Endoscopic Saphenous Vein Harvesting Research Articles

Long-Term Results of Endoscopic Versus Open Saphenous Vein Harvest for Lower Extremity Bypass

Endoscopic saphenous vein harvest (EVH) has been shown to lower wound infection rates and cost compared with conventional harvest, although long-term patency data are lacking. A small series of studies has recently suggested that patency is inferior to conventionally harvested vein technique, and we thus sought to explore this question by reviewing our cumulative experience with this technique. The short- and long-term outcomes of all lower extremity bypasses (LEBPs) using saphenous vein at one institution over a period of 8.5 years were retrospectively reviewed. A total of 363 patients averaging 67 ± 24 to 100 years of age had undergone LEBP and had charts available for review. Of these 363 patients, 170 underwent EVH (90% using a noninsufflation technique) and 193 conventional (by means of continuous or skip incisions); 48% of patients reported tissue loss and no differences in indication for surgery were noted between groups. Mean follow-up was 35.1 (range: <1-105) months. Primary patency rates were worse in the EVH group as compared with conventional at six (63.3% ± 4.0% vs. 77.3% ± 3.3%), 12 (50.4% ± 4.2% vs. 73.7% ± 3.6%), and 36 (42.2% ± 4.5% vs. 59.1% ± 4.9%) months (all p < 0.001), although these differences were largely limited to patients with limb-threat and diabetes. However, limb salvage and survival, were identical between groups. Contrary to previous experience, there were no differences in length of stay or wound complication rates. The overall results of this study show an inferior long-term patency rate for endoscopically harvested saphenous vein after LEBP in our series as a whole, and do not confirm the short-term benefit previously shown in a selected cohort. These differences were, however, minimal or absent in patients with claudication or absence of diabetes, and EVH may continue to play a role in these cases.

Impact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting

Endoscopic saphenous vein harvest (EVH) decreases leg wound infections and improves cosmesis after coronary artery bypass grafting (CABG). Recent data, however, suggest that EVH may be associated with reduced graft patency rates. The objective of this study is to assess the effect of EVH on short-term and midterm outcomes after CABG. Data were prospectively collected on all first-time isolated CABG and combined valve/CABG with saphenous vein graft between 1998 and 2007 at a single center. Patients having traditional "open" vein harvest (OVH) were compared with patients having EVH. Multivariate models were used to examine the risk-adjusted impact of EVH on postoperative leg infection, composite in-hospital adverse events, and individual and composite midterm adverse events. The study included 5,825 patients, of whom 2,004 (34.4%) had EVH. Patients having EVH were more likely to have ejection fraction less than 50% (32.0% versus 29.3%, p = 0.04), recent myocardial infarction (24.2% versus 18.3%, p < 0.0001), and left main disease (26.0% versus 22.1%, p = 0.0009). Median follow-up was 2.6 years. After risk adjustment, EVH was associated with reduced rates of leg infection (odds ratio 0.48, p = 0.003) but had no association with either in-hospital (odds ratio 0.93, p = 0.56) or midterm adverse outcomes (hazard ratio 0.93, p = 0.22). Endoscopic saphenous vein harvest was associated with reduced readmission to hospital for unstable angina (odds ratio 0.74, p = 0.01). Endoscopic saphenous vein harvest is associated with a lower rate of leg infection and is not an independent predictor of in-hospital or midterm adverse outcomes. Endoscopic saphenous vein harvest is a safe alternative to OVH for patients undergoing CABG with saphenous vein.

Femoral-Popliteal Bypass With Endoscopically Harvested Saphenous Vein in Patients With TASC D Disease of the Superficial Femoral Artery

