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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 18-21

AccuVein® fails to facilitate venous marking for saphenous veins harvesting in untrained students


1 University Hospital Center, Angers, France
2 University Hospital Rangueil, Toulouse, France
3 University Hospital Center; Faculty of Medicine, MitoVasc Institute UMR CNRS 6015/INSERM 1083, Angers University, Angers, France

Date of Submission30-Nov-2021
Date of Decision04-Jan-2022
Date of Acceptance06-Jan-2022
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Samir Henni
Médecine Vasculaire, Centre Hospitalier Universitaire, 4 Rue Larrey, 49 933 Angers Cedex 9
France
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.340416

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  Abstract 


CONTEXT: Ultrasound marking of saphenous veins before vein harvesting facilitates the surgical procedure but is time-consuming.
AIM: We evaluated the time benefit of saphenous veins marking by the AccuVein® AV400 system (AccuVein Inc., NY, USA) coupled with ultrasound, over ultrasound alone.
SETTINGS AND DESIGN: Multi-center open-label randomized interventional study in two parallel groups.
SUBJECTS AND METHODS: After randomization, saphenous veins markings were performed using either AccuVein® coupled with ultrasound or ultrasound alone. One-leg marking time, vascular physician postexamination satisfaction rating, and number of single-use felt markers used were recorded.
STATISTICAL ANALYSES: The continuous variables were compared using the Fisher test, whereas Likert scale scores were compared using the nonparametric Mann−Whitney test. The learning effect was evaluated by linear and nonlinear regression models.
RESULTS: The average duration of saphenous veins marking (459 ± 184 vs 555 ± 226 s, P = 0.116) and the number of felt markers used were not significantly different between the two techniques. Vascular physician satisfaction was significantly lower with than without the AccuVein® associated to ultrasound.
CONCLUSIONS: AccuVein® examination coupled with ultrasound as part of the marking process does not provide a significant benefit in terms of time, satisfaction, or need for markers.

Keywords: AccuVein®, coronary bypass, saphenectomy, saphenous veins marking, vascular bypass


How to cite this article:
Ramondou P, Bura-Rivière A, Mokaddem W, Hersan J, Josse C, Abraham P, Fouquet O, Bossavy JP, Lapebie FX, Henni S. AccuVein® fails to facilitate venous marking for saphenous veins harvesting in untrained students. Vasc Invest Ther 2022;5:18-21

How to cite this URL:
Ramondou P, Bura-Rivière A, Mokaddem W, Hersan J, Josse C, Abraham P, Fouquet O, Bossavy JP, Lapebie FX, Henni S. AccuVein® fails to facilitate venous marking for saphenous veins harvesting in untrained students. Vasc Invest Ther [serial online] 2022 [cited 2022 May 24];5:18-21. Available from: https://www.vitonline.org/text.asp?2022/5/1/18/340416




  Introduction Top


Saphenectomy is a surgical procedure consisting of resecting one or more saphenous veins to treat varicose veins[1],[2],[3] or to use the veins for peripheral or coronary vascular bypass.[4],[5] Sonographic marking of saphenous veins before saphenectomy is useful.[6],[7] In general it is necessary to remove the gel, draw a mark then re-apply the gel for a next mark from place to place along the leg. Visualizing and marking the vein is not difficult but is a time-consuming procedure, generating overconsumption of markers (which clog up because of ultrasound gel) and are likely to damage modern and expensive ultrasound probes. Further, venous marking is not a very rewarding act and as such, the exam is often proposed to junior operators.

The AccuVein® AV400 vein illumination system is a laser imaging system that detects superficial veins up to approximately ten mm (one cm) deep and digitally displays them through a projected red light on a ~ 50–100 cm2 large surface. A map of the vascularization is projected on the surface of the skin in real time, allowing clinicians to check vein patency and position. AccuVein® provides noninvasive imaging of the superficial veins in current practice.[8],[9] As such, the AccuVein® system could minimize standing time of the patient.

Thus, our hypothesis was that the use of the AccuVein® system to mark superficial veins (specifically at the calf level where multiple superficial varicose veins can be present) would decrease the time required to perform the marking and the need for markers and would help junior operators to develop their skill in venous imaging.


