Defining the Learning Curve of the Endovascular In Situ Saphenous Vein Bypass: Operative Data from 115 Cases by Recently Trained Surgeons

Abstract

To record surgeons' results of endovascular in situ saphenous vein (EISV) bypasses during the learning curve phase, randomly selected patients were evaluated who were undergoing EISV bypass performed by surgeons who had been recently trained in the Side Branch Occlusion system. An independent observer recorded the technical details at each operation on a standardized data sheet that included: number of coils deployed, misdeployed coils, additional incisions required to occlude side branches, irrigation volume, vein preparation time, operative time, and technical complications. Operations were stratified into four subjective categories based on the technical aspects of the operation: (1) good results; (2) good results, minor technical issues; (3) good results, major technical issues; and (4) poor results. Sixty-four surgeons performed 115 EISV bypasses. Eighty-seven (76%) of the procedures were classified as either good results or minor technical problems. Major technical problems occurred in 10 patients, and 18 patients (15%) had poor results. Neither site of the distal anastomosis nor the saphenous vein length affected the technical success of the procedure. The average volume of irrigation was 3,000 mL and mean vein preparation time was 84 minutes (range 15-300 minutes). Coils were misdeployed in 59 (51%) cases, and 49 patients (42%) required additional incisions on the leg. EISV bypass offers significant theoretical advantages over open in situ vein bypass; however, it is challenging, and technical complications occurred in nearly 25% of cases during the learning phase. Aberrant venous anatomy poses the greatest challenge to the success of the EISV, and the ability of the surgeon to recognize and respond appropriately to these anomalies often dictates the success of the procedure. Further studies will be necessary to evaluate the clinical benefits of this new technique.

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References

1. Leather RP , Shah DJ , Chang BB , et al: Resurrection of the in situ saphenous vein bypass 1000 cases later. Ann Surg 208:435-442, 1988.

2. Calligaro KD , Friedell ML , Rollins DL , et al: A comparative review of in situ versus reversed vein grafts in the 1980s. Surgery 172:247-252, 1991.

3. Hall KV : The great saphenous vein used in situ as an arterial shunt after extirpation of the vein valves. Surgery 51:492-495, 1962.

4. Dardik H , Silvestri F , Rabinowitz D , et al: Preliminary experience with a self-centering, expandable valvulotome for in situ reconstruction. Vasc Surg 31:745-750, 1997.

5. Maini BS , Andrews L , Salimi T , et al: A modified, angioscopically assisted technique for in situ saphenous vein bypass: Impact on patency, complications, and length of stay. J Vasc Surg 17:1041-1049, 1993.

6. Reifsnyder T , Bandyk D , Seabrook G , et al: Wound complications of the in situ saphenous vein bypass technique. J Vasc Surg 15:843-850, 1992.

7. Johnson EA , Cogbill TH , Strutt PJ , et al: Wound complications after infrainguinal bypass: Classification, predisposing factors, and management. Arch Surg 123:859-862, 1988.

8. Kent EC , Bartek S , Kunta KM , et al: Prospective study of wound complications in continuous infrainguinal incisions after lower limb arterial reconstruction: Incidence, risk factors, and cost. Surgery 119:378-383, 1996.

9. Schwartz ME , Harrington EB , Schanzer H : Wound complications after in situ bypass. J Vasc Surg 7:802-807, 1988.

10.

10. Wengrovitz M , Atnip RG , Gifford RM , et al: Wound complications of autogenous subcutaneous infrainguinal arterial bypass surgery: Predisposing factors and management. J Vasc Surg 11:156-163, 1990.

11.

11. Rosenthal D , Herring MB , O'Donovan T , et al: Endovascular infrainguinal in situ saphenous vein bypass: A multicenter preliminary report. J Vasc Surg 16:453-458, 1992.

12.

12. Rosenthal D , Dickson C , Rodriguez FJ , et al: Infrainguinal endovascular in situ saphenous vein bypass: Ongoing results. J Vasc Surg 20:389-395, 1994.

13.

13. Piano G , Schwartz LB , Foster L , et al: Assessing outcomes, costs, and benefits of emerging technology for minimally invasive saphenous vein in situ distal arterial bypasses. Arch Surg 133:613-618, 1998.

14.

14. Horvath KD , Gray D , Benton L , et al: Operative outcomes of minimally invasive saphenous vein harvest. Am J Surg 175:391-395, 1998.