Hemodynamic effects of carbon dioxide insufflation during endoscopic vein harvesting

BACKGROUND: A prospective study was performed assessing the hemodynamic effects of carbon dioxide (CO2) insufflation during endoscopic vein harvesting (EVH) using the Guidant Vasoview Uniport system. METHODS: Five hemodynamic and respiratory parameters (end-tidal carbon dioxide, arterial partial pressure of carbon dioxide, mean arterial pressure, mean pulmonary arterial pressure, and cardiac output), were measured in 100 consecutive patients undergoing EVH with CO2 insufflation. Data were obtained prior to commencement of EVH, 15 minutes after commencement, and 5 minutes after completion of the vein harvesting. RESULTS: No adverse hemodynamic effects were observed during CO2 insufflation. Specifically, average mean arterial pressure went from 88.77+/-9.64 to 89.13+/-8.60 to 88.24+/-8.71 mm Hg before, during, and after endoscopic vein harvesting (p = 0.291). Likewise, average mean pulmonary artery pressures were 19.76+/-4.75, 20.05+/-4.48, and 20.05+/-4.62 mm Hg (p = 0.547); and average cardiac output was 4.25+/-0.74, 4.22+/-0.73, and 4.23+/-0.69 L/min (p = 0.109) at those three intervals. Additionally, there was no evidence of significant systemic absorption of CO2 as reflected in average arterial PCO2, which remained steady at 37.42+/-5.19, 37.51+/-4.59, and 38.10+/-4.80 mm Hg (p = 0.217); and average end-tidal CO2, which was 32.10+/-3.66, 32.50+/-3.47, and 32.38+/-3.33 mm Hg (p = 0.335). In a subset of 20 patients with elevated pulmonary arterial pressure (more than 32 mm Hg), there was also no significant change in any of the parameters. CONCLUSIONS: Carbon dioxide insufflation during EVH leads to no adverse hemodynamic consequences or systemic CO2 absorption. The technique appears to be safe and well tolerated.     

CO(2) embolism during minimally invasive vein harvesting.

CO(2) embolism is a known, though rare, complication of procedures using CO(2) insufflation. We report massive cardiac right atrial CO(2) embolism during minimally invasive harvesting of a varicose great saphenous vein. The patient's hemodynamics deteriorated significantly and needed to be stabilized by emergency institution of cardiopulmonary bypass. Causes of this rare but potentially lethal complication are discussed, as well as its prediction, diagnosis, and prevention.     

糖尿病患者行冠状动脉旁路移植术中应用腔镜采集大隐静脉的临床研究

目的探讨腔镜大隐静脉采集法(endoscopic vein harvesting,EVH)对糖尿病患者行冠状动脉旁路移植术(CABG)后恢复和桥血管再狭窄的影响。方法采用非随机临床对照研究的方法,纳入2010年12月至2012年2月华西医院行冠状动脉旁路移植术合并2型糖尿病的患者,按所采用的静脉桥血管采集方式,将患者分为腔镜大隐静脉采集法(EVH)组和开放大隐静脉采集法(CVH)组,评价两组患者围手术期并发症情况。随访期间采用介入或CT冠状动脉造影评价桥血管再狭窄情况。结果共纳入51例患者,其中EVH组24例,CVH组27例。两组患者年龄、体重、基础病变程度差异均无统计学意义。两组术中体外循环时间和主动脉阻断时间差异均无统计学意义[(67.2±9.8)min vs.(68.3±14.5)min,P>0.05;(62.4±11.3)min vs.(65.2±10.3)min,P>0.05]。两组患者术后主要并发症发生率差异无统计学意义。与CVH比较,EVH能显著缩短桥血管采集时间[(35.6±6.4)minvs.(45.2±11.4)min,P<0.05],降低腿部切口延迟愈合发生率[0.0%(0/24)vs.18.5%(5/27),P<0.05]。CVH组随访9.1个月,EVH组随访9.4个月。随访期间两组并发症(胸痛、大隐静脉再狭窄)发生率差异无统计学意义(P>0.05)。结论对于合并糖尿病行CABG的患者,EVH是一种安全有效、微创快速的桥血管采集方法。     