  Subjects and Methods Top


Consecutive adult patients referred for saphenous veins marking (generally 1 day before surgical harvesting) were proposed to participate if they were affiliated to the national social security system and able to understand the protocol. Pregnant women, patients with psychiatric disorders or under law protection (prisoners) and those who denied signing informed consent form were not included. This randomized, open-labeled, two centers study, was registered in NIH ClinicalTrials.gov website before first inclusion under reference NCT03538080 (https://clinicaltrials.gov/ct2/show/NCT03538080) was approved by an ethic committee and conforms to the declaration of Helsinki.

After inclusion, age, sex, weight, and height as well as previous surgery and ongoing treatments were recorded. Then, randomization arm was openly attributed to each patient with 1:1 ratio with the EnnovClinical® software. Thereafter, according to the result of randomization, saphenous veins marking was performed either with the AccuVein® system followed by Doppler ultrasound (for veins too deep to be found by the AccuVein® system) or with the Doppler ultrasound reference method alone. In the case of bilateral surgery, the protocol marking was performed only on the right leg. The examination was performed either with the patient standing on a stepladder in cases of marking for varicose surgery, or lying down in other cases.[10] The examination time was measured by stopwatch from the beginning until the end of the saphenous veins marking to estimate the time required to perform the marking. The protocol was planned to be performed by trainee students and was initiated when the students had 3–6 months of ultrasound experience. A 30 min demonstration of AccuVein® use was performed to all the students before the start of the study.

Ultrasonography marking started at the groin fold by an ultrasound scan of the sapheno-femoral junction. Then, using a single-use skin felt marker, an ink mark was placed next to the middle of the ultrasound probe. This process was repeated step by step (2–3 cm apart) all along the saphenous vein (at the sapheno-femoral junction, at the upper, middle and lower thirds of the thigh, next to the knee, at the upper, middle and lower thirds of the leg) to reconstitute the saphenous path, which was thereafter reported to the surgeon in the consultation report.

In the case of marking with AccuVein®, the examination began by the identification of the GSV and its path was drawn directly on the skin. The AccuVein® device allows tracing the veins on dry skin wherever it is visible. Where the veins were too deep, marking was completed by ultrasound (this was almost always necessary on the medial or upper part of the thigh).

In both cases, depth and diameter of saphenous veins were finally measured using Doppler ultrasonography at eight digital tracking points, and ultrasound could also be used to confirm venous reflux if necessary.

At the end of the procedure, the physician was asked to quantify the easiness of the marking according to a Likert scale evaluating the degree of satisfaction (from one-very unsatisfactory-to five points-very satisfactory).

If a ten min-reduction of saphenous veins marking time with the AccuVein® system is expected, with a standard deviation of 10 min, 46 patients had to be included with an alpha risk of 5% and a power of 90%. Therefore, we planned to include 50 patients, 25 in each randomization arm. Statistical analyses were performed using the SPSS software (IBM-v17) CHU Angers. Mean and standard deviation of quantitative variables were determined. Differences in the time taken to perform the examination and number of markers were compared using the Fisher test, whereas differences in the Likert scale evaluation of satisfaction level were compared using the nonparametric Mann–Whitney test. The learning effect over the times required for marking was evaluated by analyzing the relationship of marking time to randomization order with linear and nonlinear regression models.[11] For all statistical tests, a two-tailed P < 0.05 indicated statistical significance.


  Results Top


Fifty patients were included, but one was excluded by the withdrawal of consent after inclusion. Twenty-five patients were randomized to the ultrasonography group and twenty-four to the AccuVein® coupled with ultrasound group. The differences observed in terms of age, weight, height, and sex between the two populations were not significant, so biometric data of the two groups were comparable [Table 1]. Note that patient 12 was performed by a highly trained senior operator (instead of a student in training) for technical reasons.
Table 1: Population characteristics, with values of the three evaluation criteria according to the technique used


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The duration of saphenous veins marking was not significantly different between the two groups (P = 0.116), although there was a tendency for the marking time to increase with the use of AccuVein® [Table 1]. Similarly, there was no significant difference in the number of single-use felt pens used (P = 0.102). On the opposite, the satisfaction of the doctors performing the marking was significantly different (P = 0.01), with a preference for ultrasound alone (mean Likert score of 4.2) compared with AccuVein® coupled with ultrasound (mean Likert score of 3).

