Anatomic
and functional study of residual autogenous greater saphenous vein after
harvest for carotid patch angioplasty
(Portuguese
PDF version)
Cláudio
Jacobovicz1, Jamal J. Hoballah2,
John D. Corson2, Iseu Affonso Costa3,
Henrique Jorge Stahlke Jr.4, Luís Henrique Gil França5
1.
Vascular Surgeon, Division of Vascular Surgery, Hospital de Clínicas,
Universidade Federal do Paraná, Curitiba, PR, Brazil.
2. Professor of Vascular Surgery, Hospital and Clinic, University
of Iowa, USA.
3. Professor, Cardiovascular Surgery Discipline, Hospital de
Clínicas, Universidade Federal do Paraná, Curitiba,
PR, Brazil.
4. Doctor. Adjunct Professor. Coordinator of the Angiology
and Vascular Surgery Courses, Hospital de Clínicas, Universidade
Federal do Paraná, Curitiba, PR, Brazil.
5.
Vascular Surgeon. Post-graduate in Surgical Clinic, Universidade Federal
do Paraná, Curitiba, PR, Brazil.
Correspondence:
Dr. Cláudio Jacobovicz
Rua Gutemberg, 216/61
CEP 80420-030 - Curitiba - PR
Brazil
Phone: +55 (41) 232.0722
E-mail: claudioj@bbs2.sul.com.br
ABSTRACT
Objective:
The purpose of this study is to assess the preservation of patency,
length and caliber of the residual greater saphenous vein after
partial proximal (thigh region) and distal (ankle region) harvest
for carotid patch angioplasty and to determine the possibility of
reusing it in any subsequent arterial procedure.
Methods: Thirty-one patients were studied after surgery of
the carotid artery using greater saphenous vein patch angioplasty
between July 1992, and January 1995, at the University of Iowa Hospitals
and Clinics, United States. Twenty-six patients with partial proximal
harvest (Group A) and five with partial distal harvest (Group B)
underwent a postoperative color duplex ultrasound scan of the residual
greater saphenous vein. The greater saphenous vein was studied in
both lower limbs and the caliber of the patent segments were recorded
at the groin, midthigh, knee, midcalf and ankle.
Results: The two groups were comparable in terms of length of
vein removed, preserved usable vein, minimum and maximum diameter.
Only two patients in Group A (7.69%) and one in Group B (20%) had
some loss of length. All of them were men, older than 77 years.
There was no patient with patency of venous segment lower than 2
mm in diameter.
Conclusion: Partial proximal or distal harvest of the greater
saphenous vein for carotid patch angioplasty has a low index of
length loss (9.67%). Although a segment of the greater saphenous
vein is used to patch the carotid artery, there is still significant
remaining length of usable vein in most patients to allow long bypass.
Key-words:
greater saphenous vein, carotid endarterectomy, patch angioplasty.
Palavras-chave: veia safena, endarterectomia das carótidas,
angioplastia.
J
Vasc Br 2003;2(4):296-302
Extraordinary
advances in vascular surgery can be attributed, in part, to an improved
knowledge and utilization of grafts in the reconstruction of arteries
and diseased veins. Even though autografts, homografts, heterografts
and synthetics have their specific importance for salvaging limbs, organs
and/or human life, the perfect vascular substitute has not yet been
found. There are certain problems that compromise the function of vascular
grafts. Surface thrombogenicity, deterioration of the biological grafts
and susceptibility to infections, principally in synthetics, still occur.
The ideal vascular graft should possess the following characteristics:
biocompatibility, non-thrombogenicity, durability, imitation of the
vessel in which it was implanted, resistance to infections and a facility
for implantation. Carrel & Guthrie (1906) clearly established the
importance of the transplanted autogenic vein for arterial circulation
in experimental studies 1.
Decades have passed since the first operation using the greater saphenous
vein (GSV) in the treatment of femoropopliteal artery disease was published.
The use of the autogenic greater saphenous vein in reconstructive operations
of small- medium diameter arteries or its use as an arterial patch are
currently recognized throughout the world as a first choice 3-6.
