Eur J Cardiothorac Surg 1999;16:S58-S60
© 1999 Elsevier Science NL
Minimally invasive saphenous vein harvesting: is there an improvement of the results with the endoscopic approach?
Frank Isgro*,
Udo Weisse,
Bernhard Voss,
Arndt-H Kiessling,
Werner Saggau
Heartcenter Ludwigshafen, Clinic for Cardiac Surgery, Bremserstrasse 73, 67063 Ludwigshafen, Germany
* Corresponding author. Tel.: +49-621-503-4050; fax: +49-621-503-4060 (Email: frank.isgro{at}t-online.de).
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Abstract
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Objectives: In the postoperative course after conventional open removal of the greater saphenous vein, wound healing disturbances are common and often painful. Therefore the primary goal of this investigation was to prove the safety and practicability of this new less invasive technique for saphenous vein harvesting and the effect on complications and morbidity. Methods: The study comprised 103 coronary artery bypass grafting (CABG) patients with an endoscopic approach to harvest the saphenous vein (MIVH). We used the VasoView II system developed by Origin, and compared the intraoperative procedure time and the clinical results with 105 equivalent patients in which a conventional open technique was used. Results: In 101 patients endoscopic vein harvesting was successful; a conversion into open technique was necessary in two patients. On average 2.6 vein segments could be harvested in the endogroup versus 2.9 segments in the opengroup. The mean procedure time was 13.2 min per segment in the endogroup compared to 12.2 min per segment in the opengroup. Relevant hematoma were found in 29 patients (27.6%) of the opengroup, whereas only nine patients (8.7%) of the endogroup revealed severe hematoma. Infection was apparent in nine patients (8.5%) after conventional vein harvesting. Two infections were found after endoscopic intervention. Conclusions: Endoscopic saphenous vein harvesting as part of a less invasive concept in cardiac surgery is a safe and after the learning curve, fast alternative to harvest the saphenous graft. The cosmetic result is excellent and the complication rate seems to be lower. It must be noted however, that the cost effectiveness of the method has to be proved and that further histological and functional studies are needed in order to check the intimal structure of the vein.
Key Words: Endoscopic vein harvesting • Coronary artery bypass grafting
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1. Introduction
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The greater saphenous vein (GSV) grafts are used in up to 98% of all coronary artery bypass grafting (CABG) cases [1]. Usual harvesting of the GSV requires a long leg incision. Although severe wound complications are rare, it is reported that wound healing disturbances occur in as high as 44% of CABG patients [2,3] with the criteria being wound edge separation, cellulitis, drainage or necrosis necessitating dressing, antibiotics or debridement [4]. Minimally invasive vein harvesting (MIVH) offers potentially less pain, faster and improved mobility and less wound morbidity owing to the smaller surface area of the incisions. Therefore we conducted a study in order to prove the safety and practicability of endoscopic saphenous vein harvesting using the VasoviewTM system (Guidant Corp., Menlo, CA) and the effect on complications and morbidity compared to the conventional open technique.
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2. Material and methods
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From March 1998 through to October 1998 103 patients underwent MIVH using the VasoViewTM system. This system utilizes CO2 insufflation to aid in both visualization and dissection (Fig. 1). These patients were compared to 105 patients with the usual open harvesting of the GSV in the same time period. Patients were randomly chosen. The operation room setup was altered only with the addition of endoscopic equipment and monitors. Preoperative vein mapping was not routinely obtained. Although identification of the GSV through the small access incision can be difficult, particularly in obese patients, with increased experience this becomes less problematic.
The procedure starts with a single 1.5–2.5 cm incision at the medial aspect of the knee. If vein from the entire leg is needed the incision should be localized below the knee, and then advancing proximally to the groin area. Once the GSV is located the balloon dissection cannula (BDC) is inserted through the blunt tip trocar (BTT) and advanced carefully along the anterior surface of the vein, the dissection being supported by the flow of CO2 with 3–5 l/min at 10–12 mmHg of pressure. Once the vein is completely exposed, the VasoView Uniport Dissection cannula is inserted through the BTT for tributary division and cauterization (Fig. 2). When all of the vein has been mobilized, it can be divided and ligated proximally and removed from the leg. Vein length and harvest time were recorded. The harvest time was defined from leg incision to skin closure as time per segment. The leg incisions were examined daily until the day of discharge.
