Eur Surg (2007) 39/2: 96–104 DOI 10.1007/s10353-007-0320-x # Springer-Verlag 2007

Endoscopic vein harvesting in coronary artery bypass surgery S. Huber, P. Bergmann, S. Schweiger, H. Ma¨chler, P. Oberwalder, and B. Rigler Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Graz, Austria Received November 11, 2006; accepted after revision February 13, 2007 # Springer-Verlag 2007

Endoskopische Venenentnahme fu¨r aortokoronare Bypassoperationen Zusammenfassung. Grundlagen: Wundheilungssto¨rungen und Wundinfektionen am Bein nach Entnahme der Vena saphena magna (VSM) fu¨r aorto-coronare Bypassoperationen (CABG) stellen eine schwerwiegende Komplikation dar. Speziell bei Patienten mit Adipositas, Diabetes mellitus und peripheren Durchblutungssto¨rungen treten vermehrt tiefreichende Wundheilungssto¨rungen mit starken Schmerzen auf. Methodik: Unser Ziel war es, die Anwendbarkeit und die Ergebnisse der endoskopischen Beinvenenentnahme zu untersuchen. Von Oktober 2002 bis November 2005 setzten wir bei 63 Patienten mit koronarer Herzerkrankung, die sich einer CABG-Operation unterziehen mussten, das VasoView+ System der Fa. Guidant zur endoskopischen Entnahme der VSM ein. Wir untersuchten Entnahmezeit und Pra¨parationszeit der Vene, intraoperative Komplikationen und Konversion zur offenen Entnahmetechnik, Qualita¨t der entnommen Vene und Anzahl an Reparaturna¨hten, Flowwerte der eingesetzten Venengrafts und postoperative Wundkomplikationen. Ergebnisse: Die mittlere Entnahmezeit betrug 37,5 min (19–72 min). Aufgrund von Blutungen und Fettgewebsansammlungen im Pra¨parationskanal musste bei 4 Patienten zur offenen Entnahmetechnik konvertiert werden. Die Qualita¨t der pra¨parierten Venen wurde mit einem Score von 1,4 auf einer Skala von 1–5 beurteilt. Die Seitena¨ste wurden ligiert und geklippt, im Mittel mussten 1,4 Lo¨cher pro Vene von ausgerissenen Seitena¨sten mit Prolene u¨berna¨ht werden. Bei einer Patientin war die Wand der endoskopisch entnommenen VSM zu du¨nn und variko¨s, sodass die Vene nicht als Bypassgraft verwendet werden konnte. Bei 17 Patienten (29%) wurde aus der endoskopisch pra¨parierten Vene ein Graft eingesetzt, bei 37 Patienten Correspondence: Stefan Huber, M.D., Division of Cardiac Surgery, Department of Surgery, Medical University of Graz, Auenbruggerplatz 36, 8036 Graz, Austria. Fax: þþ43-316-385 4672 E-mail: [email protected]

(64%) 2 Grafts und bei 4 Patienten (7%) 3 Grafts. Die Flowwerte der eingesetzten Grafts waren im Mittel 50 ml=min (10–159 ml=min). Postoperativ traten bei 22 Patienten (37%) umschriebene Ha¨matome entlang des Pra¨parationskanals auf, die bei Entlassung ga¨nzlich zuru¨ckgegangen waren. Wundheilungssto¨rungen und Wundinfektionen am Bein traten bei keinem der Patienten auf. Schlussfolgerungen: Die Vorteile der endoskopischen Entnahmetechnik der VSM sind die geringere Traumatisierung des Beines und die schmerzfreie und schnellere Mobilisierbarkeit der Patienten. Die Pra¨parationszeit der Vene ist trotz ,,learning curve‘‘ akzeptabel. Die Operationszeit wird nicht verzo¨gert. Die Visualisierung ist ausgezeichnet und die Handhabung des Systems ist schnell erlernbar. Die pra¨parierten Venen sind mit dieser Entnahmetechnik den konventionell offen entnommenen Venen ebenbu¨rtig, mit dem Vorteil der geringeren postoperativen Schmerzen und dem besseren kosmetischen Ergebnis. Die Konversionsrate zur offenen Technik ist gering (4 von 63). Postoperative Wundkomplikationen sind nicht zu erwarten. Schlu¨sselwo¨rter: Endoskopische aortokoronare Bypassoperationen.

