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Ann Thorac Surg 2000;69:520-523
© 2000 The Society of Thoracic Surgeons

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Original Articles

Endoscopic and traditional saphenous vein harvest: a histologic comparison

^a Department of Cardiovascular and Thoracic Surgery, St Vincent Hospitals and Care Centers, Indianapolis, Indiana, USA
^b Department of Cardiology, St Vincent Hospitals and Care Centers, Indianapolis, Indiana, USA

Address reprint requests to Dr Allen, 8333 Naab Rd, Suite 300, Indianapolis, IN 46260
e-mail: cvsurgeons{at}iquest.net

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Vein trauma after saphenectomy by endoscopic or longitudinal techniques may influence the progression of medial and intimal hyperplasia and ultimately affect graft patency. This study compared the histologic characteristics of saphenous veins after endoscopic and longitudinal harvest.

Methods. One hundred seventy patients who underwent elective coronary artery bypass grafting had saphenectomy performed endoscopically (n = 88) or by a longitudinal incision (n = 82). Cross-sectional specimens from endoscopically (n = 151) and longitudinally (n = 158) harvested veins were submitted for hematoxylin-eosin, trichrome, and elastin staining. Blinded histologic evaluation involved graded analysis of endothelial, smooth muscle, and elastic lamina continuity in addition to medial and adventitial connective tissue uniformity.

Results. Regardless of harvest technique, endothelial, elastic lamina, and smooth muscle continuity as well as medial and adventitial connective tissue uniformity were not significantly different.

Conclusions. Minor histologic alterations occur during saphenectomy, however, endoscopically and longitudinally harvested saphenous veins are histologically similar.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Despite increased use of arterial grafts, the greater saphenous vein (SV) remains the most commonly used conduit for coronary artery bypass grafting (CABG). Although traditional SV harvesting infrequently results in major complications such as sepsis or amputation, minor wound complications are common. Saphenectomy wound complications, depending on wound definition, have a reported incidence of 1% to 44% [1–10]. Recent reports have described endoscopic SV harvest for both cardiac [10–13] and peripheral vascular [14] procedures as a means to reduce these wound complications. In a prospective randomized trial, endoscopically harvested SV was associated with significantly fewer wound complications than the traditional longitudinal method (4% versus 19%) [10].

Criticisms of endoscopic vein harvest (EVH), however, include increased harvest time, additional hospital expense, and a potential for vein trauma that may influence long-term graft patency. This prospective study compared the histologic characteristics of SV after endoscopic and longitudinal saphenectomy.

	Material and methods

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Patient population
From December 1997 to February 1998, 170 consecutive patients who underwent elective CABG had their saphenectomy performed endoscopically (n = 88) or by a longitudinal incision (n = 82). The study format was prospective but nonrandomized. Patient demographics with regard to diabetes, peripheral vascular disease, obesity, hypertension, and venous stasis disease were similar between groups. Both saphenectomy techniques are used routinely at St Vincent Hospital and Health Care Center, and surgeon preference and assistant availability dictated the technique used on each patient. The St Vincent Institutional Review Board approved the study and written informed consent was obtained from each patient. Endoscopic saphenectomies were performed with an EVH system (Ethicon Endo Surgery, Cincinnati, OH) by two surgical technicians. To avoid the influence of the learning curve associated with this technique, each technician was experienced with this system and had completed at least 30 endoscopic harvests before the study. Traditional longitudinal SV harvests were performed by seven experienced surgical assistants who included the two endoscopic harvesters. Our endoscopic and longitudinal SV harvest techniques have been described previously [10, 11].

Specimen collection
Specimens from endoscopically (n = 151) and longitudinally (n = 158) harvested veins were obtained from 88 and 82 patients, respectively. Vein preparation using a crystalloid solution was similar for both groups. Handling of the SV by the surgeons was not controlled. To avoid the potential influence of vein preparation after harvest, an initial 0.5 cm sample was taken from the groin end of the vein immediately after its removal from the leg and before any further manipulation. Additional random 0.5 cm samples were collected during the course of the CABG operation using excess SV. Once collected, each specimen was immediately fixed in a numbered vial containing 10% formalin. Each sample vial was identified using a separate case report form that identified the patient’s hospital number, operation date, surgeon and assistant code, harvest method, and time of collection (immediately after harvest or from excess vein during the operation). Each specimen was cross sectioned and submitted for hematoxylin-eosin (to assess endothelial cellular continuity), Mason’s trichrome (to assess connective tissue and smooth muscle uniformity), and elastin (to assess elastic lamina continuity) staining according to standard laboratory protocols.

