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J Thorac Cardiovasc Surg 2000;119:69-076
© 2000 Mosby, Inc.
SURGERY FOR ACQUIRED CARDIOVASCULAR DISEASE |
From the Division of Cardiothoracic Surgery, New England Medical Center, Tufts University School of Medicine, Boston, Mass.
Address for reprints: Kamal R. Khabbaz, MD, Tufts-New England Medical Center, 750 Washington St, NEMC #266, Boston, MA 02111 (E-mail: k.khabbaz{at}es.nemc.org).
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Abstract |
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 Top Abstract IntroductionMethodsResultsDiscussionConclusionAppendix: DiscussionReferences |
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Introduction |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionAppendix: DiscussionReferences |
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1-5 and are commonly treated on an outpatient basis with oral antibiotics. However, severe leg-wound complications may prolong a patient’s hospital stay 1 or require readmission for debridement, intravenous antibiotics, and, in some cases, lower extremity revascularization for nonhealing wounds in ischemic limbs. Even when managed as an outpatient, ongoing pain from an open wound, the requirement for dressing changes, and difficulty with ambulation can reduce the patient’s quality of life.
Endoscopic vein harvesting has been shown to be effective in decreasing the development of these wound complications. 6-9
Because of the costs associated with the use of endoscopic equipment, it is important to focus our resources on those patients who will benefit most from this technology. This prospective study was designed to document the prevalence of leg-wound complications, analyze risk factors for its development, and compare the influence of several techniques on the risk of infection. It is hypothesized that the use of an endoscopic technique will decrease the morbidity associated with saphenous vein harvesting in patients found to be at high risk for leg-wound complications.
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Methods |
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The open technique entailed an incision beginning at the ankle made by using a #10 blade for the skin incision and Metzenbaum scissors, electrocautery, or both for deeper tissues. The entire vein was exposed by means of a continuous incision. Vein branches were ligated proximally with 4-0 silk and clipped distally. Hemostasis was achieved by using electrocautery (Valley Lab Force 40), with energy levels varying from 30 to 45 W. The wound was closed in layers before or during cardiopulmonary bypass by using 1 to 2 layers of running 2-0 Vicryl suture (Ethicon, CT-1). The skin was closed with either staples (Pilling Weck Visistat) or a continuous horizontal mattress subcuticular suture of 3-0 Vicryl (Ethicon, PS2) or Monocryl (Ethicon, PS2). All legs were wrapped with an elastic bandage for 24 hours. Staples were removed on the fifth postoperative day, and adhesive strips were applied. If significant lower leg edema was present, the staples were removed 1 week after discharge. The wounds were cleaned with povidone-iodine and covered with a dry sterile dressing daily for 4 days. Wounds were assessed daily in the hospital, 2 weeks after discharge, and, on an outpatient basis, whenever an infection was identified by the patient, referring physician, or visiting nurse. Follow-up was 100%. Infections were graded according to severity and location(Table I).
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We subsequently investigated the influence of endoscopic vein harvesting(Fig 1) on the occurrence of leg-wound complications in patients found by statistical analysis to be at highest risk. With the standard open technique, these patients (diabetic, obese, or both types of patients) had a 24% prevalence of leg-wound complications. From November 1997 to July 1998, we randomized 132 consecutive high-risk patients (diabetic, obese, or both types of patients) alternating between the continuous open technique and endoscopic technique. Sixty-six patients were included in each group. Variables evaluated included the following: time required to complete the harvest and prepare the vein, including number of repairs required; length of vein harvested; and time for leg closure. All procedures were performed by the same 2 physician assistants. The equipment included a VasoView system (Origin Med Systems;Fig 2), a working scope, a Tricam SL-IMP camera system, an Endoflator high flow carbon dioxide (Karl Storz Endoscopy America, Inc), a tower monitor, and a monitor suspended across from the operative field. The system, camera, and endoscopes were gas sterilized for every case. This enabled manipulation of the camera on the field, allowing for rapid changes between endoscopes.
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). Follow-up was 100% in each group.
Statistical analysis was performed with SPSS software. Continuous variables were evaluated by using the Student t test. Univariate analysis of categorical variables was done by using 
2 analysis. A multiple logistic regression analysis was used to determine which variables were independent risk factors for complications.
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Results |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionAppendix: DiscussionReferences |
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The prevalence and severity of infection correlated with the presence of diabetes, obesity, or both. In patients with both factors, the prevalence of wound infection was 24% with the continuous open technique. Also, of the patients with severe infections, 71% had one or more significant risk factors(Fig 3). The majority of leg-wound complications occurred in the lower leg, where infections tended to be more severe when compared with the upper or entire leg(Fig 4). Of the 145 patients with leg-wound complications, 17 were readmitted with severe complications that required intravenous antibiotics and, in most cases, extensive debridement. Two patients had severe peripheral vascular disease that required revascularization. Of these 17 patients, 71% had one or both of these risk factors, and their average length of hospital stay was 6 days.
