Endoscopic Vein Harvest for Infrainguinal Vascular Reconstruction and Limb Salvage in Chronic Critical Limb Ischemia
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Introduction
Autogenous greater saphenous vein is the preferred conduit for infrainguinal vascular reconstruction, and the most commonly utilized venous conduit for coronary artery bypass grafting. Harvesting for these procedures has traditionally utilized a longitudinal continuous saphenectomy incision. Wound problems can be significant with this approach and bridging techniques evolved to lessen this complication.1–5 Endoscopic vein harvesting (EVH) was introduced in the 1990s and has now become the preferred method for greater saphenous vein harvesting in coronary artery bypass grafting.6 EVH for infrainguinal vascular reconstruction has not been as frequently reported. Nevertheless, there is compelling information that EVH for infrainguinal vascular reconstruction can be accomplished with a reduction in wound morbidity and yield satisfactory conduit performance.7–12
Our experience with EVH for coronary artery bypass grafting has been favorable, paralleling that of others.13,14 We expanded our application of this technique to infrainguinal vascular reconstruction after reviewing an initial limited experience with EVH, primarily in femoral to above-knee popliteal bypass grafting for activity limiting claudication. With this favorable experience, we incorporated EVH into infrainguinal vascular reconstruction in chronic critical limb ischemia (CLI). Intuitively, a minimally invasive approach in a patient population already in a compromised position for wound complications may preclude an additional risk. This report reviews this experience and details our observations with EVH in this challenging patient population.
Materials and Methods
All patients who underwent infrainguinal vascular reconstruction for activity-limiting claudication or limb salvage in chronic CLI between January 2004 and March 2006 were reviewed retrospectively from office and hospital records. All patients were evaluated by experienced interventionalists and a single surgeon, and all imaging studies were overread by a single interventionalist. No patients were referred for primary amputation until their evaluation was complete. Treatment plans were developed and often staged, requiring both percutaneous peripheral intervention (standard and cutting balloon angioplasty, stenting, laser or directional atherectomy, and cryoplasty) and open surgery (endarterectomy, bypass grafting).
Pre-operative evaluation included cardiac clearance with percutaneous coronary intervention (PCI) utilized when necessary for treatment of significant coronary artery disease (CAD) as opposed to coronary artery bypass grafting. Pulmonary function tests and serum creatinine were used to screen for pulmonary and renal co-morbidities, with pre-operative pulmonary rehabilitation and renoprotective measures instituted as indicated. Carotid duplex scanning identified hemodynamically-significant extracranial cerebrovascular disease with carotid endarterectomy performed when necessary. Carotid stenting was not utilized. All patients received pre-operative vein mapping of the greater and lesser saphenous vein systems. Operative approach was based on pre-operative imaging. This consisted of 64-detector computed tomography (CT) angiography with a specialized protocol to identify pedal outflow or conventional angiography, to include foot angiograms.
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