Lower limb edema after great saphenous vein harvesting to be used as graft in myocardial revascularization

Abstracts

BACKGROUND: Myocardial revascularization using the great saphenous vein is still a very common surgical procedure. The edema that occurs in the operated leg causes much discomfort and requires further studies. OBJECTIVES: To describe lower limb edema secondary to great saphenous vein harvesting using the bridge technique for use as venous graft in myocardial revascularization. METHODS: Forty-four individuals previously submitted to great saphenous vein harvesting for myocardial revascularization more than 3 months before were randomly selected. Patients with factors that might interfere with formation of lower limb edema were excluded. Both operated and non-operated legs were evaluated by volumetry and perimetry of the malleolar region. Differences greater than 50 mL or higher than 2 cm between the operated and the contralateral leg were considered as presence of significant edema. Chi-square, Fisher’s, McNemar’s and Student’s t tests were used for statistical analysis. Significance level was set at 5% (a = 0.05). RESULTS: Statistically significant differences (p < 0.05) were found between operated and contralateral legs, with 56.8% of the individuals having a difference in volume greater than 50 mL and 31.9% having a difference in malleolar region perimeter greater than 2 cm. There was no association between presence of edema and sample characteristics, surgery, perioperative or late clinical complications. CONCLUSIONS: Patients submitted to resection of the great saphenous vein for coronary artery bypass grafting may evolve with edema of the operated leg.

Edema; myocardial revascularization; diagnosis; complications

CONTEXTO: A revascularização do miocárdio utilizando-se a veia safena magna ainda é procedimento cirúrgico bastante realizado na atualidade. O edema que surge no membro inferior operado causa grande desconforto e necessita ser melhor estudado. OBJETIVOS: Caracterizar o edema de membro inferior secundário a exérese da veia safena magna pela técnica de incisões escalonadas para sua utilização como enxerto venoso na revascularização do miocárdio. MÉTODOS: Foram selecionados aleatoriamente 44 indivíduos submetidos a exérese de veia safena magna para revascularização miocárdica há mais de 3 meses. Excluíram-se fatores que pudessem interferir na formação de edema dos membros inferiores. Foram avaliados por volumetria e perimetria maleolares ambos os membros inferiores. Considerou-se como presença de edema significativo a diferença de volume maior que 50 mL e maior de 2 cm em relação ao membro não-operado. Para a análise estatística foram empregados o teste do qui-quadrado, teste exato de Fisher, teste t de Student e o teste de McNemar. O nível de significância adotado foi de 5% (a = 0,05). RESULTADOS: Encontraram-se diferenças estatisticamente significativas (p < 0.05) entre os membros operados e os não-operados, sendo 56,8% com volume maior que 50 mL e 31,9% com perímetro maleolar maior que 2 cm. Não se encontrou associação entre a presença do edema e características da amostra ou da cirurgia e de intercorrências clínicas perioperatórias ou tardias. CONCLUSÕES: Pacientes submetidos a ressecções de veia safena magna para sua utilização como ponte coronariana poderão apresentar edema no membro associado.

Edema; revascularização miocárdica; diagnóstico; complicações

ORIGINAL ARTICLE

Lower limb edema after great saphenous vein harvesting to be used as graft in myocardial revascularization

Cleusa Ema Quilici Belczak^I; José Maria Pereira de Godoy^II; Rubiana Neves Ramos^III; André Luiz Tyszka^IV; Sergio Quilici Belczak^V; Roberto Augusto Caffaro^VI

PhD student, General Surgery, Faculdade de Ciências Médicas, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil. Professor, Graduate Program in Lymphovenous Rehabilitation, Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, SP, Brazil

^IIPhD. Professor. Associate professor, Cardiology and Cardiovascular Surgery, Department of Surgery, FAMERP, So Jos do Rio Preto, SP, Brazil. Researcher, CNPq

