Endoscopic greater saphenous vein harvesting reduces the morbidity of coronary artery bypass surgery

Hepatic artery reconstruction using interposition of autologous saphenous vein conduit for living donor liver transplantation: a case report

We have preferentially used the right gastroepiploic artery (RGEA) as an alternative for the recipient hepatic artery (HA) inflow during living donor liver transplantation (LDLT), but it was not always available. We herein present a case of adult LDLT with HA reconstruction using a greater saphenous vein (GSV) conduit because of the absence of the RGEA due to prior subtotal gastrectomy. A 55-year-old male patient diagnosed with hepatitis B virus-associated liver cirrhosis and secondary biliary cirrhosis underwent LDLT using a modified right liver graft. The upper abdominal cavity was heavily adhered due to prior abdominal surgeries, thus we had to sacrifice the common bile duct and the right HA completely. A 6-cm-long GSV segment was harvested from the left ankle and interposed between the recipient gastroduodenal artery and the graft HA. The patient recovered from LDLT and HA complications did not occur. However, 8 years after LDLT, chronic rejection occurred, thus repeated deceased donor liver transplantation was performed. This patient has been doing well for 2 years after retransplantation. In conclusion, we suggest that interposition of an autologous GSV conduit can be an alternative for establishing HA inflow in LDLT when other inflow source is not available.

Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Meta-Analysis of Randomized Trials and Controlled Trials

Objective

This meta-analysis sought to determine whether endoscopic vascular graft harvesting (EVH) improves clinical and resource outcomes compared with conventional open graft harvesting (OVH) in adults undergoing coronary artery bypass surgery.

Methods

A comprehensive search was undertaken to identify all randomized and nonrandomized trials of EVH versus OVH up to April 2005. The primary outcome was wound complications. Secondary outcomes included any other clinical morbidity and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were analyzed.

Results

Thirty-six trials of 9,632 patients undergoing saphenous vein harvest met the inclusion criteria (13 randomized; 23 nonrandomized). Risk of wound complications was significantly reduced by EVH compared with OVH (OR 0.31, 95% CI 0.23–0.41). Similarly, the risk of wound infections was significantly reduced (OR 0.23, 95% CI 0.20–0.53; P < 0.0001). Need for surgical wound intervention was also significantly reduced (OR 0.16, 95% CI 0.08–0.29). The incidence of pain, neuralgia, and patient satisfaction was improved with EVH compared with OVH. Postoperative myocardial infarction, stroke, reintervention for ischemia or angina recurrence, and mortality were not significantly different. Operative time was significantly increased (WMD 15.26 minutes; 95% CI 0.01, 30.51), hospital length of stay was reduced (WMD −0.85 days; 95% CI −1.55, −0.15), and readmissions were reduced (OR 0.53, 95% CI 0.29–0.98). Costs were insufficiently reported to allow for aggregate analysis.

Conclusions

Endoscopic vascular graft harvesting of the saphenous vein reduces wound complications and improves patient satisfaction and resource utilization. Further research is required to determine the incremental cost-effectiveness of EVH versus OVH.

Endoscopic Saphenous Vein Harvesting for Hemodialysis Vascular Access Creation in the Forearm: A New Approach for Arteriovenous Bridge Graft

When superficial arm veins are not suitable to create a native arteriovenous (AV) fistula, an arteriovenous bridge graft by native and/or prosthetic graft is the next best alternative. However, harvesting a native vein, such as the saphenous vein (SV), is invasive and requires a large incision. We report an endoscopic saphenous vein harvesting (ESVH) technique combined with forearm bridge grafting as a new approach for vascular access (VA).

Methods

We used the Clearglide, Endoscopic Vessel Harvesting System (Eticon, Inc.) for a less invasive SV harvesting technique. Five patients had a SV graft implant and 10 patients had a polytetrafluoroethylene (PTFE) graft implant in the forearm.

Results

The SV was harvested easily in all patients in 46 ± 2 min. There were no wound complications. All SV and PTFE grafts provided satisfactory access within 1 month; however, two declotting procedures in the SV group and five in the PTFE group were required. The PTFE group had two graft infections.

Conclusions

It is possible that a combination of ESVH and SV forearm grafting will be one of the new approaches for hemodialysis (HD) access.

Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery

Objective

The purpose of this consensus conference was to develop and update evidence-informed consensus statements and recommendations on harvesting saphenous vein and radial artery via an open as compared with endoscopic technique by systematically reviewing and performing a meta-analysis of randomized and nonrandomized clinical trials.

Methods

All randomized controlled trials and nonrandomized controlled trials included in the first the International Society for Minimally Invasive Cardiothoracic Surgery Consensus Conference and Statements,1,2 in 2005 up to November 30, 2015, were included in a systematic review and meta-analysis. Based on the resultant, 76 studies (23 randomized controlled trials and 53 nonrandomized controlled trials) on 281,459 patients analyzed, consensus statements, and recommendations were generated comparing the risks and benefits of endoscopic versus open conduit harvesting for patients undergoing coronary artery bypass grafting.

Results

Compared with open vein harvest, it is reasonable to perform endoscopic vein harvest of saphenous vein to reduce wound-related complications, postoperative length of stay, and outpatient wound management resources and to increase patient satisfaction (class I, level A). Based on the quality of the conduit and major adverse cardiac events as well as 6-month angiographic patency, endoscopic vein harvest was noninferior to open harvest. It is reasonable to perform endoscopic radial artery harvest to reduce wound-related complication and to increase patient satisfaction (class I, level B-R and B-NR, respectively) with reduction in major adverse cardiac events and noninferior patency rate at 1 and 3 to 5 years (class III, level B-R).

Conclusions

Based on the consensus statements, the consensus panel recommends (class I, level B) that endoscopic saphenous vein and radial artery harvesting should be the standard of care for patients who require these conduits for coronary revascularization.

The Application of Split-Thickness Skin Graft as an Autogenous Arterial Conduit in a Goat (Capra Hircus) Model

Adequate autogenous vein is often the limiting factor in achieving a successful infrainguinal bypass. Attempts have been made to find alternative conduits; however, these alternatives have demonstrated inferior patency rates. We attempt to show that a split-thickness skin graft conduit provides a feasible autogenous arterial conduit. Neoconduits were prepared with an autogenous split-thickness skin graft (STSG) tubularized for a length of 5-6 centimeters with an appropriate caliber match to native artery. The deep dermal side of the graft was randomized to form either the external surface or the luminal surface. The neoconduit was placed as an interposition graft in the left common carotid artery. Grafts were studied in vivo with duplex ultrasonography and ex vivo by histopathology and immunohistochemistry. Feasibility study involved 4 animals with grafts harvested for study at 24 hours (n= 2) and 7 days (n= 2). Two subsequent groups were studied to evaluate 3-month (n= 8) and 6-month (n= 5) patency. All grafts (n= 4) in the feasibility phase of the study were patent at the time of harvest without evidence of aneurysmal degeneration. In the subsequent 8 goats, grafts with the deep dermal side forming the extraluminal surface (n= 4) had a propensity to ulcerate and rupture or to become aneurysmal (75%). The patency rate of these grafts at 6 weeks was 25%. In contrast, grafts with the deep dermal side forming the intraluminal surface (n= 4) demonstrated 75% patency at 6 weeks. Because of these results the remaining goats underwent placement of neoconduits with the deep dermal side forming the luminal surface. These grafts maintained a patency rate of 80% at 6 months. Neoconduits implanted with a diameter greater than 1.5 times the native arterial diameter became aneurysmal. Histopathology demonstrated neointimal formation in all grafts patent for longer than 7 days. Immunohistochemical staining for Factor VIII/von Willebrand’s factor (vWF) was reactive in the endoluminal cells of these grafts. Immunohistochemical staining for a-smooth muscle actin demonstrated reactivity in conduits patent for greater than 1 month. Split-thickness skin may provide a feasible source for autogenous conduit in arterial reconstructions and warrants further study. Technical factors affecting patency include orientation of the deep dermal surface of the STSG and the diameter of the neoconduit at the time of implantation.

