My Saphenous Vein

“Help me hear joy and happiness as my accompaniment,
    so my bones, which You have broken, will dance in delight instead.”

Book of Psalms 51 verse 8 The VOICE Tr.

It is now 3 years ago that I received life saving surgery at Hamilton General Hospital after my heart attack or myocardial infarction. And I am grateful for receiving this gift of new hope!

I had notice a discomfort in my chest for a number of years. First when working in the garden weeding and frequent bending, I would experience dizzy (lightness) in my head and discomfort. I saw my doctor and was prescribed Ramipril .5 blood pressure pills. This issue seem to go on for years but was not getting better and I would limit my bending to once or twice at a time in order to feel well. By late 2019 it became a problem in that just moving about (say: going shopping) would make me feel disoriented and remote, with tightness in my head and feeling ‘strange’ to my environment with chest tightness and discomfort. My doctor upped the dose of my Ramipril and scheduled a visit to the cardiologist 6 months or so down the calendar. By July 2020 (beginning of the Pandemic) whenever I would exert myself, dizziness would come and at times it seemed I could easily pass out. On the morning of July 17th after a severe episode the previous day, I felt extremely uncomfortable, I called my doctor’s office and was told to go to ‘Emerge’. This call saved my life.

I am not a brave person when it comes to doctors and hospitals (having only once before in my life submitted to hernia surgery) yet I knew in myself that there was something dreadfully wrong with me and I needed to be courageous and ask for help. That help I received as the doctors could tell that I had suffered a ‘myocardial infarction’ (heart-attack). They determined that to fix me, I needed a surgical procedure to treat the coronary artery disease (CAD), which was a buildup of plaques in the arteries of my the heart. So to prepare the doctors scheduled the necessary tests: blood, ultra sound, ECG and angiography which indicated I had 4 blockages from 80% to 50%. Rather than a ‘Stent’ procedure I was advised to have the radical by-pass chest opening (CBAG -coronary artery bypass graft ) surgery. This would be a ‘best’ surgery procedure I was told and would help me get back to normal living again. This verdict was my worst fear. The surgeon would open my chest and restructure my blood flows. Very scary to me and thinking about the worst possible outcome, I told the doctor that if complications arose during surgery not to use ‘heroic’ exercises to keep me alive. I surprised myself in saying this. It seemed to me, I would be OK and so felt full of the assurance that no matter what happened I will be fine. Was it my faith in God that He would see me through? What happens if I die? What about my family?

It was already full-blown Covid time and hospital visits had been curtailed to every-other day for only 2 designated family members. The Wednesday morning after my diagnosis my wife and I were told to make up our minds quickly so I could be scheduled in by Friday. And so she and I had a quick talk about it, decided it was the best course of action.

On the day of my 79th birthday and submitted to the surgery the day after on the 24th of July at 7 AM.

I was not anxious or afraid or even upset or for that matter doubting my decision to go ahead with this procedure. When I think back I cannot believe how calm I was. My wife and son came to see me in hospital, late the evening before and we talked from a distance (it Covid-time) and I remember saying to my son: ‘Look after your Mom – I will be fine’. I think God’s spirit had already convinced me in the few days before that: 1) my health issue was serious 2) I felt assured of His nearness in telling me, all will be well and if not I would rest with Him. I remember playing a YouTube video of a song “Be not afraid” which was extremely quieting to me in that God was there for me. It helped me to set aside my anxiousness (angst) about my condition. Often I would repeat for myself the Psalmists statement of reassurance: …“I remain confident of this: I will see the goodness of the Lord in the land of the living. Wait for the Lord; be strong and take heart and wait for the Lord” (Book of Psalms nr. 27) My heart was waiting with rest in that assurance.

After being prepared for surgery: shavings and applying an antiseptic skin application I had a good night’s rest and was woken early and wheeled down the hall to the operating room.

The bi-fold doors opened as I was pushed inside and was surprised by how the room was full of equipment with a huge lamp above the table I was transferred to.

The nurses present, said ‘Good morning’ as did the surgeon and the anesthesiologist at my side. A cover was placed on my body, I was intubated and the surgeon told me to stick out my right arm, I felt him putting something in the port by my right hand. I said: ‘Do I count….’.he said: ‘if you want to’ … I started at 10 and barely got to 8 and that is the last I remember.

