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Ann Thorac Surg 1998;66:1626-1631
© 1998 The Society of Thoracic Surgeons

Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations

Sebastian Pagni, MDa, Eduardo A. Ulfe, BAa, William D. Montgomery, BSa, Daniel J. VanHimbergen, BAa, Dana J. Fisher, RNa, Laman A. Gray, Jr, MDa, Paul A. Spence, MDa

a Division of Thoracic and Cardiovascular Surgery, University of Louisville, Louisville, Kentucky, USA

Accepted for publication May 13, 1998.

Address reprint requests to Dr Spence, Division Thoracic and Cardiovascular Surgery, University of Louisville, 201 Abraham Flexner Way, Suite 1200, Louisville, KY 40202


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Leg wound complications after saphenectomy are frequent after coronary bypass operations and have a detrimental effect on postoperative quality of life and treatment cost. To reduce morbidity, we evaluated a new technique of video-assisted vein harvest.

Methods. Between March 1996 and October 1996, 50 patients had video-assisted saphenectomy (VAS) and 40 patients had the standard open technique (control group). An additional 13 patients had both procedures (hybrid group). Level of pain, edema, and wound complications were evaluated at discharge and at 2, 4, and 6 weeks postoperatively.

Results. The mean operating time for VAS patients was slightly higher than for control (60.6 ± 24.7 minutes versus 53.2 ± 21.1 minutes; p > 0.05). The average incision length in VAS patients was 13.8 ± 8.8 cm for an average of 3.3 grafts per patient. Three VAS procedures were aborted, two because of time constraints, and one because of bleeding, and a segment of vein was lost to injury. The VAS group had considerably less early postoperative pain than the control group (1.7 ± 1.2 versus 4.1 ± 1.4 [1 = mild, 10 = severe]; p < 0.005) and edema was similar for both groups. Patients in the hybrid group reported less pain in the VAS-operated leg. Serious wound infection occurred in 4 patients, with 2 patients in the control group requiring reoperation for drainage and flap reconstruction.

Conclusions. Based on this initial experience, VAS harvesting, although initially more time consuming, is a rapidly mastered technique, results in shorter overall incision length, and is associated with considerably less postoperative pain than the standard open technique.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Video-assisted saphenectomy (VAS) currently is an alternative vein-harvesting procedure for coronary artery revascularization procedures. Since first introduced [1], less-invasive videoscopic vein-harvesting techniques have been proposed and used clinically to reduce the high postoperative morbidity associated with the standard open techniques, which varies from 3% to 25% [2–4]. The aim of this new approach to vein harvesting is to keep incision length and dissection to a minimum, to decrease postoperative incision pain and major wound complications. Additionally, it is hoped that the new method will provide a better cosmetic result and will decrease the rehabilitation time, with earlier ambulation and return to work.

Early results with this technique generated great enthusiasm, and the procedure (with few variations) is now performed in many institutions. We have modified and simplified the technique initially described by Lumdsen and colleagues [1] by limiting the number and changing the location of the incisions, and by the introduction of new instrumentation. These modifications resulted in decreased operative time. We have used this modified surgical approach selectively since March 1996 and have been pleased by the excellent functional and cosmetic results.

In this study, the VAS procedure was used in 63 patients (65 legs) who had coronary artery graft bypass grafting procedures, and we prospectively evaluated the results and compared them with a control group that had the standard open technique and a group that had a combination of both procedures.


   Material and methods
Top
 Footnotes
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patients
Between March 1996 and August 1996, 63 consecutive patients had the VAS procedure at Jewish Hospital (University of Louisville). Of the total group, 50 patients had VAS only, 13 patients had VAS harvesting combined with the traditional open technique (hybrid group) in the same or contralateral leg, and another 40 patients had the standard open technique (control group). In all patients the saphenous vein was harvested for coronary bypass operation.

