Technical Modifications in Endoscopic Vein Harvest (EVH) Techniques Facilitate Use in Lower Extremity Limb Salvage Procedures

Juan Carlos Jimenez, MD, Peter F. Lawrence, MD, David A. Rigberg, MD, William J. Quinones-Baldrich, MD and Sydney Guo, MD
David Geffen School of Medicine at UCLA, Gonda (Goldschmied) Vascular Center,
Los Angeles, CA

Open saphenous vein harvest for lower extremity bypass procedures in the setting of critical limb ischemia is traditionally associated with long incisions and significant morbidity from wound complications. At our institution, over 800 endoscopic vein harvests have been performed during cardiac surgery procedures. Recent advances in harvest technology have resulted in the development of technical modifications for lower extremity arterial bypass and limb salvage. These technical modifications include limited arterial dissection prior to vein harvest, avoidance of compression wraps to the ipsilateral harvest tunnel, use of the endoscopic tunnel for conduit placement, and the use of either reversed or non-reversed graft placement. With the speed and low morbidity associated with EVH, simultaneous contralateral vein harvest may also be used over ipsilateral harvest for decreased operative times and increased efficiency.
Methods: We reviewed records for all patients who underwent minimally invasive distal bypass using endoscopic greater saphenous vein (GSV) since these modifications in operative techniques were made.
Results: Twelve patients (twelve limbs) recently underwent minimally invasive distal bypass since technical modifications have been developed. Mean patient age was 70 + 11 years. Indications for EVH were rest pain (92%) and tissue loss (83%). The mean pre-operative ankle-brachial index (ABI) was 0.5. Veins harvested were ipsilateral GSV (75%), contralateral GSV (17%) and lesser saphenous vein (8%). No upper extremity vein harvests were performed in this study, although we are now technically able to perform this procedure. Vein was adequate for bypass in eleven out of twelve patients and PTFE was used in one patient above the knee due to inadequate size and length following successful harvest. No GSV injuries related to endoscopic harvest were encountered. Two patients developed post-operative hematomas, one mild requiring no treatment and one which compressed the graft and required re-operation for successful reestablishment of patency. The initial technical success rate, primary patency and primary assisted patency rates were 92%, 92% and 92% respectively. There were no peri-operative deaths and no infectious or other wound complications noted.
Conclusions: Technical modifications in endoscopic saphenous vein harvest techniques facilitate 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. Meticulous hemostasis within the tunnel following endoscopic conduit harvest and avoidance of post-operative anticoagulation should help to prevent post-operative hematoma formation.