Much labour and study by many persons have gone into contributing to the success of what happened next, this by-pass procedure and one especially important medical doctor is: Rene Geronimo Favaloro (see picture below)

Now what followed with me, is a medical mastery, a work of precision and high skills resulting from trial and error over many years of medical experiments, theories and hands on efforts of countless medical researchers and others with bright intellectual minds and keen desires in adventurous and extremely precise discoveries to make this procedure as safe as it is today.  And the biggest player in this scenario was to be my Saphenous vein. This vein located in my left leg was considered to be healthy and could be missed in the blood -flow to my leg as the other veins would take over the necessary work. You see without this pre-ordained body part, the operation could not be successful. Since the blockages were in the arteries of the heart, this similar blood carrying part (vein) was a perfect fit as replacement needed for a new ‘detour of the heart’ blood flow. A new highway for life. A same body friendly organ that knew my blood; and the skill of the surgeon to make the connection by using a procedure called: Anastomosis (grafting) This is ‘supramicrosurgery’ and requires great skill and quick work.

You see early in the 1900s, a surgical procedure called sympathectomy — a cut on the sympathetic chain that supplies the heart—or pericardial abrasion, was used to relieve cardiac symptoms. However it had disappointing results. The French surgeon Alexis Carrel was the first to anastomose a branch of the carotid artery—in the heart of a dog. By the 1950s there were efforts by C.S. Beck; Arthur Vineberg the “Vineberg Procedure”; Mason Sones used angiography to determine vessels to be by-passed; in 1955 Sydney C. Smith MD performed cardiac surgeries using the Saphenous vein; by 1964, Soviet cardiac surgeon Vasilii Kolesov performed an artery anastomosis; also Michael DeBakey used the Saphenous vein to create a by-pass; but Argentine surgeon René G. Favaloro standardized the procedure. CABG became the standard of care for CAD patients. (all info from: Wikipedia)

Another less known medical surgeon who contributed to the expertise of this procedure was: Robert Hans Goetz. His full story can be found in an essay by Igor Konstantinov MD @ sciencedirect.com ‘Our Surgical Heritage’ .

Dr. Goetz was born in Frankfurt, Germany in 1910, of Jewish parents Johan Konrad and Emilie Goetz. He spent his early years with his grand-parents and went to a one room school in a small village in the Black Forest region, where he did quite well with his studies and was accepted to Helmholtz Ober Real Schule and achieved his matriculation in 1929 and decided he would either become a architect or a physician. Watching his family physician’s quick skills of lancing big boils without anesthesia, impressed him and he decided to choose medicine. He attended the University of Frankfurt and during the summer worked for 3 months at the local hospital and scored high grades at school. Also as a student you automatically became a member of the Nazi Party.

He spent time in the department of Dr. Albrecht Bethe, professor of physiology and learned much, getting ahead of the other classmates. By studying the peripheral circulation, he constructed a new device – a digital optical recording plethysmograph – that accurately measured changes in blood flow with each heartbeat. Dr. professor Bethe urged him to submit an article on his method for the Klinische Wochenschrift, a medical journal, which was accepted as his thesis for his MD degree. However even though he passed his MD exam ‘summa cum laude’ the Nazi Minister of the Interior declared him ‘political unreliable’ (he did not get his diploma until 62 years later in 1997)

At the end of 1933, the Nazis took full control and intended to make it impossible for Jews and other “undesirables” to continue to study medicine. All students were forced to join the National Socialist Student Organization. Access to final exams were not admitted unless you provided proof that you were a regular attendant at the Nazi rallies, lectures etc.

So he supported himself by tutoring students of his old high-school in math and chemistry. Sometime later he heard that a physician employed by a high security jail in Frankfurt was going on vacation but could not find a replacement. Goetz applied and was hired. The jail was at the opposite end of the city and he would ride his bike to the job during lunchtime. The job had one unforeseen benefit. As jail doctor he had to test the adequacy of the prison food. Instead of just a spoon full sampling, he would ask to see the complete meal. The wardens found it odd why this young doctor would do this. They did not realize that it was his only meal of the day.

