The Role of Endoscopic Vessel Harvesting in Vascular Surgery

What are the main benefits you have experienced by incorporating Endoscopic Vessel Harvesting (EVH) during vascular surgical procedures?

Hani Slim: "Thank you so much Sophie for inviting me to talk about Endoscopic Vein Harvesting. It's a pleasure and honor to present my findings about Endoscopic Vein Harvesting in bypass surgery. I have to say, just a quick introduction of myself, I work at King's College Hospital. We have got a keen interest in limb preservation, and we have got an outstanding unit when it comes to open revascularization for the limbs by the lower and upper limbs. And this is mainly through open bypass techniques.

I have mainly done all my leg bypasses for the last three years using Endoscopic Vein Harvesting. Every single patient who presented to my unit over the last three years that required a bypass, whether it's a leg or an arm, they were done using Endoscopic Vein Harvesting only. So, there was no bias selection in these cases. And I have to say the benefits I've seen over the last three years with Endoscopic Vein Harvesting were enormous. But I can summarize it into three main categories. There is the surgical benefits, the patients benefits, and last but not least and most important is the graft outcome benefits.

Speaking about the surgical benefits. I have realized within Endoscopic Vein Harvesting you minimize the need to do wounds and incisions by more than 98%. The average leg bypass will require a vein conduit of around 80 centimeters length. This is because we need to bypass from femoral-popliteal or popliteal-distal, and as such you will need a lengthy continuous vein conduit. To achieve or to have such a long conduit you will need also to do a similar length wound incision, so a femoral-popliteal bypass will require us to do an incision that starts in the groin, and goes all along the middle aspect of the thigh and the calf, almost to mid-calf, in order to take the vein to create the new bypass. This in itself will create enormous amount of complications for patients compared to the Endoscopic Vein Harvesting technique, where all I need is a 3 centimeter incision to harvest the entire length of the vein that is required for any bypass. So, the 1st and the most important benefit is the length of the incision and tissue dissection required with it. Also, the amount of time required to harvest the vein is as long as the open technique, if not even faster. So, there were no differences and with it, I had no conversion from the endoscopic to the open technique in any of the cases.

It goes without saying, if you have far much less tissue dissection and incisions, the amount of complications of the wound is significantly less. With an open harvest wound, it is well known the complication rates is up to around 20% and this will be for wound infections, to break down of edges with necrosis - You name it. Well with Endoscopic Vein Harvesting, we had zero complication in any of the wounds we have created. There have been only few bruises, but that's about it and the amount of pain that comes with this minimum incision does not compare to the amount of pain of the open vein harvest. The other patients will require constant analgesics for weeks to follow with our Endoscopic Vein Harvesting, the amount of analgesics that required is negligible. It's only related to the bypass ones and not to the harvest wound. Also, with having little wounds, the amount of blood loss is almost none where with an open technique you will have significant amount of blood loss that even requires blood transfusion post-op.

More from the surgical technique, I was able to harvest any vein in the body for my bypasses no matter how long, how small or how thin caliber it is. So, I've harvested veins from all over the body. I harvested the Great Saphenous Vein in most of the bypasses. Short saphenous vein for those who lost their veins in the past for other surgeries or for varicose veins. I harvested cephalic veins, basilic veins, jerky mini veins, and even bifid systems, which considerably comes thinner in quality. And all were harvested without any issues at all. So, this is a huge surgical benefit that I have seen from Endoscopic Vein Harvesting.

