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Ann Thorac Surg 1998;66:26-32
© 1998 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial

^a Department of Cardiovascular and Thoracic Surgery, St. Vincent Hospital and Health Care Center, Indianapolis, Indiana, USA

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

Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Background. Saphenous vein harvested with a traditional longitudinal technique often results in leg wound complications. An alternative endoscopic harvest technique may decrease these complications.

Methods. One hundred twelve patients scheduled for elective coronary artery bypass grafting were prospectively randomized to have vein harvested using either an endoscopic (group A, n = 54) or traditional technique (group B, n = 58). Groups A and B, respectively, were similar with regard to length of vein harvested (41 ± 8 cm versus 40 ± 14 cm), bypasses done (4.1 ± 1.1 versus 4.2 ± 1.4), age, preoperative risk stratification, and risks for wound complication (diabetes, sex, obesity, preoperative anemia, hypoalbuminemia, and peripheral vascular disease).

Results. Leg wound complications were significantly (p 0.02) reduced in group A (4% [2 of 51] versus 19% [11 of 58]). Univariate analysis identified traditional incision (p 0.02) and diabetes (p 0.05) as wound complication risk factors. Multiple logistic regression analysis identified only the traditional harvest technique as a risk factor for leg wound complications with no significant interaction between harvest technique and any preoperative risk factor (p 0.03). Harvest rate (0.9 ± 0.4 cm/min versus 1.2 ± 0.5 cm/min) was slower for group A (p 0.02) and conversion from endoscopic to a traditional harvest occurred in 5.6% (3 of 54) of patients.

Conclusions. In a prospective, randomized trial, saphenous vein harvested endoscopically was associated with fewer wound complications than the traditional longitudinal method.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Saphenous vein (SV) bypass grafting remains routine in most cardiac practices despite increased use of arterial conduits. Although SV harvested using a longitudinal or skin bridging technique infrequently results in major morbidity (sepsis or limb amputation), minor wound complications such as dehiscence, excessive drainage, delayed healing, cellulitis, lymphangitis, and superficial and deep infections occur in 1% to 24% of patients [1–9]. Recently, we reported an initial positive experience with endoscopic SV harvesting as an alternative to the traditional method [10]. This prospective, randomized trial compared outcomes associated with SV harvested using an endoscopic technique versus a traditional longitudinal incision.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
From October 1996 to February 1997, 112 patients scheduled for elective coronary artery bypass grafting were randomized prospectively into two groups. Patients in group A (n = 54) had their greater SV harvested using an endoscopic technique. Patients in group B (n = 58) underwent vein harvesting using a traditional longitudinal incision. Three patients (5.6%) from group A required conversion to the traditional harvesting technique because the SV was perceived as too small (2 patients) and the identification of a dual venous system (1 patient).

Study participants had isolated coronary artery disease that required at least part of their revascularization to be done using the greater SV. Exclusion criteria included emergent operation, the presence of leg decubitus ulcerations, and an active bacterial infection. This study was approved by the St. Vincent Hospital Institutional Review Board. Before enrollment and randomization each participant provided written informed consent. Both groups were demographically similar (Table 1).

Pain measurements and lower extremity edema
A visual analog scale was used to assess postoperative leg pain. The sensitivity of this type of pain evaluation has been previously validated [11–13]. Pain assessment was done 2 days postoperatively, on the day of discharge, and at the 6-week follow-up visit. The assessment scale had descriptive reference points on either end of a 10-cm horizontal line: the left end (0 cm) was designated as "no pain at all" and the right end (10 cm) was designated as "pain as bad as it could be." Ankle measurements in centimeters were made around the medial and lateral malleolus just before the operation and at the 6-week follow-up.

Surgical technique: endoscopic
Group A patients had their greater SV harvested using an endoscopic vein harvest (EVH) system (Ethicon Endo-Surgery, Inc, Cincinnati, OH) by two surgical technicians. Each technician was experienced with this system and had completed 30 endoscopic harvests before the study. The EVH technique used for this study has been previously reported [10].

Endoscopic vein harvesting is done simultaneously with sternotomy, arterial harvesting, and cannulation. The greater SV from two-thirds of the leg can usually be harvested endoscopically through a single 3-cm transverse incision made either above or below the knee (Figs 1A, 1B). If vein from the entire leg is needed, two separate incisions, one above and one below the knee, are required (Fig 1C). An average of 2.0 ± 0.1 incisions was used per patient.

View larger version (48K): [in this window] [in a new window]   Fig 1. Legs photographed 6 weeks postoperatively demonstrating typical incision locations to allow endoscopic harvest of the distal two thirds (A), proximal two thirds (B), and entire saphenous vein (C) from the leg.