This study evaluated patients undergoing femoropopliteal bypasses using endoscopically harvested vein to treat Trans-Atlantic Inter-Society Consensus (TASC) stage D lesions. Primary patency and primary assisted patency were evaluated, as were perioperative morbidity and mortality and hospital length of stay (LOS). Results for this minimally invasive alternative to femoropopliteal bypass with conventional open vein harvesting were analyzed. A retrospective analysis was performed on patients who underwent femoral-popliteal bypass with endoscopic saphenous vein harvest and angiographic TASC D anatomy. Postoperative duplex exams were evaluated, and the study end points of graft thrombosis or the development of a high-grade stenosis prompting reintervention were sought. Patient demographics, morbidity, mortality, and hospital LOS were analyzed. Twenty-seven patients meeting our inclusion criteria underwent surgery between June 2002 and June 2007. Indications for surgery in these patients were claudication (n=10), gangrene or ulceration (n=9), and ischemic rest pain (n=8). Fifty-two percent of the patients were male, 50% had cardiac disease, 65% had hypertension, 54% were diabetic, and 65% had a significant smoking history. Median LOS was 2.5 days in claudicants, 3.0 days in patients with rest pain, and 7.0 days in patients with gangrene or ulceration (p<0.05). Kaplan-Meier primary patency and primary assisted patency rates were 73.2% and 80.8% at 1 year, respectively; and these rates were maintained for 70 months. The only perioperative complication was a superficial wound infection, and two patients died during follow-up from causes unrelated to the surgery. Femoropopliteal bypass using endoscopic vein harvest is a durable reconstructive vascular procedure which can be performed with minimal postoperative morbidity, short LOS, and satisfactory long-term patency.

A Prospective Audit of Endoscopic Vein Harvesting for Coronary Artery Bypass Surgery

The objectives of this study were to: (i) assess the feasibility of minimally invasive endoscopic harvesting of the long saphenous vein or radial artery for use as conduit during coronary artery bypass surgery in the NHS setting; and (ii) investigate the results of endoscopic vein harvesting with regards to postoperative complications, ability to mobilise, and patient satisfaction. In this prospective audit, 25 consecutive patients, aged 52-90 years, undergoing either coronary artery bypass grafting alone or together with valve surgery or atrial fibrillation ablation were studied. All data were entered in purpose-designed proforma. Pre-operative risk factors including increasing age, diabetes, peripheral vascular disease, obesity, renal impairment, tobacco consumption and steroid use were documented. Time taken for harvest and conversion to traditional open vein harvest, quality of harvested vein in terms of number of repairs and vein damage were recorded. Postoperatively, we recorded harvest site wound complications, number of days to mobilise and total hospital stay. Pain score and patient satisfaction were also assessed. There was one death due to myocardial infarction; another patient had postoperative cerebrovascular accident. A total of 43 lengths of grafts were harvested, 41 were long saphenous vein and two radial artery. Vein harvest time reduced significantly from a maximum of 94 min to 34 min for two lengths of long saphenous vein. Three patients required conversion from endoscopic vein harvesting to open vein harvest. The only postoperative complication directly related to endoscopic harvesting was bruising along the tunnel created by the passage of the instruments. None of the patients had any wound complication; none required antibiotics or wound debridement. Mean time to mobilise was 3.4 days. All patients who underwent successful endoscopic vein harvesting expressed satisfaction with regards to postoperative pain and cosmetic result. Competence and ability to harvest conduit in an acceptable time frame are obtainable after a relatively low number of cases. The procedure is associated with a low number of postoperative complications and very high patient satisfaction.

Saphenous Vein Conduits Harvested by Endoscopic Technique Exhibit Structural and Functional Damage

Injury to the saphenous vein endothelium during harvest impacts patency after coronary artery bypass graft surgery. Many centers are adopting endoscopic saphenous vein harvest (ESVH) instead of using the traditional open saphenous vein harvest (OSVH) technique. Our objective was to compare the effects of ESVH and OSVH on the structural and functional viability of saphenous vein endothelium using multiphoton imaging, immunofluorescence, and biochemical techniques. Ten patients scheduled for coronary artery bypass graft surgery were prospectively identified. Each underwent ESVH for one portion and OSVH for another portion of the saphenous vein. A 1-cm segment from each portion was immediately transported to the laboratory for processing. The vessel segments were labeled with fluorescent markers to quantify cell viability (esterase activity), calcium mobilization, and generation of nitric oxide. Samples were also labeled with immunofluorescent antibodies to visualize caveolin, endothelial nitric oxide synthase, von Willebrand factor, and cadherin, and extracted to identify these proteins using Western blot techniques. All labeling, imaging, and image analysis was done in a blinded fashion. Esterase activity was significantly higher in the OSVH group (p < 0.0001). Similarly, calcium mobilization and nitric oxide production were significantly greater in the OSVH group (p = 0.0209, p < 0.0001, respectively). Immunofluoresence and Western blot techniques demonstrated an abnormal alteration in distribution of caveolin and endothelial nitric oxide synthase in the ESVH group. Our study indicates that ESVH has a detrimental effect on the saphenous vein endothelium, which may lead to decreased graft patency and worse patient outcomes.

