinical teams.

Mark Schumacher, PA-C, Chief Physician Assistant, Cardiothoracic Surgery, Mount Carmel Hospital, Columbus, Ohio, encourages the use of a basic discussion outline, as recommended by Terumo Senior Clinical Specialist Michael Fortunato, PA-C.  “I could not agree more with this plan. Success comes from good decision making, experience, and good technique while having an open communication between surgeon and team,” says Mark.  The framework below may serve as a starting point for discussions between team members during case preparation. 

Pre-operative concerns:

Topic

Clinical Characteristics

Clinical Discussion

Anatomy

Varicosities, previous vein stripping, evidence of venous stasis and history of previous phlebitis

Would vein mapping help?

Pathology

Active phlebitis or thrombophlebitis, cellulitis, peripheral vascular disease?

Could antibiotics, heparin, testing be used to rule out venous or arterial disease?

Blood disorders

Hypercoagulability may increase chance for intra-luminal clot.

Would heparin help?

Pharmacology

Is the patient currently on anti-coagulants, anti-platelet or anti-inflammatory drugs? These may increase the chance for intra-operative bleeding during harvest.

What is the risk versus benefit of discontinuing these drugs prior to surgery?

Surgical considerations

Vein or arterial conduit?

These decisions reflect the surgeon's preference. Review the cardiac catherization results to determine the need for the vein and how much is required. The size of the coronary arteries and their match to the size of the vein is based on previous vein mapping.

Intra-operative considerations:

Topic

Clinical Characteristics

Clinical Discussion

Intra-operative mapping

Determine quality and location of vein.

Consider using, if not done pre-operatively. 

Surgical site

Left or right leg, proximal or distal vein?

Pathology or anatomical concerns may dictate from where the vein is harvested.

Alterations in blood flow

Hypercoagulability

Intra-operative heparin in bolus or continue infusion (ACT>300)?

Quantity of vein

Aberrant anatomy, e.g., enlarged heart, poor quality vein

The need for more or less vein is often dictated by intra-operative factors.

Open CO2 system of insufflation for endoscopic vessel harvesting

Alterations in blood flow (stasis)

A closed system may increase the chance for intra-luminal clot. Consider using an open CO2 system.1

Optical Coherence Tomography (OCT)

Intra-luminal clot

Consider using OCT to rule out intra-luminal clot, especially in high risk patients, if using closed CO2 EVH systems or non-heparinized patients.

Care of conduit

Post-saphenectomy handling of the vein

Use of isotonic solutions with or without heparin, use of heparinized blood, gentle flushing technique with special attention to intra-luminal pressure.

Use of hemostatic agents and wrapping of legs

Reduction of hematoma formation and decrease post-operative swelling

Consider use of hemostatic agents in hemorrhagic harvest tunnels. Consider the use of platelet gel to speed- up healing. Wrap legs with pressure bandage to decrease swelling and offer pressure dressing to lessen hematoma formation.

Post-operative concerns and issues related to vessel grafts and harvest sites:

Topic

Clinical Characteristics

Clinical Discussion

Pharmacologic

Anti-coagulants, cholesterol lowering drugs

Consider anti-platelet and/or aspirin once the concern for immediate post-op bleeding has passed.  Consider use of statins to help prevent recurrent disease.

Mechanical

Cardiac rehabilitation and wound care

Early ambulation, rehabilitation intervention for increased flow to and conditioning of the vein grafts. Protocols for leg wounds, i.e., elevation and incision care.

Social

Cessation of smoking, obesity, cholesterol, diabetes

Early intervention of risk factors that may lead to graft failure.

1 Brown et al. Strategies to reduce intraluminal clot formation in endoscopically harvested saphenous veins. J Thorac Cardiovasc Surg 2007;134:1259-1265