JAPACVS Vol. 4 No. 2

VOLUME 4 •

NUMBER 2 •

SUMMER 2022 •

www.japacvs.org

APACVS J

Journal of The Association of PAs in Cardiothoracic and Vascular Surgery

ALL OR NOTHING SAPHENOUS VEIN GRAFT HARVESTING

Official Journal of The Association of Physician Assistants in Cardiothoracic and Vascular Surgery

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

JAPACVS

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editor-in-Chief Aaron R. Morton, DMSc, MMSc, PAC, ATC, FAPACVS Emory University, Atlanta, GA Associate Editor—International Anitha Chandrasekhar, BS, PA, FAPACVS Medanta the Medicity – Delhi, India

Associate Editor—Writer Development Edward A. Ranzenbach, PA-C, MPAS, CAQ-CVTS, FAPACVS, DFAAPA Forest Ranch, CA

Editor Emeritus Doug Condit, PA-C Montefiore Medical Center – New York, NY

Editorial Board David J. Bunnell, MSHS, PA-C Frostburg, University, Frostburg, MD JoAnn Montecalvo, MPAS, PA-C Winthrop University Hospital, Mineola, NY Mitesh Patel, MSHS, PA-C Baylor Scott and White, Plano, TX

David Tecchio, MPAS, MBA, PA-C Vassar Brothers Medical Center, Poughkeepsie, NY

Publisher David E. Lizotte, Jr. MPAS, PA-C, FAPACVS Executive Director APACVS

EDITORIAL MISSION: The JAPACVS is the official clinical journal of the Association of PAs in Cardiothoracic and Vascular Surgery. The mission of the JAPACVS is to improve Cardiac, Vascular and Thoracic Surgical and CVT Critical Care patient care by publishing the most innovative, timely, practice-proven educational information available for the physician assistant profession.

PUBLISHED CONTENT IN THE JAPACVS: Statements and opinions expressed in the articles and communications herein are those of the authors and not necessarily those of the Publisher or the Association of PAS in Cardiothoracic and Vascular Surgery (APACVS). The Publisher and the APACVS disclaim any responsibility or liability for such material, including but not limited to any losses or other damage incurred by readers in reliance on such content. Neither Publisher nor APACVS verify any claims or other information appearing in any of the advertisements contained in the publication and cannot take responsibility for any losses or other damage incurred by readers in reliance on thereon. Neither Publisher nor APACVS guarantees, warrants, or endorses any product or service advertised in this publication, nor do they guaranty any claim made by the manufacturer of such product or service.

SALES OFFICE APACVS 1442 Legacy Circle Fenton, MO 63026 Phone (502) 321-6155 admin@apacvs.org JAPACVS/Journal of the Association of PAs in Cardiothoracic and Vascular Surgery is published quarterly (4 issues per volume, one volume per year) by APACVS 1442 Legacy Circle, Fenton, MO 63026. Volume 4, Number 1, Winter 2022. One year subscription rates: $40 in the United States and Possessions. Single copies (prepaid only): $10 in the United States

© 2022 APACVS, INC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including by photocopy, recording, or information storage and retrieval system, without permission in writing from the publisher.

2

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Editorial 4 From the Editor’s Desk Aaron R. Morton, MMSc, PA-C, ATC, FAPACVS— Editor -In-Chief

Peer Reviewed Content 7 Efficacy of Enhanced Recovery After Surgery Protocols in Pain Contol For Patients Undergoing Video Assisted Thoracoscopic Surgery Mackenzie Steen, PA-C, DMSc Sowmyanarayanan Thuppal MD, PhD Bridget McClain Allison Sweeney Stephen Markwell, MA Stephen Hazelrigg, MD Traves Crabtree, MD Peer Reviewed Content 17 All or Nothing Saphenous Vein Graft Harvesting Sean Storey DMSc, MS, PA-C

APACVS is the only association representing Cardiac, Thoracic and Vascular Surgery and CTV Critical Care PAs. By PAs, For PAs!

3

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

_________________________________________________________________________________________________________

From the Editor's Desk

Aaron R. Morton, DMSc, MMSc, PA-C, ATC, FAPACVS Editor-in-Chief

Hello and welcome to our next issue of the Journal of the Association of Physician Assistants in Cardiothoracic and Vascular Surgery. There was a great turnout in Miami for the APACVS Annual Symposium. We greatly enjoyed getting to connect with many of the attendees and meeting several of our previous authors in person!

Among the many wonderful interactions in Miami, a few of them stood out and I feel now is a good time to share. Several attendees shared they had a topic which they felt would be of benefit to our readership, however, did not convey well or completely in the traditional printtype media of a journal. Topics such as a procedural approach, or completion of technical aspects of a procedure tend to be more visual in nature and difficult to portray with words.

These are fantastic ideas and being a digital journal makes us uniquely able to not only accept but are uniquely able to distribute. I was very excited to be able to share during our conversations our ability to accept digital media submissions, and how valuable they can be to our collective practice and understanding. If writing a traditional typeset manuscript is not something which matches well with your topic, please reach out—we will be happy to work with you on digital media content.

For those who do have ideas best fit for print media and are struggling with manuscript development, please also reach out. We have a talented associate editor for writer development and are creating an educational series on manuscript development, types of manuscripts and the research process. In short, we are eager to support your ideas in all types of media and 4

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

assist with any apprehension regarding the process that may be preventing the important sharing of topics in a peer reviewed and academic forum, to better our readership.

Please reach out if you have an idea or need help on the creation process.

-Stay safe and keep creating, -AM Aaron Morton, DMSc, MMSc, PA-C, ATC, FAPACVS

JAPACVS Editor-in-Chief editor@japacvs.org

JAPACVS publishes invited commentary and letters to the editor in response to published articles in which the authors are given the opportunity to respond .

5

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

3 million EVH procedures performed 2 decades of experience 1 passion Partnering great technology with great talent.