Venenentnahme,

Summary. Background: Leg wound complications and infections after harvesting of the greater saphenous vein (GSV) in coronary artery bypass surgery (CABG) represent a serious source of patient morbidity. Especially, in patients with obesity, diabetes and peripheral vascular disease, severe wound complications with increased pain occur more often. Methods: Our aim was to evaluate the feasibility and the results of the endoscopic saphenous vein harvesting. From October 2002 until November 2005, in 63 patients with coronary artery disease, scheduled for elective CABG surgery, endoscopic vein harvesting (EVH) was performed using the Guidant VasoView+ System. We investigated harvesting time and preparation time for the vein, intraoperative complications and conversion to traditional open harvesting, quality of the harvested vein including number of repairs needed, flow rates of the bypass grafts and postoperative wound related complications.

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Results: The mean harvesting time was 37.5 min (19– 72 min). Four patients had to be converted to the open harvesting technique because of bleeding and massive build up of fatty tissue inside the preparation tunnel. The quality of the harvested veins was assessed with a score of 1.4 on a scale ranging from 1 to 5. Side branches were either ligated or clipped. Small holes tears not suitable for tying were repaired with a prolene suture. The mean number of repairs was 1.4. In one patient, the wall of the endoscopically harvested vein was too thin and varicose, so that the vein was not suited to be used as a bypass graft. In 17 patients (29%) the EVH vein was needed for only one graft, in 37 patients (64%) the harvested vein was used for 2 grafts, and in 4 patients (7%) for 3 grafts. The mean flow rate of the EVH grafts was 50 ml=min (10–159 ml=min). Postoperatively, 22 patients (37%) had hematomas along the course of the preparation tunnel. These hematomas, however, had diminished at the time of discharge. There were no leg wound complications or infections. Conclusions: The advantages of EVH are the reduced trauma to the leg and the painless and faster mobilization of the patients. The harvesting time is acceptable despite a learning curve. The operative time is not prolonged. The visualisation of the EVH system is excellent and the handling can be adopted easily. The quality of the endoscopically harvested veins is equal to an open harvest technique, with the advantages of less postoperative pain and a better cosmetic result. The conversion rate is low (4 of 63). Postoperative wound complications are not to be expected.

been developed. In 1996, Lumsden et al. [13] proposed harvesting the saphenous vein using a video endoscope as an alternative approach to the traditional technique and termed the procedure endoscopic vein harvesting (EVH). Since then, several investigators have reported the advantage of EVH and demonstrated reduced wound infection rates as well as decreased noninfective woundrelated morbidity within a follow-up period up to 5 years [14–17]. EVH allows one to remove the vein through a small skin incision which, in addition to reduced wound-related morbidities, leads to lower postoperative leg pain and neuropathies. According to our experience, patients regain mobility sooner and patient satisfaction is improved because of the cosmetic result. In daily routine, the use of EVH has often been hindered because of the skills needed to perform this technique, the increased costs, and time constraints that are present in the operating room. Besides that, criticism has included the potential for conduit trauma during EVH. Our goal was to investigate the feasibility of the EVH method in routine cardiac bypass surgery and evaluate harvesting and preparation time, intraoperative complications and conversion rate to open technique, vein quality including number of repairs needed, flow rates of the grafts and postoperative wound-related morbidities.

Key words: Endoscopic vein harvesting, coronary artery bypass surgery.

Today, there are several different endoscopic products available. The ones most often used are the Guidant VasoView+ and the Ethicon Clearglide+ systems. Both systems use currently available video-endoscopic equipment and carbon dioxide (CO2) insufflation with dissection cannulas to separate the GSV from the surrounding tissue and bipolar cautery to deal with side branches. After proper exposure the vein is removed through a small skin incision, side branches are ligated or clipped and coronary artery bypass grafting is performed according to standard protocol.

