Towards Endoscopic No-Touch Saphenous Vein Graft Harvesting in Coronary Bypass Surgery

Abstract

The saphenous vein is the most used conduit for coronary artery bypass surgery. However, the patency rate of this graft is inferior to the internal thoracic artery patency rate, which is the gold standard. Using the conventional technique, the saphenous vein is harvested via a large open incision and excised in such a way that causes both vascular damage and wound healing complications. Consequently, vein graft patency and surgical site infection may be compromised. Graft patency is markedly improved when the saphenous vein is harvested atraumatically with minimal damage and with surrounding cushion of perivascular fat intact. However, despite the improved graft performance, wound healing complications and infection remain a problem. Although wound healing complication is reduced when using endoscopic vein harvesting, there may be a negative impact on graft performance. This is due to vascular damage associated with application of forces to the vein that are usually avoided in open vein harvesting, including traction, adventitial stripping, and venous compression. There is evidence to suggest that improved patency of endoscopically harvested saphenous veins is associated with the surgeon’s experience of the technique. Recently, endoscopic methods of harvesting have been described where the saphenous vein is removed intact and with minimal vascular damage caused. In addition, wound healing complications, infection, and scarring are reduced. While the effect of these techniques on vein graft patency have yet to be reported, the ability to obtain a superior graft with reduced wound complications will be of great benefit to patients undergoing coronary revascularization procedures.

The Controversy of Using Insufficient Great Saphenous Veins in Coronary Artery Bypass Grafting: A Comparative Morphological Analysis of Healthy and Insufficient Veins Related to the Possibility of Using Them as a Graft

“…Despite this diversity, autologous saphenous vein grafts (SVGs) remain the most commonly employed conduits in CABG, especially in cases of multivessel coronary artery disease. This preference is rooted in their established long-term patency and a reduced risk of leg wound complications [ 14 , 15 , 16 ]. However, the contentious debate persists, with some authors advocating for the use of varicose veins as bypass grafts in specific instances [ 6 , 8 , 17 ].…”

“…There are several possibilities for harvesting venous grafts, including conventional open surgery or an endovascular approach. Using the conventional technique, the saphenous vein is harvested via a large open incision and excised in such a way that causes both vascular damage and wound healing complications [ 15 ]. Over the last decade in developed countries, endoscopic vein harvesting has been the method of choice to harvest the greater saphenous vein [ 18 , 19 ].…”

How I do it: Endoscope-assisted in situ arterial reconstruction of the lower limb

“… 10 Furthermore, carbon dioxide insufflation can be used in an open or closed system, with the latter requiring the use of an occluding balloon to plug the access site and increase the tunnel pressure ≤12 mm Hg. 11 One study suggests that closed systems might be associated with vein graft thrombosis. 12 Modifications can also be made to methods of tributary occlusion, including endoscopic clip application, cautery ligation, and angiographic embolization.…”

An Obligatory Role of Perivascular Adipose Tissue in Improved Saphenous Vein Graft Patency in Coronary Artery Bypass Grafting

“…54 However, this form of harvesting may have a negative effect on graft performance because of vascular damage associated with forces to the vein that are usually avoided in open vein harvesting (OVH), including traction, adventitial stripping and venous compression. 55 To date, there have been only a few short-and mid-term follow-up trials focused on the effects of EVH and OVH of SVGs on graft patency, and the patency of EVH grafts was at best only comparable to that of OVH grafts. 56 As in cases of OVH, PVAT is also removed when using EVH (Figure 4B).…”