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When compared with the standard open technique, endoscopic harvest time was twice as long (65 ± 28 minutes vs 33 ± 20 minutes, P < .001), although the length of vein harvested was similar in both groups. A range of 0 to 10 repairs per harvest was noted, with a median of 1 and a mean of 2.8 in the endoscopic group compared with a range of 0 to 5 repairs per harvest and with a median of 0 and a mean of 0.6 in the continuous open group (P < .001;Table IV). Patients treated with the open technique had more severe infections involving larger areas of the wound. The average daily pain score was 2 on a scale from 1 to 10 through discharge and on follow-up. There was no difference in ability to ambulate or in length of stay. Seven patients in the endoscopic group required partial conversion to open on the same or contralateral side. More vein was needed in 3 patients, the vein was too superficial in the lower leg of 1 patient, excessive bleeding occurred after a branch avulsion in 1 patient, 1 patient became hemodynamically unstable necessitating rapid harvest, and 1 patient was converted because of technical difficulties. Another 3 patients required conversion to complete open technique: 2 patients had poor vein quality, and the vein could not be identified in one morbidly obese patient.
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Discussion |
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The prevalence of infection varies widely in the literature (from 1%-20%), depending to some degree on the definition of leg-wound complications, as well as the intensity of follow-up. 1-5 The Society of Thoracic Surgeons National Cardiac Database in 1998 noted a prevalence of leg-wound infection of only 1.5%, but observation may be limited to the hospital stay. 10 Thus this may significantly underestimate the true prevalence of infections because our study, as well as those of others, have shown that the mean time to diagnosis is about 2 to 3 weeks after surgery. 4 The morbidity associated with this problem, from a quality-of-care standpoint, as well as a financial standpoint, justifies the investigation of alternative techniques to potentially reduce the risk of infection in high-risk patients.
The use of smaller incisions, including bridging techniques with various devices 11-14 and a wide range of endoscopic devices now available, has enhanced the potential for decreasing morbidity from leg-wound complications. 6-9,15 We hypothesized that a bridging technique would maintain improved vascularity to superficial tissues and reduce the development of complications. We did find a significant difference in the severity of leg-wound complications, but this technique was technically difficult, often producing vein trauma and branch avulsion from overmanipulation and dissection. In addition, significant ecchymoses and hematomas commonly formed within the tunnels. Satisfactory instrumentation for this technique is still being developed and investigated.
The use of endoscopic vein harvesting has significantly decreased postoperative pain, improved mobility, decreased length of stay, and reduced the occurrence of leg-wound complications. 6-9 Although there was no significant difference in length of stay and postoperative pain in our study, we have demonstrated a significant decrease in the frequency and severity of leg-wound complications in high-risk patients by using endoscopic vein harvesting.
Some of the drawbacks to endoscopic vein harvesting include harvest and vein preparation and potential trauma to the vein during harvesting. Cable and colleagues 16 reported no significant endothelial disruption with endoscopic harvesting. In our series we averaged 2.8 repairs per vein, mainly related to small vein branch avulsions. With no previous endoscopic experience, the learning curve using the Origin system took approximately 5 to 10 cases. In our series the first 10 cases averaged 94 ± 43 minutes, whereas the last 53 cases averaged 60 ± 20 minutes(Table IV). The conversion rate in our study was 4.5%, with 3 patients requiring complete conversion to the open technique. Seven patients underwent a hybrid combination of the endoscopic and open techniques. Conversions were not related to the learning curve but were more common in patients with minimal subcutaneous tissue and those with thin fragile veins, in whom the shearing force exerted by the endoscope resulted in damage to the vein and its tributaries. Vein quality and size were also difficult to assess by using the endoscope because the vein was not directly visualized, and it could not be palpated except at the knee. With the open technique, the vein could be dilated after a small amount was harvested to assess its size and quality.
Although endoscopic vein harvesting may minimize leg-wound complications, reduce pain, and improve patient satisfaction, it remains controversial whether it is a cost-effective strategy. Disposables for the VasoView system range from $450 to $550 per case, to which must be added the initial startup cost of video, monitors, and cameras, which is approximately $45,000. The projected cost of using endoscopic vein harvesting in our high-risk population over the past 2.5 years was $273,900 (498 patients x $550). The total direct cost to our hospital for readmission for leg-wound complications in the high-risk population (17 readmitted patients) was $85,079.00. This amount divided over the entire high-risk group (n = 498) translates to a cost of $171.00 per patient per readmission. Using this simple analysis, we are unable to demonstrate any financial benefit to the use of this technique, even in our high-risk population. However, other factors, including patient satisfaction, postoperative pain, long-term morbidity, and the cost of outpatient care, may make implementation of a program of minimally invasive vein harvesting feasible.
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Conclusion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionAppendix: DiscussionReferences |
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Appendix: Discussion |
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TopAbstractIntroductionMethodsResultsDiscussionConclusionAppendix: DiscussionReferences |
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Criticisms of endoscopic vein harvest include increased harvest time, additional expense, and a potential for vein trauma. This study showed no difference between continuous and bridged incisions on retrospective analysis, as indicated in the manuscript; multivariate analysis, however, suggested the presence of diabetes and obesity as predictors of harvest wound infection. Then, in a randomized cohort of patients in this high risk subgroup, endoscopic vein harvest was associated with a prevalence of wound infection of 4.5% for the endoscopic group, with infections generally being mild to moderate, versus a 20% prevalence for the open technique group, with infections being moderate to severe. The drawbacks for the endoscopic group, however, included a doubling of the harvest time and a tripling of the need for vein repair. The conversion rate to the open technique was 4.5%, and additional incisions were required in another 10%.