Improved Leg Wound Healing with Endoscopic Saphenous Vein Harvest in Coronary Artery Bypass Graft Surgery: A Prospective Randomized Study in Asian Population

Conventional open saphenous vein harvest (OVH) for coronary artery bypass graft surgery is often associated with significant pain and morbidity. This study aims to determine whether endoscopic saphenous vein harvest (EVH) reduces leg wound morbidity and improves patient satisfaction as compared to OVH in Asian population. Between March 2005 and June 2006, 120 patients who underwent isolated CABG were prospectively randomized into EVH (n = 60) and OVH (n = 60) groups. VirtuoSaph (Terumo Cardiovascular Corp., Ann Arbor, MI, USA) harvesting system was used for EVH. We analyzed leg wound complications (ASEPSIS score), postoperative pain, satisfaction, and clinical outcomes. Fisher's exact test and Mann-Whitney U test were used for categorical and continuous variables analysis respectively. Six patients in the EVH group required conversion to open technique. Both groups had matched demographic characteristics and risk factors. Mean numbers of grafts performed were 3.2 +/- 0.6 (EVH n = 54) and 3.0 +/- 0.7 (OVH n = 60) (p = 0.03). ASEPSIS scores at postoperation days three, seven, and 21 were significantly lower in the EVH group than the OVH group (p = 0.02, p = 0.002 and p = 0.01, respectively). Wound pain scores at postoperative days three, seven, and 21 were significantly lower in the EVH group (p = 0.000, p = 0.001 and p = 0.000 respectively). Wound numbness was found in 5.7% of the EVH group and 33.3% of the OVH group patients (p = 0.01). [Six patients required conversion to open technique.] There was one hospital mortality (OVH group) and major postoperative complications were not significantly different between the groups. EVH system is a safe and effective alternative to OVH with better wound healing, reduced postoperative pain, and wound numbness. However, the higher conversion rate to OVH in Asian patients requires further evaluation.

Endoscopic vs open saphenous vein harvest for coronary artery bypass grafting: a prospective randomized trial☆

Endoscopic saphenous vein harvesting (EVH) for coronary artery bypass grafting (CABG) has been developed to reduce leg wound morbidity and improve patient satisfaction. Choosing between EVH of a short vein segment from the thigh and open venous harvesting (OVH) of a short segment from the calf represents a clinical dilemma as EVH is easiest to perform from the thigh and OVH is easiest to perform from the calf. The purpose of this study was to investigate whether leg wound morbidity was reduced after EVH of a short vein segment from the thigh compared with OVH from the calf. Secondly we investigated whether EVH would reduce length of hospital stay and improve cosmetic results. From April 2004 to June 2007, 132 patients undergoing elective isolated CABG were randomized to have a short segment of saphenous vein harvested either by the EVH or OVH technique. Clinical follow-up was scheduled at day 5 and at 1 month. Primary end-points included wound morbidity. Secondary end-points included harvest time, length of hospital stay, cosmetic results and need for additional wound care after discharge. The groups were preoperative similar. Three patients in the OVH group were excluded from the study as it became apparent that it was necessary to extend the incision beyond the knee. Harvest time was longer for the EVH group, but these patients suffered from significantly fewer cases of infectious and non-infective wound complications, with a substantial reduction in the need for post-discharge leg wound care. The purulent infection rates in the EVH and OVH groups were 0% and 11%, respectively. The overall leg wound morbidity rates regarding cellulitis, purulent infection, dehiscence and skin necrosis were 3% and 27% in the EVH and OVH groups, respectively (p<0.001). The length of hospital stay was similar. The conversion rate from EVH to OVH was 14%. The EVH group experienced less pain and better cosmetic results. EVH of a short vein segment from the thigh results in less wound morbidity and better cosmetic results compared with OVH of a short vein segment from the calf.