For over two decades, your commitment to Endoscopic Vessel Harvesting (EVH) has produced more than three million procedures.* Through eleven generations, our complete family of Vasoview products has helped create sustainable, reproducible, and long-term patient outcomes.1-5 * Data on file | 1. Ouzounian M, et al. Ann Thorac Surg. 2010;89:403–408. | 2. Ad N, et al. J Cardiovasc Surg. 2011;52:739–748. | 3. Dacey LJ, et al. Circulation. 2011;123:147–153. | 4. Grant SW, et al. Heart.

2012;98:60–64. | 5. Williams JB, et al. JAMA. 2012;308:475–484.

For more information go to getinge.com/us/education/evh/ Getinge is a registered trademark of Getinge AB, its subsidiaries, or af filiates in the United States or other countries • Copyright 2022 Getinge AB or its subsidiaries or affiliates • All rights reserved • ⚠ CAUTION: Federal (US) law restricts this device to sale by or on the order of a physician. Refer to Instructions for Use for current indications, warnings, contraindications, and precautions. • MCV00084326 REVB

Peer Reviewed Content

EFFICACY OF ENHANCED RECOVERY AFTER SURGERY PROTOCOLS IN PAIN CONTROL FOR PATIENTS UNDERGOING VIDEO ASSISTED THORACOSCOPIC SURGERY Running Head: ERAS in VATS Mackenzie Steen, PA-C, DMSc1; Sowmyanarayanan Thuppal MD, PhD1,2 ; Bridget McClain1; Allison Sweeney1; Stephen Markwell, MA1; Stephen Hazelrigg, MD1; Traves Crabtree, MD1 1Division of Cardiothoracic Surgery, Department of Surgery, Southern Illinois School of Medicine, Springfield, Illinois 2Center for Clinical Research, Southern Illinois School of Medicine, Springfield, Illinois Corresponding author: Mackenzie Steen, PA-C, DMSc, Division of Cardiothoracic Surgery, Department of Surgery, 701 N First Street, PO Box 19638, Springfield, IL 62794-9638, Phone: 217 -545-8994, Fax: 217-545-7053, E-mail: msteen56@siumed.edu

ABSTRACT Background: Enhanced Recovery After Surgery (ERAS) protocols are an increasingly utilized method of improving post-surgical outcomes, including outcomes related to pain control. One focus of ERAS is decreasing reliance on opioid-based medication.

Objective: The primary objective of this study was to evaluate the impact of ERAS protocols on patient pain scores and opioid usage after video-assisted thoracoscopic surgery (VATS).

Methods: A retrospective analysis was performed, comparing patients undergoing pulmonary resection via a VATS approach since the implementation of ERAS protocols vs. resection prior to ERAS. Outcomes including average daily pain scores, total daily usage of opioid medications as measured by IV morphine milligram equivalents (MME), rates of opioid prescription after discharge, complication rates, length of stay, 30-day readmission rates, and 30-day mortality rates were reported.

Results: A total of 287 (pre-ERAS, n = 108; ERAS, n = 55) patients from over a 2-year period were reviewed. ERAS was associated with a similar average daily self-reported pain scores compared to pre-ERAS (POD0 [6.5 vs 5.9], POD1 [6.0 vs 5.4], POD2 [4.8 vs 4.4] POD3 [3.0 vs 4.9], POD4 [6.6 vs 4.5], POD5 [6.6 vs 4.8]. ERAS was associated with similar total daily opioid administration, except for post-operative day 0 (19.0 vs 26.0, p = 0.002).

Usage of ERAS had no significant effect on any other post-operative outcomes assessed during this study.

Conclusion: Usage of scheduled, non-opioid medications as part of an ERAS protocol resulted in similar pain scores and opioid usage after minimally invasive pulmonary resection.

Keywords: ERAS, Enhanced Recovery After Surgery, VATS, opioid,

7

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

METHODS Study Design The study was approved by the Committee for Research Involving Human Subjects. A retrospective analysis was conducted between January 1, 2019 and January 3, 2021. Data was collected from all adult patients (>18 years old) undergoing VATS for resection of benign or malignant pulmonary disease including lobectomy, segmentectomy, sublobar and wedge resection, bullectomy and bleb resection, and lung biopsy. Data from patients undergoing VATS for pleural or mediastinal disease, elective thoracotomy, intra-operative conversion to thoracotomy, emergent procedures, lung-volume reduction surgery, and those undergoing robotic-assisted thoracoscopic surgery were excluded. Patients with a history of chronic opioid usage defined as the usage of opioids on all or most days for at least 3 months prior to the date of surgery were also excluded. Information regarding previous opioid usage was obtained via review of the state Prescription Monitoring Program (PMP).

Pre-ERAS Protocol Prior to implementation of ERAS, standard postoperative pain management consisted of a primarily opioid based regimen utilizing intravenous morphine, hydromorphone, or fentanyl as well as oral opioids such as tramadol and hydrocodone-acetaminophen on an as needed basis.

Acetaminophen was routinely utilized but was not given on a scheduled basis as protocol. Nonsteroidal anti-inflammatory medications and gabapentinoids were administered on a case by case basis. Intraoperative multilevel intercostal nerve blocks utilizing 0.25% bupivacaine were already part of standard practice. Thoracic epidural catheters and patient controlled analgesia pumps were not part of standard practice for VATS. Pre-ERAS standard of care did not include pre-operative administration of acetaminophen, gabapentin, or anti-inflammatories.

ERAS Protocol

In September 2021, our division of cardiothoracic surgery implemented the ERAS protocols for patients undergoing VATS. These protocols include perioperative measures to reduce pain such as scheduled preoperative administration of non-opioid oral analgesics the morning of surgery, decreasing intraoperative narcotic usage, emphasizing usage of intraoperative multilevel intercostal nerve blocks, and postoperatively increasing utilization of scheduled non-opioid analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxers, lidocaine patches, and gabapentinoids. A comprehensive list of ERAS measures are listed in Table 1.

