Prospective analysis of endoscopic vein harvesting

Endoscopic vein harvesting

Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009–2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.

Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Meta-Analysis of Randomized Trials and Controlled Trials

Objective

This meta-analysis sought to determine whether endoscopic vascular graft harvesting (EVH) improves clinical and resource outcomes compared with conventional open graft harvesting (OVH) in adults undergoing coronary artery bypass surgery.

Methods

A comprehensive search was undertaken to identify all randomized and nonrandomized trials of EVH versus OVH up to April 2005. The primary outcome was wound complications. Secondary outcomes included any other clinical morbidity and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were analyzed.

Results

Thirty-six trials of 9,632 patients undergoing saphenous vein harvest met the inclusion criteria (13 randomized; 23 nonrandomized). Risk of wound complications was significantly reduced by EVH compared with OVH (OR 0.31, 95% CI 0.23–0.41). Similarly, the risk of wound infections was significantly reduced (OR 0.23, 95% CI 0.20–0.53; P < 0.0001). Need for surgical wound intervention was also significantly reduced (OR 0.16, 95% CI 0.08–0.29). The incidence of pain, neuralgia, and patient satisfaction was improved with EVH compared with OVH. Postoperative myocardial infarction, stroke, reintervention for ischemia or angina recurrence, and mortality were not significantly different. Operative time was significantly increased (WMD 15.26 minutes; 95% CI 0.01, 30.51), hospital length of stay was reduced (WMD −0.85 days; 95% CI −1.55, −0.15), and readmissions were reduced (OR 0.53, 95% CI 0.29–0.98). Costs were insufficiently reported to allow for aggregate analysis.

Conclusions

Endoscopic vascular graft harvesting of the saphenous vein reduces wound complications and improves patient satisfaction and resource utilization. Further research is required to determine the incremental cost-effectiveness of EVH versus OVH.

Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery

Objective

The purpose of this consensus conference was to develop and update evidence-informed consensus statements and recommendations on harvesting saphenous vein and radial artery via an open as compared with endoscopic technique by systematically reviewing and performing a meta-analysis of randomized and nonrandomized clinical trials.

Methods

All randomized controlled trials and nonrandomized controlled trials included in the first the International Society for Minimally Invasive Cardiothoracic Surgery Consensus Conference and Statements,1,2 in 2005 up to November 30, 2015, were included in a systematic review and meta-analysis. Based on the resultant, 76 studies (23 randomized controlled trials and 53 nonrandomized controlled trials) on 281,459 patients analyzed, consensus statements, and recommendations were generated comparing the risks and benefits of endoscopic versus open conduit harvesting for patients undergoing coronary artery bypass grafting.

Results

Compared with open vein harvest, it is reasonable to perform endoscopic vein harvest of saphenous vein to reduce wound-related complications, postoperative length of stay, and outpatient wound management resources and to increase patient satisfaction (class I, level A). Based on the quality of the conduit and major adverse cardiac events as well as 6-month angiographic patency, endoscopic vein harvest was noninferior to open harvest. It is reasonable to perform endoscopic radial artery harvest to reduce wound-related complication and to increase patient satisfaction (class I, level B-R and B-NR, respectively) with reduction in major adverse cardiac events and noninferior patency rate at 1 and 3 to 5 years (class III, level B-R).

Conclusions

Based on the consensus statements, the consensus panel recommends (class I, level B) that endoscopic saphenous vein and radial artery harvesting should be the standard of care for patients who require these conduits for coronary revascularization.

Clinicopathological comparisons of open vein harvesting and endoscopic vein harvesting in coronary artery bypass grafting patients in Mashhad

INTRODUCTION

Harvesting of the greater saphenous vein is almost an inevitable part of coronary artery bypass grafting (CABG) operations, and it is done by two main techniques, i.e., conventional or open vein harvesting (OVH) and the minimally-invasive endoscopic vein harvesting (EVH). This study aimed to compare these two techniques in off-pump CABG procedures with respect to clinical and pathological outcomes.

METHODS

This cohort study was conducted on CABG candidates during a one-year period from October 2013 through September 2014 in the Department of Cardiac Surgery at Mashhad University of Medical Sciences. Eighty-seven patients voluntarily underwent EVH, and another 86 patients matched for age, gender, and other cardiovascular risk factors were selected for OVH. They were followed up for six weeks, and the main outcome measures were infections of the wound, pain, duration of hospital stay, and the costs of hospitalization. Paired sample t-test, independent t-test, or their non-parametric equivalents and the chi-squared test were used by SPSS version 17.0 for data analysis.

