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Endoscopic saphenous vein harvest in infrainguinal bypass surgery
Endoscopic Saphenous Vein Harvest in Infrainguinal Bypass Surgery Mark R. Robbins, MD, Steven A. Hutchinson, MD, Stephen D. Helmer, PhD, Wichita, Kansas
Autologous greater saphenous vein is considered to be the optimal material for peripheral arterial reconstruction and coronary artery revascularization. We describe a new endoscopic technique of saphenous vein harvest in infrainguinal arterial bypass surgery. METHODS: A retrospective analysis of 64 infrainguinal bypass procedures was performed comparing the standard open technique of saphenous vein harvesting with a new less invasive endoscopic technique. RESULTS: There were no differences in age, gender, indications for surgery, or proximal or distal anastomosis between the two groups. There were also no significant differences in early wound complications, early patency, and transfusion requirements. In the endoscopic group, length of operation was longer (189 versus 158 minutes; P <0.005), length of stay was shorter (5.2 versus 8.1 days; P <0.05), and postoperative day of discharge was also less (3.3 versus 5.5 days; P <0.01). CONCLUSIONS: Our findings indicate that endoscopic saphenectomy is technically feasible, leads to earlier discharge from the hospital, and leads to increased operative time. Most importantly, the procedure can be performed safely without subjecting the patient to increased risk. Am J Surg. 1998;176:586 –590. © 1998 by Excerpta Medica, Inc. BACKGROUND:
A
utologous greater saphenous vein is considered to be the best material for femoropopliteal and femorocrural arterial reconstruction, as well as for coronary artery revascularization. However, the morbidity associated with saphenous vein harvesting is significant with reported wound complications as high as 43%.1–5 Historically, the greater saphenous vein is exposed and harvested through a long continuous incision. It has been suggested that the long skin incision may be related to an increase in wound problems; therefore, there has been much interest in developing a more closed technique for saphenectomy. Several studies have shown a decreased incidence of wound
From the Department of Surgery, University of Kansas School of Medicine, Wichita, Kansas. Requests for reprints should be addressed to Steven A. Hutchinson, MD, Department of Surgery, University of Kansas School of Medicine—Wichita, 929 N. St. Francis, Wichita, Kansas 67214. Presented at the 50th Annual Meeting of the Southwestern Surgical Congress, San Antonio, Texas, April 19 –22, 1998.
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© 1998 by Excerpta Medica, Inc. All rights reserved.
infection with interrupted verses continuous incision.3,4,6,7 A closed technique using a co-axial catheter embolization system for intraoperative coil embolization of the side branches of in situ vein bypass grafts has also been described.6,7 Some preliminary studies have demonstrated a significant reduction in wound complications; however, this technique is plagued by a high rate of postoperative residual arteriovenous fistula, is costly, and time consuming, especially when learning the technique.8 Smaller incisions with laparoscopic surgery have led to improved patient comfort and earlier discharge.9 Laparoscopic equipment has been used for ligation of vein perforators in the lower extremity.10,11 More recently, a newly developed endoscopic technique of saphenous vein harvest has been described with encouraging preliminary results.12–15 Herein, we describe our experience with this minimally invasive technique in infrainguinal arterial bypass surgery.
MATERIALS AND METHODS A retrospective analysis of 64 infrainguinal bypass procedures was performed comparing the standard open technique of saphenous vein harvesting with a new less invasive endoscopic technique. From October 1996 to July 1997, 33 patients underwent 34 infrainguinal bypass procedures in which the endoscopic technique was used. The remaining 30 cases (in 28 patients) were historical controls in which the standard open technique was performed between October 1995 and October 1996. All procedures were performed by the same surgeon. Exclusion criteria included redo operations, saphenous vein harvest from contralateral leg, additional major procedures at time of operation, and use of synthetic composite graft. The efficacy of endoscopic saphenous vein harvesting was analyzed as it related to technical feasibility, length of operation, length of stay, wound complications, hospital charge, transfusion requirements, and early patency of grafts. Quantitative variables such as age, length of stay, and charge were compared by using analysis of variance. Qualitative variables such as gender, indications for revascularization, and complications were compared using chi-square analysis. Operative Technique The patient is placed supine on the operating table and the entire leg is prepared. Incisions are made over the corresponding arterial inflow and outflow sites (Figure A). Minimal modification of these incisions allows exposure of the saphenous vein for initial mobilization. Once the vein is circumferentially freed at the axial ends of the incision, a retractor and operating scope are placed into the plane of the saphenous vein, and the dissection is performed with video assistance. The instrumentation used here is commercially known as the Endo-Path (Ethicon Endo-Surgery, 0002-9610/98/$19.00 PII S0002-9610(98)00288-8
ENDOSCOPIC SAPHENOUS VEIN HARVEST/ROBBINS ET AL
TABLE I Demographics and Indications for Revascularization for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter Age Gender: male/female Indications for revascularization Rest pain Claudication Ischemic necrosis Microemboli Popliteal aneurysm
Endoscopic Procedure
Open Procedure
70.9 6 10.9 (33)* 57.6%/42.4% (n 5 33)
73.9 6 9.3 (28) 64.3%/35.7% (n 5 28)
8 (23.5)† 12 (35.3) 13 (38.2) 0 (0.0) 1 (2.9)
8 (26.7) 9 (30.0) 11 (36.7) 1 (3.3) 1 (3.3)
* Mean 6 standard deviation (number of patients). † Number of observations (percent).
