Brian W. Hummel, MD, FACS

Fort Myers, Florida

Coronary artery bypass is the most frequently performed cardiac surgical procedure in the world. It is estimated that over 300,000 patients undergo coronary bypass surgery annually in this country. The greater saphenous vein is a common conduit used in coronary revascularization. Historically, the incision required for the removal of the saphenous vein has been the longest used anywhere. As a result, the harvest of the saphenous vein is commonly associated with increased morbidity, pain and discomfort. The application of this longitudinal technique often results in the increased risk of infection and wound complications. This significantly affects the patient’s recovery phase and dominates the rehabilitative process.

Minimally invasive procedures have demonstrated several advantages, including reduced incidence of wound complications, decreased hospital stay, reduced scarring, etc. These potential benefits have prompted surgical groups to further explore minimally invasive techniques and discern their impact on healthcare savings.

With the advent of less invasive techniques in cardiac surgery and the benefits that could be derived from the application of minimally invasive endoscopic saphenous vein harvesting, Cardiac Surgical Associates of Southwest Florida implemented its use in January 1998. The initial experience was positive and demonstrated the technical feasibility of the procedure. It was found to be safe, effective and less painful for the patient. Since instituting this approach to removing the vein, almost 1,000 patients have undergone total or partial endoscopic vein harvesting during coronary artery bypass surgery.

This approach to vein harvesting involves the making of one to four one-inch "access" incisions in the leg. Subsequently, endoscopic instrumentation and fiber optic scopes are inserted to locate, dissect and harvest the saphenous vein. While the procedure may not appear technically demanding, there is a steep learning curve, which requires approximately 50 cases for the harvester to become adept with the process. As the harvester gains experience, there is a corresponding reduction in the amount of time necessary to remove the vein.

As with any new procedure, patient selection, advantages and disadvantages of the technique and cost consideration must be addressed. Moreover, the learning curve and its impact on harvest time are of concern in a healthcare environment driven by minimizing immediate costs rather than deriving long-term savings.

To examine the results of endoscopic vein harvesting, we prospectively reviewed our most recent experience. Observational and prospective data collected included individual patient demographic information, risk factor data, vein harvest operation data, intra-and postoperative complication data, as well as ambulation and leg pain data. In addition, at follow-up 30 days postdischarge, data collected included evaluation of leg pain based on patient declaration, harvest site complication data and functional capacity assessment.

Our experience has demonstrated that the application of a less-invasive surgical technique generally results in decreased postoperative pain and enhanced patient satisfaction. While endoscopic vein harvesting patients appear to ambulate with little or no difficulty following surgery, this may not be a function of the harvesting technique but of the cardiac surgery protocol employed by the hospital.

The trauma to the saphenous vein may occur during the endoscopic harvesting process, and its influence on long-term graft patency has been of concern. On visual inspection, the quality of the saphenous veins harvested using the endoscopic technique has been acceptable and has provided a satisfactory conduit for arterial revascularization. However, long-term studies will need to be conducted to discern any adverse affects that the procedure may have on long-term graft patency.

Endoscopic vein harvesting may also increase the hospital cost for providing the service. The use of disposable harvesting instruments may be responsible for increasing overall hospital cost. Moreover, the initial time devoted to vein harvesting during the learning curve may also prolong operating room time. These cost increases must by weighed against healthcare cost reductions resulting from a shorter postoperative stay, a decrease in the incidence of wound complications and a reduction in the need for readmission to the hospital. In addition, patient satisfaction and cosmetic results must also be factored into the decision-making algorithm concerning the use of the technique.

Endoscopic vein harvesting represents an emerging technology that provides a minimally invasive alternative to open vein harvest. The application of this technique can enhance patient satisfaction, reduce postoperative mobidities, shorten postoperative hospital stays and reduce the readmission rate for leg-wound complications. The benefits of these factors must be considered against the increased cost associated with the procedure and the influence that the harvesting technique may have on the long-term patency of graft. As minimally invasive saphenous vein harvesting continues to improve and evolve, and as further experience with improved instrumentation becomes a reality, the application of this technique will become the standard of care in coronary bypass surgery.