Carbon dioxide embolism during endoscopic saphenous vein harvesting in coronary artery bypass surgery

OBJECTIVES: Our objectives were to determine the incidence and severity and the time course of the CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation in coronary artery bypass surgery with transesophageal echocardiography monitoring. METHODS: Four hundred three consecutive patients scheduled for off-pump coronary artery bypass grafting surgery or femoral-to-popliteal artery bypass grafting surgery were prospectively studied. Multiplane transesophageal echocardiography with a new transgastric view was used to monitor CO(2) bubbles in the inferior vena cava and hepatic vein. RESULTS: CO(2) embolisms occurred in 17.1% of patients. Minimal, moderate, and massive CO(2) embolisms occurred in 13.1%, 3.5%, and 0.5%, respectively. The occurrence of moderate and massive CO(2) embolisms was frequently associated with the surgical manipulation of branches of saphenous veins. No significant risk factors were identified in multiple logistic regression analysis. CONCLUSION: The incidence of significant CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation procedures was more than 4%. Continuous transesophageal echocardiographic monitoring of the CO(2) bubbles in the inferior vena cava is essential in early detection and can help to prevent the development of significant CO(2) embolisms in these patients.     

The back-approach technique of endoscopic saphenous vein harvesting in coronary artery bypass grafting

PurposeOne of the concerns during endoscopic saphenous vein harvesting (EVH) in coronary artery bypass grafting (CABG) is injury to the vein or its branches. The cutting edge of bipolar electrocautery scissors, used to divide the side branches of the saphenous vein, can cause vascular injury leading to reduced graft patency. We have developed a novel back-approach technique using a C-ring to divide the wide side branches of the saphenous vein during EVH. The aim of the study was to describe the technique and assess early outcomes of EVH using this technique. The back-approach technique is as follows: (a) insert the C-ring near the target branch, (b) push the C-ring over the proximal aspect of the target branch, (c) twist the C-ring forward to capture the target branch, and (d) cut the target branch by bipolar electrocautery.MethodsWe investigated 169 patients, including 35 women (mean age 70.1 ± 8.9 years), who underwent CABG at our hospital, using a novel EVH technique. The patients were categorized as those who underwent EVH (EVH group, n = 44) or open vein harvesting (OVH) (OVH group, n = 125). This method involves the creation of a small incision (2 cm), sufficient saphenous vein dissection near the skin incision, adequate dissection to separate the vein from the surrounding tissues, and the back-approach technique with C-ring to divide the side branch of the saphenous vein. The primary endpoint was the graft patency rate, and the secondary endpoints were leg wound complications and length of hospitalization.ResultsNo significant intergroup difference was observed in early patency of saphenous vein graft patency (OVH vs. EVH = 94.7 vs. 95.6%, p = 0.763). The incidence of lower extremity wound lymphorrhea was significantly lesser (OVH: EVH = 16.0: 0.0%, p = 0.005) and the length of hospitalization was also significantly shorter in the EVH group (OVH vs. EVH = 24.2 ± 9.8 vs. 19.0 ± 5.3 days, p = 0.001).ConclusionsEVH, using the back-approach technique, showed satisfactory short-term results; therefore, this technique performed with C-ring might be effective for vein harvesting during EVH.     