Endoscopic vein harvesting: technique, outcomes, concerns & controversies

The choice of the graft conduit for coronary artery bypass grafting (CABG) has significant implications both in the short- and long-term. The patency of a coronary conduit is closely associated with an uneventful postoperative course, better long-term patient survival and superior freedom from re-intervention. The internal mammary artery is regarded as the primary conduit for CABG patients, given its association with long-term patency and survival. However, long saphenous vein (LSV) continues to be utilized universally as patients presenting for CABG often have multiple coronary territories requiring revascularization. Traditionally, the LSV has been harvested by creating incisions from the ankle up to the groin termed open vein harvesting (OVH). However, such harvesting methods are associated with incisional pain and leg wound infections. In addition, patients find such large incisions to be cosmetically unappealing. These concerns regarding wound morbidity and patient satisfaction led to the emergence of endoscopic vein harvesting (EVH). Published experience comparing OVH with EVH suggests decreased wound related complications, improved patient satisfaction, shorter hospital stay, and reduced postoperative pain at the harvest site following EVH. Despite these reported advantages concerns regarding risk of injury at the time of harvest with its potential detrimental effect on vein graft patency and clinical outcomes have prevented universal adoption of EVH. This review article provides a detailed insight into the technical aspects, outcomes, concerns, and controversies associated with EVH.

A case report of a carbon dioxide embolism caused by endoscopic vein harvesting during cardiac surgery -A case report-

A carbon dioxide (CO₂) embolism during endoscopic vein harvesting is a rare but potentially fatal complication. Early and accurate diagnosis is crucial for limiting the extent of the embolism and stabilizing the resulting cardiovascular compromise. We report a case of CO₂ embolization during endoscopic vein harvesting. Transesophageal echocardiography was instrumental in the diagnosis and management of this patient by further improving the decision making process, which resulted in the best outcome. Mid-esophageal bicaval view is the best view to determine whether a CO₂ embolism is coming from the upper or lower extremities.

Necrotizing fasciitis following endoscopic harvesting of the greater saphenous vein for coronary artery bypass graft

Clinicians should be aware of this rare, potentially lethal infection following minimally invasive vein harvesting techniques.

The greater saphenous vein (GSV) remains the most commonly harvested conduit for revascularization in coronary artery bypass grafting (CABG). Published literature shows that minimally invasive vein harvesting techniques have a significantly lower incidence of wound infection rates than conventional open vein harvesting techniques have. We report a case of necrotizing fasciitis, an infection with a mortality rate of 30% to 50%, after endoscopic harvesting of the greater saphenous vein to be used as a conduit in a CABG procedure. Though minimally invasive vein harvesting techniques have advantages of smaller incisions and a decreased overall rate of wound infection, clinicians should be aware of this potentially lethal infection that may occur.

Endoscopic vein harvesting for coronary bypass grafting: a blessing or a trojan horse?

Conventional open harvest of the great saphenous vein (GSV) during CABG results in approximately 7% donor-site complications. Using endoscopic vein harvesting (EVH) the full GSV length can be harvested through a 3 cm incision. This nonsystematic review discusses several key issues concerning EVH, based on an extensive Pubmed search. Found studies show that EVH results in reduced number of wound complications, less postoperative pain, earlier postoperative mobilisation, reduced length of hospital stay, and is more cost-effective. Initial studies did not find significant differences in graft histology, patency, or clinical outcome. However, in 2009 convincing evidence of inferior histological graft properties became available. Furthermore, an observational study showed that EVH resulted in significantly more graft stenosis, was associated with higher mortality, more myocard infarction, and more reinterventions. Most recent publications could not confirm these findings, however larger randomised controlled trials focusing on graft quality are being awaited.

Leg Wound Infections Following Greater Saphenous Vein Harvesting: Minimally Invasive Vein Harvesting Versus Conventional Vein Harvesting

Wound complications associated with long incisions used to harvest the greater saphenous vein are common and well documented. We compared leg wound infection rates, wound healing disturbances (WHDs), length of vein harvested, vein harvest time, and total surgical time between minimally invasive saphenous vein harvesting (MIVH) and conventional vein harvesting (CVH) techniques. This meta-analysis showed a significant reduction in wound infections in favor of the MIVH group (odds ratio = 0.19; 95% confidence interval = 0.14-0.25) and a significant reduction in WHDs in favor of the MIVH group (odds ratio = 0.26; 95% confidence interval = 0.20-0.34). The MIVH and CVH techniques are equivalent with respect to saphenous vein harvest time, saphenous vein harvest length, and total surgical time. A visual inspection of “funnel” plots suggests a mild to moderate publication bias. This meta-analysis suggests that leg wound infections and wound healing disturbances are reduced using MIVH techniques.

