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UKM creates history through a new vein harvesting technique performed at Universiti Kebangsaan Malaysia Medical Centre (UKMMC) in Cheras which cuts out more than just a vein.  The new technique also reduces operating time, hastens the recovery process and slices the cost of heart coronary artery bypass surgeries.

This nationally historic surgery was performed by UKMMC consultant cardiothoracic surgeon and senior lecturer, Associate Professor Dr Mohd Ramzisham Abdul Rahman. He performed the surgery with a new instrument called Vascular Micro Milling System (VMMS) which was invented by Dr Peter Hjc. Sporen of Holland. 

“The beauty of the VMMS technique is it has no camera, so it is cheap. It is so simple where you just need to hook the vein to a rod-like instrument attached to a pedal. The instrument rotates to cut the vein as it follows the vein inside the leg controlled by a foot pedal. It is an invention of Dr Sporen but he needed us and our expertise as heart surgeons to assess the instrument whether it is suitable to harvest a vein and how it can be improved,” said  Dr Ramzisham.

To appreciate the new technique and its contribution to the field of cardiothoracic surgery (heart and lungs surgery), you need to understand how a heart bypass surgery is performed.

By pass surgery and vein harvesting.

Heart bypass surgery is done for patients with coronary artery disease and one can think of it really as fancy or sophisticated plumbing. When the vein that supply blood to the heart (coronary arteries) is clogged by plaque (a buildup of fat, cholesterol and other substances) blood flow is blocked. This will slow or stop blood flow through the heart's blood vessels leading to chest pains or a heart attack. Increasing the blood flow to the heart muscle stops these from happening and lets you live longer.

What the surgeons would do is extract a blood vessel, located in the leg and use it as a conduit to bypass the blocked coronary arteries. So the vein from your leg is stitched over the clogged area to bridge over (bypass) the blocked blood vessel to the heart.  So the vein taken from your leg will act like a new highway bypassing a busy and congested area. 

Traditionally, the process of extracting a vein from the leg or vein harvesting requires a lengthy incision along the insides of the leg to retrieve the blood vessel.  This normally leaves scar marks which can run from your groin all the way down to your ankle. Not only can you kiss your dream of entering a beauty contest goodbye but the vein harvesting operation is very painful and it will take a while before you can walk straight again.

This method of opening the inside of your legs can also bring about complications such as infection and wound breakdown especially in diabetic patients. Then the resultant pain is very excruciating.

Caption: Picture of old method of vein harvesting - The skin, fat and fascia layers are sliced open to access the vein

If you are overweight or a diabetic you run the risk of losing your leg. “When you cut open the leg there will be a lot of problems, if the patient is diabetic he risks infection, if he is over weight his leg might tear open and the wound needed to be bandaged for at least one month and sometimes it may even result in amputations”, said Dr Ramzisham.

The 2 minute Vein harvesting.

Dr Ramzisham recently demonstrated how the VMMS technique works when he was operating on one of his patients. Instead of making a two or three feet long cut in the leg, using the new technique he needed to make only a two centimetre  incision, select the vein which needed to be harvested and use the VMMS to harvest the vein safely.

This is done by inserting the chosen vein which has been tagged into a micro motor (a rod like hand piece) with its own cutter. This micro motor is attached to a foot pedal to control its rotation speed. Once the vein is in the rod, the rod will rotate following the vein up to the desired length and cut it at the end.  All he has to do is pull the rod out and the vein harvested will remain intact in the rod

The best way to imagine how this works is to picture the micro motor as a piece of drinking straw and the vein as a piece of string. The end of the string is inserted into the straw, and then the straw is push forward in a rotating motion until the whole string will be covered inside the straw.  The micro motor rotating inside the leg blanketing the vein actually preserved it from any unnecessary damage.

“What we do is make a small incision and insert the vein in the rod and move the rod inside the leg following the vein and take the vein out beautifully without any damage to it. So we don’t have to cut the leg open like in previous years,” explains Dr. Ramzisham.

The whole process of inserting the micro motor into the leg and taking it out from the leg with the vein takes about two minutes. One of the patients who just had a bypass operation, Shahbuddin Yusof commented that he was expecting to see a long scar and to be in pain. “Fortunately I don’t experience this at all. This is so much better and it is not as painful as I had expected,” said Shahbuddin while getting off the bed to sit down on a chair without any problem at all.

Endoscopic vs Micro Milling vein harvesting

Another technology that has been around for several years also requires minimal incision. The procedure is known as endoscopic vein harvesting which also requires a small incision. What the surgeon does is insert a scope with a small camera and monitor the vein on the screen to help guide the removal of the vein.

Under this system a vein is identified, then two incisions are made, one at the groin and another at the knee. After severing it, the cut vein is then pulled out. This method of vein harvesting known as minimal invasive vein harvesting is also less painful and can shorten a patient’s recovery period.

Save time for surgeons

So why do we need another method of vein harvesting when the endoscopic vein harvesting has  already overcome the negative cosmetic impact and at the same time cut the recovery period for patients?

Dr Ramzisham explains that the current endoscopic vein harvesting is not free from risks or complications. There are three factors that make the VMMS better than endescopic vein harvesting. Time, cost and risk.

 “Using the endescopic method we look at the screen and insufflate carbon dioxide gas. Clip and cut takes half an hour to an hour to harvest the vein. Insufflation of the gas will cause the patients’ leg to swell up to the groin. Should the gas be absorbed into the body it can cause the patient’s blood pressure to rise during the operation and cause bleeding. It can also damage the vein and may even be fatal,” said Dr Ramzisham.

The longer a surgery takes the greater is the risk to the patient. With endoscopic it normally takes about an hour whereas the VMMS takes less than 2 minutes to harvest. This is a reduction more than 90 per cent of the time spent.

Safer for patients

Dr Ramzisham refers to a study by Dr John  H  Alexander, an Asscociate Professor in Duke University USA which was published in the July 16, 2009 issue of the New England Journal of Medicine” which linked endoscopic vein harvesting to higher mortality.

“Endoscopic vein harvesting causes less trauma to the patient which means he can recover faster. There is also less pain from scarring and shorter hospital stay, but it causes greater trauma to the vein and can damage it. The harvested vein’s durability to stand the test of time could also be affected,” said Dr Ramzisham.

This makes the VMMS technique more favourable because the vein is preserved.

Cheaper  heart by pass surgery

Another advantage of the VMMS as opposed to the endoscopic procedure is cost. Dr Ramzisham hopes to not only make heart surgery less traumatic so that the patient can get right back on the saddle and get on with his life but also make it cheaper so that it is affordable even to the poor. Unlike endoscopy where a new disposable set is needed for every surgery, the VMMS equipment can be used over and over again and with minimal maintenance.

“The beauty of micro milling system is it does not need a camera, so it is cheap. It is so simple you just hook the vein then you push the pedal and it will rotate and cut along the vein. It is swift and the device is reusable. You don’t have to throw it away like endoscopy which cost around RM 2000 every time,” said Dr Ramzisham.

How it all happened and what next?

At the moment the VMMS system patent is owned by Dr Sporen who approached Dr Ramzisham and two other surgeons to test and see whether it is suitable for by-pass operations.

 “It is an invention of Dr Sporen but he needed us and our expertise as heart surgeons to assess the instrument whether it is suitable and how it can be improved. So we did a workshop in Bangkok and we tried on fresh corpses. We tested it on five bodies and then we send the vein to the lab to find out whether the internal side of the vein harvested is damaged. In a bypass operation it is important to ensure that the vein to be used for the bypass is well preserved to ensure that it would be long lasting,” said Dr Ramzisham.