Operative Details All surgeries were performed by one of the thoracic surgeons at our institution using a two or three incision technique. After induction with general anesthesia, a double-lumen endotracheal tube was placed for lung protective single-lung ventilation. Patients were placed in lateral decubitus positions. All patients received antibiotic prophylaxis within 1 hour of incision and had sequential compression devices placed. Prior to incision, local anesthetic was injected into the incision site and a pre-emptive nerve block was performed posterior to the incision in the corresponding intercostal space. At the conclusion of the case, a 20F or 24F chest tube was inserted to the apex of the thoracic cavity, a multilevel intercostal nerve block was performed between the 3rd and 9th intercostal spaces using 20-30 mL of 0.25% bupivacaine without epinephrine, and the lung was re-inflated under direct visualization. All patients were in stable condition and extubated prior to leaving the operating room. Chest tubes were removed upon radiographic confirmation of lung expansion and resolution of air leak

8

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Data Collection Pre-operative data on patient demographics, co-morbidities, pulmonary function testing, American Society of Anesthesiologists (ASA) classification, surgical procedure, and indication for surgery were collected for both cohorts. Post-operative data collected on each subject included average daily numeric pain rating, total daily in-hospital opioid usage as measured by morphine milligram equivalents (MME), in-hospital length of stay, 30-day readmission, 30-day mortality, opioid prescription rates, postoperative complications and associated Clavien-Dindo classification.19 Pain scores were evaluated on a 10-point scale; 0 = no pain, 1-3 = mild, 4-6 = moderate; 7-10 = severe pain. In-hospital opioid usage was evaluated by totaling the subject’s daily opioid administration as measured by intravenous morphine milligram equivalents (MME). Record was also kept of whether opioids were prescribed upon discharge. Prescribed opioids included hydrocodoneacetaminophen, tramadol, acetaminophen with codeine, and oxycodone.

Data Analysis Descriptive statistics were computed for all study variables. Continuous variables were described with measures of central tendency (mean, median) and dispersion (inter-quartile range [IQR], standard deviation). Categorical variables were summarized as frequencies and percentages.

Wilcoxon rank-sum tests or independent groups’ t-tests, as appropriate, were used to compare the groups on continuous variables. Differences between the two groups on categorical variables were compared with Chi-square tests of independence. Effect size measures were also calculated and reported to describe the differences between the groups.

9

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

RESULTS A total of 287 patients over a 2-year period were obtained for review. Of this group, 163 met inclusion criteria and were included for analysis. Information on patient demographics and operative details are presented in Table 2. There was no significant difference between the two cohorts with regards to all measures assessed except for pre-operative FEV1. Patients who underwent the ERAS protocol had a lower average pre-operative FEV1 compared to the pre-ERAS cohort (84% [67% - 94%] predicted vs 70% [60% - 80%] predicted, p = 0.0021).

General postoperative outcomes for each cohort are presented in Table 3. The outcomes assessed included average length of stay, 30-day readmission rate, 30-day mortality, complication rate, and opioid utilization on discharge. Each of these outcomes were similar between groups. With regards to opioid utilization, the percentage of patients in each cohort with an opioid prescription that was written (74.8% vs 72.7%) and subsequently filled after discharge (64.5% vs 72.2%) was similar.

The findings on daily self-reported pain scores are displayed in Figure 1. Daily pain scores were similar between each cohort on postoperative days 1 through 3, (POD1 [6.5 vs 5.9], POD 2 [6.0 vs 5.4], and POD3 [4.8 vs 4.4]). Pain scores in the ERAS group were slightly higher than the pre-ERAS group on POD 4 (6.6 vs 4.5) and POD 5 (6.6 vs 4.8). However, this difference was not statistically significant. This study found no significant difference overall in daily selfreported pain scores between the two groups.

Data on median daily in-hospital opioid usage is presented in Figure 2. ERAS protocol was associated with a lower utilization of opioids on post-operative day 0 (26.0 MME vs 19.0 MME, P = 0.002). Opioid utilization was similar between each group on post-operative days 1 through 5.

10

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

11

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

12

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

DISCUSSION Opioids have long been used as the primary method of pain control after surgery.

Between growing concerns about the potential adverse effects of opioids and problems with dependency and addiction providers are continually looking for safer alternatives. This study did not find a significant difference in average daily opioid usage after pulmonary resection via VATS approach, except for on post-operative day 0. It did not find a difference in the number of opioid prescriptions written after surgery. It also did not find a significant difference in average daily pain scores between the two groups. There was no difference between the two groups with regards to length of stay, re-admission rates, mortality rates, or postoperative complications.

This study provides a unique perspective on the usage of multimodal non-opioid medications in a center which is already accustomed to utilizing many features of ERAS-centered care. Furthermore, this study is unique in its focus on minimally-invasive VATS surgeries over robotic or thoracotomy-based procedures. A previous retrospective analysis by Razi et al evaluating pain control using ERAS after thoracic surgery found a significant decrease in in-hospital opioid usage and opioid prescriptions upon discharge.18 This study focused on ERAS following thoracotomy and robotic thoracic surgery, rather than VATS. Martin et al, also found significant reductions in in-hospital morphine usage after VATS (86 vs 22, p < 0.0001) and thoracotomy (130 vs 54, p < 0.0001).21 However, similar to this institution’s study Martin did not find a significant difference in average daily pain scores in patients who underwent VATS or thoracotomy.21 A possible explanation for the lack of improvement in opioid-related outcomes after ERAS is that this institution adhered to many elements of ERAS prior to the initiation of this study. The ERAS Society and ESTS, as mentioned previously, released a set of guidelines in 2019. This department already adhered to measures including smoking cessation, usage of regional anesthesia with intercostal nerve blocks, and performing nearly all pulmonary resections through a minimally invasive approach. It has been suggested that VATS in and of itself is a form of ERAS.22 Centers which already have an aggressive commitment to VATS are likely to already implement many features of ERAS, and thus do not see a significant difference in their outcomes compared to centers with higher volumes of thoracotomy.22 It has not been the practice of this institution to use epidural anesthesia or patient-controlled analgesia for the majority of cases, with the exception of elective thoracotomy.