Introduction Despite the fact that arterial grafts are increasingly used because of more favorable long-term patency the greater saphenous vein (GSV) still remains the most common conduit in coronary artery bypass surgery (CABG). By conventional methods the saphenous vein is harvested under direct vision with the help of linear incisions along the course of the vein. These methods are associated with the potential risk of increased pain, leg edema, hematomas and wound complications such as delayed healing, lymphangitis, wound necrosis and severe wound infections [1–6]. Especially, obesity, diabetes, female gender and peripheral vascular disease have previously been reported as additional risk factors for wound complications. Although patients with peripheral vascular disease did not have a significantly higher prevalence for complications overall, infections that developed in these patients were more severe [7]. Vein harvesting has been reported even with a higher prevalence for wound complications and pain compared to median sternotomy [1]. When prospectively evaluated leg wound complications following longitudinal saphenectomy have resulted in 5–20% [8–12]. The subjective interpretation of wound complications may account for the wide variance reported in the literature. To help to reduce these complications by avoiding the long skin incisions, minimally invasive techniques have

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Methods From October 2002 to November 2005, 63 patients who met the inclusion criteria were scheduled for EVH, all performed by one surgeon (St.H). Initially, 3 consecutive cases were done under the guidance of an experienced EVH surgeon to get used to the equipment and harvesting technique. Inclusion criteria were as follows: elective coronary artery surgical patients who were in hemodynamically stable condition at induction of anaesthesia. Exclusion criteria were as follows: (1) adult coronary artery surgical patients needing an emergency revascularization or with an intra-aortic balloon pump in situ or who were in need of inotropic substances preoperatively; (2) patients who had varicose veins affecting part or the entire lower extremity; (3) patients who had undergone previous surgical procedure (saphenectomy) or suffered trauma so as to preclude the use of the saphenous vein; (4) pre-

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vious clinical history or radiologic evidence of deep vein thrombosis; (5) dermatitis or infection, which may preclude surgical procedure on the lower extremity.

Operative procedure The preoperative antibiotic treatment (Cefuroxime 1.5 g intravenously 1 hour prior to skin incision) was the same as in all cardiac procedures. The hips were externally rotated and the lower extremities were flexed at the knees. Additional supports were placed under the thighs to create a better working angle. For EVH the saphenous vein was harvested from the thigh using the Guidant VasoView+ 5 and 6 systems (Guidant, Cardiac and Vascular Surgery, Inc., Menlo Park, CA). The EVH was done simultaneously to the median sternotomy and left internal mammary artery harvest when performed. First the GSV was palpated along its course at the medial aspect of the lower extremity. Then the vein was identified through a longitudinal incision not longer than 2 cm at the crease of the knee just posterior to the medial femoral condyle. This is sometimes demanding, especially in cases of obese patients. The vein was dissected free and surrounded by a vessel loop. Subcutaneous tunnels were created proximally and distally. Side branches that were easily identified within the tunnel were ligated using 4=0 vicryl stutures. The disposable VasoView+ equipment was not opened until the vein size and quality were found suited for endoscopic harvesting. The specific VasoView+ instruments include a 7 mm
0 wide lens endoscope with a disposable translucent conical tip for blunt dissection of the vein, a harvesting cannula with an ergonomic handle with built in controls to maneuver the integrated C-ring cradle and the bipolar

Fig. 1. (1) 7 mm 0
wide lens endoscope with a translucent conical tip for blunt dissection of the vein (2). (3) Short port blunt trip trocar (BTT) with an inflatable balloon. (4) Harvesting cannula with built in controls to maneuver the integrated Cring cradle and the bipolar scissors (5)

scissors, and a short port blunt trip trocar (BTT) with an inflatable balloon (Fig. 1). In the next step, the camera system, the light source and the CO2 insufflation all mounted on an endoscopic tower opposite the surgeon were connected (Fig. 2). The conical tip was screwed on the endoscope and slid along the anterior aspect of the saphenous vein towards the groin. After 5–10 cm of blunt dissection the premounted short port BTT was moved along the endoscope into the skin incision and the built-in balloon was inflated with 20 ccm of air to create a gas tight seal inside the wound. Care had to be taken not to exceed the skin incision over 2 cm in order to accomplish a gas tight seal. CO2 was insufflated through the port into the tissue at a pressure of 12–15 mmHg and a rate of 3–5 l=min (Guidant+ recommendation). The vein was circumferentially dissected, ini-