RESULTS

The mean duration of time for vein harvesting was shorter in the EVH group (p < 0.001), and the pain score was lower (p = 0.04). No infections occurred at the site of the wound. The length of hospital stay was not significantly different for the two groups (OVH versus EVH: 8.5 ± 3.3 versus 8.4 ± 3.2 days; p-value: 0.08). Hospitalization costs were significantly higher in the EVH group (OVH versus EVH: 5.8 ± 4.7 versus 7.3 ± 2.0 million Tomman; p-value: 0.008), yet no difference was diagnosed with respect to endothelial damage in the vein grafts harvested by the EVH and OVH techniques.

CONCLUSION

EVH is considered as a minimally invasive and safe vein harvesting technique in our Center, and it can reduce the harvesting time and post-operative pain. In addition, its efficiency was similar to that of OVH.

Endoscopic vein harvesting: technique, outcomes, concerns & controversies

The choice of the graft conduit for coronary artery bypass grafting (CABG) has significant implications both in the short- and long-term. The patency of a coronary conduit is closely associated with an uneventful postoperative course, better long-term patient survival and superior freedom from re-intervention. The internal mammary artery is regarded as the primary conduit for CABG patients, given its association with long-term patency and survival. However, long saphenous vein (LSV) continues to be utilized universally as patients presenting for CABG often have multiple coronary territories requiring revascularization. Traditionally, the LSV has been harvested by creating incisions from the ankle up to the groin termed open vein harvesting (OVH). However, such harvesting methods are associated with incisional pain and leg wound infections. In addition, patients find such large incisions to be cosmetically unappealing. These concerns regarding wound morbidity and patient satisfaction led to the emergence of endoscopic vein harvesting (EVH). Published experience comparing OVH with EVH suggests decreased wound related complications, improved patient satisfaction, shorter hospital stay, and reduced postoperative pain at the harvest site following EVH. Despite these reported advantages concerns regarding risk of injury at the time of harvest with its potential detrimental effect on vein graft patency and clinical outcomes have prevented universal adoption of EVH. This review article provides a detailed insight into the technical aspects, outcomes, concerns, and controversies associated with EVH.

Endoscopic vein harvesting for coronary bypass grafting: a blessing or a trojan horse?

Conventional open harvest of the great saphenous vein (GSV) during CABG results in approximately 7% donor-site complications. Using endoscopic vein harvesting (EVH) the full GSV length can be harvested through a 3 cm incision. This nonsystematic review discusses several key issues concerning EVH, based on an extensive Pubmed search. Found studies show that EVH results in reduced number of wound complications, less postoperative pain, earlier postoperative mobilisation, reduced length of hospital stay, and is more cost-effective. Initial studies did not find significant differences in graft histology, patency, or clinical outcome. However, in 2009 convincing evidence of inferior histological graft properties became available. Furthermore, an observational study showed that EVH resulted in significantly more graft stenosis, was associated with higher mortality, more myocard infarction, and more reinterventions. Most recent publications could not confirm these findings, however larger randomised controlled trials focusing on graft quality are being awaited.

Leg Wound Infections Following Greater Saphenous Vein Harvesting: Minimally Invasive Vein Harvesting Versus Conventional Vein Harvesting

Wound complications associated with long incisions used to harvest the greater saphenous vein are common and well documented. We compared leg wound infection rates, wound healing disturbances (WHDs), length of vein harvested, vein harvest time, and total surgical time between minimally invasive saphenous vein harvesting (MIVH) and conventional vein harvesting (CVH) techniques. This meta-analysis showed a significant reduction in wound infections in favor of the MIVH group (odds ratio = 0.19; 95% confidence interval = 0.14-0.25) and a significant reduction in WHDs in favor of the MIVH group (odds ratio = 0.26; 95% confidence interval = 0.20-0.34). The MIVH and CVH techniques are equivalent with respect to saphenous vein harvest time, saphenous vein harvest length, and total surgical time. A visual inspection of “funnel” plots suggests a mild to moderate publication bias. This meta-analysis suggests that leg wound infections and wound healing disturbances are reduced using MIVH techniques.

Endoscopic harvest of saphenous vein: a lesson learned from 1,348 cases

BACKGROUND

Endoscopic harvest of saphenous vein is a relatively new technique developed to minimize the wound and postoperative complications. This technique has gained patients' acceptance and become popular in cardiac surgical practices. Because most centers have limited experience with this approach, the authors summarize the clinical profiles of patients undergoing endoscopic vessel harvest (EVH).

METHODS

Between March 2001 and August 2006, 1,348 patients (945 men and 403 women) with a mean age of 67.2 years (range, 28-89 years) underwent EVH of saphenous vein for coronary artery bypass surgery, peripheral artery reconstruction, and miscellaneous conditions. The EVH technique was performed using the Vasoview system (Guidant, Menlo Park, CA, USA) under the assistance of carbon dioxide (CO(2)) insufflation.

