Impact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting

doi:10.1016/j.athoracsur.2009.09.061

The Annals of Thoracic Surgery

Volume 89, Issue 2, February 2010, Pages 403-408

https://doi.org/10.1016/j.athoracsur.2009.09.061 Get rights and content

Background

Endoscopic saphenous vein harvest (EVH) decreases leg wound infections and improves cosmesis after coronary artery bypass grafting (CABG). Recent data, however, suggest that EVH may be associated with reduced graft patency rates. The objective of this study is to assess the effect of EVH on short-term and midterm outcomes after CABG.

Methods

Data were prospectively collected on all first-time isolated CABG and combined valve/CABG with saphenous vein graft between 1998 and 2007 at a single center. Patients having traditional “open” vein harvest (OVH) were compared with patients having EVH. Multivariate models were used to examine the risk-adjusted impact of EVH on postoperative leg infection, composite in-hospital adverse events, and individual and composite midterm adverse events.

Results

The study included 5,825 patients, of whom 2,004 (34.4%) had EVH. Patients having EVH were more likely to have ejection fraction less than 50% (32.0% versus 29.3%, p = 0.04), recent myocardial infarction (24.2% versus 18.3%, p < 0.0001), and left main disease (26.0% versus 22.1%, p = 0.0009). Median follow-up was 2.6 years. After risk adjustment, EVH was associated with reduced rates of leg infection (odds ratio 0.48, p = 0.003) but had no association with either in-hospital (odds ratio 0.93, p = 0.56) or midterm adverse outcomes (hazard ratio 0.93, p = 0.22). Endoscopic saphenous vein harvest was associated with reduced readmission to hospital for unstable angina (odds ratio 0.74, p = 0.01).

Conclusions

Endoscopic saphenous vein harvest is associated with a lower rate of leg infection and is not an independent predictor of in-hospital or midterm adverse outcomes. Endoscopic saphenous vein harvest is a safe alternative to OVH for patients undergoing CABG with saphenous vein.

Section snippets

Study Sample

All patients who underwent first-time isolated CABG or combined valve/CABG with the use of a saphenous vein graft at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, between June 1, 1998, and May 31, 2007, were identified through the Maritime Heart Center Cardiac Surgery Registry (MHCCSR). Patients with previous CABG surgery were excluded, as were cases in which both EVH and OVH techniques were used for vein harvesting. Approval from the Institutional Research Ethics Board

Results

A total of 5,825 patients formed the final study population. Of these, 2,004 (34.4%) underwent CABG or combined valve/CABG with EVH. The mean age of patients in this study was 66.4 ± 10.3 years, and 25.7% were female. A subgroup of 4,365 cases was available for linkage with administrative data and midterm analysis. Median follow-up time for patients discharged from hospital alive was 2.6 years (interquartile range, 1.0 to 4.6), and a total of 12,960 person-years of follow-up was available for

Comment

This is a large observational study examining midterm clinical outcomes of patients undergoing CABG or combined valve/CABG surgery with open or endoscopically harvested saphenous vein. We found no negative association between EVH and short-term and midterm adverse outcomes. Consistent with previous reports, EVH was associated with a reduced incidence of leg wound infections. It was also associated with a reduced rate of readmission to hospital for unstable angina.

Minimally invasive endoscopic

References (26)