Comparison of patient characteristics and risk factors for the three groups is shown in Table 1. There was a high incidence of tobacco abuse and obesity (obesity index >25) in all groups, but diabetes was higher in the VAS group than in the control group (26% versus 17.5%). Peripheral vascular disease was present in 15% of patients, and an average of 52% of the total group had some degree of anticoagulation or antiplatelet therapy immediately before or during the procedure. The VAS procedures were performed by four surgeons (44, 12, 4, and 3 cases), with three surgeons proctored by the most experienced one. The patients who had the VAS procedure were selected on the basis of their high risk for postoperative leg complications (more than two premorbid factors) and time availability.


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  		Table 1. Patient Characteristics

 
The primary endpoints that were compared were the incidence of postoperative leg pain, edema, and rate of infection. Additionally, the presence of seroma or other wound complications was analyzed, as well as procedure-related variables such as operative time, number of incisions, total wound length, number of tears and side branch avulsions, and the learning curve for the procedure. Leg pain was recorded on a 1-to-10 scale (1–3 = mild, 4–7 = moderate, and 8–10 = severe) and edema (none = 0, mild = 1, moderate = 2, severe = 3) in the operated leg was compared with the contralateral leg. In the hybrid group operative sites were compared with each other.

Infection was defined as redness, drainage, or collection in the wound or subcutaneous tract, or a collection that required drainage or debridement. Seroma was defined as a painless induration or collection under the wound or wound channel. Wounds were examined before discharge in all patients (within 5 days) and at 2, 4, and 6 weeks of follow-up, with 4 patients failing to return but all contacted by telephone at 4 weeks. Complete follow-up at 6 weeks was obtained in 86% of patients.

Statistical analysis was performed using the mean and standard error of the mean, and the two-tailed Student’s t test was used for comparison of variables between groups. P values equal to or less than 0.05 were considered significant.

Technique
Video-assisted saphenectomy is a simple procedure, but careful attention to details and patience is necessary to avoid excessive vein and tissue trauma. The patient is positioned supine and the legs prepared in the same fashion as for routine coronary operations. The operator should be preferentially on the same side of the leg to be harvested and the video monitor placed on the opposite side. No surgical assistant is required once the operator is familiar with the technique. The instruments required are shown in Figure 1 and consist of a subcutaneous dissector and retractor, 30° angled rod video camera, modified loop vein dissector, standard endoscopic scissors, and an endoclip applier (Ethicon Endosurgery, Cincinnati, OH).



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  		Fig 1. Working table with videoscopic saphenous harvest instruments. From top to bottom: subcutaneous tunneler, subcutaneous retractor, cotton tip dissector, endoscissors, endoclipapplier, and vein dissector.

 
For an entire-length vein harvest, we start the procedure through a 4-cm transverse incision on the medial aspect of the lower thigh above the knee. The saphenous vein is exposed in the wound and the subcutaneous dissector is inserted, creating a tunnel over the entire length of the vein in the thigh up to the saphenofemoral junction. This is done with video assistance (camera inserted in the shaft of the dissector) and external guidance with the other hand (Fig 2). This maneuver allows separation of the fibroadipose tissue plane over the vein, facilitating the insertion of the larger subcutaneous retractor. The retractor is now inserted, and upward retraction on the tunnel allows the vein to fall posteriorly, creating a space to work on the vein (Fig 3). Vein branches and fibrous attachments in close proximity to the incision are dissected under direct vision. The vein dissector is then inserted in the wound, and working space is guided by the retractor. The vein is circumferentially freed by the instrument by using back-and-forth movements, separating the vein from attached adipose tissue (Fig 4). Once resistance is felt or branches are visualized, the clip applier is guided into the wound, and the branches are clipped as lateral as possible on the patient side. Using standard endoscopic scissors the branches are cut leaving a stump on the saphenous vein side for tying after retrieval (Fig 5). Sufficient venospasm induced by the cutting and bleeding is rarely encountered in the tunnel (Fig 6). We noted a high incidence of tears in the conduit when clips were applied on the vein side for hemostasis, because the vein dissector caught on the clips and avulsed the branches.