Fig. 2. Surgeon performing endoscopic harvesting (left), on the opposite side the monitor, the camera system, the light source and the CO2 insufflation are mounted on an endoscopic tower

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Fig. 3. Blunt dissection of the greater saphenous vein (GSV). Anterior aspect of the vein (1) surrounded by fatty tissue (2) Fig. 4b. Separation of the vein from the surrounding tissue with the aid of CO2 pressure

Fig. 5. The greater saphenous vein and the side branches lying inside the preparation tunnel Fig. 4a. CO2 insufflation after insertion of the short port blunt tip trocar (BTT) into the skin incision. CO2 pressure creating a working tunnel and separating the vein from the fat

tially at the anterior and then the posterior aspect (Fig. 3). The CO2 pressure created a working tunnel and allowed separation of the vein from the fat with no appreciable trauma (Fig. 4a and b). Vein tributaries and side branches were identified and mobilized (Fig. 5). The endoscope was withdrawn and inserted into the harvesting cannula. The cannula was then placed through the port inside the working tunnel. For further dissection of adherent tissue and division of the side branches, the integrated C-ring cradle and the bipolar scissors (energy

level of 20 W) were used. Great care had to be taken to try to keep a distance of at least 2–3 mm between the scissors and the vein to avoid thermal damage to the GSV. Therefore, the vein lying in the tunnel was placed under gentle traction using the cradle, and the side branches were cut with the scissors (Fig. 6). Once all the side branches were divided the vein was finally inspected by sliding the C-ring along the course of the vein inside the tunnel. A second 2 cm longitudinal skin incision was made at the groin and the GSV was identified with the help of the endoscopic light source. Then the vein was divided under direct vision and the groin stump was tied using 0 vicryl sutures. The harvesting cannula was removed and CO2 was stopped.

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tying were repaired with a 7=0 prolene suture. The number of repairs was noted for each harvested vein. The preparation time until the vein was ready for use was documented. Bypass grafting was then done using standard protocol. Before sternal closure, graft flow rates were obtained by using appropriately sized Doppler flow probes (Transonic Systems Inc., Ithaca, NY). After hemostasis was confirmed a sterile towel was rolled from the groin to the knee to express any remaining blood from the tunnel. A single drainage was inserted into the tunnel in each patient. The incision sites at the knee and the groin were secured with two interrupted, absorbable stitches using 2=0 vicryl sutures. For intracutaneous closure a 3=0 vicryl running suture was used. At the end of the operation a dry dressing was applied to the incisions and the leg was wrapped with an elastic bandage and a sterile towel underneath for compression of the tunnel for 24 hours. Fig. 6. The C-ring cradle (1) and the bipolar scissors (2) (seen in detail in insert upper left) manipulating the greater saphenous vein. The vein is placed under gentle traction with the cradle and the side branch is cut with the scissors

Fig. 7. The greater saphenous vein endoscopically harvested from the thigh and removed through the 2 cm knee incision

The balloon of the short port BTT was deflated and the port was removed from the incision site. The harvesting time was recorded and the mobilized vein length was removed through the knee incision (Fig. 7). If additional length of vein was required the subcutaneous tunnel was followed distally towards the ankle and the GSV was circumferentially dissected for another 8–10 cm using standard scissors and a hook. A stab incision was then made 10 cm distally from the knee incision to gain control of the vein for ligation and division. Only in two patients the endoscopic instruments were turned around and inserted into the initial knee incision again and the GSV was followed distally using the EVH method. All side branches were either ligated with 4=0 vicryl sutures or clipped with metal clips. The quality of the vessel was assessed by the surgeon using a numerical scale from 1 (excellent) to 5 (poor). Any trauma to the vessel was noted and, if necessary, small hole tears not suitable for