Endoscopic greater saphenous vein harvesting reduces the morbidity of coronary artery bypass surgery

BACKGROUND: Most coronary artery bypass grafting (CABG) operations still involve the use of greater saphenous vein (GSV) for one or more grafts, even with the increasing use of arterial conduits for coronary revascularization. Wound complications from GSV harvesting are common, and sometimes severe. In order to reduce the morbidity of this procedure, we adopted a technique of endoscopic vein harvesting (EVH). EVH allows nearly complete harvest of the GSV, with excellent visualization, through minimal incisions. At our institution, a physician's assistant routinely performs EVH, usually while a cardiothoracic surgeon harvests an arterial conduit. In 1997, all GSV harvesting was performed by open technique. During a transition period in 1998 and 1999 we used several different endoscopic techniques. By the beginning of 2000, our technique of EVH was standardized and used routinely. METHODS: To determine whether EVH reduced the morbidity associated with conventional open vein harvesting (OVH), we reviewed the charts of all patients having primary coronary artery bypass operations utilizing GSV during the years 1997 and 2000. RESULTS: The two groups were comparable in risk factors for leg incision complications. The year 2000 EVH group had a marked reduction in the number of wound complications compared with the year 1997 OVH group (7.1% versus 26.1%, P < 0.00001). There were no significant differences between the two groups in total operative time (OVH 224 minutes, EVH 223 minutes, number of distal coronary anastomoses (OVH 3.38 +/- 0.90, EVH 3.38 +/- 0.94), or the rate of clinically apparent early graft failure. There was a significant increase in the use of sequential grafting techniques in the 2000 group (OVH 21.9%, EVH 43.6%, P < 0.00001). CONCLUSIONS: EVH reduced the morbidity associated with GSV harvesting. EVH was associated with an increased use of sequential coronary grafting techniques. EVH does not prolong operative time when performed by experienced personnel. We believe EVH should become the standard of care.     

Prospective analysis of endoscopic vein harvesting

BACKGROUND: Utilization of bridging vein harvesting (BVH) of saphenous vein grafts (SVG) for coronary artery bypass grafting (CABG) results in large wounds with great potential for pain and infection. Endoscopic vein harvesting (EVH) may significantly reduce the morbidity associated with SVG harvesting. METHODS: A prospective database of 200 matched patients receiving EVH and BVH was compared. The patients all underwent CABG done over a period of 4 months (April to August 2000). Patients were excluded if they had prior vein harvesting. RESULTS: The EVH and BVH group included 100 patients each with similar demographics. The patients in the EVH group had significantly fewer wound complications, mean days to ambulation, and total length of stay (P <0.05). There was no difference in harvest time or vein injuries. CONCLUSION: Endoscopic vein harvesting results in significantly fewer wound complications, decrease in days to ambulation, and the total length of stay. EVH is superior to BVH in patients undergoing CABG.     

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

内窥镜游离与全程切开法静脉桥血管通畅率的初步研究

目的 比较冠状动脉旁路移植术(CABG)中内窥镜与全程切开法采集大隐静脉后静脉桥血管近、中期通畅率,分析影响静脉桥血管通畅率的危险因素.方法 回顾性分析解放军总医院2006年5月至2009年5月择期行CABG中采用内窥镜游离法制备大隐静脉60例(EVH组)的临床资料,其中男34例,女26例;年龄66.6±9.2岁.同期...     

Carbon dioxide and argon gas embolism during laparoscopic hepatic resection

During laparoscopic hepatic resection, an abrupt decrease in FE'CO(2) (from 28 mmHg to 9 mmHg) associated with near cardiac arrest occurred concomitantly with hepatic vein laceration and the use of an argon beam coagulator system. During venous gas embolism, transesophageal echocardiography (TEE) proved the transpulmonary passage of the gas. In the post-operative period, the patient developed pulmonary edema and made a full recovery after 5 days. This is a case report of a possible paradoxic carbon dioxide (CO(2)) and argon gas embolism by transpulmonary passage during laparoscopic hepatic resection.     

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases

Background Endoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients’ acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH). Methods Between March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28–89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO₂) insufflation. Results Technical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients. Conclusion The findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.     

A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery.