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  		Fig 2. Introduction of the endoscopic tunneling device under internal and external guidance.

 


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  		Fig 3. Videoscopic view of the vein path in the working channel.

 


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  		Fig 4. Vein separated from the adjacent fat with the endodissector.

 


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  		Fig 5. After lateral clipping, the side branch is transected. Note the venospasm produced by the cut.

 


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  		Fig 6. Cosmetic result obtained after a full-length harvest through three incisions.

 
A second incision is performed in the medial aspect of the upper calf over the presumed path of the vein. Using the same technique, the vein is dissected upward to the level of the upper wound. Frequently, difficult side branches in the popliteal region need to be assessed directly through 1-cm incisions (usually one) (Fig 7). Then, the dissection is continued downward to the ankle until the entire length of the vein is dissected. The proximal and distal ends of the vein are controlled using either pretied endoloop ties or 1-cm incisions at the groin and ankle areas where the vein ends are clipped and cut under direct vision. We make the effort to avoid extra incisions in obese and diabetic patients, otherwise the end of the vein was ligated in an open fashion. In our experience, extra incisions have not increased the morbidity and can save much time and avoid excessive vein trauma.



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  		Fig 7. Saphenous vein harvest through upper calf incision (three graft lengths).

 
The VAS procedure is usually performed simultaneously with the opening of the chest and cannulation with the patient under systemic heparinization, and we have not noted increased intraoperative bleeding. At the end of the procedure the wounds are closed in layers and the leg wrapped with elastic bandages, which are taken off 48 hours later and changed to thigh-high elastic stockings.

For the open technique, the incision is started either in the ankle or groin, depending upon the leg habitus or expected vein quality. The patient’s side branches are clipped, and cautery use is limited. The wounds are closed in two layers using reabsorbable sutures, with subcuticular apposition of the skin.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Isolated VAS was completed in 47 of the 50 patients attempted. Three patients were converted to standard open technique, because of bleeding in 1 and time constraints in 2. One segment of vein was rendered unusable and two vein lengths had complete transection at the knee area, albeit graft lengths were adequate and no further vein harvesting was necessary. The incidence of side branch avulsion and tears was significantly higher in the videoscopic group (1.2 ± 1.6 versus 0.1 ± 0.3; p < 0.005). Operative time was higher in the VAS group, although the difference was not statistically significant (Table 2).


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  		Table 2. Operative Results

 
One patient in the control group died of myocardial infarction on postoperative day 2, and postoperative morbidity was seen in 26%, 15%, and 30.7% of the VAS, control and hybrid groups, respectively. Patients with the veins harvested by the VAS technique had considerably less perioperative pain (1.7 ± 0.5 versus 4.1 ± 1.4 [1 = mild, 10 = severe]; p < 0.0005) than the control group, as measured before discharge from the hospital. The incidence of edema and infection was similar for both groups, as shown in Table 3.


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  		Table 3. Early Perioperative Findings

 
Chronologic analysis of perioperative pain at completion of the surgical follow-up (6 weeks) is shown in Figure 8. The patients who had the VAS procedure had significantly less pain at 2 weeks compared with the controls, but there was a similar plateau for both groups thereafter. A better-controlled pain analysis was obtained in the hybrid group, with different legs or harvest sites compared with each other. Leg pain levels had similar correlation with those found in VAS and control groups separately.



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  		Fig 8. Comparison of perioperative pain in video-assisted saphenectomy (VAS) versus control groups, up to 6 weeks follow-up.

 


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  		Fig 9. Incidence of vein injury correlated to the learning curve in the first 50 patients. (A) Comparison of perioperative pain in video-assisted saphenectomy (VAS) legs and open harvested legs up to 6 weeks follow-up. (B) incidence of vein injury correlated to the learning curve.

