Learning process and results in endoscopic saphenous vein harvesting technique

Abstract

Background/Aim: Endoscopic saphenous vein graft harvesting (EVH) has been increasingly used in coronary bypass graft (CABG) surgery in recent years due to its cosmetic advantage and reduced morbidity. However, for the successful application of this technique, a learning process is required. In this study, we aimed to compare the results of the experience we obtained in the initial phase and later periods of the EVH technique. Methods: Forty patients who underwent elective CABG between July 2015 and April 2017 were included in this retrospective cohort study. The first 20 patients (Group 1) and the next 20 patients (Group 2), whose saphenous vein graft (SVG) was prepared with the EVH technique were compared. The length and preparation time of SVGs prepared with EVH, local findings such as hematoma, necrosis, wound infection, and healing, demographic data, comorbidity, intraoperative and postoperative data, postoperative intensive care and hospitalization times, cosmetic satisfaction and wearing compression stockings were recorded. Results: While the mean operation time was 201.4 (25.0) minutes in Group 1, it was 184.6 (17.1) minutes in Group 2 (P=0.018). There was no difference in the mean SVG lengths between the groups (P>0.05). While SVG preparation time was 75.3 (26.2) minutes in Group 1, it was 35.4 (6.0) minutes in Group 2 (P<0.001). The number of minor branch injuries in the SVG in Groups 1 and 2 were eight (40%), and two (10%), respectively, and all underwent primary repair (P<0.001). Mean length of hospital stay was similar between the groups (P=0.955). No hematoma, infection or necrosis requiring surgical intervention was observed in the extremity from which the SVG was taken. The use of compression stockings was longer in group 1 than in group 2 for the reduction or complete disappearance of edema (56.4 (23.3) vs 42.0 (19.4) days, P=0.040). No patient in any of the groups required rehospitalization due to infection at the saphenous vein incision site and incision healing problem. According to the satisfaction survey, cosmetic satisfaction was high in both groups (P=0.530). Conclusion: We think that after the completion of the learning process on twenty patients, the EVH technique can be used more widely, with much better results in terms of both patient cosmetic satisfaction and reducing morbidity.

Keywords

• Coronary artery bypass
• Vena saphena magna
• Endoscopic graft harvesting
• Learning process

Kaynakça

1. 1. Gültekin Y, Bolat A. Results of the first 200 open heart surgeries performed in a university hospital clinic: Kırıkkale University, Faculty of Medicine, Cardiovascular Surgery. KÜ Tıp Fak Derg. 2020;22(3):348-56. doi: 10.24938/kutfd.793704.
2. 2. Aldea GS, Bakaeen FG, Pal J. Fremes S, Head SJ, Sabik J, et al. The society of thoracic surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg. 2016;101(2):801-9. doi: 10.1016/j.athoracsur.2015.09.100.
3. 3. Motwani JG, Topol EJ. Aortocoronary saphenous vein graft disease: pathogenesis, predisposition, and prevention. Circulation 1998;97(9):916-31. doi: 10.1161/01.cir.97.9.916.
4. 4. De Vries MR, Simons KH, Jukema JW, Braun J, Quax P. Vein graft failure: from pathophysiology to clinical outcomes. Nat Rev Cardiol. 2016;13(8):451-70. doi: 10.1038/nrcardio.2016.76.
5. 5. Chukwuemekai A, Lindsay J. Modified incision for long saphenous vein harvest. Ann Thorac Surg. 1998;66(1):279-80. doi: 10.1016/s0003-4975(98)00410-x.
6. 6. L’Ecuyer PB, Murphy D, Little JR, Fraser VJ. The epidemiology of chest and leg wound infections following cardiothoracic surgery. Clin Infect Dis. 1996;22(3):424-9. doi: 10.1093/clinids/22.3.424.
7. 7. Hayward PAR, Gordon LR, Hare DL, Matalanis G, Horrigan ML, Rosalion A, et al. Comparable patencies of the radial artery and right internal thoracic artery or saphenous vein beyond 5 years: results from the radial artery patency and clinical outcomes trial. J Thorac Cardiovasc Surg. 2010;139(1):60-7. doi: 10.1016/j.jtcvs.2009.09.043.
8. 8. Sen O, Gonca S, Solakoglu S, Dalcik H, Dalcik C, Ozkara A. Comparison of conventional and no-touch techniques in harvesting saphenous vein for coronary artery bypass grafting in view of endothelial damage. Heart Surg Forum. 2013;16(4):177-83. doi: 10.1532/hsf98.20131006.

