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Ann Thorac Surg 2004;77:2076-2082
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Endoscopic vein harvest: advantages and limitations

^a Department of Cardiac Surgery, Royal Victoria Hospital, Belfast, United Kingdom

Accepted for publication November 7, 2003.

^* Address reprint requests to Dr MacGowan, Royal Victoria Hospital, Grosevenor Rd, Belfast BT12 6BA, UK
e-mail: simon.macgowan{at}royalhospitals.n-i.nhs.uk

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
BACKGROUND: Although long saphenous vein remains the most commonly used conduit in coronary revascularization, traditional open vein harvest (OVH) may lead to significantly impaired wound healing and postoperative pain. Endoscopic vein harvest (EVH) attempts to reduce this morbidity and improve patient satisfaction with no compromise in outcome.

METHODS: From September 2000 to November 2001, 108 saphenous vein harvests were prospectively randomly assigned to EVH (n = 52) or OVH (n = 56); EVH was performed with the Clearglide endoscopic vein harvest system (Cardiovations) by a single surgeon. Endpoints included impaired wound healing (ASEPSIS score), operative and harvest time, vein quality (including histology), outcome and postoperative pain (Visual Analog Scale). Follow-up was as long as 3 years.

RESULTS: The groups were well matched demographically. Endoscopic vein harvest was quicker to perform if sufficient vein for two grafts was needed (p < 0.01). Wound healing was significantly impaired (ASEPSIS score) in the OVH group compared with the EVH group (p < 0.01). The new procedure did not prolong the overall operative time (p = 0.77). Postoperative pain was less (p < 0.01) in the EVH group. Stepwise multiple regression showed age, diabetes, peripheral vascular disease, total operative time, type of procedure, length of incision, and number of vein grafts to be predictive of impaired wound healing. More late interventions were needed in the OVH group for wound-related morbidity.

CONCLUSIONS: These data demonstrate that endoscopic vein harvest results in fewer cases of impaired wound healing and reduced postoperative pain, and it does not prolong the operative time significantly nor compromise the vein quality. Furthermore, it is quicker to perform if two grafts are needed, and it reduces late interventions.

	Introduction

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
Saphenous vein has been used as a conduit since the advent of coronary artery bypass grafting. Saphenous vein harvest with conventional approach entails an incision placed over the full length of the vein to be harvested (open vein harvest [OVH]) has been identified as a source for increased wound-related morbidity [1, 2]. Several investigators have reported the advantage of avoiding such long incisions by alternative methods of harvesting the saphenous vein [3, 4].

In 1994, Lumsden and colleagues [5] proposed harvesting the saphenous vein using video endoscope and termed the procedure endoscopic vein harvest (EVH). Previous studies have demonstrated that EVH reduces wound infection rates during hospital stay but within a limited follow-up period [3, 6], which has a potential to miss later noninfective wound-related morbidity. The majority of wound-related morbidity after vein harvest develops after the discharge of the patient. In this study we have calculated the ASEPSIS score (based on a system of scores for Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, and Stay duration as inpatient), which is accurate in the quantification of impaired wound healing, and followed up all patients for as long as 36 months to ensure the capture of all wound-related morbidity [7, 8].

	Material and methods

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
Our hypothesis is that EVH is comparable with OVH in terms of wound morbidity. The endpoint was impaired wound healing as estimated by the ASEPSIS score (Appendix 1). An ASEPSIS score of 11 or more was considered as an endpoint. Secondary endpoints were postoperative pain as assessed by the Visual Analog Scale (VAS), mobility, and postdischarge interventions and complications.

Study design
From September 2000 to November 2001, 108 consecutive saphenous vein harvests were prospectively randomly assigned to EVH (n = 52) or OVH (n = 56), all performed by one surgeon. An initial 20 EVH procedures were done before commencement of the trial to overcome the learning curve (Fig 1). All patients who met the inclusion criteria were informed of the nature of trial and an informed consent was obtained from those who elected to participate in the study. Randomization was done by minimization method (Appendix 2). The Research Ethics Committee, Queens University of Belfast, approved the trial (Ref: 204/00).

View larger version (12K): [in this window] [in a new window]   Fig 1. Learning curve: total time needed to harvest vein versus number of cases. (EVH = endoscopic vein harvest.)