Usage of ERAS at this institution was not associated with an increase in postoperative complications, 30-day re-admissions, or 30-day mortality. In a review of 600 patients who underwent VATS lobectomy or segmentectomy Brunelli et al, found ERAS protocols to not be associated with a significant change in 30-day or 90-day mortality, re-admission rates, or cardiopulmonary complications.16 Similarly, Forster et al found no significant difference in cardiopulmonary complications or readmission rates after adoption of ERAS protocols for patients undergoing VATS after resection of NSCLC.14 Forster did find a decrease in average length of stay (5 vs 7 days, P = 0.004).14 The findings of this study are consistent with other studies, although there was no decrease in average length of stay.

Study Limitations This study focused on a specific subset of patients undergoing minimally invasive thoracic surgery, those undergoing pulmonary resection for primarily malignancy. This study does not evaluate the efficacy of ERAS on pain control for minimally-invasive infectious, diaphragmatic, pleural, or esophageal procedures. It also does not compare the efficacy of the protocol on post-surgical outcomes for patients undergoing robotic or thoracotomy-based procedures. However, previous studies looking at the efficacy of ERAS protocols for both of these approaches have found a decrease in in-hospital opioid usage for robotic patients and in opioid prescriptions after surgery.18 For patients undergoing thoracotomy, ERAS is associated 13

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

with a significant decrease in cardiopulmonary complications and decreased usage of thoracic epidural.20 The results obtained by this institution could likely be extended to these populations, as well as other patients who have undergone VATS for other indications.

The sample size of this study is smaller compared to similar studies evaluating ERAS protocols for pain control and other quality improvement measures.18 A larger sample size, and one in which the post-ERAS cohort was closer in volume to the pre-ERAS cohort, may have yielded different findings.

Additionally, after the initial implementation of ERAS protocols there was a several-week adjustment period in which medication compliance faltered. Certain medications used as part of the protocol, such as the anti-inflammatories and gabapentinoids, were not given as routinely.

This required additional education and collaboration with our administration and pharmacy to ensure each qualifying patient received the full protocol. This delay to achieve a higher rate of compliance may negatively impact the early efficacy of the protocol and subsequent analysis.

CONCLUSION Addition of ERAS protocols at this institution did not significantly improve postoperative outcomes or opioid utilization after VATS. This institution had implemented many features of ERAS as standard practice prior to the implementation of a formal multimodal pain management protocol. ERAS may prove beneficial to programs looking to transition from conventional pain management strategies. However, additional studies are needed to evaluate ERAS in the setting of minimally invasive thoracic surgery.

REFERENCES 1. Semenkovich TR, Hudson JL, Subramanian M, Kozower BD. Enhanced Recovery After Surgery (ERAS) in Thoracic Surgery. Thoracic – Current Readings. 2018;30(3):342-349.

Doi: 10.1053/j.semtcvs.2018.06.001.

2. Madani A, Fiore JF, Wang Y, Bejjani J, Sivakumaran L, Mata J. An enhanced recovery pathway reduces duration of stay and complications after open pulmonary lobectomy. Surg.

2015;158(4):8999-908. doi: 10.1016/j.surg.2015.04.046.

3. Dinic VD, Stajanovic MD, Markovic D, Cvetanovic V, Vukovis AZ, Jankovic RJ. Enhanced Recovery in Thoracic Surgery: A Review. Front Med. 2018;5(14): doi: 10/3389/ fmed.2018.00014. Zhao S, Chen F, Feng A, Han W, Zhang Y. Risk Factors and Prevention Strategies for Postoperative Opioid Abuse. Pain Res Manag. 2019;2019. doi: 10.1155/ 2019/7490801.

4. Batchelor TJP, Rasburn N, Abdelnour-Berchtold E, Brunelli A, Cerfolio RJ, Gonzalez M, Ljungqvist O, Petersen RH, Popescu WM, Slinger PD, Naidu, B. Guidelines for enhanced recovery after lung surgery: recommendations for the Enhanced Recovery After Surgery (ERAS) Society and the Europe an Society of Thoracic Surgeons (ESTS). Euro J CardioThorac Surg. 2019;55:91-115. doi:10/1093/ejcts/ezy301.

5. Wick EC, Grant MC, Wu CL. Postoperative Multimodal Analgesia Pain Management With Nonopioid Analgesics and Techniques: A Review. JAMA Surg. 2017;152(7):691-697. doi: 10.1001/jamasurg.2017.0898.

6. Echeverria-Villalobos M, Stoicea N, Todeschini AB, Fiorda-Diaz J, Uribe A, Weaver T, Bergese SD. Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the United States. Clin J Pain. 2020;36 (3):219-226. Doi: 10.1097/APJ..0000000000000792.

7. Echeverria-Villalobos M, Stoicea N, Todeschini AB, Fiorda-Diaz J, Uribe A, Weaver T, Bergese SD. Enhanced Recovery After Surgery (ERAS): A Perspective Review of Postoperative Pain Management Under ERAS Pathways and Its Role on Opioid Crisis in the 14

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

United States. Clin J Pain. 2020;36 (3):219-226. Doi: 10.1097/APJ..0000000000000792.

8. Brandal D, Keller MS, Lee C, et al. Impact of Enhanced Recovery After Surgery and Opioid-Free Anesthesia on Opioid Prescriptions at Discharge From the Hospital: A Historical-Prospective Study. Anesth Analg. 2017;125(5):1784-1792. Doi: 10.1213/ANE.0000000000002510.

9. Chiu C, Aleshi P, Esserman L, Inglis-Arkell C, Yap E, Whitlock EL, Harbell MW. Improved analgesia and reduced post-operative nausea and vomiting after implementation of an enhanced recovery after surgery (ERAS) pathway for total mastectomy. BMC Anesthesiology. 2018;18(41):1 -9. Doi: 10.1186/s12871-018-0505-9.

10. d’Astorg H, Fière V, Dupasquier M, Vieira TD, Szadkowski M. Enhances recovery after surgery (ERAS) protocol reduces LOS without additional adverse events in spine surgery. Orthop Traumatol – Sur. 2020;106(6):1167-1173. Doi: 10.1016/j.otsr.2020.01.017.

