February 09, 2007

Bypassing Long Incisions

Endoscopic approach at Genesis signals new trend in heart bypass surgery

DAVENPORT, Iowa - When Jerry Johnson had quadruple bypass surgery at Genesis Medical Center, Davenport, cutting-edge technology spared him the pain and difficult recovery of having long incisions in his arm and leg.

During his surgery, an artery was removed or "harvested" from his arm using only two small incisions, instead of the usual elbow to wrist incision. The pioneering procedure, called endoscopic radial artery harvest, represents a new trend in heart bypass surgery. It sets Genesis apart in the Quad Cities region and makes the hospital one of only a couple in Iowa to offer the procedure.

The new medical technology is helping to dramatically reduce the rigors of coronary artery bypass graft surgery for patients like 59-year-old Johnson of West Burlington, Iowa.

"The new direction in heart bypass surgery is to make patients feel less like they have had a very major operation. That means smaller, less-intrusive incisions," says Genesis heart surgeon Nicholas V. Augelli, M.D., who brought endoscopic radial artery harvesting to Genesis last month.

"Endoscopic vessel harvesting has tremendous potential benefits for patients because it reduces arm and leg wound complications and offers a much better result."

A new day in bypass surgery

To understand the significance of the less-invasive option is first to understand how bypass surgery is performed.

A bypass operation really includes two surgical procedures: one in which the surgeon uses a healthy blood vessel to "bypass" the blocked arteries of the heart, and the second to remove or harvest the healthy blood vessel. This blood vessel, traditionally removed from the leg, is now taken from the arm as well. It is then used to construct the bypass grafts.

Recent advances in medical technology now make it possible to harvest vessels in a minimally invasive way, through very small incisions.

"Traditionally, the vein has been removed from the leg through a long incision that may have stretched from the ankle to the groin," Dr. Augelli says. "Often, patients having this method of vein removal endure more pain from the leg incision than from the chest incision. Some patients, particularly those with diabetes, face complications that are worse than the actual heart surgery."

Although 80 percent of coronary artery bypass graft (CABG) cases performed today utilize the vein from the leg, the radial artery from the arm is harvested in about 20 percent of the bypass procedures each year. That percentage likely will grow, as more patients require multi-vessel bypass surgery or additional bypass procedures.

At Genesis, Dr. Augelli is shifting the trend and harvesting vessels with an endoscopic approach whenever possible. After the first successful endoscopic procedure last month, he also plans to use more radial arteries for bypass grafts.

"Radial arteries make more durable grafts than veins," Dr. Augelli says. "The leg veins are not really meant to hold high pressure. They are built to be in a lower pressure system, and we have altered what they were made to be and placed them in a very high-stress situation. So after a period of time, they will fail."

The survival rate of a radial artery bypass is 80 percent in 10 years -- an improvement over a 50 percent survival rate in 10 years for vein bypasses.

A less-invasive approach

During Jerry Johnson’s surgery, cardiovascular operating room nurse Drew Starenko, RNFA, removed the radial artery in the arm using an endoscopic approach. He has the distinction of being the first at Genesis –- and the first in eastern Iowa -- to remove the radial artery using Boston Scientific’s VasoView® Endoscopic Vessel Harvest System.

At the same time, cardiovascular operating room nurse Jennifer Nelson, RNFA, harvested the saphenous vein in Johnson’s leg using the endoscopic technology. That avoided the traditional long incision that can stretch from the ankle to the groin.

With the support of the entire Operating Room team, Starenko and Nelson harvested vessels in the arm and leg while Dr. Augelli removed the internal mammary artery located underneath the sternum, the most important graft and first vessel of choice for heart bypass surgery.

During the procedure, Starenko and Nelson insert the endoscopic vessel harvesting system into the incision and use it to dissect the radial artery in the arm and the saphenous vein in the leg. The system then infuses carbon dioxide gas into the tunnel, which provides the necessary space for them to harvest the vessels.

Once the vessel is separated from the surrounding tissue, they use the system to retract, cauterize and divide tributaries to the artery or vein that will be harvested. When this is completed, the vessel is harvested intact and removed from the patient’s arm or leg.

The harvested vessel is then used as a graft that Dr. Augelli sews in place to bypass the blocked coronary artery.

"It’s fascinating to be a part of the endoscopic vessel harvesting and very rewarding to see how this benefits our patients," Starenko says. "This has significantly changed wound healing for patients because now they don’t have huge incisions that need to heal, and their pain level is dramatically decreased. I’ve worked on patients who woke up from surgery unable to tell which leg I had operated on."

He credits Dr. Augelli for bringing radial artery harvesting and a more minimally invasive approach to bypass surgery at Genesis. He also credits Vari Nelson, manager of Perioperative Services, who was instrumental in allowing him and Jennifer Nelson to pursue the training. "It’s an entire team effort with everyone that’s involved in the O.R," Starenko says.

A personal perspective

At the heart of the technological advancements is the personal impact it has on bypass patients like Jerry Johnson, who have faced their own mortality during open-heart surgery.

Johnson, a farmer who prided himself on never missing a day of work in 30 years, found out he had heart disease in a roundabout way -- while he was undergoing a series of tests for bladder cancer. It turned out that his need for a quadruple bypass, mitral valve repair and aortic valve replacement would be a far more threatening to his health than the early-stage cancer.

"If he hadn’t undergone the tests for the bladder cancer, we likely wouldn’t have found out about the heart problems," says his wife, Katie Johnson. "In a way, the bladder cancer saved him because it led to the diagnosis about his heart. But the heart problem has complicated his treatment for the bladder cancer."

Jerry Johnson says he never realized that heart disease was slowing him down until after he had the bypass surgery and experienced renewed energy.

"I’d built a garage over the summer, built a house over the last two years and had been slinging cement block and running over scaffolds and never once realized I had anything wrong with my heart," he says. "I’ve had aches and pains before, but I shook them off and kept going. I thought I felt great, and this has all been quite a shock to me."

Thanks to the endoscopic technology at Genesis, he has only small scars on his forearm and a couple of small scars on his leg where the vessels were harvested and then used to restore blood flow to his heart.

Endoscopic harvest of the vessels eliminates major incisions and enables patients like Johnson to rehabilitate sooner and begin their pursuit of a heart-healthy lifestyle, Dr. Augelli says. "We’re pleased to be able to offer this less-invasive option to our patients."

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