Interact CardioVasc Thorac Surg 2007;6:783-785. doi:10.1510/icvts.2007.163956
© 2007 European Association of Cardio-Thoracic Surgery
Best evidence topic - Cardiac general |
What is the patency of the short saphenous vein when used for coronary artery bypass grafting?
Samuel Jacoba,*,
Antonios Kallikourdisa,
Hussein El-Shafeia and
Joel Dunningb
a Department of Cardio-thoracic Surgery, Aberdeen Royal Infirmary, Aberdeen, AB25 2ZN, UK
b Department of Cardio-thoracic Surgery, James Cook University Hospital, Middlesbrough, UK
Received 25 July 2007;
accepted 26 July 2007
*Corresponding author. Tel.: +44 (0)7710272021; fax: +001 281 2403244.
E-mail address: drsamueljacob{at}doctors.org.uk (S. Jacob).
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Abstract
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A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was what the patency of the short saphenous vein is, when used for coronary artery bypass grafting. Altogether 347 papers were found using the reported search, of which nine represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that small reports give a two-year patency of 77% and a six-year patency of 65% and duplex studies show that the short saphenous vein may be from 2.8 mm to 4.2 mm in diameter. However, caution should be applied when considering these patency rates as they are derived from individual studies of <40 patients. The lesser saphenous vein may be considered as an alternative to brachial or cephalic vein in patients with unsuitable long saphenous vein, and unsuitable mammary, radial or gastroepiploic arteries.
Key Words: Evidence-based medicine; Short saphenous vein; Lesser saphenous vein; Thoracic surgery; Coronary artery bypass
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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For [patients requiring coronary artery bypass grafting with limited conduit] does [the short saphenous vein] have an acceptable [patency]?
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3. Clinical scenario
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You are seeing a 67-year-old diabetic patient who had coronary artery bypass grafting 15 years ago. He felt that his last operation had transformed his life but now he presents with aortic stenosis with a gradient of 130 mmHg. He had five grafts in total the last time and both long saphenous veins were harvested, as the left side was documented as having been ‘too varicose to use in a young man’. Two vein grafts are patent but a graft to a large diagonal and the PDA are occluded with reasonable distal targets. Unfortunately the radials have no refill on Allen's testing and his diabetes makes you reluctant to use the right mammary artery. You wonder whether you could use the short saphenous vein to do the grafts for this operation.
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4. Search strategy
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Medline 1950 to May 2007 using OVID interface.
[short saphenous.mp OR lesser saphenous.mp].
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5. Search outcome
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Using the reported search, 347 papers were identified of which nine papers provided the best evidence to answer the question. These papers are summarised in Table 1.
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6. Results
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Despite the very wide search strategy of simply putting short saphenous or lesser saphenous into Medline, the range and quality of relevant papers was surprisingly poor. Also, in view of the fact that the lesser saphenous vein is often discussed as a last resort conduit but because most practicing surgeons will have at some stage either seen or used this technique on a few occasions, there are very few good quality reviews of their patency.
Foster and Kranc [2] reported the findings of angiography six years after short saphenous vein harvest in 26 patients. They reported a 65% patency which compared favourably with the upper limb vein patency of only 10%.
Reass et al. [3], Crosby and Craver [4], Salerno and Charrette [5], Wang et al. [6] and Lamphere et al. [7] all reported very small series of patients with successful lesser saphenous vein harvesting for coronary artery bypass grafting. However, their reporting of the success of the procedure was often based on clinical outcome and not angiography.
Chang et al. [8] reported the short-term clinical use of 31 lesser saphenous veins with favourable results, but postoperative angiography was not performed.
The short saphenous vein may also be occasionally used for vascular surgery. Goyal et al. [9] reported a 77% two-year patency for popliteal-crural bypasses in patients having surgery for limb salvage. Shandall et al. [10] performed duplex ultrasound on 36 lesser saphenous veins prior to popliteal bypass and found the diameter to be between 2.8 mm and 4.2 mm. They descriptively reported favourable outcomes. Several other papers described the use of the lesser saphenous vein for peripheral revascularisation but again this was only in a handful of patients and, thus, we elected not to add them to our table.
With regard to the operative technique of harvesting, a few different techniques exist. The more usual approach would be to have the hip flexed by an assistant, or alternatively the patient would be proned for harvest and then turned back over once harvest has been completed. Lamphere et al. [7] describe a neat little trick whereby the legs are elevated using a Thompson self-retaining retractor to about 45 degrees or more and the short saphenous vein harvested from below.
Chang et al. {Chang, 1993 30/id} also describe a novel technique whereby an incision is made and carried through and deep into the muscular fascia, posterior to the tibia, along the length of the leg, developing a fascial-cutaneous flap. Preoperative mapping and skin marking is used to find the vein.
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7. Clinical bottom line
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Small reports give a two-year patency of 77% and a six-year patency of 65% and duplex studies show that the short saphenous vein may be from 2.8 mm to 4.2 mm in diameter. However, caution should be applied when considering these patency rates as they are derived from individual studies of <40 patients. The lesser saphenous vein may be considered as an alternative to brachial or cephalic vein in patients with unsuitable long saphenous vein, and unsuitable mammary, radial or gastroepiploic arteries.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardiothoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003; 2:405–409.[Abstract/Free Full Text]
- Foster ED, Kranc MA. Alternative conduits for aortocoronary bypass grafting. Circulation 1989; 79:I34–I39.[Medline]
- Raess DH, Mahomed Y, Brown JW, King RD. Lesser saphenous vein as an alternative conduit of choice in coronary bypass operations. Ann Thorac Surg 1986; 41:334–336.[Abstract]
- Crosby IK, Craver JM. The lesser saphenous vein. An alternative graft for coronary revascularization. Ann Thorac Surg 1975; 6:703–705.
- Salerno TA, Charrette EJ. The short saphenous vein: an alternative to the long saphenous vein for aortocoronary bypass. Ann Thorac Surg 1978; 25:457–458.[Abstract]
- Wang LQ, Hu SS, Wang X, Xu JP, Wang W. Using the lesser saphenous vein as graft for coronary revascularization. Chung-Kuo i Hsueh Ko Hsueh Yuan Hsueh Pao Acta Academiae Medicinae Sinicae 2005; 27:496–498.
- Lamphere JA, Daily PO, Moreno RJ, Marcus S, Dembitsky WP, Adamson RM, Burr M, O'Neill P. New technique for lesser saphenous vein harvesting. Ann Thorac Surg 1995; 60:1829–1830.[Abstract/Free Full Text]
- Chang BB, Ferraris VA, Sadoff J, Shah DM, Leather RP, Berry WR, Klingman RR, Dal Col RH, Anene C. Alternative conduits for coronary revascularization: a novel approach for harvest of the lesser saphenous vein. Cardiovasc Surg 1993; 1:280–284.[Medline]
- Goyal A, Shah PM, Babu SC, Mateo RB. Popliteal-crural bypass through the posterior approach with lesser saphenous vein for limb salvage. J Vasc Surg 2002; 36:708–712.[Medline]
- Shandall AA, Leather RP, Corson JD, Kupinski AM, Shah DM. Use of the short saphenous vein in situ for popliteal-to-distal artery bypass. Am J Surg 1987; 154:240–244.[CrossRef][Medline]
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Abstract
1. Introduction