able dissection. At this point, laparoscopic instruments are used. The dissection continues caudally until the limits of the retractor are reached, at which point the vein is dissected from the distal arterial incision in a cranial direction until the vein is completely freed. Depending on the anastamotic sites and the length of vein needed, a counterincision is occasionally required. Once the dissection is complete, the vein is transected and removed from the tunnel.
RESULTS
Figure. A. The leg is prepared circumferentially and positioned with external rotation. A longitudinal incision is made at the groin for exposure of the saphenous vein and femoral artery. An additional incision is made at the site of the distal anastomosis; a counterincision is occasionally required. B. The Endo-Path equipment (from top) consists of: (a) an endoscopic dissector, (b) an endoscopic retractor, (c) a modified vein stripper, (d) an endoscopic clip applicator, and (e) endoscopic scissors (not shown). The dissector and retractor have ports for a 5-mm videoscopic lens.
Inc., Cincinnati, Ohio). It comprises a subcutaneous dissector, retractor, modified vein dissector, clip applicator, and scissors (Figure B). Standard endoscopic equipment, including a television monitor, light source, fiberoptic camera, and a 5-mm lens are also required. The subcutaneous dissector is advanced along the proximal course of the vein, and a tunnel is created. Initially, with video assistance, standard open surgical instruments such as metzenbaum scissors and clip appliers are used to the limit of comfort-
The charts of 61 patients undergoing 64 infrainguinal arterial bypass procedures, who met inclusion criteria for the study, were reviewed. Demographic information and indications for revascularization are listed in Table I. There were no differences in age, gender, indications for surgery, proximal anastomosis, or distal anastomosis between the two groups. In the endoscopic group, the proximal anastomosis was at the femoral artery in 33 cases and at the popliteal artery in 1. The proximal anastomosis was at the femoral artery in 27 and at the popliteal artery in 3 cases in the open group. The location of the distal anastomosis included the above knee popliteal artery (endo 5 4, open 5 5), the below knee popliteal and proximal tibial vessels (endo 5 25, open 5 21), and distal tibial and pedal arteries (endo 5 5, open 5 4). All patients were followed up to the time of discharge from the hospital. There were 2 early postoperative deaths. One patient in the endoscopic group with severe coronary artery disease had a significant hemoglobin drop from 11.5 mg/dL to 3.6 mg/dL resulting in cardiac arrest on postoperative day 1. There was a small harvest site hematoma; however, a source of significant blood loss could not be determined. The patient was elderly and frail, and the family declined an autopsy. The wound was not felt to be related to the abrupt drop in hemoglobin. It was felt that the most likely etiology was intraabdominal bleeding, probably in the gastrointestinal tract. The other mortality was in the open group. The patient had a myocardial infarction on postoperative day 1, resulting in hypotension and graft thrombosis. Thrombectomy was performed, but the patient subsequently died on postoperative day 8 secondary to
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TABLE II Characteristics of the Procedure and Hospitalization for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter Length of procedure Hospital stay Postoperative length of stay Preoperative hemoglobin Postoperative hemoglobin Transfusion (units pRBC) Patient charge Number of deaths
Endoscopic Procedure
Open Procedure
P Value
188.9 6 46.9 (34)* 5.2 6 3.7 (34) 3.3 6 1.6 (32) 13.8 6 2.1 (29) 10.0 6 2.6 (28) 0.65 6 1.07 (34) $21,600 6 12,413 (22) 1 (2.9%)
158.0 6 36.5 (30) 8.1 6 5.8 (30) 5.5 6 3.8 (30) 12.7 6 1.5 (27) 9.9 6 1.9 (26) 0.77 6 1.50 (30) $25,150 6 15,281 (29) 1 (3.3%)
0.005 0.05 0.01 0.05 NS NS NS NS
* Mean 6 standard deviation (number of observations). pRBC’s 5 packed red blood cells; NS 5 not significant.
TABLE III Complications for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter No complications Excessive drainage Hematoma Infection Number of procedures
Endoscopic Procedure
Open Procedure
27 (79.4)* 3 (8.8) 3 (8.8) 1 (2.9) 34 (100)
25 (83.3) 4 (13.3) 1 (3.3) 0 (0.0) 30 (100)
* Number of observations (percent).