11. Gonzalez M, Abdelnour-Berchtold E, Perentes JY, Doucet V, Zellweger M, Marcucci C, Ris H, Krueger T, Gronchi F. An enhanced recovery after surgery program for video-assisted thoraco scopic surgery anatomical lung resections is cost-effective. J Thorac Dis. 2018;10(10):5879-5888. doi: 10.21037/jtd.2018.09.100.

12. Draeger TB, Gibson VR, Fernandes G, Andaz SK. Enhanced Recovery After Thoracic Surgery (ERATS). Heart Lung Circ. 2021;30:1251-1255. Doi: 10.1016/j.jlc.2021.01.014 13. Tahiri M, Goudie E, Jouquan A, Martin J, Ferraro P, Liberman M. Enhanced recovery after video -assisted thoracoscopic surgery lobectomy: a prospective historically controlled, propensitymatched clinical study. Can J Surg. 2020;63(3): E233-E240. Doi: 10.1503-cjs.001919.

14. Forster C, Doucet V, Perentes JY, Abdelnour-Berchtold E, Zellweger M, Faouzi M, Bouchaab H, Peters S, Marcucci C, Krueger T, Rosner L, Gonzalez M. Impact of an enhanced recovery after surgery pathway on thoracoscopic lobectomy outcomes in non-small cell lung cancer patients: a propensity score-matched study. Transl Lung Cancer Res. 2021;10(1):93-103. Doi: 10.21037/tlcr20-891.

15. Rogers LJ, Bleetman D, Messenger DE, Joshi NA, Wood L, Rasburn NJ, Batchelor TJP. The impact of enhanced recovery after surgery (ERAS) protocol compliance on morbidity from resection for primary lung cancer. J Thorac Cardiovasc Surg. 2017;155(4):1843-1852. Doi: 10.1016-j.jctvs.2017.10.151.

16. Burnelli A, Thomas C, Dinesh P, Lumb A. Enhanced recovery pathway versus standard care in patients undergoing video-assisted thoracoscopic lobectomy. J Thorac Cardiovasc Surg.

2017;154(6):2084-2090. Doi: 10.1016/j/jctvs.2017.06.037.

17. Nelson DB, Mehran RJ, Mitchell KG, Correa AM, Sepesi B, Antanoff MB. Enhanced recovery after thoracic surgery is associated with improved adjuvant chemotherapy completion for nonsmall cell lung cancer. J Thorac Cardiovasc Surg. 2019;158(1):279-286. Doi: 10.1016/ j.jtcvs.2019.03.009.

18. Razi SS, Stephens-Mcdonnough JA, Haq S, Fabbro M, Sanchez AN, Epstein RH. Significant reduction of postoperative pain and opioid analgesic requirement with an Enhanced Recovery After Thoracic Surgery protocol. J Thorac Cardiovasc Surg. 2021;161(5):1689-17018 Dindo D, Demartines N, Clavien P. Classification of Surgical Complications. Ann Surg. 2004;240(2). Doi: 10.1097/01.sla.0000133083.54934.ae.

19. Dindo D, Demartines N, Clavien P. Classification of Surgical Complications. Ann Surg. 2004;240 (2). Doi: 1097/01.sla.0000133083.54934.ae.

15

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Peer Reviewed Content ALL OR NOTHING SAPHENOUS VEIN GRAFT HARVESTING Sean Storey DMSc, MS, PA-C South Shore University Hospital, Northwell Health ABSTRACT: Coronary artery bypass graft surgery remains the optimal revascularization strategy in patients with complex, ischemic, multivessel coronary artery disease. Long-term benefits of this surgical procedure are highly dependent on preserved graft patency, serving as a major factor in clinical prognosis and long-term survival. The saphenous vein remains the most utilized conduit for all non-left anterior descending territories. Employing optimal harvesting techniques to minimize saphenous vein injury during harvesting remains an important determinant in preserving graft patency. Open-vein and no-touch harvesting techniques have been shown to confer superior long-term graft patency individually as compared to traditional endoscopic techniques.

Combining these practices could synergistically provide multifactorial benefits in preserving and extending graft patency beyond other harvesting techniques. In the search to improve the most common surgical procedure in adult cardiac surgery, utilization of both open-vein and no-touch harvesting in ideal candidates could prove to be essential in positively impacting both long-term clinical outcomes and post-operative mortality.

Key Points Describe optimal surgical interventions for patients with complex, ischemic, multi-vessel coronary artery disease.

List and describe conduit selection and efficacy (Venous vs. Arterial).

Describe pathophysiology of vascular injury secondary to harvesting technique.

Review and debate practices optimizing saphenous vein harvesting and graft patency.

Significance of Conduit Harvesting Cardiovascular disease remains the leading cause of death globally, taking an estimated 17.9 million lives each year.1 Ischemic heart disease falls under this umbrella and is expected to account for 14.2% of all deaths by 2030.1,2 Coronary artery bypass graft (CABG) surgery remains the optimal revascularization strategy in patients with complex, ischemic, multivessel coronary artery disease (CAD).2-4 The continuous refinement of surgical techniques and conduit harvesting has significantly contributed to the reduction in both morbidity and mortality.5 The long-term benefits of CABG surgery are highly dependent on the preservation of continuous graft patency.6 This serves as a major determinant in the patients' clinical prognosis and long-term survival.2 Techniques to optimize saphenous vein graft (SVG) performance and improve long-term graft patency are therefore a major priority in CABG surgery.