9. 9. Souza DS, Christofferson RH, Bomfim V, Filbey D. “No-touch” technique using saphenous vein harvested with its surrounding tissue for coronary artery bypass grafting maintains an intact endothelium. Scand Cardiovasc J. 1999;33(6):323-9. doi.org/10.1080/14017439950141362.
10. 10. Hayashi I, Kashima I, Eiji Yoshikawa E. The endoscopic no-touch saphenous vein harvesting technique. Multimed Man Cardiothorac Surg. 2020 Sep 25;2020. doi: 10.1510/mmcts.2020.049.
11. 11. Bhuvaneswari K, Critchley WR, Glover AT, Nair J, Jones MT, Waterworth PD, et al. A randomized study comparing three groups of vein harvesting methods for coronary artery bypass grafting: endoscopic harvest versus standard bridging and open techniques. Interact Cardiovasc Thorac Surg. 2012;15(2):224-8. doi: 10.1093/icvts/ivs164.
12. 12. Kiani S, Desai PH, Thirumvalavan N, Kurian DJ, Flynn MM, Zhao XQ, et al. Endoscopic venous harvesting by inexperienced operators compromises venous graft remodeling. Ann Thorac Surg. 2012;93:11-8. doi: 10.1016/j.athoracsur.2011.06.026.
13. 13. Davis Z, Jacobs HK, Zhang M, Thomas C, Castellanos Y. Endoscopıc vein harvest for coronary artery bypass graftıng: technique and outcomes. J Thorac Cardiovasc Surg. 1998;116(2):228-35. doi: 10.1016/s0022-5223(98)70121-7.
14. 14. Williams JB, Peterson ED, Brennan JM, Sedrakyan A, Tavris D, Alexander JH, et al. Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308(5):475-84. doi: 10.1001/jama.2012.8363.
15. 15. Patel AN, Hebeler RF, Hamman BL, Hunnicutt C, Williams MC, Liu L, et al. Prospective analysis of endoscopic vein harvesting. Am J Surg. 2001;182(6):716-9. doi: 10.1016/s0002-9610(01)00824-8.
16. 16. Akowuah E, Burns D, Zacharias J, Kirmani BL. Endoscopic vein harvesting. J Thorac Dis. 2021;13(3):1899-908. doi: 10.21037/jtd-20-1819.
17. 17. Paletta CE, Huang DB, Fiore AC, Swartz MT, Rilloraza FL, Gardner JE. Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg. 2000;70(2):492-7. doi: 10.1016/s0003-4975(00)01414-4.
18. 18. Jonkers D, Elenbaas T, Terporten P, Nieman F, Stobberingh E. Prevalence of 90-days postoperative wound infections after cardiac surgery. European Journal of CardioThoracic Surgery 2003;23(1):97-102. doi: 10.1016/s1010-7940(02)00662-0.
19. 19. Chernyavskiy A, Volkov A, Lavrenyuk O, Terekhov I, Kareva Y. Comparative results of endoscopic and open methods of vein harvesting for coronary artery bypass grafting: a prospective randomized parallel-group trial J Kardiyotorasik Cerrahi. 2015;10:163-71. doi: 10.1186/s13019-015-0353-3.
20. 20. Wipke-Trevis DD, Stotts NA, Skov P, Carrieri-Kohlman V. Frequency, manifestations and correlates of impaired wound healing of saphenous vein harvesting incisions. Heart, Lung 1996;25(2):108-16. doi: 10.1016/s0147-9563(96)80112-9.
21. 21. Caliskan E, de Souza DR, Böning A, Liakopoulos OJ, Choi YH, Pepper J. Saphenous vein grafts in contemporary coronary artery bypass graft surgery. Cardiology 2020;17(3):155-69. doi: 10.1038/s41569-019-0249-3.
22. 22. Horvath KD, Gray D, Benton L, Hill J, Swanstroma LL. Operative outcomes of minimally invasive saphenous vein harvest. The American Journal of Surgery 1998;175(5):391-5. doi: 10.1016/S0002-9610(98)00044-0.
23. 23. Kempfert J, Rastan A, Leontyev S, Luduena M, Van Linden A, Arsalan M, et al. Current perspectives in endoscopic vessel harvesting for coronary artery bypass grafting. Expert Rev Cardiovasc. Ther 2011;9(11):1481-8. doi: 10.1586/erc.11.151.
24. 24. Grant SW, Grayson AD, Zacharias J, Dalrymple-Hay MRJ, Waterworth PD, Bridgewater B. What is the impact of endoscopic vein harvesting on clinical outcomes following coronary artery bypass graft surgery? Heart 2012;98(1):60-4. doi: 10.1136/heartjnl-2011-300600.
25. 25. Kopjar T, Dashwood MR. Endoscopic versus "no-touch" saphenous vein harvesting for coronary artery bypass grafting: a trade-off between wound healing and graft patency. Angiology. 2016;67(2):121-32. doi: 10.1177/0003319715584126.
26. 26. A. Cameron, Davis KB, Green G, Schaffet HV. Coronary bypass surgery with internal thoracic artery grafts effects on survival over a 15-year period. N Engl J Med. 1996;334:216-20. doi: 10.1056/NEJM199601253340402.