^IIIPhysical therapist, Centro Vascular João Belczak, Maringá, PR, Brazil. Graduate program, Morphology and Research Teaching Methods, Universidade Estadual de Maringá (UEM), Maringá, PR, Brazil

^IVThoracic and cardiovascular surgeon. Former resident, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil

^VResident, Vascular Surgery, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo, SP, Brazil

^VIPhD. Associate professor, Vascular Surgery, Faculdade de Ciências Médicas, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, SP, Brazil

Correspondence

ABSTRACT

Background: Myocardial revascularization using the great saphenous vein is still a very common surgical procedure. The edema that occurs in the operated leg causes much discomfort and requires further studies.

Objectives: To describe lower limb edema secondary to great saphenous vein harvesting using the bridge technique for use as venous graft in myocardial revascularization.

Methods: Forty-four individuals previously submitted to great saphenous vein harvesting for myocardial revascularization more than 3 months before were randomly selected. Patients with factors that might interfere with formation of lower limb edema were excluded. Both operated and non-operated legs were evaluated by volumetry and perimetry of the malleolar region. Differences greater than 50 mL or higher than 2 cm between the operated and the contralateral leg were considered as presence of significant edema. Chi-square, Fisher’s, McNemar’s and Student’s t tests were used for statistical analysis. Significance level was set at 5% (α = 0.05).

Results: Statistically significant differences (p < 0.05) were found between operated and contralateral legs, with 56.8% of the individuals having a difference in volume greater than 50 mL and 31.9% having a difference in malleolar region perimeter greater than 2 cm. There was no association between presence of edema and sample characteristics, surgery, perioperative or late clinical complications.

Conclusions: Patients submitted to resection of the great saphenous vein for coronary artery bypass grafting may evolve with edema of the operated leg.

Keywords: Edema, myocardial revascularization, diagnosis, complications.

Introduction

Despite advances in endovascular surgery and more frequent use of angioplasty with or without stents, conventional surgery for myocardial revascularization using venous graft and the great saphenous vein is still widely performed worldwide. It is estimated that approximately 800,000 myocardial revascularizations are performed a year.^1-3 Complications that occur in the operated lower limb have been neglected and have certainly not been properly studied.^4-6

Although cares aiming to simplify the procedure reduce surgical trauma and make scars less esthetically visible in the long term, most of these patients have clinical events in the operated limb that cause discomfort and lead to search of specialized treatment.³ In daily angiologic practice, edema in the operated leg, whose manifestation does not always bring spontaneous complaint, is frequently higher than that reported in the literature.⁷ Some individuals usually develop episodes of lymphangitis and/or recurrent erysipelas, which certainly perpetuates and aggravates the edematous condition.^8-10

This study aims at investigating secondary edema in the lower limb submitted to great saphenous vein harvesting using staggered technique to be used as venous graft in myocardial revascularization.

Methods

In an observational and cross-sectional study, 44 patients submitted to myocardial revascularization using the great saphenous vein for venous graft through the staggered technique more than 3 months ago at Clínica de Cirurgia Cardíaca de Maringá (Brazil) were randomly selected. Participants signed a consent term after being informed of the purpose of this study, which was previously submitted to appraisal and further approval by the Ethics Committee of Faculdade de Ciências Médicas da Santa Casa de São Paulo.

Inclusion criteria were patients that had been submitted to myocardial revascularization using the great saphenous vein. Exclusion criteria were patients:

- whose incision was continuous and long from the inguinal region until the malleolus;

- that had the great saphenous vein harvested from both sides or that had been submitted to previous saphenous vein stripping of the contralateral limb, whether for treatment of superficial venous hypertension caused by varicose veins, or for use on distal arterial revascularization;

- that had edema of a different etiology, such as systemic causes (renal, thyroid, hepatic, dyscrasic, etc.) or locations (trauma, rheumatic and/or orthopedic diseases), or also with venous insufficiency in the lower limbs, represented by exuberant varicose veins with or without ulcers;

- that were currently taking diuretic or hormonal medication;

- that had ulcers or skin lesions with or without continuity solution in the lower limbs;

- with lower limb ischemia;

- aged over 75 years.

