Patients undergoing coronary artery bypass grafting frequently complain more about postoperative discomfort from the site of leg vein harvesting than about their sternotomy wound. The traditional method of harvesting the greater saphenous vein, a groin-to-ankle incision, involves the longest incision used in surgical practice and may cause minor complications in up to 31 percent of patients. Major complications are believed to be rare, but the morbidity and costs of minor complications from vein harvesting comprise an area of surgical practice that requires further study. Horvath and colleagues used a prospective, nonrandomized, case-matched study that compared two new, less invasive techniques of harvesting the saphenous vein that were designed to minimize trauma and complications.
During a 10-month period, 60 patients underwent saphenous vein harvest using either the bridge technique or the endoscopic saphenous vein harvest technique. Patients undergoing emergency coronary artery bypass graft or additional cardiac procedures, and those with active infections, uncontrolled diabetes or lower extremity arterial or venous ulcerations were not included in the study. Patients were assigned to one of the two techniques by case matching. All vein harvesting was done by two physician assistants. Data on wound healing and complications were obtained two and eight weeks after surgery.
The bridge technique requires approximately four incisions in the thigh and four to five incisions in the lower leg to harvest the complete vein, leaving “bridges” of intact skin and tissue. Endoscopic saphenous vein harvesting uses a subcutaneous dissecting instrument that is guided videoscopically along the anterior surface of the vein. This technique requires an incision from 3 to 4 cm in length at selected sites and allows larger branches to be clipped or coagulated before vein removal.
The two groups of patients were well matched, although more patients in the endoscopic group suffered from peripheral vascular disease. The 29 patients who underwent harvesting using the bridge technique had an average of 5.0 incisions, and the 31 patients who underwent endoscopic vein harvesting had an average of 2.3 incisions. Although the number and total length of incisions were significantly less in the patients undergoing the endoscopic technique, the length of vein harvested was significantly longer. The total time from incision to closure, including the time for preparation of the vein, was significantly shorter with the endoscopic technique. Minor wound complications occurred in 10 patients (32 percent) who underwent endoscopic harvesting and one patient (3 percent) who underwent the bridge procedure. Most complications using the endoscopic technique were minor hematomas and, when these were excluded, the complication rate was 13 percent. The complication rate decreased during the study period. This decrease was attributed to improved staff education and experience. None of the complications prolonged the hospital stay or led to readmission. The two groups of patients had similar lengths of hospital stay and time to postoperative ambulation.
The authors conclude that saphenous vein harvesting using the endoscopic technique allows for harvesting of long segments of vein, utilizes shorter and fewer incisions, and requires less time than the bridge technique. The greater incidence of minor complications can be diminished through staff education and experience.