RESULTS

Technical success was achieved in 98.6% of the cases. Two saphenous veins were discarded because of obvious vein injury. The mean harvest time was 45 min: 68 min for the first 50 cases and 23 min for the last 200 cases. Nearly all the patients (98%) had saphenous vein harvested only from the thighs, whereas only 1.5% of the patients had saphenous vein harvested from the legs. Postoperative wound complications were experienced by 61 patients including 25 tract hematomas, 19 wound dehiscences or poor healing, 16 wound infections, and 1 overlying skin necrosis. Overall, 13 subsequent revisions were required for these complications. Detectable air embolisms occurred for 143 patients and numbness in the saphenous nerve territory for 169 patients.

CONCLUSION

The findings showed EVH of saphenous vein to be a valid alternative to open saphenectomy, providing excellent surgical results. Therefore, EVH should be considered as the standard of care for saphenous vein harvest.

Endoscopic Radial Artery Harvesting may be the Procedure of Choice for Coronary Artery Bypass Grafting

BACKGROUND

This study assessed the neurologic and cosmetic outcome of the endoscopic radial artery harvesting (ERH) technique in coronary artery bypass grafting (CABG).

METHODS AND RESULTS

The study group comprised 257 consecutive patients who underwent CABG between January 2001 and August 2005 at Kyungpook National University Hospital. The first 157 patients (open group) underwent conventional open harvesting of the radial artery and the second 100 (endoscopic group) had endoscopic harvesting. The severity of both the motor and sensory symptoms, as well as the cosmetic results, was evaluated immediately and at least 6 months after surgery. In the open group, 29 patients experienced neuralgia along the distribution of the lateral antebrachial cutaneous nerve, but none in the endoscopic group patients experienced any sensory abnormalities (p<0.05). However, neuralgia along the distribution of the superficial radial nerve was similarly observed in both groups. No one in either group complained of any motor symptoms. The patients in the endoscopic group were also satisfied with the cosmetic results.

CONCLUSIONS

ERH resulted in less neurologic complications of the hand and forearm, and outstanding aesthetics. ERH may be the procedure of choice for radial artery harvesting.

Reduction of carbon dioxide embolism for endoscopic saphenous vein harvesting

BACKGROUND

The endoscopic saphenous vein harvesting (EVH) introduced in coronary artery bypass surgery (CABG) is associated with less wound complication and postoperative pain. Carbon dioxide (CO2) insufflation is used during EVH to facilitate the procedure. The purpose of this study was to determine whether the incidence of CO2 embolism during EVH with CO2 insufflation could be reduced with lower CO2 insufflation pressure.

METHODS

Four hundred and ninety-eight consecutive patients scheduled for elective off-pump CABG were prospectively studied. These patients were randomly assigned into high and low groups in which 15 and 12 mm Hg CO2 insufflation pressures were used during EVH, respectively. Multiplane transesophageal echocardiography (TEE) with transgastric inferior vena cava view was used to monitor the appearances of CO2 bubbles. If a burst of many CO2 bubbles were found by TEE, the CO2 insufflation would be stopped until detailed examination of the operative field.

RESULTS

The incidence of CO2 embolisms in the high group of patients (13.3%) was significantly higher than that in the low group (6.5%, p < 0.05). Two episodes of emergent cessation of CO2 insufflation occurred in the high group of patients. No massive CO2 embolism with significant hemodynamic alterations occurred in either group.

CONCLUSIONS

The incidence of CO2 embolisms during EVH could be reduced with lower CO2 insufflation pressure, which, in combination with increased surgical experience and continuous TEE monitoring of the inferior vena cava, helps to reduce the risks of massive CO2 embolism.

Does Minimally Invasive Vein Harvesting Technique Affect the Quality of the Conduit for Coronary Revascularization?

The effect of minimally invasive great saphenous vein harvest on patient morbidity (wound infection and other healing disturbances) has been extensively investigated, yet its impact on the quality of the venous conduit is less well known. This study aims to review the literature with regard to macroscopic quality, postoperative myocardial infarction rates, and angiographic patency of the minimally invasive versus conventionally harvested vein using meta-analytic techniques where appropriate. Results suggest that conduits are comparable in macroscopic quality with minimally invasively harvested veins requiring more repairs prior to grafting. Postoperative myocardial infarction rates were not significantly different between groups, which is supported by the limited evidence on angiographic patency.