[Figure 1] illustrates the learning curve of saphenous marking with or without the use of the AccuVein® device. Of interest is to note that the best fit was obtained by an exponential model showing a decrease with an asymptote toward ~ 200–250 s (3.5–4 min) that was comparable to the time required by the expert operator to perform the test of patient 12.
Figure 1: Power law learning curve showing the evolution of the duration of the examination (in ordinate) as a function of the order of inclusion in the study (in abscissa)

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[Figure 2] shows the projection of the saphenous vein on the skin of the patient and the use of the marker to draw the vein position on the skin.
Figure 2: Example of the projection of the saphenous vein on the skin of the patient and the use of the marker to draw the vein position on the skin

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  Discussion Top


This study is the first to evaluate the use of the AccuVein® system for the examination of the saphenous vein for venous marking. The first studies that showed a benefit of the AccuVein® system were performed on upper limbs.[8],[12] Initial preliminary experiences with infra-red detection of superficial veins and light projection systems suggested that this type of devices could facilitate the detection of superficial veins to perform phlebectomy.[13] First uses for venous puncture in children were encouraging[14] and showed that these devices facilitated peripheral venous access for pediatric patients with difficult veins, which enhanced first-attempt success rates,[15] with a reduction in the time to place the intravenous catheter and improvements in the nurses' perception of pain.[16] Unfortunately, larger studies in both children[17],[18],[19] and adults[20] did not confirm these initial results.

The present study is an additional negative result and provides evidence that the system does not improve student learning of saphenous marking.

The AccuVein® system is designed to detect veins up to 10 mm depth. Therefore, one may speculate that an evaluation bias arises from the poor accessibility to lower limb superficial veins compared to upper limb veins. Further, in participants with venous insufficiency, veins of the lower limbs are often large and superficial.[21] Thus, it is likely that the AccuVein® system would be more effective in this population. However, in our study, the number of patients addressed for varicose surgery (n = 8) was much lower than for bypass surgery (n = 41). Thus, no statistical analysis could have been performed on this specific population.

Similarly, we have not been able to show a significant decrease in the number of felt markers used when saphenous veins marking was performed with the AccuVein® system. This may be explained by the fact that this number was already low (1.3) with the reference procedure.

Besides, the current practice in our University Hospital Center is the use of surgical indelible felt markers for venous marking. However, other types of pens, such as water soluble wax pens, could also be used. One may suggest that this type of pens, which has the main advantage of being usable through ultrasound gel, could facilitate marking and decrease saphenous marking duration.


  Conclusion Top


In conclusion, AccuVein® failed to facilitate venous marking before saphenous veins surgery in untrained vascular medicine students. Despite this disappointing result, augmented reality as proposed by the AccuVein® or other devices could prove usefulness in other contexts of venous pathology such as acute superficial vein thrombosis or assessment of chronic venous malformations characterized by the presence of very superficial venous ectasias such as Klippel-Trenaunay syndrome, in the evaluation of arterio-venous fistula for extra-renal dialysis, or in the field of foam sclerotherapy. These various applications need to be further evaluated.

Acknowledgments

The authors would like to thank Stéphanie Maréchal-Girault and Marine Mauboussin as well as the “Maison de la Recherche Clinique” of Angers and research technicians in the University Hospital in Toulouse for technical help.

Financial support and sponosrhip

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Frings N, Nelle A, Tran P, Fischer R, Krug W. Reduction of neoreflux after correctly performed ligation of the saphenofemoral junction. A randomized trial. Eur J Vasc Endovasc Surg 2004;28:246-52.  Back to cited text no. 1
    
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Perkins JM. Standard varicose vein surgery. Phlebology 2009;24 Suppl 1:34-41.  Back to cited text no. 2
    
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Yoh T, Okamura R, Nakamura Y, Kobayashi A. Divided saphenectomy for varicose vein in ambulatory surgery. Ann Vasc Dis 2014;7:195-8.  Back to cited text no. 3
    
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Eagle KA, Guyton RA, Davidoff R, Edwards FH, Ewy GA, Gardner TJ, et al. ACC/AHA 2004 guideline update for coronary artery bypass graft surgery: A report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (Committee to update the 1999 guidelines for coronary artery bypass graft surgery). Circulation 2004;110:e340-437.  Back to cited text no. 4
    