View larger version (117K): [in this window] [in a new window]   Fig 2. Operative photograph of a side branch (arrow) after clipping and transection. The stump on the vein side is not clipped and rarely bleeds.

View larger version (102K): [in this window] [in a new window]   Fig 3. Healed incisions 6 weeks postoperatively including an additional midthigh access incision used to divide a difficult anterior vein branch during harvesting of the entire saphenous vein from the leg.

Saphenous vein harvest: traditional longitudinal technique
Group B patients had their greater SV harvested by either a surgical technician or a physician assistant using a traditional longitudinal incision without skin bridges. Venous side branches are ligated with surgical clips and hemostasis along the dissection route is achieved with clips or cauterization. After vein removal, the wound is irrigated with normal saline solution followed by immediate layered closure with absorbable suture. The skin is approximated by either a subcuticular closure or with skin clips. Closed suction drains are not used. The leg is wrapped with an elastic wrap at the conclusion of the case.

Statistical analysis
Statistical analysis of continuous variables was performed using Student’s t test. Univariate comparison of categorical variables was done using Fisher’s exact test and ² analysis. Multiple logistic regression was used to determine whether the incidence of leg wound complications was influenced by interactions between preoperative clinical risk factors and the harvest method. All data were analyzed using the PC JMP Statistical Discovery Software (SAS Institute, Cary, NC). A probability value of p less than or equal to 0.05 was considered statistically significant on two-tailed testing.

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Wound complications occurred in 4% (2 of 51) of patients having EVH versus 19% (11 of 58) of patients having the traditional longitudinal incision (p 0.02). One patient in each group had leg wound complications requiring hospital readmission. Leg wound complications in group A included 1 patient with cellulitis who required readmission for 2 days of intravenous antibiotics and 1 patient with an endoscopic tunnel hematoma that did not require treatment. Leg wound complications for group B included 1 patient with cellulitis/abscess who required a 4-day hospital readmission for debridement and intravenous antibiotics; 3 patients with cellulitis who were treated as outpatients with oral antibiotics; 2 patients with cellulitis/dehiscence who were treated as outpatients with dressing changes and oral antibiotics; and 5 patients with localized wound dehiscences who required outpatient wound dressing changes without antibiotics. No lymphoceles occurred in either group. No sternal wound complications occurred in either group.

Univariate analysis of the risk factors for leg wound healing complications is summarized in Table 3. The traditional longitudinal incision technique (p 0.02) and diabetes mellitus (p 0.05) were identified as independent risk factors for leg wound complications. Analysis by multiple logistic regression demonstrated only the traditional longitudinal technique (p 0.03) as a risk factor for development of a wound complication. Although SV was harvested from the entire leg in 59% (30 of 51) of the EVH group compared with 40% (23 of 58) in the traditional group (p 0.05), the primary location of vein harvested did not influence the incidence of leg wound complications.

One death occurred in each group; both resulted from cerebrovascular accidents. There were no Q-wave myocardial infarctions in either group. Non–Q-wave myocardial infarctions occurred in 3.9% (2 of 51) of patients in group A and in 1.7% (1/58) of group B patients. There was no known acute graft closure in either group and no patient underwent angiography during the 6-week follow-up period. Although the gross quality of the vein did not appear different between harvest techniques, the number of 7-0 venous repair stitches required in each harvested vein was significantly (p 0.001) higher in the EVH group (1.6 ± 1.7) compared with the traditional group (0.4 ± 1.0).

Mean length of hospital stay for EVH patients was significantly shorter (5.6 ± 1.7 days versus 6.5 ± 2.6 days) compared to the traditional harvest group (p 0.05). Although mean diagnosis-related group-indexed overall hospital cost did not differ between groups, mean diagnosis-related group-indexed operating room costs were significantly higher when EVH was used compared to the traditional harvest technique (p 0.01).

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
Morbidity and patient dissatisfaction associated with traditional SV harvest techniques have been accepted as germane to the method and an unavoidable component of coronary artery bypass grafting (Fig 4). Leg wound complications after SV harvesting for coronary artery bypass grafting, while being reported to occur in 1% [1] to 24% [3] of patients, have received little attention. Although cardiac surgeons have intensified efforts to reduce morbidity through less invasive methods, little emphasis has been placed on improved SV harvesting techniques. The development of subcutaneous endoscopic techniques [14–16] and our initial positive experience with endoscopic harvesting of the greater SV [10] suggested that this method may reduce leg wound complications.