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft

Endoscopic versus open saphenous vein harvest for femoral to below the knee arterial bypass using saphenous vein graft

Endoscopic harvesting of saphenous vein with a small caliber

Endoscopic saphenous vein harvesting (ESVH) requires a high degree of technical expertise. However, few studies have investigated the influence of SV caliber on the technical difficulty and outcome of ESVH. We analyzed 86 consecutive patients who underwent ESVH using a VirtuoSaph(trade mark) system. SV caliber was measured in the above-knee portion by ultrasound. Patients were then divided into two groups: group A (SV caliber <3 mm, n=16), and group B (the remaining patients, n=70). ESVH procedure time and SV characteristics were compared between the groups. In group A, the SV had a larger number of side branches (11.7+/-1.2 in A, 9.8+/-0.4 in B, P=0.043) and required a longer operation time (A, 57.5+/-3.7 min; B, 43.9+/-1.9 min, P=0.0024), whereas the time required for endoscopy did not differ. Graft length (A, 27.7+/-5.0 cm; B, 25.7+/-3.7 cm) and ratio of repaired side branches (A, 26.6+/-20.5%; B, 25.7+/-23.9%) showed no significant differences. ESVH using a VirtuoSaph(trade mark) system is feasible, regardless of SV caliber. SV with a caliber of <3 mm has a larger number of side branches, thus prolonging the procedure time.

The need for monitoring during endovascular vein harvesting

We read with great interest the description of carbon dioxide embolism during endoscopic saphenous vein harvest reported by Potapov et al. [1]. It is well known that the procedure can cause hypercarbia [2] and there have been previous descriptions of carbon dioxide embolism [3] as well. The authors seem to have used transesophageal echocardiography (TEE) after the event but not during the acute crisis. They also do not mention whether or not end tidal carbon dioxide (ETCO2) monitoring was in place. Both of these modalities have been shown to enhance the diagnostic dilemmas of acute cardiovascular collapse in this setting [3,4]. A sudden decline in the ETCO2 could have been a warning for the impending hemodynamic event. Alternatively, TEE would have demonstrated the presence of gas in the right atrium and more specifically the inferior vena cava demonstrating the infra-diaphragmatic origin of the embolus. In the absence of either of these monitoring modalities, we feel that endoscopic vein harvest with carbon dioxide insufflation is unsafe. While the authors need to be commended for the successful outcome, it is possible that the institution of cardiopulmonary bypass might not always be prompt, and, that other options such as the use of pulmonary vasodilators also merit consideration.We strongly recommend inclusion of TEE and ETCO2 in patient’s monitoring especially in this setting for the safe conduct of the procedure.

Vascular Air Embolism: Lung Injury and Its Pathophysiology Also Need to Be Considered

Vascular Air Embolism: Lung Injury and Its Pathophysiology Also Need to Be Considered

Endoscopic vein harvesting in coronary artery bypass surgery

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. 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.

V1543: Endoscopic Saphenous Vein Harvest for Peyronie's Repair: A New Approach to a Classic Procedure

V1543: Endoscopic Saphenous Vein Harvest for Peyronie's Repair: A New Approach to a Classic Procedure

Transesophageal Echocardiography Failed to Detect a Patent Foramen Ovale Resulting in Cardiac Arrest During Endoscopic Saphenous Vein Harvesting in Coronary Artery Bypass Grafting Surgery

