[[300 Technical Outline of Coronary Artery Bypass Grafting]] # Preparation of Venous Conduit - Carefully maintain orientation of the reversed saphenous vein - The end furthest down the leg is now the proximal end of the vein, and that closest to the groin is the distal end of the vein - Cannulate the proximal end of the vein with an 18 gauge green angiocath on the end of a syringe full of heparinized saline flush. - This is handed to you on the request "Syringe full of flush, soft dog, angiocath" - These components are assembled together with a "soft dog", a double cushioned spring clip, clipped on to the hub of the angiocath. The syringe should be a slip tip, not a Luer Lock. - Hold the very lip of the proximal end with a coronary DeBakey forceps (two people holding the vein open only makes it more difficult), flush a little hep saline into the vein, which opens it up and aids insertion, then move the soft dog down to clip the proximal end of the vein on to the angiocath.[^a] - Lay the vein in an open warm moist laparatomy sponge - Fold the sponge closed over the vein and flush with heparinized saline, look for the flush to emerge, bloody then clear, from the end of the vein - Clip obvious leaking branches - At all times, avoid clipping too close to the vein, which may expand and cause an indentation by a clip that was too close on the branch - Double clip each significant branch - Medium-Medium, Medium-Small, Small-Small clip combinations according to size of branch - Once significant leaking branches are clipped, apply a second soft dog to the very distal end of the vein - Gently distend the vein, segment by segment - Look for smaller branches to clip - If a branch has been avulsed, perform figure-of-eight repair of leak using 7-0 prolene - Hold distended vein between and running along thumb and forefinger - Precisely perform figure-of-eight suture immediately on either side of the base of the avulsed branch - Have scrub nurse use two fingers fix the vein to the sponge on either side of the repair - Tie down - Test the repair - The vein should be reviewed with the primary surgeon, noting any unusual features including varicosities, valves, side branches and other abnormalities that may affect grafting plan. - Consider marking the vein to help prevent twisting of the conduit. [^b] - Pat the distended vein dry with a dry laparotomy sponge - Roll a skin marker against its length - Release the distal soft dog to let the saline drain from it - Leave the proximal angiocath/soft dog attached to help mark orientation, disconnect syringe - Lay it in a kidney bucket along side any other free conduits - Heparinized, papaverine solution buffered with 20 ml of blood drawn from arterial line. [^a]:Some prefer disposable or metal vein cannulae for this purpose. The vein is tied down on the flanges on the tip of the cannula. They are a good size bore, and perfuse easily. I prefer to angiocath/soft dog method, which allows the vein to spin on the angiocath when the graft is flushed, and is helpful in planning the lay of the graft. [^b]:See above footnote.