cardiac complications with a patent graft. This was the only patient in the study with failed primary patency prior to discharge. Data related to patient hospitalization and procedure are detailed in Table II. Total operative time for each patient was recorded. The mean length of operation was significantly longer in the endoscopic group (open 5 158 versus endo 5 189 minutes; P ,0.005). The mean postoperative length of stay was significantly shorter for the endoscopic group (endo 5 3.3 versus open 5 5.4 days; P ,0.01). There was not a significant difference in hospital charges. There were no significant differences in early wound complications between the two groups (Table III). There was one wound infection in the endoscopic group that extended the length of stay by approximately 1 week. Three hematomas in the endoscopic group occurred early in the experience; it is likely that this complication is directly related to the endoscopic technique. The patients do not routinely have their heparin reversed. The lower extremity is now routinely wrapped with ACE bandages postoperatively to help prevent this complication, and we have seen few hematomas since wrapping the legs postoperatively for 24 hours. Transfusion requirements and drop in hemoglobin were also analyzed to determine if harvest site bleeding was a significant problem (Table II). There was no difference between the two groups with regard to their transfusion requirements (endo 5 0.65 versus open 5 0.77 units packed red blood cells per patient) or hemoglobin drop (endo 5 27.5% versus open 5 22%). The average 588
length of incision was reduced by approximately 80% to 90% in the endoscopic group, which required two to three incisions of 2 to 7 cm each.
COMMENTS Wound complications associated with greater saphenous vein harvesting remain a significant problem. Several factors such as diabetes, tobacco use, obesity, and female gender seem to be associated with an increased incidence of wound problems.16 Various techniques have been advocated to shorten incision length, and thereby decrease wound complications. The newly developed minimally invasive video assisted technique described here, has had encouraging results in preliminary reports.12–15 The use of vein strippers to remove the vein has been advocated by some authors. However, this blind technique is associated with vein injury. By dissecting the vein under direct visualization via the video monitor, one can avoid the problem of vein injury. Vein injury can still occur, however, and may require additional attention after removal. Whether this leads to increased early postoperative thrombosis remains to be determined. There were no postoperative thrombosed grafts prior to discharge in the endoscopic group in this study. Jordon et al12 studied 65 patients who underwent endoscopic vein harvest, with a follow-up period of 1 to 24 months, and showed a primary patency rate of 84%. Another report of 30 patients with a mean follow-up of 10 months had one postoperative thrombosis at 3 months.13 Further studies are needed to confirm that this technique does not lead to early postoperative thrombosis or increased incidence of neointimal hyperplasia and subsequent graft failure. Frequently, cardiac and vascular surgeons have minimal endoscopic experience. Therefore, patience is required when undertaking this new technique. Previous studies have indicated that operative time can be significantly reduced after the initial learning phase. Jordan et al12 reported an overall average of 1 hour for saphenous vein harvest, but an average of 46 minutes in later cases when they began to use more specialized equipment. Another study documented an initial harvest time of 1.5 to 2 hours, which was reduced to 35 to 45 minutes toward the end of the study.14 In our experience, operative time was significantly lengthened (endo 5 189 minutes, open 5 158
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minutes). However, operative time for the endoscopic vein harvest since this study has decreased significantly and is now similar to the experience reported by others. The motivation behind the development of this new technique is the hope of reducing wound complications and postoperative pain. Doing this can lead to earlier mobilization, decreased postoperative length of stay, and a more rapid recovery after discharge. Although many authors indicate that shorter incisions lead to decreased morbidity, it is presently unclear whether this approach leads to decreased wound complication rates. Most of the complications in this study were minor, and given the low incidence of major wound problems, a larger number of patients must be followed up in a prospective manner before making a conclusion. Nevertheless, our findings suggest that endoscopic saphenectomy is feasible and can be accomplished without additional morbidity. Furthermore, our data indicates that this procedure leads to earlier discharge from the hospital, and show a trend toward decreased overall charges. Many factors may contribute to shorter hospitalization. A decrease in wound morbidity would certainly have a major effect on length of stay. Other factors that may affect length of stay include decreased postoperative pain, improved willingness to ambulate secondary to the psychological effects of a significant reduction in wound length, and a general trend toward shorter hospitalization as an attempt to control cost. Endoscopic saphenous vein harvest facilitates earlier discharge and shows a trend toward reducing hospital charges. Most importantly, the procedure can be performed safely without subjecting the patient to increased risk, and may offer a particular benefit by decreasing wound complications. Although the widespread application of this technique requires skeptical optimism, the potential financial and social implications of a minimally invasive technique that reduces postoperative morbidity in a procedure performed as frequently as this is enormous. This technique, when applied to peripheral vascular surgery and coronary bypass surgery, could potentially benefit as many as 500,000 patients per year.