Postoperative care and follow-up The bandage and the dressings applied in the operating room were removed after 24 hours at the ICU. The wounds were inspected and the blood loss was examined by the amount of blood in the drainage. In all cases the drainage was removed on the first postoperative day and Mepore+ dressings were applied to the wounds. There was no need for a formal postoperative pain assessment (e.g. pain score 0–4). All patients were able to fully flex their leg on the morning after operation. After the chest tubes were removed the patients were mobilized at the ward. Morphine was given on occasion and nonsteroidal anti-inflammatory drugs (NSAIDs) were prescribed as required. The wounds were inspected daily until discharge by a physician. Several items were recorded including hematomas, delay in wound healing, local inflammation and neurological signs such as disturbance of sensibility and pain. A further follow-up was performed 3 months after patient discharge by a physician at our cardiac surgical ambulatory to determine each patient’s current cardiac and leg-wound status. Follow-up was 100% at 3 months.

Results Patient characteristics and risk factors for impaired wound healing are summarized in Table 1. Of the 63 patients who met the inclusion criteria, 4 had to be converted to the open harvesting technique. These were cases that were selected for EVH, but in which the endoscopic procedure could not be completed, requiring conversion to open harvest. Cases that were selected for EVH, but where the GSV could not be identified through the knee incision or where the GSV was not suited for EVH (vein size too thin, varicose vein) were not included (total of 3 cases). In these cases the VasoView+ disposables were not opened. The reason for conversion in all 4 cases was bleeding from side branch avulsion and massive build up of fatty tissue inside the preparation tunnel. This prevented the surgeon from operating in a clear endoscopic field and forced him to convert to open harvest. These patients were excluded from further analysis but were followed up just as the

S. Huber et al.: Endoscopic vein harvesting Table 1. Demographics and risk factors for wound-related complications n ¼ 63

Variable a

66.4 y  9.5 (40–83)

Age (range) Gender Female, number (percentage) Male Obesity (BMI > 30) Diabetes mellitus Peripheral vascular disease Chronic renal failure Ejection fraction <30

10 53 7 15 9 9 5

(16%) (84%) (11%) (24%) (14%) (14%) (8%)

a

Mean values and standard deviation. BMI Body mass index.

Table 2. Vein specific variables Variable

n ¼ 59c

Harvest timea (range) Preparation timea,b

37.5 min  12.6 (19–72) 56.7 min  9.9 (40–82)

Variable

n ¼ 58d

No. of EVH vein graftsa No. of repairs neededa Graft flow ratesa (range)

1.8  0.5 1.4  1.1 50 ml=min  29.3 (10–159)

a

Mean values and standard deviation. Harvest time plus preparation of vein, including ligation of side branches. c n ¼ 59 (63 patients minus 4 patients who had to be converted). d n ¼ 58 (63 patients minus 4 patients who had to be converted, minus one patient in whom the EVH vein was not suited to be used as a bypass graft).

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Twenty-two patients (37%) had hematomas along the course of the preparation tunnel. These hematomas, however, had diminished at the time of discharge. One patient complained about altered sensations and edema formation around the knee incision site. We had no wound disruption nor wound infection in our series. None of the patients had increased pain or discomfort in the leg. Mobility was regained easily within a few days. One patient had a prolonged hospital stay because of respiratory failure and general sepsis. One patient had to be transferred to a neurological department due to cerebral infarction. The mean length of hospital stay was 10,4 days. We did not achieve a reduction of length of hospital stay. This is mainly due to insurance policies at our institution, where cardiac surgical patients are usually not discharged earlier than 10 days postoperatively, depending on the date of admission to the rehabilitation center. During the period of three months, none of the patients had leg wound complications. All of the hematomas along the preparation tunnel had disappeared, edema and sensations were no more subject of complaint by any of the patients. One patient suffered a stroke three months after the CABG surgery, all the other patients had regained their preoperative mobility. One patient showed signs of recurred angina. An angiography was done and showed a stenosis of the LAD 1 cm distally of the insertion site of the vein graft. A percutaneous coronary intervention was performed.