Exclusion criteria were as follows: (1) all adult cardiac surgical patients needing an emergency revascularization or with an intra-aortic balloon pump in situ or who are hemodynamically unstable; (2) patients who have varicose veins affecting part or the entire lower extremity; (3) patients who have undergone previous surgical procedure (saphenectomy) or suffered trauma so as to preclude the use of the saphenous vein; (4) previous clinical history of or radiologic evidence of deep vein thrombosis; (5) local factors like dermatitis or infection, which may preclude surgical procedure on the lower extremity.

Operative technique
The preoperative preparation was standardized and was similar to both groups. All study patients were anesthetized by similar induction technique. All patients received cefuroxime 1.5 g intravenously 30 minutes before the skin incision and was continued postoperatively for 48 hours (six doses in total). We used Clearglide Accel (Cardiovations, Edinburgh, Scotland) for all the cases of EVH, which uses stainless steel clips for control of tributaries. Briefly, a standard no-touch technique was used for OVH. Endoscopic vein harvest involved an incision either above or below the knee after location the vein with needle aspiration, creating a space above the vein by optical dissector, and subsequent sharp dissection with clipping and cutting of tributaries. The use of blunt dissection around the tributaries by optical dissector or endoscopic-loop was avoided, and care was taken while dissecting to avoid undue traction on vein. The detailed technique was described earlier [9].

Postoperative care
The postoperative care was standardized and was similar to both groups of patients. Chest tubes were removed and morphine infusion stopped and patients ambulated. Nonsteroidal antiinflammatory drugs (NSAIDs) were prescribed as required. The follow-up was done at 6 weeks in the out patients clinic. A final follow-up within a closing interval of 6 weeks was done by personal interview and examination and cross checked with medical records for late events such as recurrence of angina or myocardial infarction.

Statistical methods
Data were collected at various points during the in-hospital stay. The primary time-point was considered to be at discharge from the base hospital. A ² test or Fisher's exact test was used for all qualitative variables and the Mann-Whitney U test was used for quantitative variable analysis. Values are expressed as mean ± standard deviation unless otherwise specified. Correlation between variables was tested by contingency coefficient for correlation and nonparametric Spearman's correlation, rho. All explanatory variables that were thought to predict impaired wound healing were subjected to univariate analysis and then entered into stepwise multiple regression model, which was confirmed by forward and backward methods in order to assess the independent predictors of impaired wound healing (multivariate analysis). Because selection of variables that correlate with each other may result in multicollinearity and overfitting of the model, only one clinically relevant variable was chosen in case of correlation. All statistical testing used a 5% two-tailed test. Statistical analysis on the collected data was done using SPSS 11.0 software (SPSS, Chicago, IL). Nonlinear regression (curve fit) with one phase exponential decay was graphically displayed using GraphPad Prism version 3.00 for Windows, (GraphPad Software, San Diego, CA)

	Results

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
There were 139 patients who met the inclusion criteria; 19 patients were either excluded as they declined to participate in the study or showed preference toward a specific technique. Ten other patients met the exclusion criteria and were excluded. The remaining patients (n = 110) were randomly assigned to OVH (n = 56) and EVH (n = 54). There were 2 patients in the EVH group who needed conversion to OVH due to nonstandard anatomy; they were excluded from the final analysis but were followed up similar to other study patients.

Demographics, operative, and procedure-specific characteristics
The groups were comparable for demographic data, risk factors for wound infection, and operative characteristics (Table 1). In all cases, a left internal mammary graft was used in addition to vein grafts. The vein harvest specific variables are shown in Table 2. The total procedure time (harvest time plus closure time) for one length of graft was 32.6 ± 3.5 minutes (OVH, n = 8) versus 22.2 ± 3.2 minutes (EVH, n = 10); for two lengths of graft it was 43.3 ± 3.6 minutes (OVH, n = 34) versus 31.2 ± 3.3 minutes (EVH, n = 31); for three lengths of vein graft it was 63.3 ± 3.2 minutes (OVH, n = 11) versus 70.8 ± 4.9 minutes (EVH, n = 9); and for four lengths it was 72.2 ± 5.1 minutes (OVH, n = 3) versus 84.0 ± 1.4 minutes (EVH, n = 2). From this data, it appears that for up to two lengths of vein grafts EVH takes 10 minutes less (p < 0.05; Fig 2). There was no difference between the groups regarding the number of grafts used (p > 0.12). The amount of blood loss in the harvest procedure as determined by number of Raytec swabs used was significantly more in OVH (15.8 ± 4.8) compared with EVH (1.9 ± 2.5; p < 0.05). None of the patients had acute graft failure, intraoperative, or perioperative myocardial infarction. Histologic evaluation for endothelial damage did not differ between groups (light microscopy).