To the Editor: Carbon dioxide (CO2) embolization is a complication of endoscopic saphenous vein harvesting with CO2 insufflation during coronary artery bypass surgery (1,2). Lin et al. (3), using transesophageal echocardiography (TEE) to monitor CO2 bubbles in the inferior vena cava and hepatic vein, demonstrated a 4% incidence of significant CO2 embolism during endoscopic saphenous vein harvesting with CO2 insufflation procedures. An abrupt decrease in end-tidal CO2 can be a sensitive monitor for detecting CO2 embolism if the cardiovascular function, body temperature, and respiratory status remain stable. However, in the presence of hemodynamic instability capnography can be unreliable. TEE is the most reliable and sensitive method to detect CO2 embolism and is now considered to be the “gold standard” for diagnosis (4). A 78-yr-old woman with a history of angina and hypertension presented for coronary artery bypass surgery. Cardiac catheterization revealed 80% occlusion of the left anterior descending artery, 90% stenosis of the circumflex artery, and 40% stenosis of the right coronary artery. The reported ejection fraction was 60%. She was scheduled for endoscopic saphenous vein harvesting and coronary artery bypass graft surgery. Intraoperative monitors included five-lead electrocardiogram (ECG), radial artery catheter, pulmonary artery catheter, pulse oximetry, capnography, temperature, and TEE. After induction of anesthesia, her baseline TEE revealed good left ventricular function, and normal segmental wall motion in all 16 segments. Color Doppler imaging and agitated saline injection failed to demonstrate a patent foramen ovale (PFO). Endoscopic saphenous vein harvesting with CO2 insufflation at 12 mm Hg was begun. Approximately 30 min after beginning dissection, we noted a transient decrease in her arterial blood pressure from 100/60 to 70/40 mm Hg, accompanied by an increase in end-tidal CO2 to 57 mm Hg. Oxygen saturation remained at 99% with a Fio2 at 100%. This was accompanied by severe bradycardia, and ST segment changes. Mid-esophageal four-chamber views demonstrated severe biventricular global hypokinesis, with diffuse echogenic bubbles completely filling the right atrium and partially filling the right ventricle. Bubbles we seen crossing a PFO into the left atrium and left ventricle, with subsequent macroembolization to the aorta and coronary arterial system. CO2 insufflation was discontinued and cardiopulmonary resuscitation was initiated. The patient was treated with atropine, 1 mg IV push, and epinephrine and norepinephrine IV infusions. Within several minutes the bubbles cleared from the cardiac chambers, right ventricle and left ventricle wall motion normalized, as did the ECG and arterial blood pressure. Subsequent repair of the four vessels, as well as a 2.3 cm PFO, proceeded without incident. The patient was tracheally extubated 12 hours after surgery, and had no neurological sequelae. She was discharged home on the 11th postoperative day. Yoshio Okumura, MD Rodney A. Batchelder, CRNA, MS Department of Anesthesia William Beaumont Hospital Troy, Michigan [email protected]

Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures

We describe and report our results using endoscopic vein harvest (EVH) for lower extremity arterial bypass procedures, following the implementation of technical modifications specific to patients undergoing limb salvage procedures. We underwent training in EVH, followed by implementation of the technique in patients requiring limb salvage for lower extremity ischemia and aneurysms. After technical modifications in the technique were developed for limb salvage, we reviewed our experience in all patients who underwent minimally invasive distal bypass with EVH. Technical modifications include limited arterial dissection before vein harvest, the use of proximal and distal leg incisions for both exposure of arterial vessels and saphenous vein harvest, improved hemostasis techniques in the vein graft tunnel, avoidance of compression wraps to the ipsilateral harvest tunnel, complete removal of the vein with either reversed or nonreversed graft placement, and use of the endoscopic tunnel for conduit placement. Thirteen patients (14 limbs) have undergone minimally invasive distal bypass since technical modifications were implemented. Indications for EVH were rest pain (n = 12; 85.7%) and tissue loss (n = 8; 57.1%). Veins harvested were the ipsilateral great saphenous vein (n = 10; 71.4%), contralateral great saphenous vein (n = 2; 14.3%), and short saphenous vein (n = 2; 14.3%). No venous injuries occurred during endoscopic harvest, and all were used for bypass. Thirty-day primary and primary assisted patency rates were 85.7% and 92.9%, respectively. The limb salvage rate was 100%. Two patients developed postoperative hematomas, one early and one late, as a result of anticoagulation for cardiac comorbidities. Both patients required reoperation for successful re-establishment of patency. There were no perioperative deaths and no postoperative wound infections or complications. Two patients required a later prosthetic bypass, and two required a vein graft angioplasty. Complete wound healing was achieved in 75% of patients with preoperative tissue loss. Technical modifications in endoscopic saphenous vein harvest techniques facilitate their 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 and the short saphenous vein. Meticulous hemostasis within the tunnel after endoscopic conduit harvest and avoidance of postoperative anticoagulation should help to prevent postoperative hematoma formation and early graft occlusion.