 
Major leg wound morbidity requiring hospitalization occurred in 2 VAS patients (intravenous antibiotics) and in 2 control patients (intravenous antibiotics in 2 and operative debridement with flap closure in 1). Wound complications at completion of follow-up are shown in Table 3.


   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Although open full-length incision remains the gold standard method for vein harvest in coronary bypass operations, newer, less invasive harvesting techniques have been developed with the aim of decreasing the high complication rate. Wound morbidity at the harvest site is well known to the cardiovascular surgeon and has been reported to occur in up to 30% of the patients undergoing coronary artery revascularization [3–5].

Leg wound morbidity after the standard open technique is typically represented by infection, which varies from common mild cellulitis to frank soft tissue purulent infection and abscess formation. Although most infections require only local wound care and oral antibiotics, some require prolonged home care because of poor healing, especially in diabetic patients and those with ischemic legs. Less commonly, these infections require intravenous antibiotics and prolonged hospitalization, and occasionally reoperation with debridement and flap closure [6]. Lower extremity edema, seroma, hematoma, dehiscence, and skin necrosis can also affect wound sites to different degrees and are frequent causes of minor morbidity.

Perhaps the most frequent complaint in this patient population is the presence of limiting long-term incisional pain with its detrimental effects on early and midterm postoperative rehabilitation. These wound problems frequently result in repeat medical consultation. In addition to the concern of the impact of this pain in these patients’ quality of life, these problems also raise concern about the increased cost of prolonged hospital stay, prolonged outpatient treatment, and additional rehabilitation time, which are now critically analyzed by third-party payers.

Several methods have been proposed to harvest veins by limiting the length of the incision, requiring smaller wounds with skin bridges or even several small stab wounds at site branches detected by different devices. Although attractive and more frequently used in high-risk patients, these techniques are cumbersome and time-consuming and have not gained widespread acceptance [7, 8]. Lumdsen [1], in 1994, reported a new method of harvesting vein by using subcutaneous retractors initially designed for plastic surgery, and then used it for vein procurement in a series of patients who had vascular operations (Lumdsen AB, personal communication, 1994). He introduced a new concept of creating a working space between the adipose tissue planes of the leg using subcutaneous retractors, with visualization obtained through a rod scope introduced in the original device. Since his original work, the technique has undergone several modifications, including the use of new instruments.

We modified and simplified the original technique requiring an average of three small incisions. It also allows harvesting of the entire length of the greater saphenous vein without opening the groin or ankle areas, especially in high-risk patients. At the beginning of our experience, several technical problems were identified and prompted the modification of instruments and changes in different steps of the technique. As experience was gained, patients were selected more appropriately. The ideal patients were identified as moderately obese males with good fatty tissue consistency and easy separation of fatty planes. Skinny legs were problematic because of the dense fibrous tissue that promoted an increased incidence of vein injury. We estimate the learning curve to be approximately 12 to 15 procedures, and the operative time decreased notably after the first 20 procedures, according to the most experienced operator’s learning curve (Fig 9B). However, objective analysis of this variable was not possible because of different patient anatomy and body habitus, variable vein length harvested, and the ongoing proctoring of new operators.

The incidence of tears and avulsions was higher at the beginning of our experience, and we attribute it to operator learning process and steps in the technique such as medial clipping of the side branches with large clips. We learned through error that the dissector locks in the clip site promote avulsions and tears. Frequently these tears occurred in areas between graft lengths and resulted in the avoidance of a repair stitch and the loss of a few millimeters of vein. We now use smaller clips and no longer clip medially. Hemostasis in the operative tunnel is maintained by branch spasm induced by the cutting. This modification in the technique has decreased the operative time dramatically and the number of stitch repairs required per patient, with less than one each for the last 25 patients of the study. The only limiting factors remain operator experience and presence of abnormal anatomy.

