Endoscopic Harvesting of the Saphenous Vein

Endoscopic Vein Harvesting: Coronary Artery Bypass Grafting

Several prospective, randomized trials have compared endoscopic vein harvest (EVH) with traditional open saphenous harvest during CABG and have demonstrated superior outcomes for EVH. Advantages include lower wound complication rates, decreased postoperative pain, increased patient satisfaction, improved cosmesis, and equivalent graft patency rates. Griffith and colleagues performed a histologic analysis of veins harvested by open techniques and EVH. There was no difference in endothelial, smooth muscle, and elastic lamina continuity between the two groups, and medial and adventitial connective tissue uniformity was not significantly altered.

In a meta-analysis of 267,525 patients, Sastry and colleagues found that there was no statistical difference in vein graft stenosis or occlusion between open and endoscopically harvested veins when considering evidence only from randomized studies. EVH was associated with less pain and leg wound complications. At a median of 2.6 years, there was no significant difference in mortality, myocardial infarction, repeat revascularization, angina recurrence, or vein graft stenosis and occlusion.

Despite multiple supportive studies validating EVH for CABG, a recent study by Lopes and colleagues questioned the superiority of this technique. They reviewed the outcomes of 1753 patients who underwent EVH for CABG and compared them to 1247 patients in the open harvest group. They demonstrated a higher rate of vein-graft failure at 12 to 18 months in the EVH group compared with the open cohort (46.7% vs. 38%, respectively). At 3 years, EVH was also associated with higher rates of death, myocardial infarction, and repeated revascularization. Critics of this study highlighted the elevated vein-graft failure and death rates in both open and EVH groups compared with similar published series. Additional criticisms included an overall lower use of internal mammary artery conduits, which are associated with superior patency compared with vein grafts, and that 20% of the procedures in this patient cohort were performed off-pump.

A recent study performed by the Northern New England Cardiovascular Disease Study Group demonstrated a decreased risk of leg wound infections with EVH, but an increased adjusted risk of bleeding requiring a return to the operating room. Endoscopic harvest was also associated with a significant reduction in long-term mortality in these patients. The results also demonstrated that between 2001 and 2004, the use of EVH increased from 34% to 75% in patients requiring CABG.

Endoscopic Vein Harvesting: Infrainguinal Revascularization

Several studies have demonstrated similar favorable results for EVH during distal arterial bypass for limb salvage, although no randomized controlled trials have been conducted ( Table 29.1 ). Jordan and colleagues performed 164 saphenous vein EVHs for lower extremity arterial reconstructive procedures over a 6-year period. A review of patency rates using Kaplan-Meier analysis at 1, 3, and 5 years demonstrated vein graft patencies of 85%, 74%, and 68%, respectively. Fourteen patients (8.5%) developed wound infections during the 30-day postoperative period, and two patients developed harvest site hematomas. None of these wound complications led to graft failure or limb loss. The limb salvage rate was 89%.

A review by Erdoes and Milner examined the outcomes following EVH for infrainguinal arterial bypass in 214 limbs over a 6-year period. The indication for bypass was limb salvage in 88.3%, claudication in 9.3%, and trauma and aneurysm in 2.4%. Assisted primary patency at 18 months was 77.2% by Kaplan-Meier analysis. Wound complication rates were 7.5%, with 2.5% of patients requiring readmission to the hospital. Only one patient early in the series required conversion to an open harvest.

Gazoni and colleagues reported results for patients who underwent femoral to below-knee arterial bypass grafting over a 27-month period. Fifty-nine patients underwent traditional open saphenectomy, and 29 had EVH. There was a trend toward improved patency rates in the EVH group compared with open harvest, although no statistically significant difference was noted (92.8% vs. 80.6%). No significant differences were found between the two groups in postoperative complications, operative time, length of hospital stay, patency rates, limb salvage, and death. The incidence of wound complications was 3.4% in the EVH group and 15.3% in the open harvest group, although this difference also was not statistically significant. Similarly, Hines and colleagues examined outcomes over a 5-year period for 27 patients who underwent femoral-popliteal bypass with EVH in patients with Trans-Atlantic Inter-Society Consensus (TASC) D disease of the superficial femoral artery. Kaplan-Meier primary and primary assisted patency rates were 73.2% and 80.8% at 1 year, respectively, and these rates were maintained for 70 months. Only one patient developed a superficial wound infection.

Following formal systematic training by vascular surgeons and implementation of technical modifications specific to limb salvage procedures at our institution, we noted 30-day primary and primary-assisted patency rates of 85.7% and 92.9%, respectively. Kaplan-Meier primary assisted patency was 63.6%. No patients required primary amputation at 19 months. One graft occlusion occurred within 30 days as a result of a tunnel hematoma in a patient who sustained a postoperative myocardial infarction and required therapeutic anticoagulation. One late hematoma was noted, and one patient demonstrated skin necrosis at the level of the ankle requiring prolonged hospitalization. Complete wound healing was achieved in 75% of patients with preoperative tissue loss due to critical limb ischemia.

The long-term durability of EVH for lower-extremity bypass has been questioned following a study by Julliard and colleagues. Over a period of 8.5 years, 363 patients underwent infrainguinal bypass; 170 patients underwent EVH and 193 underwent traditional open saphenous vein harvest. No differences in indication for surgery were noted between groups. Primary patency rates were significantly lower in the EVH group compared with the open group at 6, 12, and 36 months. There were no differences in length of stay or wound complication rates. Limb salvage and survival were also identical between groups. The differences were not significant in patients with claudication and in those without diabetes.

Two more recent studies have demonstrated inferior patency rates when using the EVH technique for lower extremity bypass. Eid and colleagues from the University of Pittsburgh noted a graft patency rate of 43.2% in the EVH group and 69.4% in the OVH group at three years ( P = .007). However, the authors did demonstrate a decreased rate of wound complications with similar limb salvage and secondary patency rates associated with EVH compared to OVH. Santo and colleagues from the University of Oregon also demonstrated impaired primary patency at 1 and 3 years in the EVH group (71% and 52% respectively) when compared to the OVH group (58% and 41% respectively). EVH was also associated with increased need for intervention, longer operative times, shorter hospital stays, and decreased harvest site complications. Limb salvage rates and amputation-free survival was similar in both groups.

Thus despite mixed outcomes with regard to vein graft patency following EVH for infrainguinal revascularization, the decision to implement this technique must be weighed against decreased wound complication rates, diminished postoperative pain, and similar limb salvage rates compared with EVH. It is likely that graft patency rates following EVH are influenced by the surgeon's experience and technique and may improve in the future as newer technology emerges.