Histologic analysis
Histologic evaluation was conducted in a blinded fashion by one of the authors (B.F.W.). The histologic structures evaluated were the endothelial layer, elastic lamina, medial smooth muscle and connective tissue, and adventitial connective tissue (Fig 1). A numeric grading system developed for this study was used to score the uniformity, continuity, and integrity of these key histologic structures. The numeric grading system estimated the percent disruption of each histologic structure and was scored according to the following scale: 0 (intact or no disruption), 1 (< 10%), 2 (10% to 25%), 3 (25% to 50%), and 4 (> 50%).

View larger version (101K): [in this window] [in a new window]   Fig 1. Typical cross-section of greater saphenous vein demonstrating the histologic features evaluated during the study.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
The effect of the harvest methods on SV histology is summarized in Table 1. Regardless of harvest method, mild histologic disruption occurred in all layers of the venous wall. No statistically significant difference in the blinded scores of the five histologic structures evaluated was observed between endoscopically or longitudinally harvested SV. As might be expected, adventitial connective tissue disruption was greater than that observed within interior vessel layers for both harvest techniques.

	Comment

Top Abstract Introduction Material and methods Results Comment References

With the introduction of EVH the potential for increased SV trauma compared with standard harvest techniques is a valid concern. In a prospective randomized trial that compared endoscopic and traditional longitudinal SV harvest techniques, we observed no acute graft closures in either group and the incidences of perioperative myocardial infarction were similar [10]. Although these observations suggest an absence of gross endothelial damage during endoscopic harvest, they do not address histologic differences between harvest techniques that may affect long-term vein graft patency rates. The degree of histologic disruption after endoscopic and longitudinal saphenectomy observed in this trial was mild and no significant difference was noted between harvest techniques. Application of an EVH technique in patients undergoing peripheral lower extremity bypass resulted in a 97% (26 of 27) patency rate with a mean follow-up of 10 months [14]. Although endoscopically and longitudinally harvested SV appear histologically similar upon blinded analysis, only long-term longitudinal follow-up will adequately address whether graft patency in cardiac surgery is influenced by harvest technique.

Although many segments of SV were evaluated, practical considerations limit the number of vein segments that can be analyzed. Thus, one limitation of this study is the potential lack of correlation between the vein segments analyzed and the histology of the entire harvested vein. The number of samples analyzed and the constancy of data variation help in limiting this potential error. A second study limitation concerns other variables besides harvest technique that may influence SV histology such as surgical technique or when the vein segment was sampled (immediately after harvest or randomly when excess vein was available). Analysis of these data, however, demonstrated no interaction between histologic disruption and which assistant harvested and prepared the vein or when in the course of the operation the vein segment was collected.

This prospective study supports the hypothesis that an endoscopic harvest technique does not induce greater histologic trauma than that observed during traditional longitudinal saphenectomy.

	Acknowledgments

 
We thank John H. Isch, MD, Stephen W. Fess, MD, John M. Paris III, MD, and Edward B. Fitzgerald, MD, for contributing patients to this study. We also thank Marcia Schafer, certified surgical technician and first assistant and June Killey, certified surgical technician, for performing all of the endoscopic vein harvests. We acknowledge the St Vincent Hospital Foundation and Indiana Heart Institute for funding this research.

	References

Top Abstract Introduction Material and methods Results Comment References

 

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This Article Abstract Full Text (PDF) 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): Gary L. Griffith Keith B. Allen David A. Heimansohn Robert J. Robison John J. Schier Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Griffith, G. L. Articles by Shaar, C. J. Search for Related Content PubMed PubMed Citation Articles by Griffith, G. L. Articles by Shaar, C. J.