Contemporary Outcomes after Endoscopic Vein Harvesting for Lower Extremity Bypass in a Multicenter Subspecialty Practice
Brittany Landavazo1, Taylor Smith, MD2, Shir Yelovitch, PhD2, Ryan Turley, MD2
1Texas A&M School of Medicine, Round Rock, TX;2Cardiothoracic and Vascular Surgeons, Austin, TX
Background: Endoscopic vein harvesting (EVH) is considered the standard of care for coronary bypass procedures given decreased early morbidity from surgical wound complications. However, the use of EVH for lower extremity (LE) bypass remains controversial due to concerns about decreased graft patency. In 2022, the BEST-CLI Trial demonstrated patients undergoing surgical bypass with adequate GSV quality experienced a lower incidence of major adverse limb events and mortality than those who underwent endovascular repair. Despite these results, wound complications from large harvest site incisions remain a significant barrier preventing surgical bypass as being the preferred initial treatment. In order to mitigate wound complications, our practice has adopted EVH as the standard approach for harvesting bypass conduit. Here, we report our recent 5-year experience using EVH for LE bypass.
Methods: Two hundred and seven LE bypasses with EVH were evaluated from 2017-2022. The cohort included 14 vascular surgeons in 8 hospitals. The primary endpoint was 30-day surgical wound complications. Secondary endpoints included bypass patency, need for major amputation, 30-day morbidity and mortality, length of operation, and length of hospitalization. Wound complications were measured using Szigalyi’s method, with class I characterized by erythema necessitating antibiotics, class II having drainage or superficial dehiscence, and class III threatening graft integrity and requiring surgical intervention.
Results: A total of 207 LE bypasses with EVH were performed on 204 patients. Of these, 63.8% were male with a median age of 68.6±11 years old. There were no wound complications related to saphenectomy. Surgical site infections occurred in 27 (13%) patients. Nine patients (4.3%) had class I complications, 12 (5.8%) had class II complications, and 6 (2.9%) had class III complications. Cumulative patency at 30 days was 88.9% and 83.6% at 1 year (Figure 1). Twelve (5.8%) patients required major amputation at 30 days. One-year freedom from major amputation was 84.1% (Figure 2). Thirty-day postoperative stroke, MI, and death were 0.5%, 0.5%, and 2.4%, respectively. Median operative time was 3.3±1.1 h. Median length of hospitalization was 3±3.9 days.
Conclusions: EVH minimizes saphenectomy wound complications without compromising patency and limb salvage rates. Older studies suggesting lower patency rates after EVH may have been limited by older technology and inexperienced operators. Whether EVH should be standard of care for LE bypass warrants further investigation.
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