Ann Thorac Surg 2000;70:1086-1089
© 2000 The Society of Thoracic Surgeons
Supplement: cardiothoracic techniques & technologies
Endoscopic saphenous vein harvesting: initial experience and learning curve
Juan Mariano Vrancic, MDa,
Fernando Piccinini, MDa,
Guillermo Vaccarino, MDa,
Eduardo Iparraguirre, MDa,
Jorge Albertal, MDa,
Daniel Navia, MDa
a Department of Cardiovascular Surgery, Instituto Cardiovascular de Buenos Aires, Buenos Aires, Argentina
Address reprint requests to Dr Vrancic, Department of Cardiovascular Surgery, Instituto Cardiovascular de Buenos Aires, Blanco Encalada 1543, 1428 Buenos Aires, Argentina
e-mail: don{at}lvd.com.ar
Presented at the Sixth Annual Cardiothoracic Techniques and Technologies Meeing 2000, Fort Lauderdale, FL, Jan 27–29, 2000.
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Abstract
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Background. Saphenous vein remains an elective conduit for up to 85% of coronary bypass operations. It is obtained through one or numerous skin incisions, with a reported morbidity varying from 5% to 25%. The endoscopic vein harvesting (EVH) technique was developed to minimize this morbidity and to improve clinical outcomes. The aim of this study was to review the feasibility of this method, its learning curve, and changing results in a group without previous experience in this procedure.
Methods. Between July 1998 and October 1999, 179 patients for coronary artery bypass grafting underwent EVH (Vasoview Guidant, USA "double access" and Uniport), by two operators. Results were reported based on time of harvesting, length of conduits, technical details, and clinical outcomes, and divided into six groups of 30 consecutive patients each.
Results. Patient demographics were as follows: 86.03% were male, aged 64.3 ± 9.12 years (range, 43 to 92 years), with diabetes mellitus in 28.49%, obesity in 18.43%, and vascular disease in 11.17%. The EVH method was limited to the thigh in 77.65% of cases and extended to the leg in 22.35%. Patients received an average of 2.45 ± 0.58 incisions and obtained conduits had a mean length of 34.96 ± 9.65 cm (range, 15 to 70 cm). The number of venous bypasses per patient was 1.30 ± 0.59. Mean time of EVH was 47.24 ± 19.84 minutes (range, 15 to 120), with a length–time index of 0.85 ± 0.36. Primary success was achieved in 95.54%, with crossover to open technique in 4.46%. General morbidity was 8.9%, with hematoma in 1.11%, skin necrosis in 1.11%, infection in 6.7%, and readmission in 1.11%.
Conclusions. Endoscopic vein harvesting is a feasible and reproductible method, with a typical learning curve, acceptable morbidity, and unquestionable benefits for coronary artery bypass graft patients.
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Introduction
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The choice of conduits in coronary artery surgery is limited to the lower extremity superficial veins and a variety of small arteries. Even if vein graft patency decreases after postoperative year 5 because of progressive occlusion (intimal hyperplasia or atheroma), saphenous vein is used because of its versatility and easy harvesting. Entering the off-pump and totally arterial revascularization era, the saphenous vein remains an elective conduit for up to 85% of coronary bypass surgery cases.
Traditionally the saphenous vein is harvested from lower leg, thigh, or both through a long continuous incision or interrupted longitudinal incisions over its course. Wound complications such as hematoma, dehiscence, drainage, cellulitis, skin necrosis, neuralgia, and infection have led to an increased morbidity and primary complaints of patients after CABG. Complications incidence are infrequently reported and vary between 3% and 44% [1]. Modification of the harvesting technique has failed in the attempt to reduce morbidity. The actual tendency toward minimally invasive cardiac surgery is extended to minimally invasive vein harvesting. This vein approach, even a developing method, may significantly reduce the complication rate and provide major benefits to patients. The aim of this study is to analyze the feasibility of totally endoscopic vein harvesting (EVH), its learning curve, and changing results in a surgical group without any previous experience in this procedure, which has actually been used worldwide.
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Patients and methods
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Between July 1998 and December 1999, 179 consecutive patients underwent an EVH procedure. There were no exclusion criteria for this method. The procedure was performed in all cases by the same two cardiac surgeons. Patients demographics and comorbid conditions, associated with higher postoperative morbidity [2], are reported.
The equipment, provided by Guidant (Cardiac and Vascular Surgery, Inc, Menlo Park, CA), consisted of a subcutaneous dissector with an internal 0-degree wide lens and camera introduced through a 10-mm trocar. To complete vein harvesting, a specially made bipolar scissors was used through an additional 5-mm trocar. After patient 30, the equipment was changed to a Vasoview Uniport, with the vein dissector and bipolar flexible scissors introduced through a single 12-mm trocar. The surgical technique has been previously described by Crouch and associates [3]. There was no preoperative vein mapping, and the extremity selection was based on vein and skin quality. The initial skin incision was made above the knee and was longitudinal, 1.5 to 2.5 cm long. Harvesting was initially directed toward the groin region and CO2 was used by permanent insuflation to create a subcutaneous tunnel. After completing circumferential dissection, a bipolar scissors was used to divide collateral branches. A small incision was then made under endoscopic vision directly over the proximal saphenous vein to complete the procedure. If additional length was required, further distal endoscopic dissection through the initial incision was performed. When obtained, the vein was prepared at the usual manner with metal clips on lateral branches and polypropylene 7.0 suture when necessary. After hemostasis was achieved the leg was closed with a two layers continuous polyglycaprone 3.0 suture usually at the time of entering cardiopulmonary bypass. The wound was finally covered with an elastic ace bandage wrap applied to the entire leg, which was changed every 24 hours until day 15. Possible complications were reviewed daily until discharge at postoperative days 15 and 30.
