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Three Part Question

For [patients requiring coronary artery bypass grafting with limited conduit] does [the short saphenous vein] have an acceptable [patency]?

Clinical Scenario

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.

Search Strategy

Medline 1950 to May 2007 using OVID interface.
[short saphenous.mp OR lesser saphenous.mp].

Search Outcome

Using the reported search, 347 papers were identified of which nine papers provided the best evidence to answer the question. These papers are summarised.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Foster et al, 1989 USA	28 patients for 6 years, and underwent recatheterization during the study period	cohort study (level 3b)	Graft patency at 6 years	graft patency of short saphenous vein 65% In comparison it was 93% for IMA , 10% for upper extremity veins	Very small study
Raess et al, 1986, USA	6 patients were subjected to lesser saphenous veins harvest preoperative venogram performed	Case series report (Level 4)	Patency	Lesser and greater saphenous vein patency similar	Very small report with inaccurate patency reporting
Crosby et al, 1975 USA	The lesser saphenous vein used in three patients All had greater saphenous vein absent due surgical stripping Bilateral venogram performed	Case series report (Level 4)	Patency at angiogram	All grafts were open after 4 months	Case report of 3 patients
Salerno et al, 1984 Canada	Three patients With bilateral varicose vein stripping Age between 51 and 55 Bilateral venogram For short saphenous	Case series report (Level 4)	Clinical outcome	free of symptoms	None of the patients had been recatheterized for graft visualization at the time of publishing this paper
Wang et al, 2005 China	7 pieces of lesser saphenous vein from 6 patients	Case series (Level 4)	Intraoperative patency	All patent and useable at operation	No angiographic follow up. Chinese language article
Lamphere et al, 1995 USA	10 patients who had short saphenous vein harvesting	Case report (Level 4)	Clinical outcomes	Descriptive report that the patients did well	No clinical details about patient progress or angiography. This was a report of a new technique for harvest
Chang et al, 1993 USA	34 Lesser saphenous veins explored ( 31 useable) Case control study of 23 patients with lesser SV and long SV	Case control and case series (Level 4)	Operative outcome	No clinical differences between two groups	No angiography follow up data
			Complications	One lesser SV wound infection
Goyal et al, 2002 USA	21 patients with limb-threatening ischemia requiring popliteal-crural bypass who had lesser saphenous vein bypass.	Retrospective case series (Level 4)	Lesser saphenous vein patency	12 months 89% 24 months 77%	Length of short saphenous vein not reported but looked on their diagrams to be quite short.
			Limb salvage	100% at 24 months
			Complications	One evacuation of haematoma. One death from cva day 40
Shandall et al, 1987 USA	36 patients undergoing pre-operative lesser saphenous vein duplex ultrasound then use as a popliteal to distal artery bypass		Internal diameter of vein	2.8mm to 4.2mm	No objective assessment of post-operative patency
			Clincial outcomes	Verbally described as favourable

Comment(s)

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 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., Crosby and Craver, Salerno and Charrette, Wang et al. and Lamphere et al. 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. 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. reported a 77% two-year patency for popliteal-crural bypasses in patients having surgery for limb salvage. Shandall et al. 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. 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.

Clinical Bottom Line

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.

References

1. Foster ED, Kranc MA. Alternative conduits for aortocoronary bypass grafting. Circulation 1989; 79:I34–I39.
2. Raess DH, Mahomed Y, Brown JW et al. Lesser saphenous vein as an alternative conduit of choice in coronary bypass operations. Ann Thorac Surg 1986; 41:334–336.
3. Crosby IK, Craver JM. The lesser saphenous vein. An alternative graft for coronary revascularization. Ann Thorac Surg 1975; 6:703–705.
4. 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.
5. Wang LQ, Hu SS, Wang X et al. 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.
6. Lamphere JA, Daily PO, Moreno RJ et al. New technique for lesser saphenous vein harvesting. Ann Thorac Surg 1995; 60:1829–1830.
7. Chang BB, Ferraris VA, Sadoff J et al. Alternative conduits for coronary revascularization: a novel approach for harvest of the lesser saphenous vein. Cardiovasc Surg 1993; 1:280–284.
8. Goyal A, Shah PM, Babu SC et al. Popliteal-crural bypass through the posterior approach with lesser saphenous vein for limb salvage. J Vasc Surg 2002; 36:708–712.
9. Shandall AA, Leather RP, Corson JD et al. Use of the short saphenous vein in situ for popliteal-to-distal artery bypass. Am J Surg 1987; 154:240–244.