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases

BACKGROUND

Endoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients' acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH).

METHODS

Between March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28-89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO(2)) insufflation.

RESULTS

Technical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients.

CONCLUSION

The findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

OBJECTIVE

We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures.

METHODS

We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH.

RESULTS

Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss.

CONCLUSIONS

Technical modifications in endoscopic saphenous vein harvest techniques facilitate their use in lower extremity limb salvage procedures. Vascular surgeons should become familiar with these techniques to minimize vein harvest wound complications and extend the options for limb salvage conduits, including use of both the ipsilateral and contralateral saphenous vein and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.

Does Minimally Invasive Vein Harvesting Technique Affect the Quality of the Conduit for Coronary Revascularization?

The effect of minimally invasive great saphenous vein harvest on patient morbidity (wound infection and other healing disturbances) has been extensively investigated, yet its impact on the quality of the venous conduit is less well known. This study aims to review the literature with regard to macroscopic quality, postoperative myocardial infarction rates, and angiographic patency of the minimally invasive versus conventionally harvested vein using meta-analytic techniques where appropriate. Results suggest that conduits are comparable in macroscopic quality with minimally invasively harvested veins requiring more repairs prior to grafting. Postoperative myocardial infarction rates were not significantly different between groups, which is supported by the limited evidence on angiographic patency.

Encouraging results with endoscopic vein harvest for infrainguinal bypass

BACKGROUND

Wound complications after infrainguinal vein bypass remain a significant source of morbidity. Endoscopic saphenous vein harvest has emerged as a viable alternative to minimize vein harvest incisions.

METHODS

Infrainguinal bypass using endoscopic vein harvest was performed in 214 limbs in 197 consecutive patients between May 1998 and July 2004. The indication for bypass was limb salvage in 88.3%, claudication in 9.3%, and other in 2.4%. Atherosclerotic risk factors were prevalent, with diabetes mellitus in 68% and dialysis-dependent renal failure in 11.7%.

RESULTS

The procedure was successful in all but one patient. This patient was early in the series and had a friable varicose vein. Ipsilateral greater saphenous vein was used in 89.7%, contralateral greater saphenous vein in 8.4%, and lesser saphenous vein in 1.9%. Two injuries to the main trunk of the vein occurred early in the series. Assisted primary patency at a mean follow-up of 18 months (range, 1 to 48 months) is 77.2% by life-table analysis. For patients with claudication, rest pain, or minimal gangrene, the average length of stay was 3.15 days (range, 1 to 6 days). Wound complications occurred in 16 patients (7.5%), 10 of these required only local care (class I and II), and 6 had deep wounds threatening the leg or graft (class III). Only 5 patients, all with class III wounds, required readmission to the hospital for graft-related problems. There is no increase in operating room time once the learning curve is overcome. Patient satisfaction is very high.

CONCLUSION

Endoscopic saphenous vein harvest is a useful adjunct to infrainguinal vein bypass, with short length-of-hospital stay, few wound complications, and low hospital readmission rates. Endoscopic vein harvest is recommended as the procedure of choice for vein procurement for infrainguinal bypass procedures.

“Over-the-Wire” Inversion Saphenectomy:A Simple, Minimally Invasive Vein Harvesting Technique for Arterial Bypass

PURPOSE

To examine the feasibility and clinical outcome of a novel, minimally invasive technique for harvesting the great saphenous vein (GSV) for use in peripheral arterial bypass surgery.

METHODS

Between May 2001 through March 2003, 27 patients (15 men; mean age 71+/-10 years) underwent extremity bypass procedures for limb salvage (88%) or disabling claudication (12%) using the inversion technique to harvest the GSV. The veins were turned "inside out" using a unique catheter and guidewire system. With the endothelial surface exposed, valve leaflets were excised, and adherent thrombus was washed away. Veins were inverted again to turn the endothelial surface back inside the lumen for use as a bypass conduit.