View larger version (98K): [in this window] [in a new window]   Fig 4. Examples of wound complications after traditonal saphenous vein harvesting including abscess formation requiring debridement and dressing changes (A) and wound dehiscence with cellulitis (B).

Preoperative risk factors normally associated with leg wound complications include female gender, diabetes mellitus, obesity, hypoalbuminemia, anemia, peripheral vascular disease, and steroid use. Because two SV harvest methods were compared, both were considered potential risk factors for development of wound complications. Univariate analysis of preoperative risk factors identified only traditional harvest technique (p < 0.02) and diabetes (p < 0.05) as independent risk factors for development of a postoperative wound complication. Neither location of harvest site nor length of vein harvested influenced the incidence of leg wound complications in either group.

Multiple logistic regression analysis of the entire patient population demonstrated traditional harvest technique as the only significant risk factor for development of a wound complication (p < 0.03). Because diabetes was barely significant (p 0.05) as an independent risk factor, statistical significance was lost (p 0.09) during multiple logistic regression analysis. In this study, the negative influence on the incidence of leg wound complications by comorbidities such as diabetes was negated by use of the endoscopic technique.

Leg edema after traditional methods of SV harvesting is frequent but rarely permanent. Little information exists regarding its cause and impact on the development of leg wound complications. Altering the harvest method did not decrease the incidence or magnitude of ankle edema. Although EVH does not prevent development of lower extremity edema, lack of incisions in an edematous leg with obstructed lymphatics may play a role in preventing localized wound dehiscence or cellulitis.

Use of a less invasive surgical technique often translates into less postoperative pain. Mean pain scores for both groups at all observations were very low and not significantly different. We believe this reflects the effectiveness of our postoperative pain management. Patient satisfaction at the 6-week follow-up visit revealed that patients, regardless of harvest technique, were generally pleased with their harvest wounds, even when a significant wound complication had occurred. Although pain scores between groups are not different, patients who undergo EVH appear to ambulate sooner and recover quicker. This observation may be indirectly supported by the reduced hospital stay (5.6 ± 1.7 days versus 6.5 ± 2.6 days) observed in the EVH group. Although both groups are demographically similar a direct correlation of shortened hospital stay with harvest method cannot be made at this time.

Criticisms of EVH include increased harvest time, additional expense, and a potential for vein trauma. For EVH to become an integral part of any practice a surgical assistant must be given the opportunity to acquire technical proficiency during a 10- to 20-case learning curve. During the learning curve, surgeon patience and support are mandatory. With experience, harvest rate increases and the number of "helper" incisions required for a complete harvest decreases [10]. Although SV was endoscopically harvested by two experienced surgical technicians, the endoscopic harvest rate was slower than the traditional method. Continued modification of the endoscopic technique and instrumentation, such as the use of bipolar scissors, should favorably affect harvest rate.

Use of disposable endoscopic harvesting instruments was primarily responsible for the increased diagnosis-related group-indexed operating room costs in the EVH group. However, because of the decreased length of hospital stay observed in the EVH group overall hospital diagnosis-related group-indexed costs were not significantly different between groups. Further reduction in health care costs due to decreased resource utilization after discharge may be an important benefit of the EVH technique because of the reduced incidence of wound complications.

A potential for increased SV trauma during endoscopic harvesting is an important issue. No EVH patient experienced an acute graft closure and no difference in the perioperative myocardial infarction rate was noted between groups. This finding suggests the absence of gross endothelial damage; however, it does not address the possibility of long-term complications caused by subtle endothelial abnormalities, particularly considering the increased number of venous repair sutures required in the EVH group. A prospective trial involving 300 patients and 900 graft samples is nearing completion, which will evaluate potential histologic differences that may exist in veins harvested by the two methods. Application of an endoscopic vein harvest technique in patients undergoing peripheral arterial bypass resulted in a 97% (26 of 27) patency rate with a mean follow-up of 10 months [19]. Only long-term longitudinal follow-up will adequately address whether graft patency is influenced by harvest method. This prospective, randomized trial demonstrated that endoscopic harvest of the greater SV resulted in fewer postoperative leg wound complications compared with a traditional longitudinal harvest method.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 
We thank Marsha Schafer, Certified Surgical Technician and First Assistant, and June Killey, Certified Surgical Technician, for performing all the endoscopic harvests. We greatly acknowledge the support of the St. Vincent Hospital Research Department for coordination of this study and Walter W. Jolly, MD, John H. Isch, MD, John M. Paris III, MD, and Stephen W. Fess, MD, for their contribution of patients to this study.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments References

 

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