Seeing politically things were getting worse, he resigned his membership in the NS Student Organization and decided in 1934 to leave Germany and travel to Switzerland (with no medical papers and 10 marks in his pocket) where professor Dr. Bluntschli who had escaped Germany earlier, vouched for him with the Swiss authorities even though he did not obtain his medical diploma or license and gave him a job. Professor Bluntschli suggested a study of the ‘placental circulation of a primitive lemur’. With this thesis he obtained his MD degree.

By 1936 fearing German Nazi expansion might also include Switzerland, he took advantage of a opportunity to spent a year in Scotland with Professor I. De Burgh-Daly in Edinburgh. Since he was not considered a ‘bona fide’ refugee, he only received permission by the Home Office to stay for a year. When that was up he applied for a position in South Africa. He was married and sailed to Cape Town in 1937.

In 1938 the Groote Schuur hospital was opened and Dr Goetz was accepted, after writing exams, as a licensed physician. Because he was not a naturalized citizen his movements were restricted with regular reports to the police. He received however his own vascular disease unit at the Groote Schuur Hospital. His research interest caused him to question what happens with the blood pressure in a giraffe? why does he not faint when he raises his head? how does his body deal with such a large space in his long neck? So from 1950 to 1954 he ran a number of experiments with giraffes.

By 1950 he was already being recognized internationally as an authority in the field of blood circulation and his studies were published in various medical journals. He traveled and lectured in many places, including the USA. In 1957 he was appointed as a full professor at the Albert Einstein College of Medicine and an attending surgeon at the Bronx Municipal Hospital. Here he researched myocardial blood supply. His first clinical coronary artery bypass operation occurred in 1960 on May 2nd, at the Bronx on a 38 year old patient who had debilitating angina. During the operation it took Dr. Goetz 17 seconds to make the anastomosis, but it had taken him years to derive to this point and learn how to do it. This was the first clinical coronary artery bypass by Dr Goetz but only his last one. The patient was free of angina for a year. The procedure was not accepted by the medical community (in USA) and so fell into disuse as they considered it not only highly experimental but also unwarranted. The Arthur Vineberg (Canadian) procedure of ‘internal mammary artery implantation’ became the accepted method of by-pass operations in the 1960s.

But Dr Goetz was ahead of his time and his work was too new for many to comprehend. It was not until 1967 that Visilii Kolesov published a study of performing successful bypass surgeries in Russia and seven years before Favaloro attempted to do so, using the great Saphenous vein in bypass surgeries. Although Kolesov reported the first substantial experience with this kind of bypass grafting but it was Dr. Goetz who performed it first. (in USA) Dr. Goetz is considered a great example of creativity, bravery, integrity, precision and tenacity, all excellent qualities of a good medical researcher and surgeon. Dr. Goetz passed away in 2000 at Scarsdale NY.

So 5 days after my bypass surgery, I was home again. My chest incision was healing and my normal movements of walking and eating was picking up even though follow-up and after care was minimal because of Covid. Continual half-yearly checkups and examinations of my health is progressing well according to my cardiologist. My hat is off to all those who were involved in this medical advance. I now feel that many of ‘them’ were present as my surgeon and the medical team ‘cracked my bones‘; took the Saphenous vein from my leg and made the graft (detour) to bypass the blockage by my heart. My dad who had angina for years and who died in 1991 at age 79, did not receive this same gift.

I have now met others persons (men & women) who have experienced this unbelievable renewal surgery and are doing well. I am thankful for having received this blessing and Canada’s providing free benefits for this medical care. Thank you to all who helped make me whole again.

Oh, and my left leg is a bit scarred but OK for an 80+ year old! Praise God!

JS Sept 20, 2023

Note: About 15,000 people in Canada undergo coronary artery bypass grafting known as: (CABG) surgery each year. (figures from 2021) (in the USA over 450,000 per year) Note: Check at article at ‘Our Surgical Heritage’ by Igor E. Konstantinov, MD Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota Some other references: By Blausen Medical Communications, Inc. – see ticket for details, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=26986523

https://www.sciencedirect.com/science/article/abs/pii/S0003497500012649 https://en.wikipedia.org/wiki/Coronary_artery_bypass_surgery

https://www.nytimes.com/2000/12/20/us/robert-goetz-90-innovator-in-coronary-bypass-surgery.html