Data collection
To consider the impact of the learning curve, we arbitrarily divided our patients into six groups of 30 consecutive patients each (G1 to G6). We reported preoperative variables, site of harvesting, number of incisions, length, time from initial dissection to proximal vein section, number of venous bypasses, number of repairs per conduit, conversion rate to open technique, and wound complications. For statistical analysis, the Kruskal-Wallis multiple comparisons method was employed; quantitative variables were analyzed with multiple 
2 test. Univariate analysis was performed with the Fisher exact test. Statistical significance was determined at a p value less than or equal to 0.05.
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Results
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Table 1 represents the patients’ demographics. Their mean age was 64.4 ± 9.18 years (range, 43 to 92 years); 86% were male. No differences in demographic variables and comorbidity were noted among the groups. Table 2 shows intraoperative data and compares selected variables among the six groups. The number of incisions was significantly difference for G1 versus G5 and G6, and for G3 versus G5 and G6. The mean calculated length/time index was 0.85 ± 0.36 cm/min, and there was significant difference between G1 and G3 through G6, and between G2 and G3 through G6 (Fig 1). No differences were reported for repairs or for conversion to the conventional open technique. The number of bypasses with the harvested conduit showed significant differences for G2 versus G3 and G3 versus G5 and G6. There were general wound complications in 16 patients (8.9%): subcutaneous tunnel hematoma in 2 patients (1.1%), local skin necrosis scar in 2 patients (1.1%), and wound infections (identified as local drainage and positive cultures with oral antibiotics treatment required) in 12 patients (6.7%). Two of these 12 patients were readmitted for surgical debridment and endovenous antibiotics. The infection rate was similar for each of the groups. Univariate analysis was performed on risk factors, as shown in Table 3.
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Comment
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Mean age and sex were not different from previously published data for coronary patients. Comorbid conditions were selected on the basis of frequency and correlation with impaired healing of saphenous vein harvesting; these did not differ from series reported by Pagni and colleagues, Crouch and associates, and Allen and coworkers [4–6].
The highest number of incisions in group was due to our initial inability to divide collateral branches, which was rapidly corrected for subsequent cases. The increased number of incisions in G3 was attributed to the extension of the harvesting procedure to the distal leg in 50% of the patients.
The length–time index, shown in Figure 1, represents the actual state of learning. From G1 to G2 no differences due to a change in the harvesting device ("Double Access" to Uniport Vasoview) were observed. From G2 onward there was a continuous improvement, reaching in G5 and G6 the index of 1 cm/min, which was suggested by Crouch and associates as optimal for this method [5].
The number of repairs was not significantly different among groups. This would imply that the harvested vein is mainly not damaged during the endoscopic procedure, even for the first cases, a conclusion not shared by Pagni and coworkers, who reported a higher number of repairs at the beginning of their experience [4]. The conversion rate to the open technique did not show differences throughout the experience, and is comparable to previously published data by Pagni and colleagues and by Crouch and associates [4, 5]. The variations in the number of venous bypasses was not attributable to the harvesting method but, rather, to surgical strategy. The mean number of venous bypasses (1.30 ± 0.6) per patient is acceptable, considering the average patient age (64.4 ± 9.18 years).
No systemic complications due to the harvesting method occurred. Local complications were minimally higher than those reported in the Pagni and Crouch series [4, 5]. Infection, defined as local drainage and positive cultures, was due mainly to gram-negative bacteria, which are common in the groin region. According to the composite score of infection risk [7] suggested by Puskas and associates, readmission was necessary in 1 patient from the high-risk group and 1 from low-risk group. To identify the risk factors for infection in our population, we applied univariate analysis, as mentioned before. High-risk factors for infection were found to be the following: female gender, distal endoscopic dissection, time of more than 50 minutes, and three or more incisions (not reported as risk factors in previously published data). The incidence of diabetes approached statistical significance (p = 0.08). Multivariate analysis was not possible for these variables because of the relatively small number of patients, which is a limitation of the study. A cost analysis was not included in the study aims, even if it is reliable; the high cost may represent an important factor at the time of defining the harvesting method.
Endoscopic vein harvesting per se is a feasible method, even for surgeons without experience in this kind of procedure. It implies a training period, as considered in our series of approximately 30 patients. The learning curve means improvement of the length–time index, but not a reduction in complication rates (wound infection, repairs, or conversion to open technique). Cost analysis may be the subject of future studies.
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Acknowledgments
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We thank Ruth Henquin, MD, for her assistance with the statistical analysis.
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References
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Abstract
Introduction