View larger version (16K): [in this window] [in a new window]   Fig 2. Total procedure time versus number of vein grafts. (EVH = endoscopic vein harvest; OVH = open vein harvest.)

	Comment

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

A scoring tool to identify impairment in wound healing is more appropriate to compare the impact of operative procedure instead simply contrasting crude infection rate. The ASEPSIS score is commonly used to determine impaired wound healing and has been validated in cardiac surgical patients [7, 8, 10]. In our study, there was a significantly higher ASEPSIS score in the OVH group compared with the EVH group. None of the patients in either group developed severe wound infection, but 6 patients showed minor and 3 patients showed moderate wound infection. Overall, 96% of the patients in the EVH group had satisfactory healing of the wound compared with 71% in the OVH group. Predominantly wounds around the ankle and groin areas showed increasing scores for impaired wound healing (90%). The absence of early graft failure, intraoperative or perioperative myocardial infarction together with comparable vein quality by histology are indications that the new procedure does not cause endothelial damage. Previous studies showed no histologic evidence of increased endothelial damage by EVH, although late vein graft patency was not assessed [11–13]. However, peripheral vein bypass grafts harvested by endoscopic methods have shown similar patency rates when compared with conventional harvest.

Postoperative pain, restriction of movements at knee and ankle, and edema influence the postoperative mobility of the patients, and these are more common in patients with OVH. These results are similar to other studies that also found less postoperative pain and improved mobility using EVH [14, 15]. Patients who showed restriction of ankle movement compared with their preoperative status frequently had disturbance of wound healing over the lower leg. Restriction of knee joint movements was more common in those who had incisions over the knee, or in close proximity to it, and edema of the leg.

This is the first study to look at the long-term impact and outcome of vein harvest procedures in terms of harvest site wound healing. Several investigators have shown that the majority of postoperative wound complications related to vein harvest present after discharge [8, 16]; our findings agree with their findings. Most patients (89%) in this study were discharged from the hospital by day 6 and the remaining by day 7. Our data show that OVH leads to disturbed wound healing, which is reflected in the increased need for both visits by district nurses (for extra dressings) and patients seeking consultations with their general practioner. Ten patients received antibiotics from their general practioner, but only in 2 patients were pathogenic microorganisms isolated.

Postoperative edema is a significant cause for morbidity after vein harvest [15]. After discharge, the majority of patients in the OVH group complained of edema affecting the harvested leg, with 6 patients still complaining of residual edema of the harvested leg at 1 year. The majority of the patients continued to experience restriction of ankle movement associated with leg edema at subsequent follow-up visits. We believe this may be due to partial interruption of lymphatic drainage due to the long incision needed to harvest the vein in the OVH group. Injection preparations of lower extremity have shown that the superficial lymphatics run in a narrow band of adipose tissue overlying the great saphenous vein and do not communicate with the deep lymphatics [17, 18]. Another cause of morbidity after vein harvest is altered sensation, which has been reported in as many as 70% at 20 months of follow-up [19]. In this study there was a significant difference between patients who had altered sensation in the harvested leg in the endoscopic harvest and open harvest groups. The reduced incidence of altered sensation in the endoscopic group is due to dissection being performed close to the adventitia and avoidance of a large incision. The new technique needed fewer late interventions by the patient's general practioner and district nurses.

Open vein harvest uses a long incisions and has been found to lead to significant wound morbidity. Endoscopic vein harvest minimizes the length of incisions. The advantage of EVH over the multiple bridging techniques is that it avoids traction on the vein while being harvested, thus minimizing trauma to the endothelium. In addition, the videoscopic vision, (although two-dimensional) allows the surgeon to dissect under vision throughout the procedure. Previous studies have shown that this technique is feasible but takes longer to perform. This in part is due to considering only the harvest time and not the overall procedure time [3, 6]. Another aspect not previously reported is the amount of blood loss. Endoscopic vein harvest is associated with minimal blood loss, potentially reducing the exposure to blood products.