RESULTS

Inversion vein harvesting and arterial bypass were completed in 24 (89%) of 27 patients; 2 patients were treated with synthetic grafts because of small GSVs. Another patient was found after vein harvesting to have inadequate arterial outflow despite a good quality conduit. The average vein length was 45+/-10 cm; a mean 4+/-1 incisions were made, including those for arterial exposure. Incisions made to divide vein tributaries averaged 2 cm in length. Duration of vein harvesting was 25 minutes (range 5-80). Wound complications were minor (2 hematomas, 2 cases of erythema, 2 seromas). Of 6 grafts that occluded after 30 days, 5 involved small-diameter vein grafts (< 3.5 mm). At a mean 12 months, primary and assisted primary graft patency rates were 88% (14/16) and 94% (15/ 16), respectively, for grafts with minimum diameters > or = 4 mm versus 38% (3/8) primary patency for veins < 4 mm (n = 8, p < 0.001). The limb salvage rate was 92% (22/24).

CONCLUSIONS

Over-the-wire inversion saphenectomy is a simple and reliable minimally invasive technique for arterial bypass. Incisions are small and cosmetically superior to those of the traditional long incision method. One-year follow-up suggests that grafts harvested by inversion technique have excellent durability when the minimum vein diameter is > or = 4 mm, as determined by preoperative vein mapping.

[Morphological changes in aorto-coronary vein graft--the analysis of autopsy and biopsy material]

BACKGROUND

Patients with implanted aortic coronary grafts have different survival time, which raises the question why the efficacy of graft implants is so poor. The aim of this study was to present the results of the analysis of morphological changes in the vein grafts taken after the death of patients who died after surgery in different time intervals, as well to present the analysis of the grafts obtained after surgical reintervention.

METHODS

The total number of 656 grafts of 308 dead patients was analyzed, as well as 76 grafts from 40 patients who underwent surgical reintervention. According to the duration of the graft since surgical intervention until death, all the analyzed changes were divided into two groups: a) early changes and complications, and b) late changes and complications in aorto-coronary vein grafts.

RESULTS

After the autopsy, 518 vein grafts from the first group were evaluated histopathologically. Changes were found in the form of small or large areas with peeled endothelium in 266 grafts, with the insudation of fibrin and thrombocytes in such places, subendothelial edema, and occlusive thrombosis of the graft lumen. Significant stenosis, which occurred distally from the anastomoses, was present in 118 grafts without changes in the walls of the graft, and there was significant narrowing of the graft lumen in 134 vein grafts due to intimal hyperplasia. In the second group, 138 grafts were histopathologically analyzed after autopsy. Significant hyperplasia was present in 117 grafts with the migration of smooth muscle cells from media into intima, and in 21 grafts there were atheromatous plaques. In 120 veins analyzed before the graft implantation, the lesion or the lack of endothelium was found, as well as the penetration of fibrin and blood elements and intimal hyperplasia. In 46 veins analyzed before the graft implantation, significant intimal hyperplasia with the elevated number of smooth muscle cells was found.

CONCLUSION

The most frequent lesions in the grafts were the lesions of the endothelium, which caused thrombosis formation and lumen occlusion. Intimal hyperplasia in patients with longer survival time occurred due to the migration of smooth muscle cells from the media, or due to the formation of atherosclerotic plaques, which caused graft lumen stenosis or thrombosis.

Carbon dioxide embolism during endoscopic saphenous vein harvesting in coronary artery bypass surgery

OBJECTIVES

Our objectives were to determine the incidence and severity and the time course of the CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation in coronary artery bypass surgery with transesophageal echocardiography monitoring.

METHODS

Four hundred three consecutive patients scheduled for off-pump coronary artery bypass grafting surgery or femoral-to-popliteal artery bypass grafting surgery were prospectively studied. Multiplane transesophageal echocardiography with a new transgastric view was used to monitor CO(2) bubbles in the inferior vena cava and hepatic vein.

RESULTS

CO(2) embolisms occurred in 17.1% of patients. Minimal, moderate, and massive CO(2) embolisms occurred in 13.1%, 3.5%, and 0.5%, respectively. The occurrence of moderate and massive CO(2) embolisms was frequently associated with the surgical manipulation of branches of saphenous veins. No significant risk factors were identified in multiple logistic regression analysis.

CONCLUSION

The incidence of significant CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation procedures was more than 4%. Continuous transesophageal echocardiographic monitoring of the CO(2) bubbles in the inferior vena cava is essential in early detection and can help to prevent the development of significant CO(2) embolisms in these patients.