b

other EVH patients at three months. In one patient, EVH was completed, but when the quality of the vein was assessed by the surgeon the vein was not suited to be used as a bypass graft. The vein was varicose and the wall was too thin, so that the surgeon decided to harvest the right internal mammary artery as well and do a total arterial revascularization. This patient was excluded from graft analysis (number of vein grafts and repairs, flow measurements) and further follow-up (Table 2). In our series we demonstrate that the long saphenous vein can be harvested using an endoscopic technique. Macroscopically, the quality of vein is similar to an open harvest technique. The number of repairs needed is not increased. The harvesting time decreases as experience and skills improve. EVH does not prolong the operative time nor compromise the vein quality. The vein specific variables are shown in Table 2. In 17 patients (29%), the EVH vein was needed for only one graft, in 37 patients (64%), the harvested vein was used for 2 grafts, and in 4 patients (7%), for 3 grafts. In 7 patients (12%), the GSV was followed distally towards the ankle and ligated and divided using a stab incision. The quality of the harvested veins was assessed by the surgeon with a score of 1.4 (scale 1–5). The flow rates of the EVH grafts were similar to the flow rates we normally observe in CABG surgery.

Discussion Leg wound complications after saphenous vein harvesting in CABG are an underappreciated source of serious patient morbidity. They may prolong the hospital stay or necessitate readmission for debridement and intravenous antibiotics. This will increase hospital costs, as well as costs for outpatient visits with oral antibiotics, painful dressing changes and outpatient debridement. Perhaps more important, they affect the patient’s quality of life by causing persistent pain, discomfort and difficulty with proper mobilization [9]. The cause of wound complications, more importantly infections, is mainly due to tissue trauma, exposure and wound closure methods. The main advantage of endoscopic harvesting is the reduction of these factors. Obesity, diabetes, female gender and peripheral vascular disease have been reported as additional risk factors for wound complications [3]. Although a decreased incidence of wound-related morbidities and leg pain of EVH compared with traditional open harvest has been demonstrated in both randomized [8, 9, 15, 18, 19] and nonrandomized studies [20], criticism has hindered a broader adoption of EVH by cardiac surgeons: (1) the potential trauma to the vein during EVH which may result in premature graft failure, (2) additional surgical time and (3) increased costs due to use of disposable instruments. The potential for increased vein trauma during EVH is an important factor. Damage may occur during harvesting process by mechanical irritation as well as thermal injury from cauterisation. Cable et al. [21] reported no significant endothelium disruption

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using EVH. Yoshida et al. [22] propose that bipolar cauterization, as used in EVH, has been shown to produce less scattering of thermal injuries in vascular grafts compared with unipolar cautery. Acute perioperative events that might be associated with severe graft trauma have been observed for both endoscopic and open harvest techniques with similar frequencies [8]. However, premature graft failure that might be attributed to EVH has not been reported in long term follow-up [14–17, 23]. In our series we did not find any early graft failure, clot formation in the harvested vein nor increased perioperative or intraoperative myocardial infarction. In subsequent blinded histologic comparison of the endothelium of endoscopically versus traditionally harvested vein grafts, no significant difference was noted between either technique [9, 14, 24–26]. Endothelial dysfunction has been reported with traction injury during vein harvesting with bridged incisions, but not with EVH [27]. In this regard, EVH has not been shown to compromise the histologic integrity [24, 25, 28] or functional properties [21, 26, 29] of the endothelial, medial and adventitial layers. Moreover, the short-term 6 month patency rate of EVH veins, as assessed by contrast-enhanced electron beam computed tomography [16] compares favorably with those earlier reported for traditional open harvest. Angiography has shown similar 3-month [30] and 6-month [17] patency rates of vein grafts of both EVH and open harvesting techniques. Allen et al. [14] showed similar 5-year event-free survival rates (freedom from death, myocardial infarction, recurrent angina, or congestive heart failure) 75% endoscopic versus 74% open harvest, p ¼ 0.85. Another consideration is the time it takes to learn and to perform the EVH technique. In order for a new technique to be generally accepted, it must not significantly prolong or delay the operation. We have observed that a surgeon without any previous endoscopic experience needs to employ the VasoView+ system on several patients in order to feel at ease with the equipment. After 10–15 cases, one should feel confident with the procedure (Fig. 8). We confirm the experience of other authors, who have proposed that the harvesting time decreases significantly the more experience the surgeon has, and that the operating time is not prolonged [7, 9, 14, 19]. Increasing experience also leads to a decreased conversion rate. Our series contained 4 such patients. All of