When we are talking about patient benefit, of course the patient with such less wounds will recover far much quicker. So, the impact on them from comorbidities is significantly less. We've noticed that they can mobilize much faster and can be discharged home much sooner than compared to open technique. We've noticed they develop far, much less comorbidities, such as heart attacks or acute renal failure or even the need for blood transfusion, compared to the open technique. And I think this might be related to the less amount of pain they had and less amount of opiates they had or painkillers they had, that have impacted their kidneys in one way or another. Also, the patient satisfaction was completely different to those on open technique, and in our unit some of my colleagues do the open technique and you can easily see a patient who had an open surgery sitting next to a patient with Endoscopic Vein Harvesting. How fast and how fast the recovery is and how satisfied the patient is with his smaller incisions he had from the Endoscopic Vein Harvesting. Also, we've noticed that they are far much lower risk of developing lymph edema because you don't tend to dissect the lymphatics in the groin while harvesting the Great Saphenous Vein. And most important, and this is the key point, I want to focus on patient benefits, is that when we looked at the mortality rate, as we do with all our studies, I've realized that when the mortality rate for the Endoscopic Vein Harvesting bypasses patients were only 2.5% compared to normally, which is around 12% in the same cohort of patients I had, when I used to do the open harvest technique. And the 12% is more or less similar to worldwide studies, which ranges between 10 to 15%. So, I'm not entirely certain why they had significantly less one year mortality, but it was clear evidence that this is something to take notice of. When we talk about bypasses, we speak about the impact benefit on the graft, i.e. Is this technique good for the vein or is it going to damage the vein? And the way to assess this is what we call the outcome at a year of its patency rate. And we measure the patency rate in the primary patency and the secondary patency rate. And also, we looked into the numbers of patients that might have lost their leg if the grafts became blocked with time. And I was very pleased and surprised to find that the primary patency rate is 72% compared to my traditional open harvesting of around 54%. And the secondary patency rate is 90%, which is outstanding. And it is as strong as any results from worldwide studies on open harvesting bypass surgery results. The major amputation rate for blocked graft was only that of 2.5%, which is also an excellent result. So, all in all, the test for the graft durability was very good, taking into consideration that the bypasses we've done were complex bypasses, not selective and fem-popliteal, so the fem-popliteal bypasses were only 1/4 of the cases. The majority were those of distal and ultra-distal bypass, which means the tibial and the pedal vessels, which are more challenging and smaller, and these are the true grafts that test the durability of such conduits. So, all in all, the benefits on all fronts, the surgical, the patients, and the graft outcome is significant and enormous."

During what types of procedures do you utilize Endoscopic Vessel Harvesting (EVH)?

Hani Slim: "I have utilized EVH in every single bypass I needed to do over the last three years. So, any patients presenting to the unit that requires a limb bypass, whether it's a leg bypass or an arm bypass for critical ischemia or for aneurism disease or for any other disease, I utilized Endoscopic Vein Harvesting. 90% of the bypasses were for the leg bypasses and these were all different levels from femoral-popliteal, to popliteal to distal and tibial bypasses and pedal bypasses. And by default, the division of these bypasses is around 23% were popliteal bypasses, 40% were tibial bypasses, and around 37% were pedal bypasses. There is another 8% where for upper limb and these are bypasses to either axillary or brachial and also a lot were for palmar arch bypasses, and we are one of the unique centers worldwide that do such ultra complex bypasses to the palmer arch for critical upper limb ischia. I've also utilized EVH with other form of bypasses, so I've done it in aortic to mesenteric artery bypass. And I've done it in a carotid-to-carotid bypass, where it was very, very helpful as well because you spare the patient big dissections and big scars in the legs. But most important, I've also utilized the Endoscopic Vein Harvesting in different settings, so I've used it in elective bypasses as well as in emergency bypasses. And it is then, when I realized how important Endoscopic Vein Harvesting is in open surgery."

How do you see the role of Endoscopic Vessel Harvesting (EVH) evolving in vascular surgery?

Hani Slim: "I have no doubt that the role of Endoscopic Vein Harvesting is only going to increase significantly as we go forward. I have presented, and my team have presented, the data of our Endoscopic Vein Harvesting results for the last three years in three international major conferences. The first was for the Vascular Society of Great Britain and Ireland, it was presented in Dublin last year. As well as we presented in the United Emirates Vascular Society International Conference also last year. And more recently, I presented the complete data in the combined 10th International Kings as well as the 18th International Wound Symposium in Turkey, just recently. And every single vascular surgeon who was in the audience was extremely, interested in the results and very encouraged by what we presented. The interest in moving forward and switching from open to Endoscopic Vein Harvesting, you can clearly see it in all the new vascular surgeons, who are very keen to come and learn and they were very keen to come and visit, to see how we do it. And I think to move things forward, we will start courses about how we utilize the Endoscopic Vein Harvesting as part of the MINOR-approach, which I have no doubt it will revolutionize the way we approach open surgery overall."