Its advantages over other grafts and synthetics increase in the performance
of long arterial bypass surgeries and in more distal anastomoses, contrasting
with the results that are obtained from using other sources of the autogenic
vein, expanded polytetrafluoroethylene (PTFE) and Dacron, principally
in infragenicular positions 7.
The use of the greater saphenous vein, currently very valued, is limited.
This vein can be varicose, sclerosed, or present other characteristics
that impede its use as a graft or arterial patch. In these cases, other
sources should be used, such as the lesser saphenous vein of the arms
(basilic and cephalic), or the contralateral or residual ipsilateral
GSV 4,6,8,9. The use of these alternatives sources
is usually limited by their diameter and length, creating a need for
one or more venous anastomoses for the confection of more appropriate
grafts 10,11.
After endarterectomies or carotid artery surgeries, closure with the
patch is indicated to reduce possible residual or late stenoses.
Few surgeons disagree that the autologous GSV presents the best theoretical
and concrete advantages. It is easy to handle and confection into a
patch, allows for excellent hemostasis and has an endothelium
cell surface. Some disadvantages are the possible complications at the
location of the withdrawal, discomfort (due to an additional incision
in the lower limb), and the possibility that the GSV may be needed for
future arterial bypass surgeries 12,13. The evaluation
of the GSV after partial proximal or distal removal that is utilized
as a patch in carotid artery surgery is of extreme importance,
as is its anatomical and functional post-removal characteristic.
This study has the following objectives: a) evaluate the anatomical
and functional characteristics of the remaining GSV after partial proximal
(thigh region) and distal (ankle region) harvest for carotid angioplasties
(the evaluation is performed using a vascular echo-Doppler); b) confirm
the possibility of residual GSV use for later arterial surgeries.
PATIENTS
AND METHOD
The study
involved 31 patients who were submitted to carotid artery surgery and
needed a arteriotomy closure venous patch. The surgery was performed
by the Division of Vascular Surgery at the University of Iowa, in Iowa
City of the United States between July 1992 and January 1995. Nine patients
were females and 22 were males. Thirty were submitted to carotid artery
endarterectomy, and only was in re-operation after a carotid subclavian
bypass. In all of the cases, the venous segment removed for carotid
artery angioplasty came from the greater saphenous vein in the thigh
regions (26 patients) and the ankle (five patients). Patients submitted
to the removal of the branch segment, or double system GSV carriers
were not included in this study. The medical examination chosen for
the anatomic and functional evaluation of the GSV (as well its possible
use for future arterial procedures) was the vascular echo-Doppler (Acuson
128 XP color duplex ultrasound scanner Acuson Corporation, Mountain
View, California). The linear transducers that were used for the procedure
operated at a power of 7.5 Megahertz (effective penetration of 4 cm).
Researchers from the Vascular Surgery Division of the University of
Iowa Hospitals and Clinics performed all the examinations. The author
of this article (Cláudio Jacobovicz), as well as a group of registered
vascular technologists from the same department, also assisted in the
operations. The examinations were performed between February 1995 and
February 1996. During the procedure, the patients remained in a supine
position, in proclive at 30 degrees, and with the lower limbs in external
rotation. The GSV system was thoroughly evaluated in both of the lower
limbs, with the diameters measured at five separate points: the inguinal
region (4 cm beneath the ligament), the thigh, the knee, the leg and
the ankle (4 cm above the malleolar prominence). The distance between
the incision made for the removal of the GSV used in the confection
of the carotid patch and the beginning of the patent remaining venous
system was measured (up to 5 cm considered normal). The lengths of both
the incision and the patent or occluded GSV grafts were evaluated. When
the residual GSV was removed from the proximal (thigh region) and distal
(ankle region) segment for carotid angioplasty, it was divided into
three classes: a) Patent, with a normal diameter; b) Patent, with a
highly reduced diameter to be used as an arterial substitute (diameter
2 mm less than that of the echo-Doppler, which normally underestimates
the real diameter by 1 mm); c) Occluded (when it was not possible to
visualize the patent vein between the two permeable segments or between
the surgical incision and the beginning of the patent segment).