The most common utilized conduit to supplement the left internal mammary artery (LIMA) in CABG surgery is the SVG.7,8 Although extensive medical literature has demonstrated the benefits (i.e., greater longer-term patency and long-term survival benefits) associated with arterial grafts (i.e., radial artery, right internal mammary artery), complications of ischemia, graft spams, sternal healing (bilateral internal mammary harvesting in diabetics), anatomical limitations (i.e., insufficient collateral compensation) offsets the advantages provided by this conduit selection. 2,6,9 16

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

SVGs are indispensable to CABG surgery and provide diverse advantages including: emergent ease of access, shorter harvesting times, and sufficient length to bypass multiple distal coronary targets.2 Additionally, clinical factors (i.e., advanced age) or emergent surgical interventions (i.e., aortic root or valve surgery requiring conduit to bypass acutely occluded coronary arteries) highlight situations where SVGs are suitable and readily available for immediate harvesting.2 Vascular Injury and Barotrauma Clinical laboratory studies have demonstrated that damage to conduits during vessel harvesting and preparation influences both short and long-term patency.2,6 Traditional endoscopic vein harvesting (EVH) use of carbon dioxide (CO2) insufflation to maintain tunnel visualization has been shown to promote unfavorable local and systemic environments.10 The closed tunnel EVH permits passive systemic absorption of CO2, resulting in hypercarbia and tissue acidosis.10 The external pressurized CO2 (12-15 mmHg of insufflation) and endoscopic dissection further introduces extravascular stresses that could lead to detrimental changes in conduit integrity.10 Additionally, common SVG preparation consists of stripping vein conduits of its adventitial layer and vessel distention to overcome vascular spasms.6 The vascular manipulation and mechanical stress from these techniques can result in both intimal and luminal wall damage, predisposing the conduit to possible remodeling and accelerated intimal hyperplasia. 6,11 To avoid vascular insult, the development of “no-touch” saphenous vein harvesting was introduced.11 This technique involves harvesting a SVG pedicle (open harvesting, encompassing the saphenous vein and intact surrounding perivascular tissue), without direct vessel contact, which reduces vascular spasms and need for repeated pressure distention.11 The reduction of vascular distention decreases barotrauma and preserves luminal endothelium, retaining local nitric-oxide levels and slowing the development of intimal hyperplasia.2 Preservation of the perivascular tissue provides external structural support to prevent conduit kinking (preventing accelerated intimal hyperplasia and subsequent atherosclerosis) and retention of the vasa vasorum (retaining vessel wall perfusion and reduced ischemic damage).2 Perivascular adipose tissues anticontractile factors (i.e., nitric oxide, leptin) may also provide additional anti-spasmatic properties to preserve graft patency, which can significantly benefit patients with poor coronary anatomy (i.e., small coronary artery targets with poor distal runoff).2

17

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Figure 1. Histological, cellular, and ultrasound comparison of no-touch (NT) and conventional (C) saphenous vein graft harvesting.

Upper panel: Transverse NT vs. C saphenous vein that were prepared for coronary artery bypass surgery. NT intima is thrown into folds around the lumen (L), vein wall media remains thick with smooth muscle cells, and intact adventitia (red arrow indicating vasa vasorum). C intima folds are absent with a thinner media wall secondary to distention, and absence of adventitia due to its removal. Lower panel: Damage comparison in NT vs. C saphenous vein. Panel A (NT) shows an intact endothelial lining, compared to D (C) minimal lining. Panel B (NT) shows uniformly shaped and distributed smooth much versus E (C) variable smooth muscle distribution. Panel C (NT) displays intact vasa vasorum (Arrow-lumens), while F (C) shows only remnants of this layer.12

Optimizing Conduit Patency Rates CABG surgery continues to be the most common procedure performed in adult cardiac surgery and remains the standard of care for patients with complex coronary artery lesions. 5,13 The weak point of this procedure remains to be the limited long-term patency rates of saphenous vein grafts.5,14 Alternative conduits, such as arterial grafts, have been investigated in the literature.

Gaudino et al. literature review of six randomized, controlled trials analyzing the long-term (>2 years) outcomes among patients that were randomly assigned to undergo either radial artery (RA) grafting or SVG to supplement the LIMA graft during isolated CABG surgery, found that longterm patency rates and mortality benefits were more commonly seen among RA conduits.7 Even with supportive evidence favoring arterial grafts, limitations for their use still exist: prolonged harvesting time, increased bleeding, limited graft length, compromised collateral flow leading to ischemia, limiting graft durability secondary to severe peripheral arterial disease, graft spasms, delayed sternal healing, and diminished post-operative motor and/or sensory strength surrounding anatomic harvest site.6,15,16 With these benefits and limitation considered, the long saphenous vein remains the preferred conduits in CABG surgery.11,15 Saphenous vein’s superficial anatomical position expedites harvesting time, decreases the incidence of bleeding, and provides adequate length to bypass multiple distal culprit lesions, which makes this conduit essential to CABG surgery.2,13,14 Harvesting of the saphenous veins can be performed by direct visualization (open-harvest) or by minimally invasive EVH.13 Open harvest allows for quicker access and shorter harvesting time with direct visualization and mobilization of the saphenous vein.13 Due to the large open incision, this technique incurs a greater risk for wound complications and possible increase in length 18

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

of hospital stay.13 EVH’s minimally invasive approach has abundant evidence to support its improved wound-related outcomes due to its minimal incisional approach, with comparable “short-term” patency rates to open-harvest techniques.13,15 Kodia et al. systematic review evaluating “long-term” patency (>1 year) rates in patients that underwent CABG surgery (n=18,131) with either open (n=10,873) or endoscopic SVG harvesting (n=7,258) found graft patency beyond one year was significantly higher among open saphenous vein harvest as compared to EVH (Open 82.3% versus EVH 75.1%, OR 0.61 (CI, 0.43-0.87), P=0.01).13 Among clinical trials, the Randomized Endovein Graft Prospective (REGROUP) multicenter, randomized clinical trial (n=1150) investigated saphenous vein graft harvesting techniques (Open (n=574) versus EVH (n=576)) effect on long-term adverse cardiac events (death from any cause, nonfatal myocardial infarction, repeat revascularization).17 The REGROUP clinical trial accounted for harvester experience and techniques in order to limit variability.17 Expert endoscopic veingraft harvesters were required to have a minimal of >100 EVH cases, certified low conversion rate (<5%) to open harvesting, and > 2-year experience to participate.17 The results of the study ultimately found that the risk of major cardiac events between open and endoscopic SVG harvesting were not significantly different (Open 15.5% versus EVH 13.9%, hazard ratio 1.12, (CI, 0.83-1.51), P=0.47).17 Both large-scale systematic review and clinical trial suggest that open SVG harvesting confer similar clinical outcomes and long-term patency as EVH among patients undergoing CABG surgery 13, 17 To further optimize open saphenous vein harvesting, utilization of the “no-touch” pedicle technique could possibly provide additional multifactorial benefits and prolong long-term SVG patency rates.2,16 Figure 2: Endoscopic versus open saphenous vein harvesting approach

