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Ann Thorac Surg 1997;64:265-266
© 1997 The Society of Thoracic Surgeons

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How To Do It

Endoscopic Saphenous Vein Harvesting

Department of Cardiovascular and Thoracic Surgery, St. Vincent Medical Center, Indianapolis, Indiana

Accepted for publication January 10, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Results References

 
Although the use of arterial conduit has decreased the amount of saphenous vein required for routine coronary artery bypass grafting, the saphenous vein as a bypass conduit remains an essential component of most practices. We describe the technique of endoscopic vein harvest that, in our initial experience with 30 patients, has improved patient satisfaction and decreased the complications associated with traditional harvest techniques.

	Introduction

Top Footnotes Abstract Introduction Technique Results References

 
Although major complications such as sepsis and amputation occur infrequently after saphenous vein harvesting using traditional longitudinal or skin bridging techniques, minor complications such as wound dehiscence, chronic edema, wound drainage, and superficial and deep infections are frequent [1–3]. In an attempt to improve patient satisfaction and decrease leg wound complications, we evaluated the technique of endoscopic vein harvesting, which is described herein.

	Technique

Top Footnotes Abstract Introduction Technique Results References

 
The operating room setup is altered only with the addition of endoscopic equipment and monitors. Because dissection along the vein is done both superiorly and inferiorly, two monitors are ideal to avoid having to reposition the endoscopic cart as the direction of the vein harvest changes. Overcrowding the operating room with additional equipment can be circumvented by routing the video picture into existing overhead monitors.

Preoperative vein mapping is not routinely obtained. Although identification of the saphenous vein through the initial small access incision can be difficult, particularly in obese patients, with increased experience this becomes less problematic. There were no conversions from endoscopic vein harvesting to the traditional open technique in our first 30 patients. Furthermore, the added expense of routine preoperative vein mapping is not justified because conversion to an open technique is simple and straightforward.

Greater saphenous vein from approximately two thirds of the leg can usually be endoscopically harvested through a single 2.5-cm transverse incision made either above or below the knee (Figs 1A, 1B). If vein from the entire leg is needed then two separate incisions, one above and one below the knee, are used (Fig 1C). In the latter situation, the vein above and below the knee is endoscopically harvested while the short segment of the vein bridging the knee is harvested under direct vision through the two incisions. This technique significantly expedites a sometimes difficult and slower endoscopic dissection across the knee, where more geniculate branches are often present.

View larger version (77K): [in this window] [in a new window]   Fig 1. . Typical incision locations to allow endoscopic removal of the proximal two thirds (A), distal two thirds (B), and the entire saphenous vein (C) from the leg.

Visualization and division of side branches is usually straightforward. With the endoscopic clip applier (Ethicon Endo-Surgery), a single clip is applied to the side branch 3 to 5 mm away from the vein. Endoscopic scissors (Ethicon Endo-Surgery) are used to transect the branch between the clip and the vein. The unclipped branch on the vein side usually does not bleed. Unipolar and bipolar cautery have not been used to divided branches. Division of anterior branches, which are found most commonly at the junction of the distal and middle third of the thigh, is more taxing and will challenge even the most patient surgeons or assistants in their initial cases. During the learning curve, additional "helper" incisions may be needed to facilitate difficult side branch division. Additional incisions also may be needed at either the groin or ankle to expedite transection of the respective ends of the vein. With experience, however, the endoscopic clip applier and endoscopic scissors can be used to secure and then transect the proximal and distal vein; side branches are secured upon removal of the vein from the leg.

The subcutaneous dissection tunnel is loosely packed with an antibiotic-soaked laparotomy pad and the incisions are closed after heparin reversal. To reduce postoperative tunnel dead space and prevent fluid accumulation, the leg is wrapped with an elastic bandage immediately after removal of the sterile drapes; the elastic bandage is left on the leg for 4 days, with wounds inspected daily.

	Results

Top Footnotes Abstract Introduction Technique Results References

 
From June 17, 1996, through September 15, 1996, thirty consecutive patients who have required multivessel coronary artery bypass grafting have undergone endoscopic vein harvesting. Average patient age was 70 years (range, 51 to 82 years), with 73% (22/30) men and 27% (8/30) women. An average of 2.8 venous grafts and 1.2 arterial grafts were done per patient. During the initial 5- to 8-case learning curve, harvesting time was 1 to 2 hours compared with the current time of 35 to 45 minutes. An average of 1.5 (range, one to four) 2.5-cm transverse incisions were made per patient. Initial cases often required three to four incisions; however, the last 15 patients have required only one or two incisions. Endoscopic vein harvesting in the first 30 patients was performed by a single surgeon. Surgical assistants now perform endoscopic vein harvesting simultaneous with sternotomy, arterial harvesting, and cannulation.

With 100% follow-up at 4 weeks, only 1 patient (3.3%), an 80-year-old steroid-dependent, obese, diabetic woman, has had any minor or major wound complications. This patient required readmission for cellulitis of her lower extremity, which required intravenous antibiotics and debridement. Although not prospectively evaluated, postoperative pain, edema, and wound complications appear decreased while patient satisfaction has been immense (Fig 2). A prospective, randomized trial comparing endoscopic with traditional vein harvesting techniques is underway to confirm these retrospective positive impressions.

View larger version (121K): [in this window] [in a new window]   Fig 2. . Legs photographed 4 weeks postoperatively demonstrating healed incisions after removal of the distal two thirds (A) and entire greater saphenous vein (B).

	Footnotes

Top Footnotes Abstract Introduction Technique Results References

 
Address reprint requests to Dr Allen, 8333 Naab Rd, Suite 300, Indianapolis, IN 46260.

	References

Top Footnotes Abstract Introduction Technique Results References

 

1. Lavee J, Schneiderman J, Yorav S, et al. Complications of saphenous vein harvesting following coronary artery bypass surgery. J Cardiovasc Surg 1989;30:989–91.[Medline]
2. Delaria GA, Hunter JA, Goldfin MD, et al. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg 1981;81:403–7.[Abstract]
3. Lee KS, Reinstein L. Lower limb amputation of the donor site extremity after coronary artery bypass grafting surgery. Arch Phys Med Rehabil 1989;67:564–5.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Keith B. Allen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Allen, K. B. Articles by Shaar, C. J. Search for Related Content PubMed PubMed Citation Articles by Allen, K. B. Articles by Shaar, C. J.