The need for monitoring during endovascular vein harvesting

Abstract

We read with great interest the description of carbon dioxide embolism during endoscopic saphenous vein harvest reported by Potapov et al. [1]. It is well known that the procedure can cause hypercarbia [2] and there have been previous descriptions of carbon dioxide embolism [3] as well. The authors seem to have used transesophageal echocardiography (TEE) after the event but not during the acute crisis. They also do not mention whether or not end tidal carbon dioxide (ETCO2) monitoring was in place. Both of these modalities have been shown to enhance the diagnostic dilemmas of acute cardiovascular collapse in this setting [3,4]. A sudden decline in the ETCO2 could have been a warning for the impending hemodynamic event. Alternatively, TEE would have demonstrated the presence of gas in the right atrium and more specifically the inferior vena cava demonstrating the infra-diaphragmatic origin of the embolus. In the absence of either of these monitoring modalities, we feel that endoscopic vein harvest with carbon dioxide insufflation is unsafe. While the authors need to be commended for the successful outcome, it is possible that the institution of cardiopulmonary bypass might not always be prompt, and, that other options such as the use of pulmonary vasodilators also merit consideration.We strongly recommend inclusion of TEE and ETCO2 in patient’s monitoring especially in this setting for the safe conduct of the procedure.