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Background: Endoscopic saphenous vein harvest has been explored as a minimally invasive alternative to a long continuous leg incision for removal of the greater saphenous vein. The endoscopic technique uses limited incisions (2-4) with extended "skin bridges" and videoscopic equipment for the dissection and removal of the greater saphenous vein. This study was undertaken to evaluate the long-term durability of saphenous vein grafts harvested by an endoscopic technique and used for lower extremity arterial revascularization., Methods: All patients who underwent endoscopic saphenous vein harvesting for lower extremity arterial bypass grafting were prospectively followed for graft patency and risk factors. Grafts were surveyed with serial duplex scans at 3- to 6-month intervals over this 5-year study. Life-table methods were used to assess graft survival. A computerized registry and medical records were reviewed to determine graft patency and patient survival., Results: From September 1994 to August 2000, 164 lower extremity arterial saphenous vein grafts harvested by an endoscopic technique were used for lower extremity arterial bypass grafting in 150 patients. The patient population included 111 males (75%) and 112 smokers (75%), but also included a high-risk cohort of 65 diabetic patients (43%) and 15 patients undergoing dialysis/renal transplant (10%). Twenty-eight patients (19%) died within the study period. With life-table methods, 1-, 3-, and 5-year secondary patency rates were 85% (+/- 3.2%), 74% (+/- 5.7%), and 68% (+/- 11.6%). Of the 30 failed grafts, 7 (4%) failed in the first month related to inadequate runoff (4), cardiac instability (2), and an additional surgical procedure (1). Twenty-three grafts (14%) failed between 1 and 42 months. Twenty-two (16%) of these 134 patent grafts underwent a second procedure to maintain patency (13 as primary-assisted patency and 9 as secondary patency)., Conclusions: Endoscopic saphenous vein harvest for lower extremity arterial reconstruction provides a satisfactory conduit for lower extremity bypass grafting. Although increased manipulation from this limited access technique may incite an injury response in the vein, these vein grafts can maintain an adequate patency for lower extremity bypass grafting.

Introduction: Percutaneous transluminal angioplasty with stenting (PTAS) has been considered a potential alternative to carotid endarterectomy (CEA) for stroke prevention. Interventionalists have suggested that PTAS carries less anesthetic risk than CEA. The treatment of carotid stenosis with local or regional anesthesia (LRA) allows direct intraprocedural neurologic evaluation and avoids the potential risks of general anesthesia., Methods: We retrospectively analyzed the clinical charts of 377 patients who underwent 414 procedures for the elective treatment of carotid stenosis in 433 cerebral hemispheres with LRA between August 1994 and May 1997. Group I (312 hemispheres) underwent PTAS, and group II (121 hemispheres) underwent CEA., Results: The indications for treatment included the following: asymptomatic severe stenosis (n = 272; 62.8%), transient ischemic attack (TIA; n = 100; 23.1%), and prior stroke (n = 61; 14.1%). The early neurologic results for the patients in group I (n = 268) included 11 TIAs (4.1%), 23 strokes (8.6%), and 3 deaths (1.1%). The early neurologic results for the patients in group II (n = 109) included 2 TIAs (1.8%), one stroke (0.9%), and no deaths. The total stroke and death rates were 9.7% for the patients in group I and 0.9% for the patients in group II (P = .0015). The cardiopulmonary events that led to additional monitoring were evident after 96 procedures in group I (32.8%) and 21 procedures in group II (17.4%; P = .002)., Conclusion: PTAS carries a higher neurologic risk and requires more monitoring than CEA in the treatment of patients with carotid artery stenosis with LRA. The proposed benefit for the use of PTAS to avoid general anesthesia cannot be justified when compared with CEA performed with LRA.

Purpose: Saphenous vein harvesting remains a significant source of morbidity that occurs in 1% to 24% of patients who require lower extremity bypass or coronary artery bypass grafting. In an attempt to reduce complications associated with this procedure, we have used a new, minimally invasive technique to remove the greater saphenous vein., Methods: The video-assisted technique uses currently available video-endoscopic equipment with mechanical retraction to dissect the saphenous vein with two to three limited incisions. After initial vein exposure is accomplished through limited incisions, mechanical retraction is maintained with an endoplastic retractor or an endoscopic saphenous vein retractor. The dissection is visualized on the video monitor to isolate and control side branches, the vein is removed, and arterial bypass grafting is then accomplished as a reverse vein graft., Results: Between Sep. 1994 and July 1996, 65 patients underwent 68 arterial bypass operations in which the greater saphenous vein was harvested with video-assisted techniques. Indications for bypass grafting included 31 patients with ischemic ulceration, 23 with rest pain, 11 with claudication, and three with popliteal aneurysms. Of the 68 bypass procedures performed, 52 were to below-knee vessels, 22 of which included tibial or peroneal anastomoses. Sixty-four patients (98.5%) had no significant complications related to this video-assisted technique. For all patients, the average time-required to remove a 45 cm vein segment was 60 minutes. The average time using the more recently developed endoscopic saphenous vein retractor was 46 minutes. The median postoperative length of stay was 6 days. One patient had bleeding into the leg related to the video-assisted technique. Three patients (4.4%) required rehospitalization for wound care related to arterial access sites. Patency has been confirmed in 84% of grafts followed-up for a range of 1 to 24 months., Conclusions: In this report representing a series of unselected patients, video-assisted saphenous vein harvesting was technically feasible and had no immediate contraindications. The greater saphenous vein can be removed with minimally invasive techniques, leading to an acceptable morbidity rate, and is a satisfactory conduit for arterial bypass procedures. A prospective clinical trial may be justified to further evaluate the use of this technique in decreasing postoperative morbidity rates, shortening hospitalization, and improving patient care.