Minimally invasive endoscopic video-assisted in situ bypass: first 15 cases

The purpose of the present study was to determine the feasibility of endoscopic video-assisted (EVA) in situ bypass with greater saphenous vein (SV) for femorotibial revascularization. Fifteen consecutive patients who underwent EVA lower extremity revascularization were included in the present report. EVA in situ bypass was successfully accomplished in 12 of 15 (80%) patients. Two patients had major SV injuries (endoscopic scissors), and 6 patients had minor SV injuries (dissecting ring, clip applicator, valvulotome). Postoperatively, 2 patients developed subcutaneous abscesses in the thigh graft tunnel, and 5 patients developed minor calf wound necrosis. Eight of 12 (67%) EVA in situ bypasses were patent at 6- to 32-month follow-up (mean, 24 months), and 2 of 12 (17%) patients died with patent EVA in situ bypasses; one other patient experienced EVA in situ bypass thrombosis 6 months postoperatively without further surgical treatment. Ten of 12 (83%) patients who underwent EVA in situ bypass had successful surgical outcomes, and 11 of 12 (92%) avoided major amputation; 1 patient eventually required below-knee amputation because of nonhealing foot lesions despite a patent EVA in situ bypass. We conclude that EVA in situ bypass with SV is a practical technique for limiting the length and number of incisions necessary to completely eliminate SV tributaries. On the basis of experience gained from the present series, we recommend the following: 1) strategic placement of the initial small skin incisions to maximize exposure of the SV and inflow/outflow arteries; 2) beginning gas insufflation into the perivenous space during initial SV dissection, rather than after creation of the perivenous tunnel; 3) no transection of clipped SV tributaries with the endoscopic scissors; 4) minimal use of the dissecting ring to expose the SV and its tributaries, instead using continuous gas insufflation and the balloon dissector; and 5) completion angiography to inspect the bypass graft and runoff.