DISCUSSION James H. Thomas, MD (Kansas City, Kansas): I think we’d all agree with Dr. Robbins that the ultimate goal of alternative methods of harvesting the saphenous vein— that is, in contrast to the open method—are threefold: to decrease the postoperative pain; decrease wound complications; and ultimately decrease the length of hospital stay, which should, of course, affect hospital cost. This was a retrospective study in which the authors found a decrease in the duration of stay in patients who underwent retrieval of the saphenous vein endoscopically, interestingly enough without a difference in wound complications or a decrease in hospital charges. Now, there are a great number of factors that affect both of these issues, that is, the incidence of wound complications, as well as the duration of hospital stay. And I was glad that Dr. Robbins
REFERENCES 1. Reifsnyder T, Bandyk D, Seabrook G, et al. Wound complications of the in situ saphenous vein bypass technique. J Vasc Surg. 1992;15:843– 850. 2. Wipke-Tevis DD, Stotts NA, Skov P, Carrieri-Kohlman V. Frequency, manifestations, and correlates of impaired healing of saphenous vein harvest incisions. Heart Lung. 1996;25:108 –116. 3. Wengrovitz M, Atnip RG, Girrord RRM, et al. Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management. J Vasc Surg. 1990; 11:156 –163. 4. Schwartz ME, Harrington EB, Schanzer H. Wound complications after in situ bypass. J Vasc Surg. 1988;7:802– 807. 5. Johnson JA, Cogbill TH, Strutt PJ, Gunderson AL. Wound complications after infrainguinal bypass. Arch Surg. 1988;123:859 – 862. 6. Wittens CHA, van Dijk LC, du Boise NAJJ, van Urk H. A new “closed” in situ vein bypass technique. Eur J Vasc Surg. 1994;8: 166 –170. 7. Van Dijk LC, van Urk H, du Boise NAJJ, et al. A new “closed” in situ bypass technique results in a reduced wound complication rate. Eur J Vasc Surg. 1995;10:162–167. 8. Chervu A, Ahn SS, McNamara TO, Dorsey D. Endovascular obliteration of in situ saphenous vein arteriovenous fistula during bypass. Ann Vasc Surg. 1993;7:320 –324. 9. Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. NEJM. 1991;324:1073–1078. 10. Jugenheimer M, Juninger T. Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis. World J Surg. 1992;16:971–975. 11. Gloviczki P, Cambria RA, Rhee RY, et al. Surgical technique and preliminary results of endoscopic subfascial division of perforating veins. J Vasc Surg. 1996;23:517–523. 12. Jordan WD Jr, Voellinger DC, Schroeder PT, McDowell HA. Video-assisted saphenous vein harvest: the evolution of a new technique. J Vasc Surg. 1997;26:405– 414. 13. Lumsden AB, Eaves JC III, Jordan WD. Subcutaneous, videoassisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg. 1996;4:771–776. 14. Allen KB, Shaar CJ. Endoscopic saphenous vein harvesting. Ann Thorac Surg. 1997;64:265–266. 15. Cable DC, Dearani JA. Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy. Ann Thorac Surg. 1997;64:1183–1185. 16. Utley JR, Thomason ME, Wallace DJ, et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg. 1989;98:147–149.
referred to some of these issues in his presentation. The validity of the conclusions in this study, however, is affected by a number of issues. Probably, most importantly, this is a retrospective study. There are a number of faults with retrospective studies. For instance, in this particular study, the discharge criteria are not very clear to me. In addition, there is a small number of patients in each of these groups and a very small number of patients in the subset who underwent very distal reconstructions. And these people are perhaps at higher risk for wound complications, at least in the experience of most of us. I have a number of questions. How many of these patients were diabetic? What was the extent of foot sepsis in this group of patients? Do you routinely identify the saphenous vein by insufflation and mark its location? Do you have any information about the performance status of these patients?
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This may be a major determinant of how soon patients leave the hospital in contrast to some of the other issues. Finally, what were your criteria for hospital discharge and why was there no decrease in hospital charges? Glenn C. Hunter, MD (San Antonio, Texas): How many of these people have below-knee bypasses? One of the things I’ve noticed from using this technique, they don’t get as much leg swelling. Did you notice this as well in your patients?
CLOSING Mark R. Robbins, MD: We did not specifically look at premorbid conditions, such as diabetes, which predispose to wound problems. However, we did look at other factors such as indication for revascularization and location of distal anastomosis that affect postoperative wound complications. Patients who undergo surgery for limb preservation certainly have a higher incidence of wound complications, as well as those with very distal bypasses. With the numbers in this study, it would be difficult to show a correlation between these factors and wound complications, and therefore it is important to continue to follow up these patients to work these questions out. The main purpose of our study was to show that this technique is a reasonable alternative to the standard open method, and has several potential advantages.
590
In response to the question concerning preoperative saphenous vein mapping, we do not routinely do this, and this has not caused a problem. This study has the shortcomings common to all retrospective studies, pertaining to patient selection, control population, and control of more specific variables such as discharge criteria, and classification of wound complications. Criteria for discharge are highly subjective and operator dependent. Because there was only one operating surgeon in this study, it was felt the variability would be minimal. As for evaluation of performance status after discharge, we are continuing to follow up these patients to make this determination. In response to the question about no decrease in cost despite a decrease in postoperative stay, I think this is multifactorial as well. There was a general trend toward decreased hospital charges in our study that was not statistically significant. One factor may be an increase in operative time, which would increase the cost of the procedure. The disposable endoscopic equipment used is approximately $400 per case, which would increase the cost as well. As we gather more data in larger series, I think it is likely that there will be a significant reduction in cost. In response to Dr. Hunter’s question, I believe approximately 80% of our bypasses were below the knee.