Encouraging results with endoscopic vein harvest for infrainguinal bypass

BACKGROUND

Wound complications after infrainguinal vein bypass remain a significant source of morbidity. Endoscopic saphenous vein harvest has emerged as a viable alternative to minimize vein harvest incisions.

METHODS

Infrainguinal bypass using endoscopic vein harvest was performed in 214 limbs in 197 consecutive patients between May 1998 and July 2004. The indication for bypass was limb salvage in 88.3%, claudication in 9.3%, and other in 2.4%. Atherosclerotic risk factors were prevalent, with diabetes mellitus in 68% and dialysis-dependent renal failure in 11.7%.

RESULTS

The procedure was successful in all but one patient. This patient was early in the series and had a friable varicose vein. Ipsilateral greater saphenous vein was used in 89.7%, contralateral greater saphenous vein in 8.4%, and lesser saphenous vein in 1.9%. Two injuries to the main trunk of the vein occurred early in the series. Assisted primary patency at a mean follow-up of 18 months (range, 1 to 48 months) is 77.2% by life-table analysis. For patients with claudication, rest pain, or minimal gangrene, the average length of stay was 3.15 days (range, 1 to 6 days). Wound complications occurred in 16 patients (7.5%), 10 of these required only local care (class I and II), and 6 had deep wounds threatening the leg or graft (class III). Only 5 patients, all with class III wounds, required readmission to the hospital for graft-related problems. There is no increase in operating room time once the learning curve is overcome. Patient satisfaction is very high.

CONCLUSION

Endoscopic saphenous vein harvest is a useful adjunct to infrainguinal vein bypass, with short length-of-hospital stay, few wound complications, and low hospital readmission rates. Endoscopic vein harvest is recommended as the procedure of choice for vein procurement for infrainguinal bypass procedures.

Endoscopic radial artery harvesting is better than the open technique

BACKGROUND

Radial arteries are being used more often for coronary artery bypass grafting. A minimally invasive technique was devised for harvesting vessels and compared with the traditional harvesting technique.

METHODS

In a prospective study of 200 consecutive patients undergoing coronary artery bypass grafting, 100 patients had traditional open radial artery harvesting and 100 underwent endoscopic radial artery harvesting. All patients had a preoperative modified Allen's test with Doppler imaging. The traditional technique involved a longitudinal incision over the radial aspect of the arm from the wrist to the antecubital fossa. The radial artery was dissected subfascially and removed. The endoscopic technique involved a 3-cm incision over the radial aspect of the arm. A vessel loop was placed around the artery and carbon dioxide was insufflated into the wound. The radial artery was dissected to the brachial artery and ligated with an Endo-loop ligature. The branches were divided with bipolar electrocautery and ligated with clips. Patients were evaluated for postoperative pain, bleeding, neuralgias, infection, and any adverse events. A p value of less than 0.05 was considered significant.

RESULTS

All 200 radial arteries were successfully harvested and used as grafts. Patients who had undergone endoscopic radial artery harvesting had significantly fewer major complications than patients who underwent the open technique: hematomas (five versus no complications) or wound infections requiring antibiotics (seven versus one complication). The occurrence of major neuralgias that restricted function were also significantly lower postoperatively and 1, 3, and 6 months later (ten versus one, eight versus one, five versus zero, and one versus zero, respectively).

CONCLUSIONS

Endoscopic radial artery harvesting results in good cosmetic results, useable grafts, and minimal neuralgias. Endoscopic radial artery harvesting is better than traditional open radial artery harvesting.

Carbon dioxide embolism during endoscopic saphenous vein harvesting in coronary artery bypass surgery

OBJECTIVES

Our objectives were to determine the incidence and severity and the time course of the CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation in coronary artery bypass surgery with transesophageal echocardiography monitoring.

METHODS

Four hundred three consecutive patients scheduled for off-pump coronary artery bypass grafting surgery or femoral-to-popliteal artery bypass grafting surgery were prospectively studied. Multiplane transesophageal echocardiography with a new transgastric view was used to monitor CO(2) bubbles in the inferior vena cava and hepatic vein.

RESULTS

CO(2) embolisms occurred in 17.1% of patients. Minimal, moderate, and massive CO(2) embolisms occurred in 13.1%, 3.5%, and 0.5%, respectively. The occurrence of moderate and massive CO(2) embolisms was frequently associated with the surgical manipulation of branches of saphenous veins. No significant risk factors were identified in multiple logistic regression analysis.

CONCLUSION

The incidence of significant CO(2) embolism during endoscopic saphenous vein harvesting with CO(2) insufflation procedures was more than 4%. Continuous transesophageal echocardiographic monitoring of the CO(2) bubbles in the inferior vena cava is essential in early detection and can help to prevent the development of significant CO(2) embolisms in these patients.