All patients were submitted to perimetric measurements in the morning, always by the same physical therapist, 1 cm from the ankle, considering variations larger than 2 cm, and volumetry with use of the technique of water displacement, considering variations larger than 50 mL. Association between the edema and diabetes, infection, healing time and surgical characteristics, such as number and length of incisions and further occurrence of paresthesia was evaluated.

Chi-square test, Fisher's exact test, Student's t test and McNemar's test were used for statistical analysis (alpha error = 5%).

Results

All individuals in the sample were right-handed and no patients were morbid obese. Thirty-two were men and 12 were women, ages ranging between 47-75 years. Thirty-six patients were Caucasian, three were black, one was yellow and four were mulattos.

Limb surgery was performed on the right side in only five patients; in the remaining 39 all surgeries were performed on the left side due to technical preference. Nineteen patients were diabetic and two women had family lipedema of the lower limbs.

Individuals were divided into three groups as to time between surgery and evaluation date: group I (up to 1 year), eight individuals (18.2%); group II (1-5 years), 23 individuals (52.3%); and group III (more than 5 years), 13 individuals (29.5%).

Of 44 patients, 24 reported occurrence and feeling of edema in the operated leg, with onset between 30 days and 6 months after the surgery. Thirty-three patients (75%) had larger perimeters in operated legs, seven (15.9%) had equal perimeters, and four (9.1%) reported lower perimeters. Volumetry showed 35 (79.5%) individuals with larger volumes in the operated leg, two (4.6%) with equal volumes, and seven (15.9%) with lower volumes. In nine (20.5%) patients who complained of edema in the operated limb, there was no significant volume that justified presence of edema, and in four (9.1%) there were increased volumes in the non-operated leg, as shown in Table 1.

The largest differences in volume of operated and non-operated limbs were found in the four patients that had episode of erysipelas in the last postoperative period, with mean 320 mL in favor of the operated limb. There was no relation between presence of edema and other characteristics of the sample, such as diabetes, infection and healing time or with surgical characteristics, such as number and length of incisions and further occurrence of paresthesia.

Discussion

This study shows that great saphenous vein harvesting for coronary bypass is associated with development of postoperative edema in the limb submitted to the procedure. Feeling of edema was found in 54.5%, which was not coincident in 20.5%, showing that the patient often has the feeling of edema, but does not actually have it. However, there was no relation with diabetes, infection, paresthesia, healing time and/or incision length.

It is known that the dominant side is usually larger,^11,12 therefore it is worth stressing that all patients in the sample were right-handed (100%) and were mostly submitted to surgery on the left side (88.6%). Thus, the fact of finding a significant increase in volume in the operated side confirms actual presence of edema.

Terada et al.¹³ evaluated origin of edema after great saphenous vein harvesting, assuming it has venous origin, and used color Doppler ultrasound to study the superficial and deep venous system of operated edematous limbs. The authors did not find any anatomical or functional anomaly that justified formation of such edema. On the other hand, it is known that lymphatic lesions, which may occur when the great saphenous vein is dissected and harvested due to the close relationship between themselves and the venous and lymphatic systems from the embryological, anatomical and functional perspective, might explain origin of the edema as a consequence of ruptured parallel lymphatic sides, as well as the entire great trunk venous tract.

A study evaluating 302 patients in similar conditions to the present sample found history of erysipelas in 21. Such patients had the largest volumes, suggesting lymphatic involvement in the edema,⁹ which is in agreement with this study. There is evidence in the literature that recurrent erysipelas is a condition associated with lymphedema.¹⁴ Such data are in favor of a strong interference of the lymphatic system in the edema after great saphenous vein harvesting, which in a near future will certainly be better evaluated and perhaps confirmed by lymphoscintigraphic studies.