Fig. 8. Decrease in time required to harvest the greater saphenous vein as our experience increased. Total time needed to harvest vein versus number of cases

Fig. 9. Conversions to open vein harvest marked as red dots. Conversions were cases 4, 10, 14 and 15

the conversions occurred within the surgeon’s first 15 cases (Fig. 9). The main reason for conversion was bleeding and massive build-up of fatty tissue inside the preparation tunnel preventing the surgeon from proceeding with the harvest. Other reasons for conversion can be an inability to locate the vein or inadequate vein size. Certain landmarks are used to determine the typical course of the GSV. Palpating the vein from the ankle to the knee usually helps to locate the vein. On very obese patients the use of vein mapping by ultrasound might be helpful [19, 31]. The vein size also plays an important role in whether an EVH procedure can be accomplished successfully. If the vein that is located appears to be too thin or too large (like in varicose veins), one may look for a more suitably sized vein in the other leg or convert to the open technique from the beginning. Dissection of a vein that is too thin or too fragile may result in damage to the vein and the side branches because of the shearing force exerted by the endoscope. Besides, a decent amount of subcutaneous tissue allows an easier dissection of the vein and usually contributes to a successful endoscopic harvest. For the first few cases, it is helpful to select patients that are not too obese or too muscular and where the GSV can be palpated at the knee area. It is advisable not to open the disposable EVH equipment until the vein has been identified and the size and the quality appear suited for endoscopic harvesting. The additional costs associated with EVH are clearly an issue. Disposables for the VasoView+ system range from a 400 to a 450 per case. On the other hand, costs associated with wound complications are the result of additional admissions, wound care, debridement and antibiotic use. Previous studies have shown that these interventions are more common with the open harvesting technique, especially in patients with a higher risk for wound complications [7–9, 15, 19]. Overall savings based on improved wound healing and therefore less additional treatment and reduced length of hospital stay may counterbalance the added costs of the EVH equipment. For patients at low risk for wound complications, justification for use of EVH would mainly be cosmetic. However, a patient’s perception of ‘‘less surgery’’ and improved mobility due to less leg discomfort could improve the patient’s quality of life. Overall, all of our patients who received EVH have expressed satisfaction with their results (Fig. 10). As a limitation we have to mention that we did not compare patients who received EVH with patients who

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Fig. 10. Comparison of leg incisions. (A) Bridged incisions made to harvest the greater saphenous vein from the groin to the knee using the traditional open harvest technique. (B) Incision made to harvest the greater saphenous vein from the knee to the groin using the endoscopic technique. Each picture was taken on the 7th postoperative day

received traditional open saphenous harvesting, because the rate of leg wound complications and infections with the open method is less than 0.2% at our institution. We believe that endoscopic vein harvesting offers an attractive alternative to the open technique and that the use of CO2 insufflation offers advantages over alternative endoscopic techniques. EVH can be easily adopted and accomplished in a decent time and has been shown to reduce postoperative pain, discomfort and additional woundrelated morbidities. Furthermore, histologic evaluation [9, 14, 24–26, 28] shows no significant trauma to the saphenous vein.

10.

The authors did not receive grants from Guidant, Cardiac and Vascular Surgery Inc., Menlo Park, CA.

12.

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