Endoscopic vein harvesting: a guide for approaching difficult cases and assessing patients preoperatively.

Coronary artery bypass grafting remains the most commonly performed cardiac surgical procedure worldwide. The long saphenous vein still presides as the first choice conduit as a second graft in multivessel coronary artery bypass grafting surgery. Traditionally, the long saphenous vein has been harvested with an open approach which can potentially result in significant wound complications in certain circumstances. Endoscopic vein harvesting is a minimally invasive vein harvesting technique, which requires a single 2-3 cm incision and is associated with a quicker return to normal daily activities, decreased wound complications and better quality of life in the longer term. There is a learning curve associated with endoscopic vein harvesting adoption and there are certain patient factors that can prove to be challenging when adopting an endoscopic approach. This commentary aims to provide a concise guide of certain challenging patient factors that operators may encounter during endoscopic vein harvesting, and how to approach these patients in both the preoperative and intraoperative settings. We suggest that with appropriate planning and awareness of the challenging patient factors and problematic venous anatomy that exists, the operator can consistently formulate a strategy for ensuring a successful endoscopic harvest.

Thymic carcinoma presenting as atypical chest pain.

A 58-year-old woman with a 2-month history of atypical chest pain was referred to the chest pain clinic by the general practitioner. Exercise stress test was positive and subsequent coronary angiogram revealed significant triple vessel disease with left ventricular impairment requiring a coronary artery bypass graft (CABG). The patient had a chest X-ray as part of the preoperative work up. Chest X-ray revealed a large anterior mediastinal mass. Subsequent thorax CT revealed a 7.2 cm anterior mediastinal mass. CT-guided biopsy of the mass revealed the diagnosis of a poorly differentiated thymic basaloid carcinoma. The patient was successfully treated with concomitant surgery involving complete resection of the mass and a CABG procedure.

Automated implantable cardioverter defibrillator lead infection in a patient with previous superior vena cava thrombosis.

We present a case of a 44-year-old woman who presented with cough, pleuritic chest pain and fever leading to a diagnosis of pneumonia±pulmonary embolism. She had a history of familial hypertrophic obstructive cardiomyopathy (HOCM), for which an automated implantable cardioverter defibrillator (AICD) had been implanted, and a subsequent superior vena cava (SVC) thrombus, for which she was anticoagulated with warfarin. On admission, blood cultures grew a coagulase-negative Staphylococcus. CT pulmonary angiogram and transoesophageal echocardiography (TOE) were performed and revealed large vegetations adherent to the AICD leads with complete occlusion of the SVC. The infected leads were the source of sepsis. Open surgery was planned. For cardiopulmonary bypass, the venous cannula was inserted in the inferior vena cava (IVC) and a completely bloodless field was obtained in the right atrium allowing for the extraction of the AICD leads completely, along with the adherent vegetations from within.