Minimally invasive saphenous vein harvesting for coronary artery bypass grafting

Despite the steadily increasing use of arterial grafts, the greater saphenous vein remains the most commonly used conduit for coronary artery bypass grafting (CABG). Utilized sporadically in the late 1950s and early 1960s, saphenous vein use for coronary artery bypass grafting increased exponentially in the 1970s and 1980s. Patency rates following coronary bypass grafting using saphenous vein have been reported to be 78%, 65%, and 57%at 1, 5, and 10 years respectively [1]. The saphenous vein has been proven versatile, has provided reliable results, and remains central to the conduct of surgical revascularization of the heart. Traditionally, the greater saphenous vein has been harvested via a continuous or near continuous incision on the medial aspect of the lower extremity [2]. This approach is attractive in several ways as it provides excellent exposure, is rapid, does not require specialized equipment, and can be carried out by team members with basic surgical skills such as physician's assistants and surgical trainees. Unfortunately, complications such as wound infections and seromas are frequently associated with the long incisions required for the open technique. Wound infection rates from 14% to 26% have been reported [3-5] and overall complication rates as high as 43%have been described [6]. Co-morbidities such as obesity, peripheral vascular disease, and diabetes are all associated with increased wound complication rates and are prevalent in this patient population. The high rate of complications associated with lower extremity vein harvest incisions is not unexpected given the debilitated, aging population of patients currently undergoing coronary artery bypass surgery. The highly varied rates of complications reported in studies of saphenous vein harvest may be explained by differing definitions of complications, duration and quality of follow-up, and variations in patient population and surgical technique. Because the majority of complications related to lower extremity harvest incisions develop after hospital discharge, studies without formal follow-up often underestimate wound complications. The high complication rate associated with saphenous vein harvest and the growing trend to less invasive surgical techniques has motivated cardiac surgical teams to explore ways of minimizing the morbidity associated with traditional saphenous vein harvest. Endoscopic vein harvest was reported by Lumsden in 1994 [7] and has slowly gained acceptance in the practice of cardiac surgery. This chapter will outline the techniques, benefits, and limitations of minimally invasive vein harvest techniques for use in coronary artery bypass surgery (Table 39.1).