Standard Surgical Skin Markers Should Be Avoided for Intraoperative Vein Graft Marking during Cardiac and Peripheral Bypass Operations.

Abstract

One cause of early graft failure following coronary and peripheral vein grafting is kinking or mechanical twisting of the conduit. The blind tunneling necessitated in peripheral bypasses can lead to this consequence (1). In coronary artery bypass grafting (CABG), grafts to the posterior branches of the right or circumflex coronary arteries are placed to the back of the heart and are generally the longest aortocoronary grafts. These grafts are particularly prone to twisting and kinking. Additionally, single vein grafts to two or more coronary branches (“sequential vein grafts”) present special challenges with respect to maintenance of proper alignment (2, 3). The coronary vein graft failure rate at 1 year in the PRoject of Ex vivo Vein graft ENgineering via Transfection IV (PREVENT IV) cohort was 25%, suggesting that early graft failure is a significant problem (4, 5). The incidence of vein graft failure due to twisting or kinking is not well studied, though some reports estimate that obstructing lesions, including but not limited to twisting or kinking, account for 15–25% of early (<1 year) graft failures (6–8). Preparation and preservation techniques have advanced the field of solid organ allotransplantation, but vein graft failure rates suggest room for improvement in the handling of saphenous vein (SV) harvested for autotransplantation. Interventions for ex vivo graft treatment, including appropriate choice of preservation solution and minimization of manual pressure distension via chemical vasodilators such as papaverine, have been proposed (9–12). Additionally, the “no-touch” technique has emerged as a method of minimizing detrimental handling of graft during harvest with adventitial preservation (4, 13–15). Marking of the SV graft using a surgical skin marker in an “off-label” fashion represents another such preparation technique and is the most commonly employed method of preventing graft torsion (16). This marking allows for the maintenance of continuous alignment along the length of the vein in the same longitudinal plane. These lines provide a visible guide for surgeons to use during conduit routing and tunneling to avoid mechanical obstructions related to vein alignment (17). While operating rooms have adapted less traumatic methods of vein harvest, preservation, and distension, surgical skin marker use remains ubiquitous as the primary method to maintain graft orientation. The use of surgical skin markers during graft preparation is toxic to the tissue and impairs physiologic function (16). We argue that the data support avoidance of standard surgical skin markers for marking on vascular tissue; We further contend that brilliant blue FCF (for coloring food) may represent a viable alternative dye for intraoperative graft marking.