A simple examination, such as volumetry, can be used to evaluate such patients and can also suggest a possible presence of clinical or subclinical lymphedema in the associated limb. One of the limitations of this study was the lack of confirmation of the lymphedema using a more specific diagnostic method, such as, for example, lymphoscintigraphy.

It can be claimed that presence of edema serves as a warning to presence and development of a likely secondary lymphedema, which justifies prophylactic cares to be adopted to prevent infections that might worsen the edematous condition irreversibly.

Conclusion

Patients submitted to great saphenous vein resections to be used in coronary bypass can have secondary edema in the associated limb, whose origin is probably due to lymphatic trauma in the sector.

References

• 1. De Milto L, Costello AM. Coronary artery bypass graft surgery. Gale Encyclopedia of Surgery. Gale: The Gale Group; 2004. http://www.healthline.com/galecontent/coronary-artery- bypass-graft-surgery-1 Acessado: 29/02/2008.
• 2. Favoloro RG. Critical analysis of coronary bypass graft surgery: a 30 year journey. J Am Coll Cardiol. 1998;31(4Suppl B):1B-63B.
• 3. Tyszka AL, Fucuda LS, Tormena EB, Campos ACL. Obtenção da veia safena magna através de acesso minimamente invasivo para revascularizações miocárdicas. Rev Bras Cir Cardiovasc. 2001;16:105-13.
• 4. Bruxton B, Acar C, Suma H, et al. Conduits. In: Bruxton B, Frazier OH, Westaby S. Ischemic heart disease surgical management. London: Mosby; 1999. p. 139-77.
• 5. Reid R, Simcock JW, Chisholm L, Dobbs B, Frizelle FA. Postdischarge clean wound infections: incidence underestimated and risk factors overemphasized. ANZ J Surg. 2002;72:339-43.
• 6. Garland R, Frizelle FA, Dobbs BR, Singh H. A retrospective audit long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting. Eur J Cardio- Thoracic Surg. 2003;23:950-5.
• 7. Lavee J, Schneiderman J, Yorav S, Shewach-Millet M, Adar R. Complications of saphenous vein harvesting following coronary artery bypass surgery. J Cardiovasc Surg (Torino). 1989;30:989-91.
• 8. Schoppelrey HP, Breit R. [Erysipelas after leg vein harvesting for aortocoronary bypass operation]. Hautarzt. 1996;47:909-12.
• 9. Dan M, Heller K, Shapira I, Vidne B, Shibolet S. Incidence of erysipelas following venectomy for coronary artery. Infection. 1987;15:107-8.
• 10. Eckel L. Die vene als transplantat: aortokoronarer und peripherer venenbypass. Z Kardiol. 1991;80:73-7.
• 11. Belczak CEQ, Godoy JMP, Seidel AC, Silva JA, Cavalheri Jr G, Belczak SQ. Influência da atividade diária na volumetria dos membros inferiores medida por perimetria e por pletismografia de água. J Vasc Bras. 2004;3:304-10.
• 12. Nilsson S, Haugen GB. Volumetry in evaluation of swelling in the ankle and foot. J Oslo City Hosp. 1981;31:11-5.
• 13. Terada Y, Fukuda S, Tohda E, Kigawa I, Wanibuchi Y, Mitsui T. Venous function and delayed leg swelling following saphenectomy in coronary artery bypass grafting. J Thorac Cardiovasc Surg. 1999;47:559-62.
• 14. de Godoy JM, de Godoy MF, Valente A, Camacho EL, Paiva EV. Lymphoscintigraphic evaluation in patients after erysipelas. Lymphology. 2000;33:177-80.

Publication Dates

• Publication in this collection
  20 Mar 2009
• Date of issue
  Mar 2009

History

• Received
  16 Sept 2008
• Accepted
  24 Nov 2008