The Student's t test was used for independent samples, taking into consideration
the homogeneity of variances confirmed by the non-parametric Mann-Whitney
test. The test was applied (1) because it does not demand from the variable
the condition of normality, and (2) because the difference in the size
of Groups A (n = 26) and B (n = 5). The Fisher Exact Test 14,15
was used to evaluate the proportions. In all of the tests, the significance
level adopted was 5% (0.05).
RESULTS
In Group
A (segment of the greater saphenous vein removed from the thigh region)
the age of the patients varied between 51 and 81 years (with an average
of 67.6) and in Group B (GSV removed from the ankle region) between
60 and 80 years (with an average age of 68.2). The follow-up varied
between three and 39 months for Group A (average of 20.6) and in Group
B between three and 36 (average of 18.2).
Table 1 shows the main variables analyzed in this study. The first variable
contrasts the length of the segment of the greater saphenous vein removed
from Groups A and B. Two patients from Group A and one from Group B
were submitted to the removal of the venous segment for myocardial revascularization
surgery together with carotid surgery. The second variable is the patent
GSV segments after the proximal (Group A) and distal (Group B) segment
harvest. The third variable refers to the proportion of the remaining
patent segment of the GSV in Groups A and B in relation to total potential
(100%). The other variables evaluate the minimum and maximum diameters
of the residual GSV in relation to the two groups.
 Table
1- Variables of Groups A and B regarding the greater saphenous vein
(GSV)
 |
| Variable
|
Group
A |
Group
B |
|
| Segment
removed* |
14.61
cm ±3.11 |
19.60
cm± 19.83 |
| Length
of the residual segment† |
54.42
cm ±12.36 |
54.20
cm± 20.52 |
| Proportion
of the remaining patent segment of the GSV‡ |
77.75%
±8.08 |
73.98%±
24.08 |
| Minimum
diameter of the GSV§ |
3.21
mm± 0.59 |
3.00
mm± 0.14 |
| Maximum
diameter of the GSV|| |
4.14
mm± 0.90 |
3.76
mm± 0.57 |
|
*P
= 0.14 ( there is no statistically significant difference obtained from
the Mann-Whitney test).
†P = 0.37 (there is no statistically significant difference
obtained from the Mann-Whitney test).
‡P = 0.24 (there is no statistically significant difference
obtained from the Mann-Whitney test).
§P = 0.40 (there is no statistically significant difference
obtained from the Mann-Whitney test).
¦P = 0.35 (there is no statistically significant difference
obtained from the Mann-Whitney test).
Table 2
displays the anatomic-functional characteristic of the remaining GSV
in relation to the permeability and caliber in Group A (n = 26).
Table
2- Permeability and caliber of the GSV in Group A
|
| Permeability
and Caliber |
Frequency |
|
| Normal
diameter |
24
(92.31%) |
| Diameter
of less than 2 mm |
0
(0.00%) |
| Occluded
|
2
(7.69%) |
| Total
|
26 |
|
Among
the patients, 92.31% presented a remaining GSV with an adequate diameter
after the partial proximal harvest, without losses.
Two patients (7.69%) had a loss of 38 and 22 cm. These two patients
were 77 and 78 year-old males who both suffered from hypertension.
No patient presented a patent GSV segment with a diameter of less than
2 mm.
Table 3 displays the same condition as it relates to Group B (n = 5).
Table
3- Permeability and caliber of the GSV in Group B
|
| Permeability
and Caliber |
Frequency
|
|
| Normal
diameter ) |
4
(80% |
| Diameter
of less than 2 mm |
0
(0%) |
| Occluded
|
1 (20%) |
| Total
|
5 |
|
|
Eighty
percent of the patients presented a remaining GSV with an adequate diameter
after the partial distal harvest, without losses. One patient (20%)
had a loss of 21 cm. This patient was an 80 year-old male who suffered
from hypertension. Not one patient presented a patent segment of the
remaining GSV with a diameter of less than 2 millimeters. There is no
statistically significant difference between Groups A and B according
to the Fisher Exact Test (P = 0,42).
Table 4 displays the anatomical-functional condition of the patent residual
GSV in relation to length in Group A (n = 26).