Left panel is a transverse section of saphenous vein prepared with endoscopic vein harvesting (EVH). Arrow indicating intimal damage/tearing. Middle panel to the left shows EVH incisional access. Middle panel to the right shows the extended incision utilized for both open and NT harvesting. Right panel is a transverse section of NT harvested saphenous vein with intact and undamaged vascular layers.12

Extending Conduit Harvesting Choices The long-term patency of SVG remains a major challenge in cardiothoracic surgery and various harvesting techniques reviewed in the medical literature shows great promise addressing this issue.6 Kodia et al. investigation of 18,131 patients undergoing CABG with either open or EVH techniques highlighted the benefits of open harvesting and the positive effect on long-term SVG patency.13 Open saphenous vein harvesting provides ease of access and shorter harvesting time that can prove to be beneficial in emergent situations.2 With the addition of “no-touch” saphenous vein harvesting to existing open-harvest techniques, superior long-term SVG patency rates could possibly be achieved.

19

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

Early medical literature from Souza et al. mirrored these benefits in their 2006 randomized longitudinal clinical trial comparing graft patency among conventional (n=52, SVG harvested with vein stripping, distention, and stored in normal saline) and no-touch harvesting (n=52, SVG removed with surrounding peri-vascular tissue, not distended, and stored in heparinized blood).6 The post-operative angiographic results from their study found superior post-operative graft patency rates among no-touch groups at both 18 months (89%: Conventional. 95%: No-Touch) and 8.5 years (76%: Conventional. 90%: No-Touch. P=0.01).6 Similar results were seen among Samano et al. 2015 single center randomized clinical trial (Conventional harvest: n=52, SVG stripped & distended. No-touch harvest: n=52, pedicle & without distention) data that found SVG patency at a mean 16 year post-operative angiographic follow up to be 64% in conventional group versus 83% in no-touch group (P=0.03).18 More recent 2021 multicenter randomized, controlled trial (n=2655) data by Tian et al. comparing conventional (n=1318) and no-touch (n=1337) saphenous vein graft harvesting found no-touch groups to have significantly lower rates of vein occlusion at both 3 months (2.8% no-touch versus 4.8% conventional, OR 0.57 (95% CI, 0.410.80), P<0.001) and 12 months (3.7% no touch versus 6.5% conventional, OR, 0.56 (95% CI, 0.410.76), P<000.1) by CT angiography.19 This chronological review of medical literature demonstrates repeated benefits supporting the use of no-touch harvesting. Currently, open harvest notouch technique is recognized as Class IIaB (Class IIa: weight of evidence in favor of efficacy, Level B: data derived from single randomized clinical trial or large non-randomized studies) recommendation, while EVH is Class IIaA (Level A: data derived from multiple randomized clinical trials or meta-analysis) among the 2018 European Society of Cardiology and the European Association for Cardiothoracic Surgery guidelines on myocardial revascularization.12, 20 As clinical literature continues to investigate “no-touch” saphenous vein harvesting, the advantages surrounding its ability to preserve and extend graft patency have been well documented since its introduction in 1996.19 With average vein graft occlusion rates ranging from 5% to 13% at 1 month and 10% to 15% within 1 year after CABG surgery, strategies to optimize harvesting techniques remain paramount.19 The no-touch pedicle approach serves as an excellent alternative to arterial conduits, forgoing the complication and limitations surrounding arterial graft harvesting and candidacy.21 Application of the no-touch technique in selected patients undergoing open vein harvesting shows promise in synergistically improving both their long-term and postoperative mortality after CABG surgery.

References 1. World Health Organization. The Top 10 Causes of Death. World Health Statistics 2012.

Published May 24, 2018. Accessed November 21, 2020.

2. Samano N, Dashwood M, Souza D. No-touch vein grafts and the destiny of venous revasculari zation in coronary artery bypass grafting-a 25th anniversary perspective. Ann Cardiothorac Surg. 2018;7(5):681-685. doi:10.21037/acs.2018.05.15 3. Ganyukov V, Kochergin N, Shilov A, et al. Randomized Clinical Trial of Surgical vs. Percutaneous vs. Hybrid Revascularization in Multivessel Coronary Artery Disease: Residual Myocardial Ischemia and Clinical Outcomes at One Year-Hybrid Coronary Revascularization Versus Stenting or Surgery (HREVS). J Interv Cardiol. 2020;2020:5458064. Published 2020 Jan 3. doi:10.1155/2020/5458064 4. Zhao Q, Zhu Y, Xu Z, et al. Effect of Ticagrelor Plus Aspirin, Ticagrelor Alone, or Aspirin Alone on Saphenous Vein Graft Patency 1 Year After Coronary Artery Bypass Grafting: A Random 20

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

ized Clinical Trial. JAMA. 2018;319(16):1677-1686. doi:10.1001/jama.2018.3197 5. Bakaeen F. CABG: A Continuing Evolution. Cleve Clin J Med. 2017;84(12 Suppl 4):e15-e19. doi:10.3949/ccjm.84.s4.04.

6. Souza DS, Johansson B, Bojö L, et al. Harvesting the Saphenous Vein with Surrounding Tissue for CABG Provides Long-Term Graft Patency Comparable to the Left Internal Thoracic Artery: Results of a Randomized Longitudinal Trial. J Thorac Cardiovasc Surg. 2006;132(2):373-378. doi:10.1016/ j.jtcvs.2006.04.002.