In our study, we compared the total procedure time and found that it is quicker if one or two grafts are needed, but that this advantage is lost if three or more than three vein grafts are needed. We believe this difference is due to technical considerations as sufficient length for two vein grafts can be expeditiously harvested once the camera and video monitor are in place. If more vein is required, the operator must adjust the monitor and recommence dissection, all of which may add as many as 15 minutes. The total procedure time can even be more prolonged if a segment of vein is found to be unusable. Another limitation of the technique is partially varicose veins (with intervening lengths that may be suitable or only conduit available), which are difficult to harvest using the new technique owing to the risk of bleeding. Although there were twice as many injuries to the vein in the EVH group, it did not reach statistical significance (Table 2; p = 0.10), as outlined in our earlier publication the increased injuries seem to be due to working in a confined space with fencing effect of the instruments and not due to the learning curve.

In our experience the learning curve is approximately 20 patients. The number of cases depend on prior experience, understanding of the anatomy, and familiarity with endoscopic procedures. We did not use any preoperative mapping or use of ultrasound devices for locating the vein. Our technique uses a simple and economical method of locating the vein by using a 2 mL syringe mounted with a hypodermic needle (24G). This easily localizes the vein by aspiration. The puncture made by the needle is small and is similar in terms of trauma to the deairing maneuvers. We have used this technique successfully in all cases.

We found that increasing age, presence of diabetes, presence of peripheral vascular disease, overall operative time, number of vein grafts harvested, length of incision, and open harvest procedure were the important predictors of increasing ASEPSIS score. Our study demonstrates better wound healing in the EVH group. The technique is also quicker than OVH for two segments of veins. Using the technique for three or more segments of vein trades increased procedure time for reduced wound-related morbidity, although this increased total procedure time did not have any impact on the overall operative time.

	Acknowledgments

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
We would like to thank Dr Gordon Cran, BSc Dip Stat, PhD C Stat, Medical Statistician, Queen's University of Belfast, for the support given regarding the statistical analysis. We would also like to thank Cardiovations, Ltd, Edinburgh, for leasing the camera and monitor for the trial period.

	Appendix 1

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
Scoring system
The ASEPSIS (Additional treatment, Serous discharge, Erythema, Purulent exudate, Separation of deep tissues, Isolation of bacteria, Stay duration as inpatient) scoring system can be used to quantitate postoperative wound infections. It was initially designed for evaluating the effectiveness of antibiotic prophylaxis prior to cardiac surgery but has been proposed as a method to compare wound care. The surgical site is inspected on 5 of the first 7 days after surgery, with the wound scored based on the findings of serous exudate, erythema, purlent exudate, and separation of deep tissue). Additional information on wound treatments, culture findings, and delayed discharge is then analyzed.

Appendix Wound ASEPSIS Scores

Variables in ASEPSIS Proportion of Wound Affected and Points Scored 0 1%–20% 20%–39% 40%–59% 60%–79% >80% Serous exudate 0 1 2 3 4 5 Erythema 0 1 2 3 4 5 Purulent exudate 0 2 4 6 8 10 Separation of deep tissues 0 2 4 6 8 10 Additional treatment No Yes Antibiotics for wound 0 10 Drainage under LA 0 5 Drainage under GA 0 10 Isolation of pathogens 0 10 Stay (inpatient) prolonged, >14 days 0 5

Appendix ASEPSIS Scoring Criteria

ASEPSIS Score Interpretation 0–10 Satisfactory healing 11–20 Disturbance of healing 21–30 Minor wound infection 31–40 Moderate wound infection > 40 Severe wound infection

ASEPSIS score = SUM (points from 4 daily wound inspection parameters) + (points for antibiotics) + (points of pus drainage) + (points for wound debridement) + (points for bacterial isolation) + (points for prolonged hospitalization).

	Appendix 2

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 References

 
Randomization by minimization method
If we regard the patients for the trial as arriving one at a time, then the first patient is given a treatment at random. For each subsequent patient, a treatment arm is determined, which would lead to better balance between the treatment groups with respect to the variables of interest (in the present trial we used age, sex, presence of peripheral vascular disease, diabetes mellitus, and body mass index. The patient is then randomly assigned using a weighting in favor of the treatment, which would minimize the imbalance. For example, a weighting of 4 to 1 can be used, so there is an 80% chance of each patient getting the treatment that minimizes the imbalance.

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Appendix 1 Appendix 2 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): Pramod Bonde Alastair N. J. Graham Simon W. MacGowan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bonde, P. Articles by MacGowan, S. W. Search for Related Content PubMed PubMed Citation Articles by Bonde, P. Articles by MacGowan, S. W. Related Collections Coronary disease