The Change of Arterial Blood Gas during Endoscopic Saphenous Vein Harvesting for Coronary Artery Bypass Grafting

Background: Endoscopic surgical procedure has recently been applied to not only intraabdominal or intrathoracic surgery but also saphenous vein harvesting, because it is less invasive and more cosmetically advantageous. Carbon dioxide insufflation during an endoscopic saphenous vein harvesting may cause an adverse effects on arterial blood gas and hemodynamic variables. This study was conducted to evaluate the safety of carbon dioxide insufflation during endoscopic saphenous vein harvesting. Methods: Patients in ASA physical status III or IV, scheduled for an endoscopic saphenous vein harvesting (n=30) were gathered for the evaluation. Until the end of the procedure, controlled mechanical ventilation (tidal volume: 10 ml/kg, respiratory rate: 10 rates/min) and ventilator mode was fixed in this tidal volume and respiratory rate. Arterial blood gas analysis, end-tidal carbon dioxide, blood pressure and heart rate were measured before and at 10, 20, 30, 40 minutes after carbon dioxide insufflation. Results: Preinsufflation values of PaCO2 (partial pressure of arterial carbon dioxide) and PETCO2 (partial pressure of end-tidal carbon dioxide) were 33.4 ± 3.6 mmHg and 24.1 ± 4.1 mmHg, respectively. PaCO2 was significantly increased at 30 and 40 minutes after carbon dioxide insufflation (40.1 ± 7.4 mmHg and 41.4 ± 8.6 mmHg). PETCO2 was significantly increased at 20, 30 and 40 minutes after carbon dioxide insufflation(27.6 ± 5.5 mmHg, 28.9 ± 7.0 mmHg and 29.6 ± 7.8 mmHg). But, the magnitude of difference between PaCO2 and PETCO2 was not significantly different. Conclusions: During endoscopic saphenous vein harvesting, PaCO2 was significantly increased compared with preinsufflation values. Careful monitoring of PaCO2 is mandatory during the procedure.

Experience of Endoscopic Saphenous Vein Harvest in Coronary Artery Bypass Grafting

冠動脈バイパス術（CABG）において，内視鏡下大伏在静脈（SVG）採取（ESVH）を129例に行った．SVGを採取した創は小さく，美容的に患者は満足していた．創合併症は皮下トンネル部の血腫を1.6%，リンパ漏を0.8％に認めたが創感染はなく，満足できるものであった．術後造影を行った症例におけるSVGの開存率は90.0%であり．ESVHを行った他の報告と比べ遜色はなかった．当院にて行った従来の開放採取におけるSVGの開存率（91.8%）と比較しても有意差はなかった．CABGにおいてESVHは低侵襲である一方，開存率も同等であり，有用な方法であると考える．

Reduction of Carbon Dioxide Embolism for Endoscopic Saphenous Vein Harvesting

Reduction of Carbon Dioxide Embolism for Endoscopic Saphenous Vein Harvesting

Endoskopický odběr vena saphena magna pro revaskularizaci myokardu. Pooperační a střednědobé výsledky souboru 100 nemocných

Endoskopický odběr vena saphena magna pro revaskularizaci myokardu. Pooperační a střednědobé výsledky souboru 100 nemocných

Reduction of Carbon Dioxide Embolism for Endoscopic Saphenous Vein Harvesting

The endoscopic saphenous vein harvesting (EVH) introduced in coronary artery bypass surgery (CABG) is associated with less wound complication and postoperative pain. Carbon dioxide (CO2) insufflation is used during EVH to facilitate the procedure. The purpose of this study was to determine whether the incidence of CO2 embolism during EVH with CO2 insufflation could be reduced with lower CO2 insufflation pressure. Four hundred and ninety-eight consecutive patients scheduled for elective off-pump CABG were prospectively studied. These patients were randomly assigned into high and low groups in which 15 and 12 mm Hg CO2 insufflation pressures were used during EVH, respectively. Multiplane transesophageal echocardiography (TEE) with transgastric inferior vena cava view was used to monitor the appearances of CO2 bubbles. If a burst of many CO2 bubbles were found by TEE, the CO2 insufflation would be stopped until detailed examination of the operative field. The incidence of CO2 embolisms in the high group of patients (13.3%) was significantly higher than that in the low group (6.5%, p < 0.05). Two episodes of emergent cessation of CO2 insufflation occurred in the high group of patients. No massive CO2 embolism with significant hemodynamic alterations occurred in either group. The incidence of CO2 embolisms during EVH could be reduced with lower CO2 insufflation pressure, which, in combination with increased surgical experience and continuous TEE monitoring of the inferior vena cava, helps to reduce the risks of massive CO2 embolism.