Asian Cardiovasc Thorac Ann 2000;8:146-149
© 2000 Asia Publishing EXchange Pte Ltd
Endoscopic Vein Surgery in Lower Extremities With VasoView System
Masayuki Hirokawa, MD, PhD,
Katsushi Oda, MD, PhD,
Akira Yamamoto, MD,
Hideaki Nishimori, MD, PhD,
Atsushi Hata, MD, PhD,
Takashi Fukutomi, MD,
Kunihiko Hirose, MD, PhD,
Shiro Sasaguri, MD, PhD
Department of Surgery II
Kochi Medical School
Nankoku, Kochi, Japan
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For reprint information contact: Masayuki Hirokawa, MD, PhD Tel: 81 888 80 2375 Fax: 81 888 80 2376 email: gea01265{at}nifty.com Department of Surgery II, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan.
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Abstract
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The VasoView system was used for endoscopic saphenous vein harvesting in 10 coronary artery bypass patients and for endoscopic subfascial division of perforating veins in 8 patients with varicose veins. In both procedures, the surface of the saphenous vein and the subfascial plane were dissected using the VasoView dissection cannula. An operative tunnel was subsequently created by inflating and deflating the balloon and maintained by carbon dioxide insufflation. The branches of the saphenous vein and the perforating veins were divided with bipolar scissors under endoscopic vision. In endoscopic saphenous vein harvesting, the mean graft length was 31.5 ± 7.5 cm and the mean number of skin incisions was 3 ± 1.2. In endoscopic subfascial division of perforating veins, 3.4 ± 1.7 veins were divided. The VasoView system is attributed with a decrease in complications after vein surgery in the lower extremities.
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Introduction
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As part of the trend towards minimally invasive surgery, endoscopic saphenous vein harvesting (ESVH) was developed to decrease morbidity resulting from traditional saphenous vein harvesting.1–3 ESVH involving endoscopic dissection and carbon dioxide (CO2) insufflation with the VasoView balloon dissection system (Origin Medsystems, Inc., Menlo Park, CA, USA) was introduced to obtain better visualization and easier manipulation. The VasoView system was also applied to endoscopic subfascial division of perforating veins (ESDP) in cases of lower leg varicose veins.
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Patients and Methods
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From March 1998 through February 1999, ESVH was performed in 10 coronary artery bypass patients (7 men, 3 women) with a mean age of 64.9 ± 5.3 years. ESDP was performed in 8 patients (1 man, 7 women; 9 legs) who were selected because of skin changes such as pigmen-tation or ulcer, resulting from varicose veins. The mean age was 63.8 ± 7.4 years. One patient had an active ulcer at the time of operation.
The VasoView system includes a balloon dissection cannula, an orbital dissection cannula, and bipolar endo-scissors (Figure 1
). The VasoView balloon dissection cannula is equipped with a translucent cone-shaped tip and a balloon (40 mL). The dissection cannula with an endoscope can create a working space by inflating and deflating the balloon while dissecting either the surface of the saphenous vein or the subfascial plane, under clear endoscopic vision.
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Figure 1. The orbital dissector with dissecting ring (upper) and the VasoView balloon dissection cannula.
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For ESVH, the patient was positioned supine with the legs in a slight frog-leg position. A 2.5-cm incision was made just above the knee and the saphenous vein was exposed under direct vision. The VasoView balloon dissection cannula with an extra-long 5-mm diameter endoscope was placed on the anterior surface of the saphenous vein through the skin incision and the course of the vein was easily identified under endoscopic vision (Figure 2A). The cannula was advanced gently and carefully along the vein by inflating and deflating the balloon while dissecting the anterior surface of the vein (Figure 3). The inferior surface of the saphenous vein was dissected by the same technique. Care was taken to avoid avulsion of branches under the vein because there are perforating branches into the muscle. A short blunt-tip trocar was inserted into the incision and the tunnel was inflated with CO2 gas to 12 mm Hg pressure to maintain the operative space. The saphenous vein with branches at both sides was exposed in the subcutaneous tunnel under endoscopic vision (Figure 2B). The saphenous vein was skeletonized with a ringed dissecting cannula and its branches were divided with either bipolar scissors or UltraShears (Autosuture; USSC, Norwalk, CT, USA). After dissecting the whole length of the saphenous vein, both ends of the vein were ligated and divided and the vein was removed. The harvested saphenous vein was used for grafts in coronary artery bypass surgery.
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Figure 3. During endoscopic saphenous vein harvesting, the surface of the saphenous vein is dissected with a VasoView balloon dissection cannula with an endoscope, while inflating and deflating the balloon.
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For ESDP, preoperative mapping of incompetent per-forating veins was obtained by color duplex scanning. The patient was positioned supine with the legs in a slight frog-leg position. A 2-cm incision was made below the knee and the subcutaneous fascia was exposed and incised under direct vision. The dissection cannula with an endoscope was inserted beneath the fascia and advanced to dissect between the fascia and the muscle under endoscopic vision. The perforating vein was easily viewed while dissecting the subfascial plane (Figure 2C
). A PDB balloon (Origin Medsystems, Inc., Menlo Park, CA, USA) was inserted into the subfascial plane through the incision and inflated to dilate a space. A short blunt-tip trocar was inserted into the incision and the subfascial cavity was inflated with CO2 gas to 12 mm Hg pressure. Under CO2 insufflation, perforating veins in the subfascial space were clearly identified and divided with UltraShears (Figure 2D). After dividing all perforating veins identified, a 3-cm incision was made in the groin and the saphenofemoral junction was dissected. The great saphenous vein was stripped from the leg incision below the knee in the usual fashion. A drain was inserted into the subcutaneous space following removal of the saphenous vein.