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Lopes FC, Oliveira OW, Moreira DG, Santos MA, Oliveira JL, Cruz CB, et al. Use of doppler ultrasound for saphenous vein mapping to obtain grafts for coronary artery bypass grafting. Braz J Cardiovasc Surg 2018;33:189-93.  Back to cited text no. 5
    
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Allen KB, Shaar CJ. Facile location of the saphenous vein during endoscopic vessel harvesting. Ann Thorac Surg 2000;69:295-7.  Back to cited text no. 6
    
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Wong JK, Duncan JL, Nichols DM. Whole-leg duplex mapping for varicose veins: Observations on patterns of reflux in recurrent and primary legs, with clinical correlation. Eur J Vasc Endovasc Surg 2003;25:267-75.  Back to cited text no. 7
    
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Lee H, Lee SH, Kim SJ, Choi WI, Lee JH, Choi IJ. Variations of the cubital superficial vein investigated by using the intravenous illuminator. Anat Cell Biol 2015;48:62-5.  Back to cited text no. 8
    
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Sánchez-Morago GV, Sánchez Coello MD, Villafranca Casanoves A, Cantero Almena JM, Migallón Buitrago ME, Carrero Caballero MC. Viewing veins with AccuVein AV300. Rev Enferm 2010;33:33-8.  Back to cited text no. 9
    
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García Carriazo M, Gómez de las Heras C, Mármol Vázquez P, Ramos Solís MF. Doppler ultrasound study and venous mapping in chronic venous insufficiency. Radiologia 2016;58:7-15.  Back to cited text no. 10
    
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Grange P, Mulla M. Learning the “learning curve”. Surgery 2015;157:8-9.  Back to cited text no. 11
    
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Miyake RK, Zeman HD, Duarte FH, Kikuchi R, Ramacciotti E, Lovhoiden G, et al. Vein imaging: A new method of near infrared imaging, where a processed image is projected onto the skin for the enhancement of vein treatment. Dermatol Surg 2006;32:1031-8.  Back to cited text no. 13
    
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Strehle EM. Making the invisible visible: Near-infrared spectroscopy and phlebotomy in children. Telemed J E Health 2010;16:889-93.  Back to cited text no. 14
    
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Kim MJ, Park JM, Rhee N, Je SM, Hong SH, Lee YM, et al. Efficacy of VeinViewer in pediatric peripheral intravenous access: A randomized controlled trial. Eur J Pediatr 2012;171:1121-5.  Back to cited text no. 15
    
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Chapman LL, Sullivan B, Pacheco AL, Draleau CP, Becker BM. VeinViewer-assisted Intravenous catheter placement in a pediatric emergency department. Acad Emerg Med 2011;18:966-71.  Back to cited text no. 16
    
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Kaddoum RN, Anghelescu DL, Parish ME, Wright BB, Trujillo L, Wu J, et al. A randomized controlled trial comparing the AccuVein AV300 device to standard insertion technique for intravenous cannulation of anesthetized children. Paediatr Anaesth 2012;22:884-9.  Back to cited text no. 17
    
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Perry AM, Caviness AC, Hsu DC. Efficacy of a near-infrared light device in pediatric intravenous cannulation: A randomized controlled trial. Pediatr Emerg Care 2011;27:5-10.  Back to cited text no. 18
    
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Rothbart A, Yu P, Müller-Lobeck L, Spies CD, Wernecke KD, Nachtigall I. Peripheral intravenous cannulation with support of infrared laser vein viewing system in a pre-operation setting in pediatric patients. BMC Res Notes 2015;8:463.  Back to cited text no. 19
    
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Aulagnier J, Hoc C, Mathieu E, Dreyfus JF, Fischler M, Le Guen M. Efficacy of AccuVein to facilitate peripheral intravenous placement in adults presenting to an emergency department: A randomized clinical trial. Acad Emerg Med 2014;21:858-63.  Back to cited text no. 20
    
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Radhakrishnan N, George D, Jayakrishnan R, Sumi S, Kartha CC. Vein size and disease severity in chronic venous diseases. Int J Angiol 2018;27:185-9.  Back to cited text no. 21
    


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