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Autologous greater saphenous vein is considered to be the optimal material for peripheral arterial reconstruction and coronary artery revascularization. We describe a new endoscopic technique of saphenous vein harvest in infrainguinal arterial bypass surgery. METHODS: A retrospective analysis of 64 infrainguinal bypass procedures was performed comparing the standard open technique of saphenous vein harvesting with a new less invasive endoscopic technique. RESULTS: There were no differences in age, gender, indications for surgery, or proximal or distal anastomosis between the two groups. There were also no significant differences in early wound complications, early patency, and transfusion requirements. In the endoscopic group, length of operation was longer (189 versus 158 minutes; P <0.005), length of stay was shorter (5.2 versus 8.1 days; P <0.05), and postoperative day of discharge was also less (3.3 versus 5.5 days; P <0.01). CONCLUSIONS: Our findings indicate that endoscopic saphenectomy is technically feasible, leads to earlier discharge from the hospital, and leads to increased operative time. Most importantly, the procedure can be performed safely without subjecting the patient to increased risk. Am J Surg. 1998;176:586 –590. © 1998 by Excerpta Medica, Inc. BACKGROUND:
A
utologous greater saphenous vein is considered to be the best material for femoropopliteal and femorocrural arterial reconstruction, as well as for coronary artery revascularization. However, the morbidity associated with saphenous vein harvesting is significant with reported wound complications as high as 43%.1–5 Historically, the greater saphenous vein is exposed and harvested through a long continuous incision. It has been suggested that the long skin incision may be related to an increase in wound problems; therefore, there has been much interest in developing a more closed technique for saphenectomy. Several studies have shown a decreased incidence of wound
From the Department of Surgery, University of Kansas School of Medicine, Wichita, Kansas. Requests for reprints should be addressed to Steven A. Hutchinson, MD, Department of Surgery, University of Kansas School of Medicine—Wichita, 929 N. St. Francis, Wichita, Kansas 67214. Presented at the 50th Annual Meeting of the Southwestern Surgical Congress, San Antonio, Texas, April 19 –22, 1998.
586
© 1998 by Excerpta Medica, Inc. All rights reserved.
infection with interrupted verses continuous incision.3,4,6,7 A closed technique using a co-axial catheter embolization system for intraoperative coil embolization of the side branches of in situ vein bypass grafts has also been described.6,7 Some preliminary studies have demonstrated a significant reduction in wound complications; however, this technique is plagued by a high rate of postoperative residual arteriovenous fistula, is costly, and time consuming, especially when learning the technique.8 Smaller incisions with laparoscopic surgery have led to improved patient comfort and earlier discharge.9 Laparoscopic equipment has been used for ligation of vein perforators in the lower extremity.10,11 More recently, a newly developed endoscopic technique of saphenous vein harvest has been described with encouraging preliminary results.12–15 Herein, we describe our experience with this minimally invasive technique in infrainguinal arterial bypass surgery.
MATERIALS AND METHODS A retrospective analysis of 64 infrainguinal bypass procedures was performed comparing the standard open technique of saphenous vein harvesting with a new less invasive endoscopic technique. From October 1996 to July 1997, 33 patients underwent 34 infrainguinal bypass procedures in which the endoscopic technique was used. The remaining 30 cases (in 28 patients) were historical controls in which the standard open technique was performed between October 1995 and October 1996. All procedures were performed by the same surgeon. Exclusion criteria included redo operations, saphenous vein harvest from contralateral leg, additional major procedures at time of operation, and use of synthetic composite graft. The efficacy of endoscopic saphenous vein harvesting was analyzed as it related to technical feasibility, length of operation, length of stay, wound complications, hospital charge, transfusion requirements, and early patency of grafts. Quantitative variables such as age, length of stay, and charge were compared by using analysis of variance. Qualitative variables such as gender, indications for revascularization, and complications were compared using chi-square analysis. Operative Technique The patient is placed supine on the operating table and the entire leg is prepared. Incisions are made over the corresponding arterial inflow and outflow sites (Figure A). Minimal modification of these incisions allows exposure of the saphenous vein for initial mobilization. Once the vein is circumferentially freed at the axial ends of the incision, a retractor and operating scope are placed into the plane of the saphenous vein, and the dissection is performed with video assistance. The instrumentation used here is commercially known as the Endo-Path (Ethicon Endo-Surgery, 0002-9610/98/$19.00 PII S0002-9610(98)00288-8
ENDOSCOPIC SAPHENOUS VEIN HARVEST/ROBBINS ET AL
TABLE I Demographics and Indications for Revascularization for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter Age Gender: male/female Indications for revascularization Rest pain Claudication Ischemic necrosis Microemboli Popliteal aneurysm
Endoscopic Procedure
Open Procedure
70.9 6 10.9 (33)* 57.6%/42.4% (n 5 33)
73.9 6 9.3 (28) 64.3%/35.7% (n 5 28)
8 (23.5)† 12 (35.3) 13 (38.2) 0 (0.0) 1 (2.9)
8 (26.7) 9 (30.0) 11 (36.7) 1 (3.3) 1 (3.3)
* Mean 6 standard deviation (number of patients). † Number of observations (percent).
able dissection. At this point, laparoscopic instruments are used. The dissection continues caudally until the limits of the retractor are reached, at which point the vein is dissected from the distal arterial incision in a cranial direction until the vein is completely freed. Depending on the anastamotic sites and the length of vein needed, a counterincision is occasionally required. Once the dissection is complete, the vein is transected and removed from the tunnel.
