Compromised Bypass Graft Outcomes after Minimal-Incision Vein Harvest

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Thomas E. Brothers, MD, Rana Pullatt, MD, Jacob G. Robison, MD, Bruce M. Elliott, MD.
Medical University of South Carolina, Charleston, SC, USA.

BACKGROUND: Minimal incision techniques for vein harvest may lessen wound complications after lower extremity revascularization, but long term patency and limb salvage data are lacking.
METHODS: A retrospective case-control study was performed of all patients undergoing lower extremity revascularization using reversed autogenous greater saphenous vein (GSV) by a single vascular surgeon over the last decade. Outcome measures consisted of Kaplan-Meier life table and cumulative sum failure (CUSUM) analysis of patency and limb salvage collected from a prospective computerized vascular registry supplemented by retrospective chart review.
RESULTS: The technique of reversed GSV harvest through a long single incision (SI, n=133) was gradually abandoned in favor of multiple limited incisions with (n=85) or without (n=106) endoscopy. On preliminary analysis, endoscopy did not affect outcomes, so all limited incision patients were evaluated as a single group (MinI, n=191). No differences were observed between MinI and SI patients for demographic data, risk factors, or primary indications (claudication 5% v 8%, rest pain 29% v 28%, tissue loss 50% v 54%). Bypass was performed more frequently to the popliteal artery in MinI patients (38% v 20%, P<0.01), while pedal/tibial bypasses of popliteal origin were less common (22% v 40%, P<0.01) Despite a lower proportion of distal bypass grafts, five year primary patency (38% v 60%, P<0.01) and limb salvage (59% v 75%, P<0.05) were worse after MinI vein harvest, and disadvantaged secondary patency (51% v 66%, P<0.07) approached, but did not attain, statistical significance. Especially among pedal/tibial bypasses, MinI harvest was inferior in primary (33% v 62%, P<0.01) and secondary (45% v 66%, P<0.05) patency and limb salvage (53% v 100%, P<0.001) No learning curve was evident by CUSUM for primary patency at 12 months. No difference in wound complications was observed (8% v 9%).
CONCLUSIONS: Graft patency and limb salvage deteriorated during the time when minimal incision techniques of GSV harvest with or without endoscopy were adopted. This observation raises concern regarding the advisability of limiting the extent of the incision at the potential cost of compromised outcomes, due perhaps to an increase in endothelial injury during procurement.

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