T. Athanasiou et al.
Leg wound infection after coronary artery bypass grafting: a meta-analysis comparing minimally invasive versus conventional vein harvesting
Ann Thorac Surg
(2003)
J.M. Bitondo et al.
Endoscopic versus open saphenous vein harvest: a comparison of postoperative wound complications
Ann Thorac Surg
(2002)
P. Bonde et al.
Endoscopic vein harvest: advantages and limitations
Ann Thorac Surg
(2004)
B. Kiaii et al.
A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery
J Thorac Cardiovasc Surg
(2002)
A.N. Patel et al.
Prospective analysis of endoscopic vein harvesting
Am J Surg
(2001)
J.D. Puskas et al.
A randomized trial of endoscopic versus open saphenous vein harvest in coronary bypass surgery
Ann Thorac Surg
(1999)
K.L. Yun et al.
Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates
J Thorac Cardiovasc Surg
(2005)
G.L. Griffith et al.
Endoscopic and traditional saphenous vein harvest: a histologic comparison
Ann Thorac Surg
(2000)
M.J. Magee et al.
Coronary artery bypass graft failure after on-pump and off-pump coronary artery bypass: findings from PREVENT IV
Ann Thorac Surg
(2008)
L.J. Rousou et al.
Saphenous vein conduits harvested by endoscopic technique exhibit structural and functional damage
Ann Thorac Surg
(2009)

C. Rao et al.

Is minimally invasive harvesting of the great saphenous vein for coronary artery bypass surgery a cost-effective technique?

J Thorac Cardiovasc Surg

(2008)

O. Aziz et al.

Does minimally invasive vein harvesting technique affect the quality of the conduit for coronary revascularization?

Ann Thorac Surg

(2005)

M. Nowicki et al.

Immunocytochemical study on endothelial integrity of saphenous vein grafts harvested by minimally invasive surgery with the use of vascular mayo stripersA randomized controlled trial

Eur J Vasc Endovasc Surg

(2004)

Cited by (77)

