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Vein Drama:  My experience with the wild and wonderful world of EVH

Posted by Liza Szelkowski, PA-C on Oct 27, 2017 10:25:39 AM

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As the years go by, I feel like I’ve become better equipped to handle any situation I face at work.  I’m not saying I always know exactly what to do, but the experience I have obtained over the years has given me a large tool box to work from.  I can usually get out of any situation with a minimal amount stress.  Unfortunately, this same principle does not apply to vein harvesting. The bad veins always find me.  I have a running joke at work that I can create drama in any vein harvesting situation.  Don’t get me wrong; I always find a way to get the vein out, and rarely will it need any repairs.  But sometimes I think it takes years off of my life.  As I sat and thought about this I realized that difficult veins have given me a tool box for vein harvesting too.  Experienced harvesters will have heard these tips before, but for any new comers to EVH, I thought I’d share a few of the tools that have helped me along the way. 

I always say that finding the vein is half the battle.  I have moved my incision several times in the interest of increasing my ability to find the vein quickly.  When I was trained in EVH, I was taught to make a vertical incision in the thigh, just above the medial condyle of the knee.  I eventually moved that incision 90 degrees in an effort to cut across a longer area where I might find the vein.  After that, I moved down to the level of the knee and made an oblique incision there.  Finally, I have moved the incision down a few inches more, to below the condyles of the knee.  You may have to deal with more branches there, but there is often less tissue in this location.  My colleagues all have several methods for finding the vein that they have shared with me as well.  Many of the newer PAs use ultrasound guidance every time.  I have to admit, I haven’t been as open to adapting that technique as I should.  If another colleague of mine can’t find the vein right away, she hooks up the scope to search with the cone in the tissue just above the incision.  Finally, if I spend more than 10 minutes trying to find a vein, I’ll often just go look on the opposite leg.  Sometimes it’s just a different angle, or that the vein is just in a more normal anatomical position.  But it can save you time, rather than just continuing to search in the original leg.

One of the most important things I tell people when I’m teaching them how to take vein is to keep moving forward.  When you get to a difficult branch, or tissue that is stuck, it’s easy to get hung up in the same spot for many minutes.  This costs you valuable time. When you get stuck somewhere, don’t stay in that spot for more than a minute or so.  Move on, and work on something else.  Many times, as you work through your dissection, some of the angles change, and you will come back to the same spot and find that it is now easy to dissect.

Death by drowning is one of the most painful ways to fail at EVH.  Sometimes you hit something unexpected and your tunnel fills before you can control the bleeding.  These situations may not be able to be prevented.  But many times, I’ll look at a huge branch and know that it’s going to be hard to get around it.  Save yourself a crisis.  Leave this branch for last.  Mark the leg on the outside first, and then cauterize and cut the branch.  This way, if you do have bleeding that you can’t control, your vein is already dissected and you will be able to get it out of the leg.  Then you can make a tiny incision where you had marked the leg in order to fix the bleeding. 

Once in a while, it’s time for the leg to be closed, and there is an unsightly amount of blood coming from it.  You’re looking at it thinking that everything went fine during the harvest, and you have no idea what is bleeding.  Pressure stops most bleeding from the leg if you know where to apply it.  First, determine if the bleeding is coming from the upper or lower leg.  Next, role the leg to clear the tunnel of blood.  Then apply pressure about 3 inches from the incision in the direction the bleeding is coming from.  With your other hand, take a lap pad and role the leg.  If no blood comes out of the incision, move the hand that is holding pressure up another three inches, apply pressure, and role the leg again.  Repeat this process until blood continues to come out of the incision with repeated rolling. When this happens, you know you have moved above the level where the bleeding is coming from.  Move back down a few inches and apply firm pressure with a few laps, using both your hands.  If possible, continue to hold for 10 minutes.  Than recheck the leg. Sometimes, it may take a second period of holding, but this almost always works.

Vein harvesting is probably one of the most important jobs of the cardiac surgery PA.  If fact, it is one of the skills that makes us unique.  Repetition is the key to a smooth and fast vein harvest and preparation.  That’s not to say some insider tips can’t help out.  Hopefully you’ve learned some here.

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Topics: EVH endo vein harvesting Cardiac Surgery, EVH