RESULTS
Figure. A. The leg is prepared circumferentially and positioned with external rotation. A longitudinal incision is made at the groin for exposure of the saphenous vein and femoral artery. An additional incision is made at the site of the distal anastomosis; a counterincision is occasionally required. B. The Endo-Path equipment (from top) consists of: (a) an endoscopic dissector, (b) an endoscopic retractor, (c) a modified vein stripper, (d) an endoscopic clip applicator, and (e) endoscopic scissors (not shown). The dissector and retractor have ports for a 5-mm videoscopic lens.
Inc., Cincinnati, Ohio). It comprises a subcutaneous dissector, retractor, modified vein dissector, clip applicator, and scissors (Figure B). Standard endoscopic equipment, including a television monitor, light source, fiberoptic camera, and a 5-mm lens are also required. The subcutaneous dissector is advanced along the proximal course of the vein, and a tunnel is created. Initially, with video assistance, standard open surgical instruments such as metzenbaum scissors and clip appliers are used to the limit of comfort-
The charts of 61 patients undergoing 64 infrainguinal arterial bypass procedures, who met inclusion criteria for the study, were reviewed. Demographic information and indications for revascularization are listed in Table I. There were no differences in age, gender, indications for surgery, proximal anastomosis, or distal anastomosis between the two groups. In the endoscopic group, the proximal anastomosis was at the femoral artery in 33 cases and at the popliteal artery in 1. The proximal anastomosis was at the femoral artery in 27 and at the popliteal artery in 3 cases in the open group. The location of the distal anastomosis included the above knee popliteal artery (endo 5 4, open 5 5), the below knee popliteal and proximal tibial vessels (endo 5 25, open 5 21), and distal tibial and pedal arteries (endo 5 5, open 5 4). All patients were followed up to the time of discharge from the hospital. There were 2 early postoperative deaths. One patient in the endoscopic group with severe coronary artery disease had a significant hemoglobin drop from 11.5 mg/dL to 3.6 mg/dL resulting in cardiac arrest on postoperative day 1. There was a small harvest site hematoma; however, a source of significant blood loss could not be determined. The patient was elderly and frail, and the family declined an autopsy. The wound was not felt to be related to the abrupt drop in hemoglobin. It was felt that the most likely etiology was intraabdominal bleeding, probably in the gastrointestinal tract. The other mortality was in the open group. The patient had a myocardial infarction on postoperative day 1, resulting in hypotension and graft thrombosis. Thrombectomy was performed, but the patient subsequently died on postoperative day 8 secondary to
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TABLE II Characteristics of the Procedure and Hospitalization for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter Length of procedure Hospital stay Postoperative length of stay Preoperative hemoglobin Postoperative hemoglobin Transfusion (units pRBC) Patient charge Number of deaths
Endoscopic Procedure
Open Procedure
P Value
188.9 6 46.9 (34)* 5.2 6 3.7 (34) 3.3 6 1.6 (32) 13.8 6 2.1 (29) 10.0 6 2.6 (28) 0.65 6 1.07 (34) $21,600 6 12,413 (22) 1 (2.9%)
158.0 6 36.5 (30) 8.1 6 5.8 (30) 5.5 6 3.8 (30) 12.7 6 1.5 (27) 9.9 6 1.9 (26) 0.77 6 1.50 (30) $25,150 6 15,281 (29) 1 (3.3%)
0.005 0.05 0.01 0.05 NS NS NS NS
* Mean 6 standard deviation (number of observations). pRBC’s 5 packed red blood cells; NS 5 not significant.
TABLE III Complications for Patients Who Received Peripheral Arterial Reconstruction by the Standard Open Procedure or Endoscopic Procedure Parameter No complications Excessive drainage Hematoma Infection Number of procedures
Endoscopic Procedure
Open Procedure
27 (79.4)* 3 (8.8) 3 (8.8) 1 (2.9) 34 (100)
25 (83.3) 4 (13.3) 1 (3.3) 0 (0.0) 30 (100)
* Number of observations (percent).