7. Gaudino M, Benedetto U, Fremes S, et al. Radial-Artery or Saphenous-Vein Grafts in Coronary -Artery Bypass Surgery. N Engl J Med. 2018;378(22):2069-2077. doi:10.1056/EJMoa1716026 8. Deb S, Singh SK, de Souza D, et al. Superior SVG: No Touch Saphenous Harvesting to Improve Patency Following Coronary Bypass Grafting (A Multi-Centre Randomized Control Trial, NCT01047449). J Cardiothorac Surg. 2019;14(1):85. Published 2019 May 2. doi:10.1186/ s13019-019-0887-x.

9. Cancelli G, Audisio K, Chadow D, Soletti GJ, Gaudino M. The evidence for radial artery graft ing: When and when not?. JTCVS Tech. 2021;10:114-119. Published 2021 Sep 24. doi:10.1016/ j.xjtc.2021.09.039.

10. Krishnamoorthy B, Critchley WR, Nair J, et al. Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting.

Innovations (Phila). 2017;12(5):320-328. doi:10.1097/IMI.0000000000000405.

11. Verma S, Lovren F, Pan Y, et al. Pedicled No-Touch Saphenous Vein Graft Harvest Limits Vascular Smooth Muscle Cell Activation: The PATENT Saphenous Vein Graft Study. Eur J Cardiothorac Surg. 2014;45(4):717-725. doi:10.1093/ejcts/ezt560.

12. Samano N, Souza D, Pinheiro BB, Kopjar T, Dashwood M. Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance. Braz J Cardiovasc Surg. 2020;35(1):91-99. Published 2020 Feb 1. doi:10.21470/1678-9741-2019-0238.

13. Kodia K, Patel S, Weber MP, et al. Graft Patency After Open Versus Endoscopic Saphenous Vein Harvest in Coronary Artery Bypass Grafting Surgery: A Systematic Review and Metaanalysis. Ann Cardiothorac Surg. 2018;7(5):586-597. doi:10.21037/acs.2018.07.05 14. Jannati M, Navaei MR, Ronizi LG. A Comparative Review of the Outcomes of Using Arterial Versus Venous Conduits in Coronary Artery Bypass Graft (CABG). J Family Med Prim Care.

2019;8(9):2768-2773. Published 2019 Sep 30. doi:10.4103/jfmpc.jfmpc_367_19.

15. Krishnamoorthy B, Critchley WR, Thompson AJ, et al. Study Comparing Vein Integrity and Clinical Outcomes in Open Vein Harvesting and 2 Types of Endoscopic Vein Harvesting for Coronary Artery Bypass Grafting: The VICO Randomized Clinical Trial (Vein Integrity and Clinical Outcomes). Circulation. 2017;136(18):1688-1702. doi:10.1161/ CIRCULATIONAHA.117.028261 16. Jiang Q, Yang Y, Sun H, Tang Y, Lv F, Hu S. Stable hemodynamics within "no-touch" saphe nous vein graft. Ann Thorac Cardiovasc Surg. 2020;26(2):88-94. doi:10.5761/atcs.oa.1900156.

17. Zenati MA, Bhatt DL, Bakaeen FG, et al. Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass. N Engl J Med. 2019;380(2):132-141. doi:10.1056/ NEJMoa1812390 21

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery

18. Samano N, Geijer H, Liden M, Fremes S, Bodin L, Souza D. The No-Touch Saphenous Vein for Coronary Artery Bypass Grafting Maintains a Patency, After 16 Years, Comparable to the Left Internal Thoracic Artery: A randomized trial. J Thorac Cardiovasc Surg. 2015;150(4):880888. doi:10.1016/j.jtcvs.2015.07.027.

19. Tian M, Wang X, Sun H, et al. No-Touch Versus Conventional Vein Harvesting Techniques at 12 Months After Coronary Artery Bypass Grafting Surgery: Multicenter Randomized, Controlled Trial. Circulation. 2021;144(14):1120-1129. doi:10.1161/ CIRCULATIONAHA.121.055525.

20. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization [published correction appears in Eur Heart J. 2019 Oct 1;40(37):3096]. Eur Heart J. 2019;40(2):87-165. doi:10.1093/eurheartj/ehy394.

21. Dreifaldt M, Mannion JD, Geijer H, Lidén M, Bodin L, Souza D. The no-touch saphenous vein is an excellent alternative conduit to the radial artery 8 years after coronary artery bypass grafting: A randomized trial. J Thorac Cardiovasc Surg. 2021;161(2):624-630. doi:10.1016/ j.jtcvs.2019.09.177.

Copyright Figure 1 & 2: This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Additional References Utilized: 9. Cancelli G, Audisio K, Chadow D, Soletti GJ, Gaudino M. The evidence for radial artery grafting: When and when not?. JTCVS Tech. 2021;10:114-119. Published 2021 Sep 24. doi:10.1016/j.xjtc.2021.09.039 10. Krishnamoorthy B, Critchley WR, Nair J, et al. Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting.

Innovations (Phila). 2017;12(5):320-328. doi:10.1097/IMI.0000000000000405 17. Zenati MA, Bhatt DL, Bakaeen FG, et al. Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass. N Engl J Med. 2019;380(2):132-141. doi:10.1056/ NEJMoa1812390.

19. Tian M, Wang X, Sun H, et al. No-Touch Versus Conventional Vein Harvesting Techniques at 12 Months After Coronary Artery Bypass Grafting Surgery: Multicenter Randomized, Controlled Trial. Circulation. 2021;144(14):1120-1129. doi:10.1161/CIRCULATIONAHA.121.055525 21. Dreifaldt M, Mannion JD, Geijer H, Lidén M, Bodin L, Souza D. The no-touch saphenous vein is an excellent alternative conduit to the radial artery 8 years after coronary artery bypass grafting: A randomized trial. J Thorac Cardiovasc Surg. 2021;161(2):624-630. doi:10.1016/ j.jtcvs.2019.09.177

22

Journal of the Association of PAs in Cardiothoracic and Vascular Surgery