I have the following questions.
What was the prevalence of wound infection in patients with diabetes and obesity in your retrospective analysis in terms of the bridging technique? You chose the continuous technique because no difference was alluded to. The bridging technique, with its lower equipment costs and apparent clinical benefit in other series, may have provided for a more fair comparison to the endoscopic group.
Operative use of carbon dioxide has been associated with hypercapnia, acidosis, and hypothermia. Did you observe any of these or other complications with the carbon dioxide insufflation?
Other studies suggest that endoscopic harvest does not increase endothelial damage. Did you perform any histologic studies on your patients?
Your study focused on wound infection, but were there any differences between the 2 techniques in terms of hematomas, saphenous neuralgia, or lymphedema?
Although your study did not show any in-hospital cost savings, we might expect a cost savings for this high-risk group in terms of resource use after discharge, as well as a quicker return to work, things that are more difficult to quantify.
With increasing use of arterial grafts, our practice has isolated the use of endoscopic vein harvest to the thigh with a single incision, keeping the wound away from the flexion point at the knee. Some of your photographs indicate a close approximation of your incision to this flexion point. Could this have accounted for the similar amount of discomfort reported by the endoscopic group compared with the group treated with the open technique? The pain scales also are somewhat subjective. Did you look at narcotic use as well?
Dr Allen S. Hudspeth (Winston-Salem, NC). It is interesting to me that neither the presenter nor the discussant mentioned anything about the heart. When we first started out to put more blood into the myocardium with these operations, and certainly the conduits are critical, we started initially taking veins out through little keyholes, and we found that we damaged the veins.
I would be very interested and would believe these improvements if we had evidence that these grafts were just as good or better than the ones we have had. Some people have said you can either mutilate the leg or mutilate the vein. I wonder if you might comment on what the results of these vein grafts were.
Dr Keith B. Allen (Indianapolis, Ind). Your study mirrors the prospective randomized study that we presented at last year’s meeting of the Society of Thoracic Surgeons and was published last year in The Annals of Thoracic Surgery. Our results are exceedingly similar. Although one can debate which endoscopic technique to use, I applaud you in evaluating this particular technology and encourage surgeons to use this technique. Saphenectomy wound complications are grossly underestimated in coronary artery surgery and deserve more attention.
We have recently submitted a histologic analysis in 150 patients that demonstrated no difference in endothelial, medial, or adventitial trauma, and I would strongly suggest that this is a very good technique.
Mr Carpino. Dr March, I appreciate your comments. Referring to the prevalence of infection with the diabetic and obese patients with the bridging technique, I do not have those numbers at hand. Today I wanted to specifically focus on the comparison of open versus endoscopic techniques. We did evaluate the bridging technique as part of this study.
The group of patients that had the bridging technique did have more diabetic and obese patients compared with the open group. Open versus bridging were not exactly demographically similar; however, as you noted from my manuscript, there is no difference in prevalence of infection between the 2 groups. The severity of infections with patients who have undergone the bridging technique was much less than the patients who had the open technique.
We have noticed no problems with CO2 retention, although I was speaking with some people yesterday, and they had reported one incident of high CO2 during a vein harvest that the anesthesiologist had to correct for, with a CO2 level as high as 64. But we had no problems with elevated CO2 during our procedures.
Histologic evaluation has been touched on. We personally did not do studies, but Dr Cable did a study of the histologic evaluation of veins after endoscopic harvesting, I believe it was a few years back, which showed no intimal injury, and as was discussed by Dr Allen, that seems pretty consistent. However, I would say that if you are going to do an evaluation, there are intimal injuries from smaller avulsed branches requiring 7-0 repairs, and there has got to be a potential for thrombosis or early stenosis. We had no returns for angina or perioperative myocardial infarctions in our groups, and I believe that is pretty similar for most of the other people who have published on endoscopic vein harvesting.
A question on difference of hematomas and edema: We did not follow edema very well in our study. It has been reported in a few other studies regarding edema, and there seemed to be no difference in previous studies.
As far as hematomas, we did see a fair amount of hematomas in the thigh in the patients who had the endoscopic technique performed. We keep the legs wrapped in Ace bandages for 48 hours, hoping to decrease the prevalence of hematomas. We even tried putting drains in, but that did not seem to make a difference. This did not seem to adversely affect the patients’ recovery, did not cause infection, seemed to resolve quickly on its own, and by 2-week follow-up, most of the patients had resolution of these hematomas.
I did not document an increased use of narcotics with patients who had the open technique compared with the endoscopic technique.
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Footnotes |
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Read at the Seventy-ninth Annual Meeting of The American Association for Thoracic Surgery, New Orleans, La, April 18-21, 1999.
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