Table
4- Length of GSV in Group A
|
| Length
of GSV |
Frequency
|
|
| Less
than 30 cm |
1
(3.85%) |
| Between
31 and 45 cm |
4
(15.38%) |
| Between
46 and 60 cm |
10
(38.46%) |
| Longer
than 61 cm |
11
(42.30%) |
| Total
|
26 |
|
The only
patient that displayed a patent residual venous segment with a length
of less than 30 cm had been previously submitted to myocardial revascularization
surgery that involved the use of the ipsilateral GSV.
Of the four patients that presented a residual GSV segment of between
31 and 45 centimeters, two were submitted to myocardial revascularization
surgery together with carotid artery surgery. For the other two patients,
there was GSV segment loss after the partial proximal harvest.
Table 5 displays the same data for Group B (n = 5).
Table
5 - Length of GSV in Group B
|
| Length
of GSV |
Frequency |
|
| Less
than 30 cm |
1
(20%) |
| Between
31 and 45 cm |
1
(20%) |
| Between
46 and 60 cm |
0
(0%) |
| Longer
than 61 cm |
3
(60%) |
| Total
|
5 |
|
The patient
that displayed a patent residual venous segment with a length of less
than 30 cm had been previously submitted to myocardial revascularization
surgery. For the only patient that presented loss after the partial
distal harvest, the residual vein segment was 31 and 45 cm after the
surgery. There is no statistically significant difference between Groups
A and B according to the Fisher exact test (P = 0.56).
DISCUSSION
Carotid
artery surgery is one of the most commonly practiced arterial surgical
procedures in the United States and in other developed countries.
In July 1993, the American Heart Association organized a consensus conference
for the modernization of carotid artery surgical practices, principally
in terms of indications. Current indications for the surgery were outlined
at the conference through multidisciplinary study (vascular surgeons,
neurologists and neurosurgeons). The determining factors were the symptomology
of the patient, the surgical risk and the level of experience of the
surgeon. This type of surgery is currently considered to provide a better
result than clinical treatment when properly indicated (proven in symptomatic
patients with stenosis equal or superior to 70%), and when performed
by experienced surgeons 16.
There is still no consensus among surgeons in relation to the benefit
of using the patch in carotid artery surgery. Many advocate angioplasty
with the patch as a sound alternative in relation to primary
closure, citing the following advantages: lower incidence of thrombosis,
perioperative CVA, reversible ischemic neurological deficit, and later,
recurrent carotid artery stenosis 17.
Hertzer et al. gave an account of a perioperative cerebral vascular
accident in 1.30% of the 1273 patients submitted to venous angioplasty
of the carotid artery. This result is compared with 3.30% in the patients
submitted to carotid angioplasty using synthetic materials, and also
those submitted to primary arteriotomy closure closure 18.
Dardik et al. reported on the use of everted cervical veins in the confection
of the patch for carotid artery surgery. The results were comparable
with those of the GSV in relation to moderate and severe stenosis in
five years. They defend the use of everted cervical veins to preserve
the GSV and also as a way to avoid incisions in the lower extremities
19.
The autologous GSV utilized as a patch in carotid artery surgery causes
little peri- and postoperative bleeding, is handled with facility and
is less thrombogenic than synthetics due to the presence of the endothelial
surface 13. However, it requires an additional incision
in the lower limb, which can be associated with scarring.
The ideal material for arteriotomy closure after carotid artery surgery
should be strong and durable, readily usable, resistant to infections,
and should serve as a source of endothelial cells for the operated segment.
It is hoped that these characteristics reduce the risk of thrombosis,
embolism, and later, recurrent stenosis. If the ideal material for the
arterial patch does not exist, the greater saphenous vein appears
to currently be the most favorable option.
In terms of its use as an arterial substitute, it is considered a first
choice (principally in the lower limbs). Frequently, studies report
permeability in five years between 75% and 85% in the femoropopliteal
position, with several advantages compared to synthetics 20.
Due to their high importance, many surgeons approve of the use of synthetics
in a supragenicular position in order to salvage the GSV for future
arterial procedures 21. On the other hand, there are
those that believe that the GSV should also be considered a first choice
in these cases 22.