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Results
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In ESVH, the mean graft length was 31.5 ± 7.5 cm, there were 3 ± 1.2 skin incisions, and the duration of the harvesting procedure was 53.5 ± 19.8 minutes (range, 25 to 80 minutes). Of the 10 grafts harvested, 7 were used for coronary artery bypass procedures. The early graft patency rate was 100%. One patient had a subcutaneous hematoma in the thigh. No wound infection or delayed healing were seen after ESVH.
In ESDP, a mean of 3.4 ± 1.7 perforating veins were divided, the operating time was 159 ± 34 minutes, and blood loss was 46.3 ± 81.8 mL. All patients also had saphenous vein stripping and one patient underwent simultaneous bilateral ESDP. There were 3 complications related to ESDP: one subfascial hematoma with calf pain and 2 cases of dysesthesia in the area of distribution of the saphenous nerve. The patient who had an active ulcer achieved complete ulcer healing (Figures 4A and 4B) and remained healed at 3 months after the operation.
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Figure 4. A venous ulcer in the lower leg (A) before and (B) after endoscopic subfascial division of perforating veins (ESDP).
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Discussion
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The VasoView system developed for endoscopic saphe-nous vein harvesting in coronary artery bypass grafting enables comprehensive endoscopic surgery as distinct from other complex video-assisted systems.1–3 Either the surface of the saphenous vein or the subfascial plane was dissected with the VasoView balloon dissection cannula that was equipped with a translucent cone-shaped tip and a balloon. Operative spaces were subsequently created by inflating and deflating the balloon and maintained by CO2 insufflation. The balloon inflation-deflation technique significantly expedited the dissection process. CO2 insufflation gave an expanded space to locate either the branches of the saphenous vein or the perforators, so that manipulation of the instruments was improved. There was no incidence of severe subcutaneous emphysema or other complications due to CO2 insufflation.
After harvesting the saphenous vein using the conventional longitudinal skin incision, complications such as wound dehiscence, wound infection, and chronic edema fre-quently occur. Utley and colleagues4 reported a wound complication rate of 24.3% after the standard method of saphenous vein harvest. This study showed that wound complications after the endoscopic technique were decreased, the length of the skin incision was shorter, and postoperative scarring was less conspicuous (Figure 5) after the endoscopic procedure compared to the conven-tional method.
Direct ligation of incompetent perforating veins as described by Linton5 was reported to be effective in healing ulcers and decreasing symptoms of chronic venous insufficiency. However, it is associated with significant wound complications such as delayed wound healing, skin necrosis, and wound infection. Despite the intro-duction of an endoscopic technique for subfascial division of perforating veins to decrease such complications, in conventional endoscopic approaches, blunt dissection of the subfascial plane might cause damage to the perforators, resulting in difficulty of endoscopic viewing.6–8 Moreover, in the subfascial space, the visual field of the surgeon is insufficient without CO2 insufflation. Gloviczki and colleagues9 introduced ESDP with CO2 insufflation and the use of a tourniquet, but they insufflated CO2 to a pressure of 30 mm Hg. The technique used in this series requires neither a tourniquet nor a high pressure of CO2. The advantages of this technique are that it does not damage the perforators while dissecting the subfascial plane with the use of the optical dissection cannula, and it can maintain an extensive operative space with CO2 insufflation at a pressure of 12 mm Hg that avoids missing the perforators. Using this technique, the number of incisions is reduced to 2, one in the groin and one below the knee, resulting in effective treatment while reducing patient discomfort.
It was concluded that the VasoView balloon dissection system readily and quickly created an operative space for endoscopic vein surgery in the lower extremities. A decrease in wound complications, reduced morbidity, and excellent cosmetic results in both saphenous vein harvesting and subfascial division of perforating veins are attributed to the use of this system.
Presented at the 7th Annual Meeting of The Asian Society for Cardiovascular Surgery, Singapore, May 28–31, 1999.
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References
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Tevaearai HT, Mueller XM, Segesser LK. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg 1997;63:S119–21.
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Pagni S, Ulfe EA, Montgomery WD, VanHimbergen DJ, Fisher DJ, Gray LA, et al. Clinical experience with the video-assisted saphenectomy procedure for coronary bypass operations. Ann Thorac Surg 1998;66:1626–31.[Abstract/Free Full Text]
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Utley JR, Thomason ME, Wallace DJ, Mutch DW, Staton L, Brown V, et al. Preoperative correlates of impaired wound healing after saphenous vein excision. J Thorac Cardiovasc Surg 1989;98:147–9.[Abstract]
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Linton RR. The communicating veins of the lower leg and the operative technic for their ligation. Ann Surg 1938; 107:582–93.[Medline]
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Pierik EGJM, Wittens CHA, Urk H. Subfascial endoscopic ligation in the treatment of incompetent perforating veins. Eur J Vasc Endovasc Surg 1995;9:38–41.[Medline]
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Abstract
Introduction