cardiac complications with a patent graft. This was the only patient in the study with failed primary patency prior to discharge. Data related to patient hospitalization and procedure are detailed in Table II. Total operative time for each patient was recorded. The mean length of operation was significantly longer in the endoscopic group (open 5 158 versus endo 5 189 minutes; P ,0.005). The mean postoperative length of stay was significantly shorter for the endoscopic group (endo 5 3.3 versus open 5 5.4 days; P ,0.01). There was not a significant difference in hospital charges. There were no significant differences in early wound complications between the two groups (Table III). There was one wound infection in the endoscopic group that extended the length of stay by approximately 1 week. Three hematomas in the endoscopic group occurred early in the experience; it is likely that this complication is directly related to the endoscopic technique. The patients do not routinely have their heparin reversed. The lower extremity is now routinely wrapped with ACE bandages postoperatively to help prevent this complication, and we have seen few hematomas since wrapping the legs postoperatively for 24 hours. Transfusion requirements and drop in hemoglobin were also analyzed to determine if harvest site bleeding was a significant problem (Table II). There was no difference between the two groups with regard to their transfusion requirements (endo 5 0.65 versus open 5 0.77 units packed red blood cells per patient) or hemoglobin drop (endo 5 27.5% versus open 5 22%). The average 588
length of incision was reduced by approximately 80% to 90% in the endoscopic group, which required two to three incisions of 2 to 7 cm each.
COMMENTS Wound complications associated with greater saphenous vein harvesting remain a significant problem. Several factors such as diabetes, tobacco use, obesity, and female gender seem to be associated with an increased incidence of wound problems.16 Various techniques have been advocated to shorten incision length, and thereby decrease wound complications. The newly developed minimally invasive video assisted technique described here, has had encouraging results in preliminary reports.12–15 The use of vein strippers to remove the vein has been advocated by some authors. However, this blind technique is associated with vein injury. By dissecting the vein under direct visualization via the video monitor, one can avoid the problem of vein injury. Vein injury can still occur, however, and may require additional attention after removal. Whether this leads to increased early postoperative thrombosis remains to be determined. There were no postoperative thrombosed grafts prior to discharge in the endoscopic group in this study. Jordon et al12 studied 65 patients who underwent endoscopic vein harvest, with a follow-up period of 1 to 24 months, and showed a primary patency rate of 84%. Another report of 30 patients with a mean follow-up of 10 months had one postoperative thrombosis at 3 months.13 Further studies are needed to confirm that this technique does not lead to early postoperative thrombosis or increased incidence of neointimal hyperplasia and subsequent graft failure. Frequently, cardiac and vascular surgeons have minimal endoscopic experience. Therefore, patience is required when undertaking this new technique. Previous studies have indicated that operative time can be significantly reduced after the initial learning phase. Jordan et al12 reported an overall average of 1 hour for saphenous vein harvest, but an average of 46 minutes in later cases when they began to use more specialized equipment. Another study documented an initial harvest time of 1.5 to 2 hours, which was reduced to 35 to 45 minutes toward the end of the study.14 In our experience, operative time was significantly lengthened (endo 5 189 minutes, open 5 158
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minutes). However, operative time for the endoscopic vein harvest since this study has decreased significantly and is now similar to the experience reported by others. The motivation behind the development of this new technique is the hope of reducing wound complications and postoperative pain. Doing this can lead to earlier mobilization, decreased postoperative length of stay, and a more rapid recovery after discharge. Although many authors indicate that shorter incisions lead to decreased morbidity, it is presently unclear whether this approach leads to decreased wound complication rates. Most of the complications in this study were minor, and given the low incidence of major wound problems, a larger number of patients must be followed up in a prospective manner before making a conclusion. Nevertheless, our findings suggest that endoscopic saphenectomy is feasible and can be accomplished without additional morbidity. Furthermore, our data indicates that this procedure leads to earlier discharge from the hospital, and show a trend toward decreased overall charges. Many factors may contribute to shorter hospitalization. A decrease in wound morbidity would certainly have a major effect on length of stay. Other factors that may affect length of stay include decreased postoperative pain, improved willingness to ambulate secondary to the psychological effects of a significant reduction in wound length, and a general trend toward shorter hospitalization as an attempt to control cost. Endoscopic saphenous vein harvest facilitates earlier discharge and shows a trend toward reducing hospital charges. Most importantly, the procedure can be performed safely without subjecting the patient to increased risk, and may offer a particular benefit by decreasing wound complications. Although the widespread application of this technique requires skeptical optimism, the potential financial and social implications of a minimally invasive technique that reduces postoperative morbidity in a procedure performed as frequently as this is enormous. This technique, when applied to peripheral vascular surgery and coronary bypass surgery, could potentially benefit as many as 500,000 patients per year.