In a comparative study, Rutherford et al. (1990) demonstrated that the
partial proximal and distal harvest of the GSV presented similar results
in terms of the parameters and diameters of the patent segment (79%
and 93% of patients, respectively, presented a remaining patent GSV
segment greater than 30 cm). However, when compared with the high ligature,
the preservation of the GSV is smaller 23.
The main question of this study is whether the proximal (in the thigh
region) or distal (in the ankle region) harvest should be used as a
patch in carotid artery surgery, particularly for patients that
present systemic atherosclerosis disease. In the future, these patients
may require another arterial surgical procedure and the anatomical and
functional condition of the GSV (residual the partial proximal or distal
harvest) is of particular importance.
Factors such as diameter, thickness of the venous wall and post-harvest
morbidity should always be evaluated at the moment of surgery.
Perhaps the most important observation of the present study was the
excellent anatomical and functional preservation of the GSV after partial
proximal (Group A) and distal (Group B) harvest. Of the 31 patients
evaluated, only three (9.67%) presented venous segment loss. Two patients
in the partial removal at the thigh level (7.69%) with a loss of between
38 and 22 cm, and one patient in the removal at the ankle level (20%)
with a loss of 21 cm. Therefore, 92.31% of the patients submitted to
partial proximal harvest and 80% submitted to distal harvest presented
an excellent preservation of the greater saphenous vein.
Of the three patients that experienced venous segment loss, all were
males between the ages of 77 and 80 years that suffered from systemic
arterial hypertension. This study found no relationship between venous
segment loss and the other factors related to atherosclerosis (diabetes
mellitus, smoking and hyperlipidemia). There were no statistically significant
difference between the two groups in terms of the size of the surgical
incisions, the patent vein segments, or the minimum and maximum diameters
of the residual veins. The main importance is not in the comparison
between the two groups, but in the positive permeability indicators
of the remaining segment.
The total potential of the GSV (100%) in both groups was superior to
74%. It should be noted that three patients were submitted to myocardial
revascularization surgery together with the carotid artery endarterectomy.
In these patients, the harvest of the GSV segment was consequently larger
and with a smaller residual segment.
None of the patients presented a patent segment with a diameter of less
than 2 mm when measured with the echo-Doppler. This device normally
underestimates the real measurement by 1 mm. Three millimeters is considered
the minimum diameter for the vein if it is to be used as an arterial
substitute.
Approximately 30 cm in venous length is necessary for the supragenicular
femoropopliteal arterial bypass, 45 cm for the infragenicular femoropopliteal
bypass and 60 cm for the femoral-tibial bypass. By using the second
or third segment of the profound femoral artery as the location of the
proximal anastomosis whenever possible, these measurements can be reduced
by 10 cm.
Of the patients in Group A, 96% had a patent residual GSV segment greater
than 30 cm and with an excellent anatomical and functional characteristic.
Comparatively, in Group B this number was 80%. There were no statistically
significant differences between the two groups.
Even though many surgeons considered patients that were submitted to
a previous partial GSV harvest as an indication for the use of other
grafts for arterial surgeries, this is not demonstrated in the present
study. The great majority of patients present a remaining GSV segment
with an adequate length and anatomical and functional characteristics.
Many of these patients suffer from diffuse disease. Therefore, at least
some of these patients many need other arterial surgeries in the future,
whether they be peripheral or not. In these cases, the ideal solution
would be to map the residual GSV in the preoperative stage using an
echo-Doppler. This is a non-invasive exam and is of great importance.
The exam allows for the visualization of the entire length of greater
and lesser saphenous veins and also allows for the study of the profound
venous system from the lower vena cava to the peroneal veins. Criteria
for obstruction and reflux can be evaluated, and not including radiation,
it is the ideal exam for serialized studies 24. By
using the exam, one can avoid unnecessary explorations that consume
time and can cause scarring, which is more common in patients that suffer
from diabetes, obesity and smoking 25.
CONCLUSION
The partial
harvest of the greater saphenous vein at the thigh level (proximal)
or at the ankle level (distal) for venous carotid angioplasty presents
an excellent anatomical and functional preservation of the remaining
venous segment. In addition, its previous utilization as a patch for
carotid angioplasties does not exclude its use in future arterial procedures.
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