Is endoscopic harvesting bad for saphenous vein graft patency in coronary surgery?

Abstract

Purpose of review Endoscopic vein harvest (EVH) has quickly been adopted as standard-of-care for CABG. Despite clear advantages in terms of wound morbidity, healing, pain and patient satisfaction, data from recent large clinical trials have called its safety into question. Recent findings Post hoc analyses of a variety of prospective trials have suggested EVH is associated with decreased graft patency, and higher rates of cardiovascular complications (e.g. myocardial infarction, need for repeat revascularization) and mortality. Imaging studies of veins procured by EVH have revealed retained clot and vascular injury, particularly when technicians are during their “learning curve”. These findings may alter the quality of the conduit and therefore the outcome of the bypass graft. Elucidating the mechanisms that underlie any differences in results produced by the open and endoscopic procedures would help better inform clinical practice and the development of targeted strategies to improve EVH. Summary Clear clinical advantages over traditional open vein harvest have allowed EVH to rapidly become the standard-of-care for harvesting of one or more vein grafts during CABG. Conduit quality, suggested to be equivalent by early studies, has come into question as groups with varying levels of experience have adopted the endoscopic technique. Elucidating the principles of “best practice” for vein harvest will likely help shorten the learning curve and improve the safety of EVH.

The use of minimally invasive videoscopic technique in large vessel and cardiac surgery. Does the potentially increased difficulty bring benefits to the patient?

“…Minimally invasive techniques are areas that require proper training and a high repeatability of results [10]. The nature of training in cardiac surgery impacts on the interest in harvesting veins in endoscopic fashion.…”

Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance

“…The benefits of EVH and improved wound healing are well accepted, nevertheless there are conflicting reports regarding the patency of SVGs prepared by this method. At best, it appears that the patency of EVH grafts is comparable to those prepared by OVH [66][67][68][69] . Although EVH is suggested to be 'minimally invasive' in terms of vessel exposure, wound healing, and scarring, manipulation by instruments and insufflation by CO 2 cause considerable vascular trauma.…”

“…Although EVH is suggested to be 'minimally invasive' in terms of vessel exposure, wound healing, and scarring, manipulation by instruments and insufflation by CO 2 cause considerable vascular trauma. This potentially impacts on the SV's function as a bypass graft [69][70][71] . The damage inflicted effects not only on the endothelium, but also on other parts of the SV, including the intima and adventitia [69,70] , as well as the perivascular fat [22] , as seen in Figure 5 from Kiani et al, 2011 [69] , and Kopjar et al, 2016 [22] .…”

“…This potentially impacts on the SV's function as a bypass graft [69][70][71] . The damage inflicted effects not only on the endothelium, but also on other parts of the SV, including the intima and adventitia [69,70] , as well as the perivascular fat [22] , as seen in Figure 5 from Kiani et al, 2011 [69] , and Kopjar et al, 2016 [22] . When considering that EVH SVG's patency is, at best, comparable to OVH's patency, it seems reasonable to assume that NT SVGs will be superior to those prepared by EVH.…”

“…The perivascular layers and endothelium are damaged. The arrow shows intimal tearing (Kiani et al [69] , 2011).…”