BACKGROUND: The purpose of this study was to determine whether or not endoscopic vein harvest is a reliable, beneficial, and cost-effective method for saphenous vein harvest in coronary bypass surgery (CABG). METHODS: A total of 100 patients having primary CABG were prospectively randomized to either endoscopic (EVH; n = 47) or open saphenous vein harvest (OVH; n = 50). Three patients in the EVH group required both techniques and were excluded from analysis. RESULTS: The groups did not differ in preoperative characteristics, including: age, gender, left ventricular function, height, weight, percent over ideal body weight, incidence of diabetes, peripheral vascular disease, or preoperative laboratory values (creatinine, albumin, or hematocrit). The EVH group had longer vein harvest and preparation times than the OVH group, while the incision length was significantly shorter. There was no difference between groups in mortality, perioperative myocardial infarction, intensive care unit or postoperative length of stay, blood product utilization, or discharge laboratory measures. There was more drainage noted from leg incisions at hospital discharge in the OVH (34%) versus EVH group (8%; p = 0.001), but more ecchymosis in the EVH group. Although there was a trend towards reduced leg incision pain in the EVH group, there was no statistically significant difference in pain or in the quality of life measure at any point in time. There was no difference between groups in readmission to hospital, administration of antibiotics, or incidence of leg infection. While mean hospital charges for the EVH group were approximately $1,500 greater than for OVH, this difference did not reach statistical significance. CONCLUSIONS: EVH is a safe, reliable, and cost-neutral method for saphenous vein harvest. The best indication for EVH may be in patients who are at increased risk for wound infection and in those for whom cosmesis is a major concern.     

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

BACKGROUND: Although the use of endoscopic vein harvest (EVH) in coronary artery bypass grafting is accepted, few studies have documented the implementation of EVH in peripheral vascular disease surgery. We hypothesized that EVH improves outcomes compared with open vein harvest (OVH) in patients undergoing femoral to below the knee arterial bypass surgery. METHODS: The charts of 144 consecutive patients undergoing infrainguinal bypass surgery over the course of 27 months were reviewed. A femoral to below the knee arterial bypass with saphenous vein was done in 88 patients (29 had EVH, 59 had OVH). The preoperative characteristics evaluated were age, gender, renal function, history of diabetes, hypertension, tobacco use, and previous infrainguinal bypass surgery on the affected side. End points included wound complications, length of hospital stay, operative time, angiographic and operative interventions for graft occlusion, patency rates, limb salvage, acute renal failure, myocardial infarction, and death. RESULTS: Patient characteristics and demographics were similar in the EVH and OVH groups. No operative intervention for occlusion was required in the EVH group (0/29) compared with 13.4% in the OVH group (8/59) (P = .03). At the mean follow-up time of 21 months, primary patency rate was 92.8% in the EVH group and 80.6% in the OVH group (P = .12). No significant differences were found between the EVH and OVH groups in postoperative complications, length of hospital stay, operative time, patency rates, limb salvage, and death. CONCLUSION: Despite our initial concerns of damaging the venous conduit with a minimally invasive approach to saphenous vein harvest, EVH in our experience has resulted in a trend toward improved patency rates and decreased infectious wound complications while affording the benefit of improved cosmesis. An endoscopic approach results in smaller incisions, decreased interventions for occlusion, and improved outcomes compared with OVH. EVH is the procedure of choice for harvesting saphenous vein for femoral to below the knee arterial bypass surgery.     

Early experience of endoscopic vein harvesting for CABG

Objectives As the traditional method of saphenous vein harvesting is associated with nagging leg wound problems, we tried to incorporate this relatively new technique of endoscopic vein harvesting (EVH) in to our regular coronary artery bypass grafting (CABG) Programme. Methods Selected patients (based on affordability, obesity, availability of operator and vein quality on inspection) were offered endoscopic vein harvesting (EVH) for CABG. Vasoview 6 (Guidant, U.S.A) Endoscopic dissector was used with carbon dioxide insufflation. As this was our initial experience, only thigh veins were tried. If additional veins were required or the endoscopically harvested veins were of unacceptable quality, additional vein was harvested by open method. Impacts on cost and operative time, discard rate and leg wound complications were noted. Results We have so far attempted EVH on 86 patients. In one (first), the whole vein had to be discarded and in two others, parts of the vein were not used. Additional vein harvesting was done in 4 patients. EVH was converted to Vein stripping in one patient due to bleeding while branch division and poor visibility. No leg wound complications occurred in any of these patients. Additional time spent was approximately 45–50mts in the first few patients. Of late this has reduced to 25–30 mts. Additional material cost was Rs.3000 per patient. Conclusion With experience, EVH can be a valuable additional tool in the CABG set up with the advantage of reduced leg incision and consequent reduction in leg wound problems with minimal increase in the operative time and cost.     

