Mid-term outcomes for Endoscopic versus Open Vein Harvest: a case control study

Abstract

BackgroundSaphenous vein remains the most common conduit for coronary artery bypass grafting with increasing uptake of minimally invasive harvesting techniques. While Endoscopic Vein Harvest (EVH) has been demonstrated to improve early morbidity compared to Open Vein Harvest (OVH), recent literature suggests that this may be at the expense of graft patency at one year and survival at three years.MethodsWe undertook a retrospective single-centre, single-surgeon, case-control study of EVH (n = 89) and OVH (n = 182). The primary endpoint was death with secondary endpoints including acute coronary syndrome, revascularisation or other major adverse cardiac events. Freedom from angina, wound complications and self-rated health status were also assessed. Where repeat angiography had been performed, this was reviewed.ResultsBoth groups were well matched demographically and for peri-operative characteristics. All cause mortality was 2/89 (2%) and 11/182 (6%) in the EVH and OVH groups respectively. This was shown by Cox Log-Rank analysis to be non-significant (p = 0.65), even if adjusting for inpatient mortality (p = 0.74). There was no difference in the rates of freedom from angina (p = 1.00), re-admission (p = 0.78) or need for further anti-anginals (p = 1.00). There was a significant reduction in the incidence of leg wound infections and complications in the endoscopic group (EVH: 7%; OVH: 28%; p = 0.0008) and the skew of high patient self-rated health scores in the EVH group (61% compared to 52% in the open group) approached statistical significance (p = 0.06).ConclusionsWhile aware of the limitations of this small retrospective study, we are heartened by the preliminary results and consider our data to be justification for continuing to provide patients the opportunity to have minimally invasive conduit harvest in our centre. More robust evidence is still required to elucidate the implications of endoscopic techniques on conduit patency and patient outcome, but until the results of a large, prospective and randomised trial are available, we believe we can confidently offer our patients the option and benefits of EVH.

What is the impact of endoscopic vein harvesting on clinical outcomes following coronary artery bypass graft surgery?

“…Two single-centre studies and one multi-centre cohort study have found that EVH does not increase the rate of adverse clinical outcomes following CABG 13 15 16. The multi-centre analysis of the Northern New England data from 2001 to 2004 found EVH to be associated with a significant reduction in long-term mortality (adjusted HR 0.74, 95% CI 0.60 to 0.92) 16.…”

“…Unlike this present study, Dacey et al found EVH to be associated with an increased adjusted risk of requiring a return to the operating theatre (2.4 vs 1.7; p = 0.03) 16. The single-centre analysis by Ouzounian et al found EVH to have no association with either in-hospital (OR 0.93, p=0.56) or midterm adverse outcomes (HR 0.93, p=0.22), and the patients from the UK single-centre study were included in this grouped analysis 13 15…”

“…A number of single-centre studies have found no association between EVH and midterm adverse clinical outcomes, and a subsequent multi-centre study found EVH to be associated with reduced long-term mortality 13 15 16. However, an analysis of data from the ROOBY (Randomised On/Off Bypass) trial found EVH to be associated with lower rates of vein graft patency and higher rates of repeat revascularisation 17.…”

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

“…The rapid adoption of EVH results from a dramatic reduction in invasiveness compared to the open, traditional vein harvesting (OVH) technique. Several studies have shown 2- and 3-fold improvements in the rate of wound-related complications and infections for EVH 2,3 . The significant reduction in incision length when grafts are procured using EVH yields less wound-related pain (WMD=1.95, P=0.06; 95% CI: –0.10–4.01) 4 , and increased patient satisfaction 5 compared to OVH.…”

A comprehensive review on learning curve associated problems in endoscopic vein harvesting and the requirement for a standardised training programme

“…Coronary artery bypass grafting (CABG) is one of the most common cardiac surgical procedures performed worldwide [ 1 ]. Despite arterial conduits having a superior long-term graft patency rate, the long saphenous vein is still the first choice conduit as a second graft in multi-vessel bypass grafts [ 2 , 3 ].…”