Although for vascular cases the knee and groin area require dissection, in our experience harvesting veins for coronary bypass grafting, such regions can be spared from incisions, especially in high-risk patients. When all side branches have been controlled, a small stab wound with clipping or the use of endoloops usually suffice for control of the conduit ends. However, the latter is more time consuming and is used for obese diabetic patients. We do not hesitate to make additional small incisions at difficult branch sites, and we believe that approach saves operative time and avoids vein injury.

The initial clinical results show that the incidence of early postoperative pain is considerably less in the VAS patients. Although there is clearly subjectivity involved in pain perception and analysis, the pain results in the VAS group were corroborated by similar grading in the hybrid group. The incidence of edema was similar in both groups and did not limit patient recovery. The etiologic factors involved in the development of leg swelling are unknown and are not avoided by either technique. The incidence of seroma and wound induration has dramatically decreased (1 in the last 20 patients) since we changed our postoperative protocol, which includes elastic wrapping of the leg up to 48 hours and then thigh-high elastic stockings up to 7 days.

Minor wound complications were more common in the VAS group and included a higher rate of cellulitis, seroma, and hematoma formation. These complications seemed not to increase the postoperative pain and were not seen as a serious problem by patients; however, it may have predisposed to the increased rate in minor wound infection observed in the VAS group. Major wound infection was rare and occurred more often in the control group, with two patients requiring prolonged hospitalization and one requiring reoperation by plastic surgeons to reconstruct a necrotic wound.

In summary, we believe that VAS is a promising vein-harvesting technique. Despite being initially more time-consuming, it can be learned easily. In our experience, this procedure is associated with considerably less pain and overall shorter incision length than the open technique, and it allows for the harvesting of the entire length of the vein. It has also resulted in earlier and more comfortable ambulation, better cosmesis, and greater patient acceptance. The current experience with video-assisted procedures in general has shown that refinement of the technique resulting in better outcome correlates directly with both overcoming the learning curve and the development of new instrumentation. This procedure is a safe alternative to harvest vein for cardiovascular procedures, especially in high-risk patients. The higher cost initially might be offset by the lower major morbidity rate seen in the perioperative period. Effects of this technique on conduit function and patency are currently being evaluated and will be factorial in deciding the future viability of this technique.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 
Supported by a grant from Jewish Hospital Health Care System and Ethicon Endosurgery.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Lumdsen A.B., Eaves F.F. Subcutaneous video-assisted vein harvest. Perspect Vasc Surg 1994;7:44-55.
  2. DeLaria G.A., Hunter J.A., Goldin M.D., Serry C., Javid H., Najafi H. Leg wound complications associated with coronary revascularization. J Thorac Cardiovasc Surg 1981;81:403-407.[Abstract]
  3. Utley J.R., Thomason M.E., Wallace D.J., et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg 1989;98:47-49.
  4. Farrington M., Webster M., Fenn A., Philips I. Study of cardiothoracic wound infection at St. Thomas’ Hospital. Br J Surg 1985;72:759-762.[Medline]
  5. Shuhaiber H., Chugh T., Shuhaiber S.P., Ghosh D. Wound infection in cardiac surgery. J Cardiovasc Surg 1987;28:139-142.[Medline]
  6. Scher L.A., Samson R.H., Ketosugbo A., Gupta S.K., Ascer E., Veith F.J. Prevention and management of ischemic complications of vein harvest incisions in cardiac surgery. Angiology 1986;37:119-123.
  7. Meldrum-Hanna W., Ross D., Johnson D., Deal C. Long saphenous vein harvesting. Aust N Z J Surg 1986;56:923-924.[Medline]
  8. Dimitri W.R., West I.E., Williams B.T. A quick and atraumatic method of autologous vein harvesting using the subcutaneous extraluminal dissector. J Cardiovasc Surg 1987;28:103-111.[Medline]



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