Statistical analysis was by SPSS using Student's t-test and significant difference was considered at P-value less than 0.05.
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3. Results
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Patients demographics are summarized in Table 1
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The mean age was 60.2 years in the MIVH patients and 63.8 years in the patients with open harvesting of the GSV. Male patients, predominated in both groups. (73 patients (p) and 65p).
Comorbidities associated with wound healing problems were noted and showed no significant difference in both groups (Table 1). Most of the patients were scheduled for elektive CABG (88p and 90p, respectively) but also combined procedures (aortic valve replacement and CABG) and minimally invasive CABG operations using the ‘Dresden Technique' had been performed (Table 2
).
There was a total of 268 vein grafts removed endscopically for a mean of 2.6 segments per patient and 304 vein grafts harvested conventionally for a mean of 2.9 segments per patient in the open group (Table 2). The mean procedure time was equivalent reaching 171 min in patients with MIVH and 166 min in patients without MIVH (Table 2). The average time for the removal of one vein segment, calculated from leg incision to wound closure differed not significantly for both groups (13.2 min vs. 12.2 min) (Table 2).
Wound healing, as outlined in Table 2, was excellent in 91 (88.3%) of the patients with MIVH and 76 (63.8%) of the patients with conventional open vein harvesting (P<0.001).
The wound complications included hematoma and ecchymosis (9p vs. 29p, P<0.001) and infection, cellulitis (2p vs. 9p, P<0.001; Table 2).
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4. Comment
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Harvesting the saphenous vein may be complicated by damage to the vein or more commonly by wound problems postoperatively. Wound complications of the saphenous vein harvest site are as high as 44% of coronary artery bypass patients [2].
DeLaria and colleagues found that although wound complications of the vein harvest incision were uncommon, their presence doubled the length of hospital stay [5].
In our trial, patients with endoscopic saphenectomy performed much better compared to patients with traditional vein harvesting technique.
However, a certain percentage of visible hematoma has to be considered, most probably related to early systemic heparinization and the use of endoclips for ligation of the proximal stump in the first 50 patients.
Patient satisfaction is most unequivocally immense [6] and postoperative mobilization far better, beside the unquestionable improved cosmetics.
The potential for increased trauma to saphenous vein during the endoscopic approach must be addressed. There were no known acute vein graft closures, which would imply no severe intimal damage but does not exclude the risk of subtle endothelial damage with its long term implications. Therefore a prospective, randomized trail focusing on the early and late patency rate of the endoscopically harvested saphenous vein graft is underway in order to prove the functionality and integrity of the grafts.
More histomorphological studies are needed focusing on the effects of bipolar electrocoagulation to the saphenous vein.
In conclusion, the minimally invasive approach for harvesting the greater saphenous vein as state of the art procedure is a very elegant, practicable, safe and after the learning curve fast procedure with a tremendous impact on patients satisfaction and clinical outcome.
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Footnotes
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Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3– 5, 1998.
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References
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- Virmani R, Atkinson JB, Forman MB. Aortocoronary saphenous vein bypass grafts. Cardiovasc Clin 1988;18:41-62.[Medline]
- Wipke-Tevis DD, Stotts NA, Skow P, Carrieri-Kohlmann V. Frequency. Manifestations and correlated of impaired healing of sphenous vein harvest incisions. Heart Lung 1996;25:108-116.
- Lavee J, Schneidermann J, Yorav S, Schewach-Millet M, Adar R. Complications of saphenous vein harvesting following coronary artery bypass surgery. J Cardiovasc Surg 1989;30:989-991.[Medline]
- Utley JR, Thomasen BS, Wallace KS. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg 1989;98:147-149.[Abstract]
- DeLaria GA, Hunter JA, Goldin MD, Serry C, Javid H, Najatifi H. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg 1981;81(3):403-407.[Abstract]
- Allen KB, Schaar CJ. Endoscopic saphenous vein harvesting. Am Thorac Surg 1997;64:265-266.[Abstract/Free Full Text]
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Abstract
1. Introduction
