title: Technical modifications in endoscopic vein harvest techniques facilitate their use in lower extremity limb salvage procedures.
abstract: 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.
authors.affiliation: David Geffen School of Medicine at UCLA, Gonda (Goldschmied) Vascular Center, Los Angeles, CA 90095, USA.
authors.forename: Juan Carlos
authors.initials: JC
authors.lastname: Jimenez
authors.forename: Peter F
authors.initials: PF
authors.lastname: Lawrence
authors.forename: David A
authors.initials: DA
authors.lastname: Rigberg
authors.forename: William J
authors.initials: WJ
authors.lastname: Quinones-Baldrich
mesh_terms: D000368:Aged; D000783:Aneurysm / Q000503:physiopathology / Q000601:surgery*; D002140:California; D015331:Cohort Studies; D004502:Education, Medical, Continuing; D004724:Endoscopy / Q000009:adverse effects / Q000193:education / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006406:Hematoma / Q000209:etiology; D006801:Humans; D007511:Ischemia / Q000503:physiopathology / Q000601:surgery*; D023821:Limb Salvage / Q000009:adverse effects / Q000193:education / Q000379:methods*; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D012086:Reoperation; D012501:Saphenous Vein / Q000637:transplantation*; D013997:Time Factors; D020858:Tissue and Organ Harvesting / Q000009:adverse effects / Q000193:education / Q000379:methods*; D016896:Treatment Outcome; D014654:Vascular Patency; D014656:Vascular Surgical Procedures / Q000379:methods