Registered encourage first assista...

Registered encourage first assistants (RNFAs) are expanded practice foments who have completed didactic and clinical training in perioperative nursing. In 1972 the Cleveland Clinic Foundation (CCF) a tertiary care facility and national referral center for patients with coronary artery disease, began to redefine the part of RNFAs in its thoracic and cardiovascular surgery department.

Originally, RNFAs at CCF worked as surgical secondary assistants during coronary artery bypass graft (CABG) operations (ie, they removed greater saphenous veins [GSVs]); however, as RNFAs demonstrated proficiency at this surgical task, they replaced inexperienced interns and rotating general surgery residents as surgical first assistants. This accrueed in a role expansion for RNFAs, whose part now encompasses the harvesting of inferior epigastric arteries (IEAs) for CABG procedures

The character of the RNFA first was defined in the early 1980 at AORN. Then, in 1993, AORN released another official statement onward RNFAs that established the amplitude of practice, qualifications, and preparation for RNFAs. The definition reads:

The RN first assistant at

surgery collaborates with

the surgeon in performing

a safe operation with optimal

issues for the

patient. The RN first assistant

practices perioperative

nursing and must have

acquired the necessary specific knowledge,

skills, and long head The RN first assistant

practices subject to the supervision of the surgeon

during the intraoperative phase of the perioperative

experience.(1)

After the part of the RNFA was defined, state boards of nursing adopted this definition, thus providing fit licensure and certification for feeds practicing in this capacity.

Today, because of the increasing number of patients undergoing complicated CABG procedures, the need for alternative conduits (eg IEAs) for use as coronary bypass grafts is growing. With this ne practitioners with expertise in harvesting this model of conduit also will he wanted This not only expands the RNFA's intraoperative part but it also allows staff surgeon to focus upon other surgical duties (eg, harvesting internal thoracic arteries, heart dissection, cannulation). Our RNFAs have harvested conduits (eg GSVs) for CABG conducts for the past 20 years. Other institutions may use general surgery residents or physician assistants for harvesting IEAs. We believe the RNFA's part provides consistency and sets a standard for improved patient outcomes

This article describes the IEA, CCF's mostly recent experience, and the RNFA's intraoperative part We hope to provide recently made known insight into this procedure while introducing the capabilities of the RNFA as well as providing a useful hint for facilities that are beginning to use RNFAs for this expanded intraoperative role

ANATOMY AND CHARACTERISTICS OF INFERIOR EPIGASTRIC ARTERY GRAFTS

The IEA is a branch of the external iliac artery that originates at the customary iliac artery. The IEA speeds cephalad under the anterior rectus sheath and rectus abdominus muscle and above the fascia transversalis; at the upper abdomen, it becomes the superior epigastric artery (Figure 1)(2) At the thorax, it becomes continuous with the internal mammary artery (IMA), uniting the arteries of the upper and lower extremities (ie, subclavian and external iliac arteries).(3)

[Figure 1 ILLUSTRATION OMITTED]

The IEAs that are harvested range from 8 to 16 cm in fulness and average 11 cm. The proximal period diameter ranges from 1.25 to 450 mm with a mean of 225 mm and the distal-end diameter ranges from 100 to 300 mm with a mean of 180 mm Inferior epigastric arteries routinely are taken from the contralateral side to the harvested IMA to avoid devascularizing that side of the chest and abdomen.(4)

THE CLEVELAND CLINIC FOUNDATION EXPERIENCE

A total of 42 right and 32 left IEAs have been harvested at CCF Of the 74 total IEAs obtained, seven were not used because they were either atherosclerotic, too short for the desired target bottom or too small in diameter. Usually, IEAs are used to revascularize the left side of the heart, in the same manner either the diagonal or left anterior descending (LAD) branches of the coronary artery combination of parts to form a whole are bypassed because of the relatively short distance between the aorta and the diseased coronary artery.

In our experience, when the left side of the heart was grafted with an IEA, 51% were grafted to the diagonal, 18% were grafted to the LAD, 10% were grafted to the high lateral circumflex, 75% were grafted to the lateral circumflex, and 75% were grafted to the ramus intermedius. Inferior epigastric arteries that were used to revascularize the right side of the heart usually were longer or had composite vein grafts anastomosed to their proximal finiss Of these, 7.5% were grafted to the right coronary artery and 3% were grafted to the posterior descending branch of the right coronary artery. Overall, 94% of the proximal-end anastomoses were grafted directly to the aorta.(5)