27. 27. Brata R, Horacekb J, Sieja J. Endoscopic vs open saphenous vein harvest for coronary artery bypass grafting: A leg-related morbidity and histological comparison. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2013;157(1):70-74. doi: 10.5507/bp.2012.011.
28. 28. Sastry P, Rivinius R, Harvey R, Parker RA, Rahm AK, Thomas D, et al. The influence of endoscopic vein harvesting on outcomes after coronary bypass grafting: a meta-analysis of 267,525 patients. Review Eur J Cardiothorac Surg. 2013;44(6):980-9. doi: 10.1093/ejcts/ezt121.
29. 29. Sargın A, Aşkar FZ, Kocabaş SN. Açık kalp cerrahisinde postoperatif solunum sistemi komplikasyonlarının preoperatif, intraoperatif ve postoperatif belirleyicileri. GKDA Derg. 2013;19(4):175-83. doi:10.5222/GKDAD.2013.175.
30. 30. Güzela NÖ, Kaymakçı Ş. The effects of three dıfferent warmıng methods on preventıon of postoperatıve hypothermıa after coronary artery bypass surgery. Ege Üniversitesi Hemşirelik Yüksek Okulu Dergisi 2003;19:11-7.
31. 31. Tamim M, Al-Sanei A, Bukhari E, Canver C. Endoscopic saphenous vein harvesting: results of our initial experience Turkish J Thorac Cardiovasc Surg. 2008;16(3):162-6.
32. 32. KM Chiu, CL Chen, SH Chu, TY Lin. Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases. Surg Endosc. 2008;22(1):183-7. doi: 10.1007/s00464-007-9522-3
33. 33. Krishnamoorthy B, Critchley WR, Venkateswaran RV, Barnard J, Caress A, Fildes JE, et al. A comprehensive review on learning curve associated problems in endoscopic vein harvesting and the requirement for a standardised training programme. J Cardiothorac Surg. 2016;11:45-53. doi: 10.1186/s13019-016-0442-y.
34. 34. Lopes FC, Oliveira OWB, Moreira DG, Dos Santos MA, de Oliveira JLR, Cruz CB, et al. Use of doppler ultrasound for saphenous vein mapping to obtain grafts for coronary artery bypass grafting. Clinical Trial Braz J Cardiovasc Surg. 2018;33(2):189-93. doi: 10.21470/1678-9741-2017-0201.
35. 35. Bitondo JM, Daggett WM, Torchiana DF, Akins CW, Hilgenberg AD, Vlahakes GJ, et al. Endoscopic versus open saphenous vein harvest: a comparison of postoperative wound complications. Ann Thorac Surg. 2002;73(2):523-28. doi: 10.1016/S0003-4975(01)03334-3.
36. 36. Luckraz H, Cartwrigh C, Nagarajan K, Kaur P, Nevill A. Major adverse cardiac and cerebrovascular event (MACE) and patients ’quality of life after endoscopic vein harvesting as compared with open vein harvest (MAQEH): a pilot study. Open Heart 2018;5(1):694-4. doi: 10.1136/openhrt-2017-000694.
37. 37. Fron K. Comparison of endoscopic and traditional saphenous vein harvesting used as coronary artery bypass grafting material in patients with increased risk of postoperative infection. Annales Academiae Medicae Silesiensis 2020;74:149-56.
38. 38. Çitrak F, Alpar SE. Çiçek S. Koroner baypas cerrahisinde iki farklı yöntemle venöz greft hazırlanmasının postoperatif dönemde yaşam kalitesi üzerine etkisi. Damar Cer Derg. 2015;24(3):172-83.
39. 39. Şen O, Kadiroğulları E. Koroner bypass operasyonlarında safen ven grefti hazırlama tekniklerinin karşılaştırılması. Turk J Clin Lab. 2018;9(2):110-3.
40. 40. Morris RJ, Butler MT, Samuels LE. Minimally invasive saphenous vein harvesting. The Annals of Thoracic Surgery 1998;66(3):1026-8. doi: 10.1016/s0003-4975(98)00709-7.
41. 41. Arıtürk C, Ökten M, Güllü Ü, Şenay Ş, Toraman F, Karabulut H, et al. Cerrah Deneyimi endoskopik safen ven grefti hazırlanmasında komplikasyon oranını azaltıyor. GKDA Derg. 2015 21(3):147-51. doi:10.5222/GKDAD.2015.147.
42. 42. Coppoolse R, Rees W, Krech R, Hufnagel M, Seufert K, Warnecke H. Routine minimal invasive vein harvesting reduces postoperative morbidity in cardiac bypass procedures. Clinical report of 1400 patients. European Journal of Cardio-Thoracic Surgery 1999;16(2):61-6. doi: 10.1093/ejcts/16.Supplement_2.S61.
43. 43. Luckraz H, Kaur P, Bhabra M, Mishra KP, Nagarajan K,Kumari N, et al. Endoscopic vein harvest in patients at high risk for leg wound complications: A cost–benefit analysis of an initial experience. American Journal of Infection Control. 2016;44(12):1606-10. doi: 10.1016/j.ajic.2016.06.016.