Endoscopic vein harvest: advantages and limitations

BACKGROUND: Although long saphenous vein remains the most commonly used conduit in coronary revascularization, traditional open vein harvest (OVH) may lead to significantly impaired wound healing and postoperative pain. Endoscopic vein harvest (EVH) attempts to reduce this morbidity and improve patient satisfaction with no compromise in outcome. METHODS: From September 2000 to November 2001, 108 saphenous vein harvests were prospectively randomly assigned to EVH (n = 52) or OVH (n = 56); EVH was performed with the Clearglide endoscopic vein harvest system (Cardiovations) by a single surgeon. Endpoints included impaired wound healing (ASEPSIS score), operative and harvest time, vein quality (including histology), outcome and postoperative pain (Visual Analog Scale). Follow-up was as long as 3 years. RESULTS: The groups were well matched demographically. Endoscopic vein harvest was quicker to perform if sufficient vein for two grafts was needed (p < 0.01). Wound healing was significantly impaired (ASEPSIS score) in the OVH group compared with the EVH group (p < 0.01). The new procedure did not prolong the overall operative time (p = 0.77). Postoperative pain was less (p < 0.01) in the EVH group. Stepwise multiple regression showed age, diabetes, peripheral vascular disease, total operative time, type of procedure, length of incision, and number of vein grafts to be predictive of impaired wound healing. More late interventions were needed in the OVH group for wound-related morbidity. CONCLUSIONS: These data demonstrate that endoscopic vein harvest results in fewer cases of impaired wound healing and reduced postoperative pain, and it does not prolong the operative time significantly nor compromise the vein quality. Furthermore, it is quicker to perform if two grafts are needed, and it reduces late interventions.     

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

OBJECTIVE: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.     

Endoskopische Saphenektomie in der Koronarchirurgie

Despite increasing establishment of total arterial revascularization of the myocardium, the great saphenous vein remains an essential component of coronary bypass surgery. Until recently, the conventional technique of open vein harvesting (OVH) and its advancement, the so-called bridge technology, were standard techniques in bypass surgery. In appreciation of minimally invasive surgery, the endoscopic vein harvesting (EVH) was developed. Especially in consideration of cosmetic results and patient contentment but also within regard to frequency and severity of postsurgical wound complication and infection, EVH presents an appealing alternative to extraction of graft material for myocardial revascularization. Controversy on quality and long-term patency of EVH graft material continues. However, recent trials were not able to show a significant difference with regard to patient outcome and bypass patency. Therefore, the EVH technique is currently considered to be a safe alternative to conventional OVH. However, in light of today??s heterogeneous data situation, further scientific studies are required in order to meet criteria for evidence-based medicine in this field.     

Endoscopic versus open great saphenous vein harvesting for femoral to popliteal artery bypass

Objective

Conflicting data exist on outcomes of open vein harvest (OVH) and endoscopic vein harvest (EVH) for infrainguinal bypass. The purpose of this study was to compare outcomes between OVH and EVH in femoral to popliteal artery bypasses.

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

Abstract Objective: 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. Methods: 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. Results: 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. Conclusion: 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.     

Transesophageal echocardiographic diagnosis of carbon dioxide embolism during minimally invasive saphenous vein harvesting and treatment with inhaled epoprostenol

IMPLICATIONS: We describe a patient scheduled for coronary artery bypass who developed carbon dioxide (CO2) embolism with acute pulmonary hypertension during endoscopic saphenectomy. Transesophageal echocardiography was useful in the diagnosis of CO2 embolism and to assess response to inhaled epoprostenol.