Uniportal Endoscopic Vein Harvest Using the Three-Step Haemostatic Technique—A Modified Approach
2022, Heart Lung and Circulation
Endoscopic venous harvest (EVH) has become widely adopted in routine elective coronary artery bypass graft operations given it reduces surgical-site infections and improves wound cosmesis. The conventional EVH involves a ‘stab and grab’ incision at the inguinal crease, which is a hard-to-reach area for routine wound care. This paper describes the steps of the uniportal EVH, which transects the venous conduit, omitting the need for a stab incision at the groin.
Mid-term and long-term outcomes of endoscopic versus open vein harvesting for coronary artery bypass: A systematic review and meta-analysis
2019, International Journal of Surgery
Citation Excerpt :
The incidence of leg-wound complications was significantly lower in EVH group than that in the OVH group (0.75% versus 2.92%; OR 0.19, 95% CI 0.12–0.30; P < 0.001) (Table 2 and Supplemental Fig. 2). The rate of MACE was illustrated in thirteen studies [6,8,9,22,23,25,27–29,33,35,37,40], however, significant differences were absent between EVH and OVH (IRR 1.01, 95% CI 0.54–1.90; P = 0.98) (Fig. 3). Results for the comparison of graft patency are shown in Fig. 4.
Two prevalent harvesting techniques are routinely utilized in coronary artery bypass grafting (CABG): endoscopic vein harvesting (EVH) and open vein harvesting (OVH). Our purpose is to compare mid-term and long-term outcomes between these two techniques for CABG.
After the acquisition of evidence, available studies assessing both harvesting techniques with follow-up precondition (a minimum of one year) were identified. The primary outcome was all-cause mortality. Secondary outcomes of interest included the number of intra-operative graft injuries, leg-wound complications, in-hospital mortality, major adverse cardiac events (MACE) and graft patency.
Twenty-two studies including 27911 patients were identified. The incidences of all-cause mortality, in-hospital death, and MACE were similar between EVH and OVH. EVH was associated with more graft injuries (weighted mean difference (WMD) 0.73; 95% confidence interval (CI) 0.18–1.28; P = 0.009), lower mid-term graft patency (odds ratio (OR) 0.80; 95% CI 0.70–0.91; P = 0.0005), and decreased long-term graft patency (OR 0.15, 95% CI 0.04–0.61; P = 0.008) as compared with OVH. Fewer leg-wound complications were observed in endoscopic harvesting as compared to conventional technique (OR 0.19, 95% CI 0.12–0.30; P < 0.001). Data from subgroup analysis suggested study period as a key factor affecting the outcomes for graft patency.
The risks for all-cause mortality, in-hospital death, and MACE are similar between EVH and OVH. EVH increases conduit injuries and lowers mid-long term graft patency rates, however, study period, with growing surgical expertise, may be associated with better outcomes.
Benefits of Endoscopic Vein Harvesting in Coronary Artery Bypass Grafting
2019, Annals of Thoracic Surgery
Earlier reports concerning endoscopic vein harvesting have been controversial regarding the patency of the vein graft after coronary artery bypass grafting (CABG). In addition, data on the quality of life are lacking. In this study, we investigated our experience with endoscopic vein harvesting with regard to these end points.
The analysis included patients undergoing isolated CABG between 2012 and 2016. Patients were divided in 2 groups stratified by the technique of saphenous vein harvesting: open vs endoscopic. Primary end points were the rate of repeat revascularization and leg wound complications. Secondary end points were the physical and mental quality of life scores of the 36-Item Short Form Health Survey questionnaire. Cox proportional hazard analysis was performed to adjust the end point of repeat revascularization for relevant covariates.
The open group included 2123 patients, and the endoscopic group included 883 patients. Overall mortality was not significantly different between the groups (P = .060). Revascularization-free survival was similar between the groups (adjusted hazard ratio, 0.65; 95% confidence interval, 0.42 to 1.02; P = .059). Endoscopic vein harvesting was significantly associated with a decreased hazard for the combined end point of death or repeat revascularization (adjusted hazard ratio, 0.64; 95% confidence interval, 0.46 to 0.90; P = .009). Significantly more leg wound complications were seen in the open group (24 vs 0; P = .002). Postoperative quality of life showed no significant differences between the 2 groups.
Apart from the benefits on leg wound complications, endoscopic vein harvesting was comparable to open vein harvesting in the rate of repeat revascularization and quality of life.
Commentary on: Endoscopic vein harvesting for coronary artery bypass grafting in the UK: what we believe and what we do. A Commentary on the article “Use of endoscopic vein harvesting (EVH) during coronary artery bypass grafting in United Kingdom: The EVH survey”, Int J Surg 2019;69:146-151
2019, International Journal of Surgery
Use of endoscopic vein harvesting (EVH) during coronary artery bypass grafting in United Kingdom: The EVH survey
2019, International Journal of Surgery
Endoscopic vein harvesting (EVH) is growing in popularity and is the method of choice in many centers worldwide as it is associated with lower complication rates compared to the open vein harvesting. The aim of this study was to determine the current use of EVH during coronary artery bypass grafting among cardiac surgeons in United Kingdom and identify the main concerns that limit the use of this technique.
We developed an online survey with 16 questions about the use of EVH. An invitation to participate was sent to all the adult cardiac surgeons currently in practice in United Kingdom.
A total of 139 surgeons (52%) of 267 currently in practice across 48 different hospitals completed the survey. Twenty five percent of responding surgeons always use EVH while 44% use it for <10% cases. Forty eight percent of responders regard EVH as an expensive technique and 90% believe that EVH is associated with fewer leg wound issues. Seventy five percent of responding surgeons will use it for their patients due to no leg wound issues while 25% believe that the concerns about patency of EVH are genuine.
The majority of UK cardiac surgeons responding to this survey will preferentially consider EVH for obese and diabetic patients and are convinced by its beneficial impact in reducing leg wound complications. However, the reported routine use of EVH is low. Concerns about cost and patency of the endoscopically harvested vein are the possible barriers for universal adoption of EVH in the United Kingdom.
Saphenous vein composite graft based on the left internal thoracic artery: A vein by any other name!
2018, Journal of Thoracic and Cardiovascular Surgery

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Original articleAdult cardiacImpact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting

Background

Methods

Results

Conclusions

Section snippets

Study Sample

Results

Comment

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Eur J Vasc Endovasc Surg

Original article
Adult cardiac
Impact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting