- Email: [email protected]
Endoscopic vein harvest for infrainguinal arterial bypass
From the Western Vascular Society
Endoscopic vein harvest for infrainguinal arterial bypass Sarah M. Wartman, MD, Karen Woo, MD, Gabriel Herscu, MD, Michael Morell, MD, Vahagn Nikolian, MD, Miguel Manzur, MD, and Fred A. Weaver, MD, Los Angeles, Calif Background: Endoscopic harvest of saphenous vein for infrainguinal arterial bypass decreases incision length and was initially documented to decrease wound complications without adversely affecting patency. However, recent studies have shown lower patency without a wound complication benefit. We sought to further define the wound complication and patency rates of endoscopic harvest compared with open harvest in infrainguinal arterial bypass procedures. Methods: Infrainguinal bypasses performed from 2000 to 2011 were analyzed. Only procedures using a single segment of great saphenous vein were included. Cases were grouped according to endoscopic or open harvest and were frequencymatched for body mass index and diabetes. Baseline characteristics were compared. Univariate and multivariate analysis was performed to determine correlation of baseline data and harvest method on wound complications and patency. Results: The study included 76 bypasses; 35 in the endoscopic harvest group and 41 in the open harvest group. Baseline characteristics between the endoscopic and open harvest groups were not significantly different, with the exception of mean age, which was older in the endoscopic harvest group, and carotid artery disease, which was more common in the open harvest group. There was no significant difference between endoscopic and open harvest in 30-day wound complication rates (29% vs 27%; P [ .87) or in the other perioperative variables, aside from decreased narcotic use in the endoscopic harvest group (P [ .01). Mean follow-up was 747 days. There was no significant difference in 3-year primary (47% vs 49%; P [ .8), 3-year primary-assisted (88% vs 73%; P [ .1), or secondary patency rates (92% vs 76%; P [ .09) at 3 years between the endoscopic and open harvest groups. High body mass index improved primary patency in the endoscopic harvest group (P [ .02), but had no effect on patency in the open harvest group (P [ .15). Patients requiring hemodialysis had increased risk for loss of primary assisted patency in both groups (endoscopic, P [ .02; open, P [ .02) and decreased secondary patency in the open harvest group (P [ .04). Conclusions: Endoscopic and open harvest techniques for infrainguinal arterial bypass provide similar rates of wound complications and bypass patency, whereas hemodialysis negatively affects patency after both harvest methods. Endoscopic harvest is associated with the need for less perioperative narcotics, suggesting a potential benefit of endoscopic harvest that deserves further study. (J Vasc Surg 2013;57:1489-94.)
The great saphenous vein (GSV) remains the conduit of choice for infrainguinal arterial bypass procedures due to its superior long-term patency and resistance to infection.1 Traditionally, continuous or skip incisions along the length of the vein have been used to harvest the GSV, and multiple authors have shown that an increased incision length is associated with an increased risk for wound complications, with reported rates as high as 40%.2-5 More recently, endoscopic harvest (EH) of the GSV, which minimizes the skin incision, has been used in an attempt to mitigate the risk of wound complications. Initial studies from the cardiac literature found that EH decreased the rate of wound complications compared with
From the Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California. Author conflict of interest: none. Presented at the Twenty-seventh Annual Meeting of the Western Vascular Society, Park City, Utah, September 22-25, 2012. Reprint requests: Fred A. Weaver, MD, 1520 San Pablo St., Ste 4300, Los Angeles, CA 90033-4612 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.12.029
open harvest (OH) techniques without compromising coronary bypass graft patency.2,6 Early reported experience with EH for infrainguinal bypass had similar findings,7,8 but some follow-up studies in the cardiac and vascular literature have reported decreased graft patency with no advantage in wound complications.9-13 This study evaluated our experience with EH for infrainguinal arterial bypass, specifically focusing on the incidence of wound complications and graft patency compared with a series of case-matched control patients who underwent OH. METHODS A retrospective case-control study was performed of infrainguinal arterial bypasses performed at the Keck Medical Center of the University of Southern California between 2000 and 2011. Bypasses were performed using EH or OH for the GSV. The EH and OH groups were frequencymatched for diabetes and body mass index (BMI). Only bypasses using a single segment of GSV were included. Demographics abstracted were age, sex, smoking status, BMI, and American Society of Anesthesiologists Physical Status Classification. Comorbidities included diabetes, hypertension, hyperlipidemia, coronary artery disease (CAD), carotid disease, renal failure, and pulmonary disease. A history of previous ipsilateral revascularization 1489
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including endovascular and open procedures was also recorded. Operative details collected included distal bypass target, vein size defined as smallest diameter on preoperative vein mapping by duplex ultrasound imaging; concomitant procedures, including amputation, endarterectomy, and endovascular intervention; and total operative time. Postoperative outcomes evaluated were hospital length of stay, use of narcotics (normalized to morphine sulfate equivalents), and wound complications, including all wound-related readmissions #30 days. Wound complications were categorized as those that were treated with antibiotics only, those that required surgical intervention, and those that required removal of the bypass. All EHs were performed using consecutive generations of the Maquet Vasoview Endoscopic Vessel Harvesting System (Maquet Cardiovascular, LLC, Wayne, NJ). We currently use the Hemopro 2. A single surgeon, with assistance from the vascular fellow, performed all of the EHs. The technique, in brief, is as follows: Intraoperative ultrasound imaging was used to localize the GSV just above the knee. A 2-cm longitudinal incision was made directly over the vein. The GSV was exposed and encircled with a silastic loop. A conical dissector tip mounted on a 7-mm 0 endoscope was introduced into the subcutaneous space, and a port with an inflatable balloon was used to ensure a tight seal for carbon dioxide insufflation. The GSV was bluntly dissected along its length to the saphenofemoral junction using the conical dissector, leaving the vein suspended in the subcutaneous tunnel by its branches. The Vasoview harvesting cannula was then placed over the endoscope and all venous branches were ligated using the retractable C-ring and dissector and divided using cautery, which was bipolar in older versions and is now direct current. In selected patients, the entire procedure was then repeated in the reverse direction to harvest the GSV segment below the knee. This was most commonly used for distal tibial revascularization, whereas for bypasses terminating in the popliteal artery below the knee, the initial endoscopic harvest incision was simply extended for harvest of the below-knee GSV and then deepened to expose the popliteal artery. After the EH was completed, the vein was removed from the harvest tunnel, and all branches were ligated by suture before the bypass procedure. The OHs were performed by multiple surgeons in the surgical group using a single, continuous, longitudinal incision along the GSV. To avoid skin flaps, a limited incision was performed at the saphenofemoral junction and extended distally with a scalpel along the leg as the vein was dissected out and its exact location was determined. All bypasses for both harvest types were placed in the reversed orientation. The dissection bed and harvest tunnel were used for placement of the graft within the leg for the OHs and EHs, respectively. At completion of the bypass, all patients underwent duplex scanning in the operating room. Any abnormalities were addressed before the operation was completed.
Table I. Patient baseline characteristics and comorbidities Variable Age, years BMI, kg/m2 Sex Male Female Tobaccoa Diabetesb Hypertension Hyperlipidemia Coronary artery diseasec Carotid diseased Hemodialysis Pulmonary diseasee ASA class 1 2 3 4 Previous ipsilateral revascularizationf
EH (n ¼ 35)
OH (n ¼ 41)
P
72 6 11 26 6 5
67 6 10 28 6 5
.03 .19 .67
23 12 9 17 30 21 18 3 4 4
(66) (34) (26) (49) (86) (60) (51) (9) (11) (11)
25 16 8 26 35 20 23 13 12 1
(61) (39) (20) (63) (85) (49) (56) (32) (29) (2)
2 9 22 2 5
(6) (26) (63) (6) (14)
1 6 23 11 11
(2) (15) (56) (27) (27)
.52 .19 .97 .33 .68 .01 .06 .12 .08
.18
ASA, American Society of Anesthesiologists; BMI, body mass index; EH, endoscopic harvest; OH, open harvest. Continuous data are shown as mean 6 standard deviation and categoric data as number (%). a All current or former smokers. b All patients carrying the diagnosis of diabetes, whether controlled by diet or requiring medications. c All patients with the diagnosis of coronary artery disease based on report or imaging. d Defined as >50% stenosis on duplex ultrasound imaging. e All patients carrying diagnosis of chronic obstructive pulmonary disease, with documented abnormal pulmonary function tests or with home oxygen requirement. f Angioplasty/stent, bypass, or both.
Routine graft surveillance by ultrasound imaging was performed at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. If a hemodynamically significant stenosis was identified on surveillance duplex imaging, an angiogram was performed and an endovascular or open revision was performed, as appropriate. The primary outcome measures were the 30-day wound complication rate, 3-year primary patency, 3-year primary assisted patency, and 3-year secondary patency. Statistical analysis was performed using the SAS 9.2 software (SAS Institute Inc, Cary, NC). Summary results for continuous variables are reported as mean 6 standard deviation and as frequency (percent) for categoric variables. Two-group comparisons were assessed by the independent samples t-test or the Wilcoxon rank sum test, as appropriate, for continuous variables and by c2 test or the Fisher exact test for categoric variables. Procedure patency rates at assessment were calculated by the life-table method as outlined by the Society for Vascular Surgery Ad Hoc Committee on Reporting Standards. Univariate analysis was performed to determine factors (Tables I, II) that were significantly associated with wound complications and graft patency in the OH and EH groups. Multivariate
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Table II. Perioperative variables Variable Target vessela Popliteal Infrapopliteal Vein size,b mm Length of operation, minutes Hospital length of stay, days Narcotic use,c mg
EH (n ¼ 35) OH (n ¼ 41) 14 (40) 21 (60) 2.4 6 0.8 252 6 72 6.6 6 7.5 4.7 6 3
14 (34) 27 (66) 2.5 6 0.6 248 6 76 7.7 6 5.2 8.07 6 7.1
Table III. Wound complications and 30-day readmission P .6
Variable
.63 .80 .48 .01d
Wound complications Overall Antibiotics Operativea Graft removal Readmissionb
EH, Endoscopic harvest; OH, open harvest. Continuous data are shown as mean 6 standard deviation and categoric data as number (%). a Distal bypass target; popliteal vs infrapopliteal. b Smallest diameter in mm on preoperative ultrasound imaging. c Average mg of morphine or calculated equivalent morphine dose taken per day. d Statistically significant (P < .05).
Cox proportional hazard models were created if indicated to assess for the association of variables found significant on univariate analysis. A value of P < .05 was considered significant. RESULTS The study included 76 bypasses: 35 in the EH group and 41 in the OH group. Patients in the EH group were older than in the OH group, and more patients in OH group had carotid disease (Table I). There were no other significant differences in baseline characteristics between the two groups. Mean follow-up was 747 days (2.4 years). Mean operative time, length of stay, bypass target, and vein size for EH vs OH were not significantly different (Table II). Patients in the OH group used significantly more narcotics to control postoperative pain than EH patients (P ¼ .01). There were no significant difference at 30 days between EH and OH in the three categories of wound complications or overall (Table III). The rate of wound complications was not significantly affected by baseline characteristics, preoperative risk factors, or bypass target. There was no significant difference in 3-year primary patency rates (47% vs 49%; P ¼ .8; Fig 1), 3-year primary assisted patency rates (88% vs 73%; P ¼ .1; Fig 2), or secondary patency rates (92% vs 76%; P ¼ .09; Fig 3) at 3 years between the EH and OH groups. High BMI (P ¼ .02) was associated with improved primary patency in the EH group but not in the OH group (P ¼ .15). For primary assisted patency, hemodialysis (HD) increased the risk of graft loss in the EH (P ¼ .02) and OH (P ¼ .02) groups and negatively affected secondary graft patency in the OH group (P ¼ .04). DISCUSSION Lumsden et al5 first described EH for infrainguinal bypass in 1994 and published their initial experience with 30 cases in 1996. In the same time frame, the Endosaph vein harvesting system (Covidien, Mansfield, Mass) was
EH (n ¼ 35), No. (%) 10 2 8 0 8
(29) (6) (23) (0) (11)
OH (n ¼ 41), No. (%) 11 5 6 0 10
(27) (12) (20) (0) (13)
P .87 .33 .36 . .87
EH, Endoscopic harvest; OH, open harvest. a Included all wounds that had to be reopened at any point, ranging from bedside opening and packing to a return to the operating room. b Wound-related readmission at 30 days.
introduced by General Surgical Innovations with a balloon dissection technique for exposing the GSV. There have subsequently been significant improvements in this technology with the development of a variety of harvesting tools. We prefer the Vasoview Hemopro 2 for its ease of use, image quality, and use of carbon dioxide insufflation. Currently, EH is used for most coronary artery bypass procedures, but the penetration in the vascular surgery community has been limited.3,7,9,11,14 EH was initially shown to improve outcomes compared with OH with regard to incidence of wound complications. Early studies, which were largely performed in patients undergoing a coronary artery bypass procedure, found consistently lower wound complication rates at vein harvest sites after EH. A series published in 1998 of coronary bypass patients demonstrated a wound complication rate of 4% using EH vs 19% with OH (P < .02).2 A metaanalysis of all randomized controlled trials from 1965 to 2002 in which EH was used for coronary bypass procedures showed a significantly lower wound complication rate compared with OH (OR, 0.22).15 The findings in the vascular literature for EH vs OH for infrainguinal arterial bypass have been less salutary. An early study published in 2001 found a significantly lower wound complication rate for EH than for OH (8% vs 24%; P < .02).7 A subsequent study published in 2006 of 144 consecutive patients undergoing infrainguinal bypass procedures demonstrated a trend toward lower wound infection rates in EH, but no statistically significant difference in wound infections or overall wound complications between EH and OH.9 Similarly, a more recent study published in 2011 demonstrated a 30-day morbidity rate of 30% overall for both groups, with nearly identical wound complication rates for EH and OH (16.6% vs 17.1%).11 Our experience is consistent with these more recent reports. In addition, our study did not show any significant effect of diabetes, BMI, or any other perioperative variable on the incidence of wound complications in either group. A recent review from 1990 to 2005 assessing the effect of diabetes on outcomes of infrainguinal arterial bypass procedures found inconsistent data on the effect of diabetes
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Fig 1. Primary patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
on complications, with some studies showing increased wound complications and others showing no difference.16 In addition, multiple other studies that have evaluated diabetes as a comorbidity demonstrate varying data for wound complications and graft patencydwith its influence noted to be independent of either technique or absent after multivariate analysis.2,11 We found no significant difference in primary, primary assisted, or secondary graft patency between the EH and OH groups. Several other authors have also demonstrated no difference in graft patency by vein harvest method.7,9 In contrast, more recent studies have demonstrated inferior patency for EH vein grafts.11,12 Reasons why the method of EH may adversely influence graft patency include excessive endoscopic manipulation and injury of the vein and division of vein branches that results in vein trauma. Histologic evaluation has been performed in an attempt to compare the vein damage incurred during EH and OH. Although most studies showed no difference in cell viability,17-20 one study did suggest that EH may be associated with a greater alteration in functional and structural proteins.21 Unfortunately, the authors did not study whether short-term or long-term graft patency was compromised by these findings. One obvious source of excessive vein trauma during EH could be the technique and technology used. In our study, a single surgeon performed all of the EHs, which allowed for consistency in technique within the EH group. In addition, some changes occurred in the vein harvesting technology during this 10-year periodda factor that cannot be controlled for in a retrospective study. Given that the type of cautery and the extent of thermal spread was an essential component of updates to the harvest system, it is possible that this could have affected the vein grafts. Five systems are currently available for GSV harvest, and all have been used to some degree in the reported series on EH. A comparison of reports does not appear to demonstrate any obvious differences between the device that was used and graft patency (Table IV). Despite this, minimizing excessive vein trauma is imperative for any harvest technique used, the essentials being optimum
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Fig 2. Primary assisted patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
Fig 3. Secondary patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
visualization, gentle vein mobilization, and atraumatic division of GSV branches. An increasing BMI had a positive influence on primary graft patency. This is an interesting finding and consistent with our own clinical impression; namely, that patients with greater BMI provide more generous endoscopic working space for vein harvest, whereas patients with limited subcutaneous tissue actually create a challenge with regards to the available working space. Narrow working space results in suboptimal vein visualization, possibly leading to excessive vein manipulation and injury. This is particularly true when harvesting the saphenous vein below the knee, where the subcutaneous working space is at a premium. This factor provides a potential source of worse patency seen in reports of EH for infrainguinal arterial bypasses, although these studies did not include BMI in their baseline characteristics or evaluate the effect of BMI on patency with EH.11,13 Likewise, other series investigating the effect of BMI on patency did not look specifically at EH.22 Consequently, a potential area for further study is confirming this finding and defining the parameters of BMI that may optimize the selection of patients for EH.
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Table IV. Patency and wound complications by harvest device Primary patency, % First author Illig,10 2003 Pullat,13 2006 Julliard,11 2011 Illig,7 2001 Gazoni9 2006
Wound complication, %
Device
EH
OH
P
EH
OH
P
Ethicon EVHa Ethicon EVH EndoSaphb EndoSaph Vasoview 6c
92 44 Favors OH 93 92.8
91 59 Favors OH 85 80.6
NS .045 .05 NS .16
20.4 6 16.6 8 13.8
34.1 9 17.1 24 16.9
<.02 .54 NS <.02 1
EH, Endoscopic harvest; NS, not significant; OH, open harvest. a Also known as Clearglide, initially developed by Ethicon, currently owned by Sorin; technology previously used clips and dissection without CO2, newer versions use open CO2 insufflation and bipolar cautery. b Initially developed by General Surgical Innovations, currently owned by Covidien; technology uses dissection without CO2, additional instruments required for additional functions. c Initially developed by Guidant, currently owned by Maquet; technology initially used bipolar cautery, now with direct current device, closed CO2 system for insufflation.
HD dependency negatively affected primary assisted patency in both groups, but only increased the risk for loss of secondary patency in the OH group. Our study, however, had a lower number of HD patients in the EH group than in the OH group (4 vs 12). The small number of HD patients overall and in the EH group limits any implications of this finding. Nevertheless, the effect of HD on patency and the improvement in secondary patency in the EH group suggests additional study in this patient cohort may be of benefit. Narcotic use, defined as average morphine dosedor calculated equivalent morphine sulfate dose per day of hospitalizationdwas significantly higher in the OH group (Table II). Because our medical records had no data on pain score until 2008, we used the dose of narcotics as a surrogate for pain level. Although not directly related to the outcomes evaluated in this study, postoperative pain is a factor that is clinically relevant and has the potential to significantly affect patient quality of life and mobility. An increasing postoperative pain score negatively correlates with mobility,19,23 and better pain control and improved mobility have both been demonstrated with EH.6,23 Functional outcomes have become an integral part of the discussion when evaluating the success of infrainguinal bypass24,25 and should be a consideration when choosing a harvest technique. This study is retrospective, and our findings need to be interpreted in that context, but this is also true for nearly all other studies that have been published on this subject.7,9-11,13,26 Obviously, conducting a randomized controlled study could provide better data upon which to judge EH; however, this is unlikely to recruit many patients. Most patients, if given the choice, would likely choosedbased on cosmesis aloneda limited incision vs an incision along the entire length of their lower extremity. As such, it is unlikely that a randomized controlled study of EH vs OH will ever be performed. However, if one assumes that graft patency and wound complications are similar for EH and OH, the benefit of minimizing pain and thereby improving mobility and cosmesis suggests
a potential advantage for EH. This requires further study with more specific assessments of pain scale, narcotic use, mobility, and quality of life. CONCLUSIONS We found no significant differences in wound complication and graft patency rates between OH and EH techniques during infrainguinal bypass procedures. Two variables were identifieddBMI and HD dependencydthat may affect the selection of patients for either technique. However, further study is required to confirm that this clinical utility exists. Finally, our experience suggests that EH may be associated with less pain and decreased need for narcotic analgesia. Given that pain is one of the limiting factors in the return to preoperative mobility after infrainguinal arterial bypass procedures, this finding deserves further study. AUTHOR CONTRIBUTIONS Conception and design: KW, GH, FW Analysis and interpretation: SW, KW, GH, FW Data collection: SW, GH, MM, VN, MM Writing the article: SW, KW, GH, MM, VN, MM, FW Critical revision of the article: SW, KW, FW Final approval of the article: SW, KW, GH, MM, VN, MM, FW Statistical analysis: KW, SW Obtained funding: Not applicable Overall responsibility: FW REFERENCES 1. Veith FJ, Gupta SK, Ascer E, White-Flores S, Samson RH, Scher LA, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3: 104-14. 2. Allen KB, Griffith GL, Heimansohn DA, Robison RJ, Matheny RG, Schier JJ, et al. Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial. Ann Thorac Surg 1998;66:26-31; discussion: 32. 3. Erdoes LS, Milner TP. Encouraging results with endoscopic vein harvest for infrainguinal bypass. J Vasc Surg 2005;42:442-8.
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4. Kent KC, Bartek S, Kuntz KM, Anninos E, Skillman JJ. Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost. Surgery 1996;119:378-83. 5. Lumsden AB, Eaves FF 3rd, Ofenloch JC, Jordan WD. Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg 1996;4:771-6. 6. Kiaii B, Moon BC, Massel D, Langlois Y, Austin TW, Willoughby A, et al. A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery. J Thorac Cardiovasc Surg 2002;123:204-12. 7. Illig KA, Rhodes JM, Sternbach Y, Shortell CK, Davies MG, Green RM. Reduction in wound morbidity rates following endoscopic saphenous vein harvest. Ann Vasc Surg 2001;15:104-9. 8. Jordan WD Jr, Alcocer F, Voellinger DC, Wirthlin DJ. The durability of endoscopic saphenous vein grafts: a 5-year observational study. J Vasc Surg 2001;34:434-9. 9. Gazoni LM, Carty R, Skinner J, Cherry KJ, Harthun NL, Kron IL, et al. Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft. J Vasc Surg 2006;44:282-7; discussion: 287-8. 10. Illig KA, Rhodes JM, Sternbach Y, Green RM. Financial impact of endoscopic vein harvest for infrainguinal bypass. J Vasc Surg 2003;37: 323-30. 11. Julliard W, Katzen J, Nabozny M, Young K, Glass C, Singh MJ, et al. Long-term results of endoscopic versus open saphenous vein harvest for lower extremity bypass. Ann Vasc Surg 2011;25:101-7. 12. Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med 2009;361:235-44. 13. Pullatt R, Brothers TE, Robison JG, Elliott BM. Compromised bypass graft outcomes after minimal-incision vein harvest. J Vasc Surg 2006;44:289-94; discussion: 294-5. 14. Dacey LJ, Braxton JH Jr, Kramer RS, Schmoker JD, Charlesworth DC, Helm RE, et al. Long-term outcomes of endoscopic vein harvesting after coronary artery bypass grafting. Circulation 2011;123:147-53. 15. Athanasiou T, Aziz O, Skapinakis P, Perunovic B, Hart J, Crossman MC, et al. Leg wound infection after coronary artery bypass grafting: a meta-analysis comparing minimally invasive versus conventional vein harvesting. Ann Thorac Surg 2003;76:2141-6.
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16. Weiss JS, Sumpio BE. Review of prevalence and outcome of vascular disease in patients with diabetes mellitus. Eur J Vasc Endovasc Surg 2006;31:143-50. 17. Alrawi SJ, Raju R, Alshkaki G, Acinapura AJ, Cunningham JN Jr. Saphenous vein endothelial cell viability: a comparative study of endoscopic and open saphenectomy for coronary artery bypass grafting. JSLS 2001;5:37-45. 18. Black EA, Guzik TJ, West NE, Campbell K, Pillai R, Ratnatunga C, et al. Minimally invasive saphenous vein harvesting: effects on endothelial and smooth muscle function. Ann Thorac Surg 2001;71: 1503-7. 19. Bonde P, Graham AN, MacGowan SW. Endoscopic vein harvest: advantages and limitations. Ann Thorac Surg 2004;77:2076-82. 20. Meyer DM, Rogers TE, Jessen ME, Estrera AS, Chin AK. Histologic evidence of the safety of endoscopic saphenous vein graft preparation. Ann Thorac Surg 2000;70:487-91. 21. Rousou LJ, Taylor KB, Lu XG, Healey N, Crittenden MD, Khuri SF, et al. Saphenous vein conduits harvested by endoscopic technique exhibit structural and functional damage. Ann Thorac Surg 2009;87:62-70. 22. Patel VI, Hamdan AD, Schermerhorn ML, Hile C, Dahlberg S, Campbell DR, et al. Lower extremity arterial revascularization in obese patients. J Vasc Surg 2007;46:738-42. 23. Pagni S, Ulfe EA, Montgomery WD, VanHimbergen DJ, Fisher DJ, Gray LA Jr, et al. Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations. Ann Thorac Surg 1998;66:1626-31. 24. Nicoloff AD, Taylor LM Jr, McLafferty RB, Moneta GL, Porter JM. Patient recovery after infrainguinal bypass grafting for limb salvage. J Vasc Surg 1998;27:256-63; discussion: 264-6. 25. Taylor SM, Cull DL, Kalbaugh CA, Cass AL, Harmon SA, Langan EM 3rd, et al. Critical analysis of clinical success after surgical bypass for lower-extremity ischemic tissue loss using a standardized definition combining multiple parameters: a new paradigm of outcomes assessment. J Am Coll Surg 2007;204:831-8; discussion: 838-9. 26. Jimenez JC, Lawrence PF, Rigberg DA, Quinones-Baldrich WJ. Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures. J Vasc Surg 2007;45:549-53. Submitted Oct 3, 2012; accepted Dec 2, 2012.
Endoscopic vein harvest for infrainguinal arterial bypass Sarah M. Wartman, MD, Karen Woo, MD, Gabriel Herscu, MD, Michael Morell, MD, Vahagn Nikolian, MD, Miguel Manzur, MD, and Fred A. Weaver, MD, Los Angeles, Calif Background: Endoscopic harvest of saphenous vein for infrainguinal arterial bypass decreases incision length and was initially documented to decrease wound complications without adversely affecting patency. However, recent studies have shown lower patency without a wound complication benefit. We sought to further define the wound complication and patency rates of endoscopic harvest compared with open harvest in infrainguinal arterial bypass procedures. Methods: Infrainguinal bypasses performed from 2000 to 2011 were analyzed. Only procedures using a single segment of great saphenous vein were included. Cases were grouped according to endoscopic or open harvest and were frequencymatched for body mass index and diabetes. Baseline characteristics were compared. Univariate and multivariate analysis was performed to determine correlation of baseline data and harvest method on wound complications and patency. Results: The study included 76 bypasses; 35 in the endoscopic harvest group and 41 in the open harvest group. Baseline characteristics between the endoscopic and open harvest groups were not significantly different, with the exception of mean age, which was older in the endoscopic harvest group, and carotid artery disease, which was more common in the open harvest group. There was no significant difference between endoscopic and open harvest in 30-day wound complication rates (29% vs 27%; P [ .87) or in the other perioperative variables, aside from decreased narcotic use in the endoscopic harvest group (P [ .01). Mean follow-up was 747 days. There was no significant difference in 3-year primary (47% vs 49%; P [ .8), 3-year primary-assisted (88% vs 73%; P [ .1), or secondary patency rates (92% vs 76%; P [ .09) at 3 years between the endoscopic and open harvest groups. High body mass index improved primary patency in the endoscopic harvest group (P [ .02), but had no effect on patency in the open harvest group (P [ .15). Patients requiring hemodialysis had increased risk for loss of primary assisted patency in both groups (endoscopic, P [ .02; open, P [ .02) and decreased secondary patency in the open harvest group (P [ .04). Conclusions: Endoscopic and open harvest techniques for infrainguinal arterial bypass provide similar rates of wound complications and bypass patency, whereas hemodialysis negatively affects patency after both harvest methods. Endoscopic harvest is associated with the need for less perioperative narcotics, suggesting a potential benefit of endoscopic harvest that deserves further study. (J Vasc Surg 2013;57:1489-94.)
The great saphenous vein (GSV) remains the conduit of choice for infrainguinal arterial bypass procedures due to its superior long-term patency and resistance to infection.1 Traditionally, continuous or skip incisions along the length of the vein have been used to harvest the GSV, and multiple authors have shown that an increased incision length is associated with an increased risk for wound complications, with reported rates as high as 40%.2-5 More recently, endoscopic harvest (EH) of the GSV, which minimizes the skin incision, has been used in an attempt to mitigate the risk of wound complications. Initial studies from the cardiac literature found that EH decreased the rate of wound complications compared with
From the Division of Vascular Surgery and Endovascular Therapy, Keck Medical Center, University of Southern California. Author conflict of interest: none. Presented at the Twenty-seventh Annual Meeting of the Western Vascular Society, Park City, Utah, September 22-25, 2012. Reprint requests: Fred A. Weaver, MD, 1520 San Pablo St., Ste 4300, Los Angeles, CA 90033-4612 (e-mail: [email protected]). The editors and reviewers of this article have no relevant financial relationships to disclose per the JVS policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 0741-5214/$36.00 Copyright Ó 2013 by the Society for Vascular Surgery. http://dx.doi.org/10.1016/j.jvs.2012.12.029
open harvest (OH) techniques without compromising coronary bypass graft patency.2,6 Early reported experience with EH for infrainguinal bypass had similar findings,7,8 but some follow-up studies in the cardiac and vascular literature have reported decreased graft patency with no advantage in wound complications.9-13 This study evaluated our experience with EH for infrainguinal arterial bypass, specifically focusing on the incidence of wound complications and graft patency compared with a series of case-matched control patients who underwent OH. METHODS A retrospective case-control study was performed of infrainguinal arterial bypasses performed at the Keck Medical Center of the University of Southern California between 2000 and 2011. Bypasses were performed using EH or OH for the GSV. The EH and OH groups were frequencymatched for diabetes and body mass index (BMI). Only bypasses using a single segment of GSV were included. Demographics abstracted were age, sex, smoking status, BMI, and American Society of Anesthesiologists Physical Status Classification. Comorbidities included diabetes, hypertension, hyperlipidemia, coronary artery disease (CAD), carotid disease, renal failure, and pulmonary disease. A history of previous ipsilateral revascularization 1489
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including endovascular and open procedures was also recorded. Operative details collected included distal bypass target, vein size defined as smallest diameter on preoperative vein mapping by duplex ultrasound imaging; concomitant procedures, including amputation, endarterectomy, and endovascular intervention; and total operative time. Postoperative outcomes evaluated were hospital length of stay, use of narcotics (normalized to morphine sulfate equivalents), and wound complications, including all wound-related readmissions #30 days. Wound complications were categorized as those that were treated with antibiotics only, those that required surgical intervention, and those that required removal of the bypass. All EHs were performed using consecutive generations of the Maquet Vasoview Endoscopic Vessel Harvesting System (Maquet Cardiovascular, LLC, Wayne, NJ). We currently use the Hemopro 2. A single surgeon, with assistance from the vascular fellow, performed all of the EHs. The technique, in brief, is as follows: Intraoperative ultrasound imaging was used to localize the GSV just above the knee. A 2-cm longitudinal incision was made directly over the vein. The GSV was exposed and encircled with a silastic loop. A conical dissector tip mounted on a 7-mm 0 endoscope was introduced into the subcutaneous space, and a port with an inflatable balloon was used to ensure a tight seal for carbon dioxide insufflation. The GSV was bluntly dissected along its length to the saphenofemoral junction using the conical dissector, leaving the vein suspended in the subcutaneous tunnel by its branches. The Vasoview harvesting cannula was then placed over the endoscope and all venous branches were ligated using the retractable C-ring and dissector and divided using cautery, which was bipolar in older versions and is now direct current. In selected patients, the entire procedure was then repeated in the reverse direction to harvest the GSV segment below the knee. This was most commonly used for distal tibial revascularization, whereas for bypasses terminating in the popliteal artery below the knee, the initial endoscopic harvest incision was simply extended for harvest of the below-knee GSV and then deepened to expose the popliteal artery. After the EH was completed, the vein was removed from the harvest tunnel, and all branches were ligated by suture before the bypass procedure. The OHs were performed by multiple surgeons in the surgical group using a single, continuous, longitudinal incision along the GSV. To avoid skin flaps, a limited incision was performed at the saphenofemoral junction and extended distally with a scalpel along the leg as the vein was dissected out and its exact location was determined. All bypasses for both harvest types were placed in the reversed orientation. The dissection bed and harvest tunnel were used for placement of the graft within the leg for the OHs and EHs, respectively. At completion of the bypass, all patients underwent duplex scanning in the operating room. Any abnormalities were addressed before the operation was completed.
Table I. Patient baseline characteristics and comorbidities Variable Age, years BMI, kg/m2 Sex Male Female Tobaccoa Diabetesb Hypertension Hyperlipidemia Coronary artery diseasec Carotid diseased Hemodialysis Pulmonary diseasee ASA class 1 2 3 4 Previous ipsilateral revascularizationf
EH (n ¼ 35)
OH (n ¼ 41)
P
72 6 11 26 6 5
67 6 10 28 6 5
.03 .19 .67
23 12 9 17 30 21 18 3 4 4
(66) (34) (26) (49) (86) (60) (51) (9) (11) (11)
25 16 8 26 35 20 23 13 12 1
(61) (39) (20) (63) (85) (49) (56) (32) (29) (2)
2 9 22 2 5
(6) (26) (63) (6) (14)
1 6 23 11 11
(2) (15) (56) (27) (27)
.52 .19 .97 .33 .68 .01 .06 .12 .08
.18
ASA, American Society of Anesthesiologists; BMI, body mass index; EH, endoscopic harvest; OH, open harvest. Continuous data are shown as mean 6 standard deviation and categoric data as number (%). a All current or former smokers. b All patients carrying the diagnosis of diabetes, whether controlled by diet or requiring medications. c All patients with the diagnosis of coronary artery disease based on report or imaging. d Defined as >50% stenosis on duplex ultrasound imaging. e All patients carrying diagnosis of chronic obstructive pulmonary disease, with documented abnormal pulmonary function tests or with home oxygen requirement. f Angioplasty/stent, bypass, or both.
Routine graft surveillance by ultrasound imaging was performed at 1, 3, 6, 12, 18 and 24 months, and yearly thereafter. If a hemodynamically significant stenosis was identified on surveillance duplex imaging, an angiogram was performed and an endovascular or open revision was performed, as appropriate. The primary outcome measures were the 30-day wound complication rate, 3-year primary patency, 3-year primary assisted patency, and 3-year secondary patency. Statistical analysis was performed using the SAS 9.2 software (SAS Institute Inc, Cary, NC). Summary results for continuous variables are reported as mean 6 standard deviation and as frequency (percent) for categoric variables. Two-group comparisons were assessed by the independent samples t-test or the Wilcoxon rank sum test, as appropriate, for continuous variables and by c2 test or the Fisher exact test for categoric variables. Procedure patency rates at assessment were calculated by the life-table method as outlined by the Society for Vascular Surgery Ad Hoc Committee on Reporting Standards. Univariate analysis was performed to determine factors (Tables I, II) that were significantly associated with wound complications and graft patency in the OH and EH groups. Multivariate
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Table II. Perioperative variables Variable Target vessela Popliteal Infrapopliteal Vein size,b mm Length of operation, minutes Hospital length of stay, days Narcotic use,c mg
EH (n ¼ 35) OH (n ¼ 41) 14 (40) 21 (60) 2.4 6 0.8 252 6 72 6.6 6 7.5 4.7 6 3
14 (34) 27 (66) 2.5 6 0.6 248 6 76 7.7 6 5.2 8.07 6 7.1
Table III. Wound complications and 30-day readmission P .6
Variable
.63 .80 .48 .01d
Wound complications Overall Antibiotics Operativea Graft removal Readmissionb
EH, Endoscopic harvest; OH, open harvest. Continuous data are shown as mean 6 standard deviation and categoric data as number (%). a Distal bypass target; popliteal vs infrapopliteal. b Smallest diameter in mm on preoperative ultrasound imaging. c Average mg of morphine or calculated equivalent morphine dose taken per day. d Statistically significant (P < .05).
Cox proportional hazard models were created if indicated to assess for the association of variables found significant on univariate analysis. A value of P < .05 was considered significant. RESULTS The study included 76 bypasses: 35 in the EH group and 41 in the OH group. Patients in the EH group were older than in the OH group, and more patients in OH group had carotid disease (Table I). There were no other significant differences in baseline characteristics between the two groups. Mean follow-up was 747 days (2.4 years). Mean operative time, length of stay, bypass target, and vein size for EH vs OH were not significantly different (Table II). Patients in the OH group used significantly more narcotics to control postoperative pain than EH patients (P ¼ .01). There were no significant difference at 30 days between EH and OH in the three categories of wound complications or overall (Table III). The rate of wound complications was not significantly affected by baseline characteristics, preoperative risk factors, or bypass target. There was no significant difference in 3-year primary patency rates (47% vs 49%; P ¼ .8; Fig 1), 3-year primary assisted patency rates (88% vs 73%; P ¼ .1; Fig 2), or secondary patency rates (92% vs 76%; P ¼ .09; Fig 3) at 3 years between the EH and OH groups. High BMI (P ¼ .02) was associated with improved primary patency in the EH group but not in the OH group (P ¼ .15). For primary assisted patency, hemodialysis (HD) increased the risk of graft loss in the EH (P ¼ .02) and OH (P ¼ .02) groups and negatively affected secondary graft patency in the OH group (P ¼ .04). DISCUSSION Lumsden et al5 first described EH for infrainguinal bypass in 1994 and published their initial experience with 30 cases in 1996. In the same time frame, the Endosaph vein harvesting system (Covidien, Mansfield, Mass) was
EH (n ¼ 35), No. (%) 10 2 8 0 8
(29) (6) (23) (0) (11)
OH (n ¼ 41), No. (%) 11 5 6 0 10
(27) (12) (20) (0) (13)
P .87 .33 .36 . .87
EH, Endoscopic harvest; OH, open harvest. a Included all wounds that had to be reopened at any point, ranging from bedside opening and packing to a return to the operating room. b Wound-related readmission at 30 days.
introduced by General Surgical Innovations with a balloon dissection technique for exposing the GSV. There have subsequently been significant improvements in this technology with the development of a variety of harvesting tools. We prefer the Vasoview Hemopro 2 for its ease of use, image quality, and use of carbon dioxide insufflation. Currently, EH is used for most coronary artery bypass procedures, but the penetration in the vascular surgery community has been limited.3,7,9,11,14 EH was initially shown to improve outcomes compared with OH with regard to incidence of wound complications. Early studies, which were largely performed in patients undergoing a coronary artery bypass procedure, found consistently lower wound complication rates at vein harvest sites after EH. A series published in 1998 of coronary bypass patients demonstrated a wound complication rate of 4% using EH vs 19% with OH (P < .02).2 A metaanalysis of all randomized controlled trials from 1965 to 2002 in which EH was used for coronary bypass procedures showed a significantly lower wound complication rate compared with OH (OR, 0.22).15 The findings in the vascular literature for EH vs OH for infrainguinal arterial bypass have been less salutary. An early study published in 2001 found a significantly lower wound complication rate for EH than for OH (8% vs 24%; P < .02).7 A subsequent study published in 2006 of 144 consecutive patients undergoing infrainguinal bypass procedures demonstrated a trend toward lower wound infection rates in EH, but no statistically significant difference in wound infections or overall wound complications between EH and OH.9 Similarly, a more recent study published in 2011 demonstrated a 30-day morbidity rate of 30% overall for both groups, with nearly identical wound complication rates for EH and OH (16.6% vs 17.1%).11 Our experience is consistent with these more recent reports. In addition, our study did not show any significant effect of diabetes, BMI, or any other perioperative variable on the incidence of wound complications in either group. A recent review from 1990 to 2005 assessing the effect of diabetes on outcomes of infrainguinal arterial bypass procedures found inconsistent data on the effect of diabetes
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Fig 1. Primary patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
on complications, with some studies showing increased wound complications and others showing no difference.16 In addition, multiple other studies that have evaluated diabetes as a comorbidity demonstrate varying data for wound complications and graft patencydwith its influence noted to be independent of either technique or absent after multivariate analysis.2,11 We found no significant difference in primary, primary assisted, or secondary graft patency between the EH and OH groups. Several other authors have also demonstrated no difference in graft patency by vein harvest method.7,9 In contrast, more recent studies have demonstrated inferior patency for EH vein grafts.11,12 Reasons why the method of EH may adversely influence graft patency include excessive endoscopic manipulation and injury of the vein and division of vein branches that results in vein trauma. Histologic evaluation has been performed in an attempt to compare the vein damage incurred during EH and OH. Although most studies showed no difference in cell viability,17-20 one study did suggest that EH may be associated with a greater alteration in functional and structural proteins.21 Unfortunately, the authors did not study whether short-term or long-term graft patency was compromised by these findings. One obvious source of excessive vein trauma during EH could be the technique and technology used. In our study, a single surgeon performed all of the EHs, which allowed for consistency in technique within the EH group. In addition, some changes occurred in the vein harvesting technology during this 10-year periodda factor that cannot be controlled for in a retrospective study. Given that the type of cautery and the extent of thermal spread was an essential component of updates to the harvest system, it is possible that this could have affected the vein grafts. Five systems are currently available for GSV harvest, and all have been used to some degree in the reported series on EH. A comparison of reports does not appear to demonstrate any obvious differences between the device that was used and graft patency (Table IV). Despite this, minimizing excessive vein trauma is imperative for any harvest technique used, the essentials being optimum
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Fig 2. Primary assisted patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
Fig 3. Secondary patency is shown for endoscopic harvest (EH) vs open harvest (OH). The error bars show the standard error.
visualization, gentle vein mobilization, and atraumatic division of GSV branches. An increasing BMI had a positive influence on primary graft patency. This is an interesting finding and consistent with our own clinical impression; namely, that patients with greater BMI provide more generous endoscopic working space for vein harvest, whereas patients with limited subcutaneous tissue actually create a challenge with regards to the available working space. Narrow working space results in suboptimal vein visualization, possibly leading to excessive vein manipulation and injury. This is particularly true when harvesting the saphenous vein below the knee, where the subcutaneous working space is at a premium. This factor provides a potential source of worse patency seen in reports of EH for infrainguinal arterial bypasses, although these studies did not include BMI in their baseline characteristics or evaluate the effect of BMI on patency with EH.11,13 Likewise, other series investigating the effect of BMI on patency did not look specifically at EH.22 Consequently, a potential area for further study is confirming this finding and defining the parameters of BMI that may optimize the selection of patients for EH.
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Table IV. Patency and wound complications by harvest device Primary patency, % First author Illig,10 2003 Pullat,13 2006 Julliard,11 2011 Illig,7 2001 Gazoni9 2006
Wound complication, %
Device
EH
OH
P
EH
OH
P
Ethicon EVHa Ethicon EVH EndoSaphb EndoSaph Vasoview 6c
92 44 Favors OH 93 92.8
91 59 Favors OH 85 80.6
NS .045 .05 NS .16
20.4 6 16.6 8 13.8
34.1 9 17.1 24 16.9
<.02 .54 NS <.02 1
EH, Endoscopic harvest; NS, not significant; OH, open harvest. a Also known as Clearglide, initially developed by Ethicon, currently owned by Sorin; technology previously used clips and dissection without CO2, newer versions use open CO2 insufflation and bipolar cautery. b Initially developed by General Surgical Innovations, currently owned by Covidien; technology uses dissection without CO2, additional instruments required for additional functions. c Initially developed by Guidant, currently owned by Maquet; technology initially used bipolar cautery, now with direct current device, closed CO2 system for insufflation.
HD dependency negatively affected primary assisted patency in both groups, but only increased the risk for loss of secondary patency in the OH group. Our study, however, had a lower number of HD patients in the EH group than in the OH group (4 vs 12). The small number of HD patients overall and in the EH group limits any implications of this finding. Nevertheless, the effect of HD on patency and the improvement in secondary patency in the EH group suggests additional study in this patient cohort may be of benefit. Narcotic use, defined as average morphine dosedor calculated equivalent morphine sulfate dose per day of hospitalizationdwas significantly higher in the OH group (Table II). Because our medical records had no data on pain score until 2008, we used the dose of narcotics as a surrogate for pain level. Although not directly related to the outcomes evaluated in this study, postoperative pain is a factor that is clinically relevant and has the potential to significantly affect patient quality of life and mobility. An increasing postoperative pain score negatively correlates with mobility,19,23 and better pain control and improved mobility have both been demonstrated with EH.6,23 Functional outcomes have become an integral part of the discussion when evaluating the success of infrainguinal bypass24,25 and should be a consideration when choosing a harvest technique. This study is retrospective, and our findings need to be interpreted in that context, but this is also true for nearly all other studies that have been published on this subject.7,9-11,13,26 Obviously, conducting a randomized controlled study could provide better data upon which to judge EH; however, this is unlikely to recruit many patients. Most patients, if given the choice, would likely choosedbased on cosmesis aloneda limited incision vs an incision along the entire length of their lower extremity. As such, it is unlikely that a randomized controlled study of EH vs OH will ever be performed. However, if one assumes that graft patency and wound complications are similar for EH and OH, the benefit of minimizing pain and thereby improving mobility and cosmesis suggests
a potential advantage for EH. This requires further study with more specific assessments of pain scale, narcotic use, mobility, and quality of life. CONCLUSIONS We found no significant differences in wound complication and graft patency rates between OH and EH techniques during infrainguinal bypass procedures. Two variables were identifieddBMI and HD dependencydthat may affect the selection of patients for either technique. However, further study is required to confirm that this clinical utility exists. Finally, our experience suggests that EH may be associated with less pain and decreased need for narcotic analgesia. Given that pain is one of the limiting factors in the return to preoperative mobility after infrainguinal arterial bypass procedures, this finding deserves further study. AUTHOR CONTRIBUTIONS Conception and design: KW, GH, FW Analysis and interpretation: SW, KW, GH, FW Data collection: SW, GH, MM, VN, MM Writing the article: SW, KW, GH, MM, VN, MM, FW Critical revision of the article: SW, KW, FW Final approval of the article: SW, KW, GH, MM, VN, MM, FW Statistical analysis: KW, SW Obtained funding: Not applicable Overall responsibility: FW REFERENCES 1. Veith FJ, Gupta SK, Ascer E, White-Flores S, Samson RH, Scher LA, et al. Six-year prospective multicenter randomized comparison of autologous saphenous vein and expanded polytetrafluoroethylene grafts in infrainguinal arterial reconstructions. J Vasc Surg 1986;3: 104-14. 2. Allen KB, Griffith GL, Heimansohn DA, Robison RJ, Matheny RG, Schier JJ, et al. Endoscopic versus traditional saphenous vein harvesting: a prospective, randomized trial. Ann Thorac Surg 1998;66:26-31; discussion: 32. 3. Erdoes LS, Milner TP. Encouraging results with endoscopic vein harvest for infrainguinal bypass. J Vasc Surg 2005;42:442-8.