DISCUSSION James H. Thomas, MD (Kansas City, Kansas): I think we’d all agree with Dr. Robbins that the ultimate goal of alternative methods of harvesting the saphenous vein— that is, in contrast to the open method—are threefold: to decrease the postoperative pain; decrease wound complications; and ultimately decrease the length of hospital stay, which should, of course, affect hospital cost. This was a retrospective study in which the authors found a decrease in the duration of stay in patients who underwent retrieval of the saphenous vein endoscopically, interestingly enough without a difference in wound complications or a decrease in hospital charges. Now, there are a great number of factors that affect both of these issues, that is, the incidence of wound complications, as well as the duration of hospital stay. And I was glad that Dr. Robbins
REFERENCES 1. Reifsnyder T, Bandyk D, Seabrook G, et al. Wound complications of the in situ saphenous vein bypass technique. J Vasc Surg. 1992;15:843– 850. 2. Wipke-Tevis DD, Stotts NA, Skov P, Carrieri-Kohlman V. Frequency, manifestations, and correlates of impaired healing of saphenous vein harvest incisions. Heart Lung. 1996;25:108 –116. 3. Wengrovitz M, Atnip RG, Girrord RRM, et al. Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: predisposing factors and management. J Vasc Surg. 1990; 11:156 –163. 4. Schwartz ME, Harrington EB, Schanzer H. Wound complications after in situ bypass. J Vasc Surg. 1988;7:802– 807. 5. Johnson JA, Cogbill TH, Strutt PJ, Gunderson AL. Wound complications after infrainguinal bypass. Arch Surg. 1988;123:859 – 862. 6. Wittens CHA, van Dijk LC, du Boise NAJJ, van Urk H. A new “closed” in situ vein bypass technique. Eur J Vasc Surg. 1994;8: 166 –170. 7. Van Dijk LC, van Urk H, du Boise NAJJ, et al. A new “closed” in situ bypass technique results in a reduced wound complication rate. Eur J Vasc Surg. 1995;10:162–167. 8. Chervu A, Ahn SS, McNamara TO, Dorsey D. Endovascular obliteration of in situ saphenous vein arteriovenous fistula during bypass. Ann Vasc Surg. 1993;7:320 –324. 9. Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. NEJM. 1991;324:1073–1078. 10. Jugenheimer M, Juninger T. Endoscopic subfascial sectioning of incompetent perforating veins in treatment of primary varicosis. World J Surg. 1992;16:971–975. 11. Gloviczki P, Cambria RA, Rhee RY, et al. Surgical technique and preliminary results of endoscopic subfascial division of perforating veins. J Vasc Surg. 1996;23:517–523. 12. Jordan WD Jr, Voellinger DC, Schroeder PT, McDowell HA. Video-assisted saphenous vein harvest: the evolution of a new technique. J Vasc Surg. 1997;26:405– 414. 13. Lumsden AB, Eaves JC III, Jordan WD. Subcutaneous, videoassisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg. 1996;4:771–776. 14. Allen KB, Shaar CJ. Endoscopic saphenous vein harvesting. Ann Thorac Surg. 1997;64:265–266. 15. Cable DC, Dearani JA. Endoscopic saphenous vein harvesting: minimally invasive video-assisted saphenectomy. Ann Thorac Surg. 1997;64:1183–1185. 16. Utley JR, Thomason ME, Wallace DJ, et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg. 1989;98:147–149.
referred to some of these issues in his presentation. The validity of the conclusions in this study, however, is affected by a number of issues. Probably, most importantly, this is a retrospective study. There are a number of faults with retrospective studies. For instance, in this particular study, the discharge criteria are not very clear to me. In addition, there is a small number of patients in each of these groups and a very small number of patients in the subset who underwent very distal reconstructions. And these people are perhaps at higher risk for wound complications, at least in the experience of most of us. I have a number of questions. How many of these patients were diabetic? What was the extent of foot sepsis in this group of patients? Do you routinely identify the saphenous vein by insufflation and mark its location? Do you have any information about the performance status of these patients?
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This may be a major determinant of how soon patients leave the hospital in contrast to some of the other issues. Finally, what were your criteria for hospital discharge and why was there no decrease in hospital charges? Glenn C. Hunter, MD (San Antonio, Texas): How many of these people have below-knee bypasses? One of the things I’ve noticed from using this technique, they don’t get as much leg swelling. Did you notice this as well in your patients?
CLOSING Mark R. Robbins, MD: We did not specifically look at premorbid conditions, such as diabetes, which predispose to wound problems. However, we did look at other factors such as indication for revascularization and location of distal anastomosis that affect postoperative wound complications. Patients who undergo surgery for limb preservation certainly have a higher incidence of wound complications, as well as those with very distal bypasses. With the numbers in this study, it would be difficult to show a correlation between these factors and wound complications, and therefore it is important to continue to follow up these patients to work these questions out. The main purpose of our study was to show that this technique is a reasonable alternative to the standard open method, and has several potential advantages.
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In response to the question concerning preoperative saphenous vein mapping, we do not routinely do this, and this has not caused a problem. This study has the shortcomings common to all retrospective studies, pertaining to patient selection, control population, and control of more specific variables such as discharge criteria, and classification of wound complications. Criteria for discharge are highly subjective and operator dependent. Because there was only one operating surgeon in this study, it was felt the variability would be minimal. As for evaluation of performance status after discharge, we are continuing to follow up these patients to make this determination. In response to the question about no decrease in cost despite a decrease in postoperative stay, I think this is multifactorial as well. There was a general trend toward decreased hospital charges in our study that was not statistically significant. One factor may be an increase in operative time, which would increase the cost of the procedure. The disposable endoscopic equipment used is approximately $400 per case, which would increase the cost as well. As we gather more data in larger series, I think it is likely that there will be a significant reduction in cost. In response to Dr. Hunter’s question, I believe approximately 80% of our bypasses were below the knee.
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