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4. Kent KC, Bartek S, Kuntz KM, Anninos E, Skillman JJ. Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: incidence, risk factors, and cost. Surgery 1996;119:378-83. 5. Lumsden AB, Eaves FF 3rd, Ofenloch JC, Jordan WD. Subcutaneous, video-assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg 1996;4:771-6. 6. Kiaii B, Moon BC, Massel D, Langlois Y, Austin TW, Willoughby A, et al. A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery. J Thorac Cardiovasc Surg 2002;123:204-12. 7. Illig KA, Rhodes JM, Sternbach Y, Shortell CK, Davies MG, Green RM. Reduction in wound morbidity rates following endoscopic saphenous vein harvest. Ann Vasc Surg 2001;15:104-9. 8. Jordan WD Jr, Alcocer F, Voellinger DC, Wirthlin DJ. The durability of endoscopic saphenous vein grafts: a 5-year observational study. J Vasc Surg 2001;34:434-9. 9. Gazoni LM, Carty R, Skinner J, Cherry KJ, Harthun NL, Kron IL, et al. Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft. J Vasc Surg 2006;44:282-7; discussion: 287-8. 10. Illig KA, Rhodes JM, Sternbach Y, Green RM. Financial impact of endoscopic vein harvest for infrainguinal bypass. J Vasc Surg 2003;37: 323-30. 11. Julliard W, Katzen J, Nabozny M, Young K, Glass C, Singh MJ, et al. Long-term results of endoscopic versus open saphenous vein harvest for lower extremity bypass. Ann Vasc Surg 2011;25:101-7. 12. Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, et al. Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. N Engl J Med 2009;361:235-44. 13. Pullatt R, Brothers TE, Robison JG, Elliott BM. Compromised bypass graft outcomes after minimal-incision vein harvest. J Vasc Surg 2006;44:289-94; discussion: 294-5. 14. Dacey LJ, Braxton JH Jr, Kramer RS, Schmoker JD, Charlesworth DC, Helm RE, et al. Long-term outcomes of endoscopic vein harvesting after coronary artery bypass grafting. Circulation 2011;123:147-53. 15. Athanasiou T, Aziz O, Skapinakis P, Perunovic B, Hart J, Crossman MC, et al. Leg wound infection after coronary artery bypass grafting: a meta-analysis comparing minimally invasive versus conventional vein harvesting. Ann Thorac Surg 2003;76:2141-6.
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16. Weiss JS, Sumpio BE. Review of prevalence and outcome of vascular disease in patients with diabetes mellitus. Eur J Vasc Endovasc Surg 2006;31:143-50. 17. Alrawi SJ, Raju R, Alshkaki G, Acinapura AJ, Cunningham JN Jr. Saphenous vein endothelial cell viability: a comparative study of endoscopic and open saphenectomy for coronary artery bypass grafting. JSLS 2001;5:37-45. 18. Black EA, Guzik TJ, West NE, Campbell K, Pillai R, Ratnatunga C, et al. Minimally invasive saphenous vein harvesting: effects on endothelial and smooth muscle function. Ann Thorac Surg 2001;71: 1503-7. 19. Bonde P, Graham AN, MacGowan SW. Endoscopic vein harvest: advantages and limitations. Ann Thorac Surg 2004;77:2076-82. 20. Meyer DM, Rogers TE, Jessen ME, Estrera AS, Chin AK. Histologic evidence of the safety of endoscopic saphenous vein graft preparation. Ann Thorac Surg 2000;70:487-91. 21. Rousou LJ, Taylor KB, Lu XG, Healey N, Crittenden MD, Khuri SF, et al. Saphenous vein conduits harvested by endoscopic technique exhibit structural and functional damage. Ann Thorac Surg 2009;87:62-70. 22. Patel VI, Hamdan AD, Schermerhorn ML, Hile C, Dahlberg S, Campbell DR, et al. Lower extremity arterial revascularization in obese patients. J Vasc Surg 2007;46:738-42. 23. Pagni S, Ulfe EA, Montgomery WD, VanHimbergen DJ, Fisher DJ, Gray LA Jr, et al. Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations. Ann Thorac Surg 1998;66:1626-31. 24. Nicoloff AD, Taylor LM Jr, McLafferty RB, Moneta GL, Porter JM. Patient recovery after infrainguinal bypass grafting for limb salvage. J Vasc Surg 1998;27:256-63; discussion: 264-6. 25. Taylor SM, Cull DL, Kalbaugh CA, Cass AL, Harmon SA, Langan EM 3rd, et al. Critical analysis of clinical success after surgical bypass for lower-extremity ischemic tissue loss using a standardized definition combining multiple parameters: a new paradigm of outcomes assessment. J Am Coll Surg 2007;204:831-8; discussion: 838-9. 26. Jimenez JC, Lawrence PF, Rigberg DA, Quinones-Baldrich WJ. Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures. J Vasc Surg 2007;45:549-53. Submitted Oct 3, 2012; accepted Dec 2, 2012.