Saphenous vein graft longevity: open or endoscopic, with VEST or without?

Abstract

We have read the article by Sandner et al. with great interest. The authors have undertaken a post hoc analysis of the VEST III Trial to examine the impact of open versus endoscopic harvesting techniques on saphenous vein graft patency and degree of intimal hyperplasia. As already acknowledged by the authors, these results should be viewed as hypothesis generating because of the inherent limitations of a post hoc, unplanned analysis. The key findings of the paper point towards a better saphenous vein graft patency and reduced intimal hyperplasia of open harvest technique compared to endoscopic harvest. The reduced graft patency associated with endoscopic harvest has already been suggested in the literature [1], and this could be related to several factors. Endoscopic vein harvest is a relatively newly established technique where graft patency is influenced by the operator experience, something that has not been accounted for in the VEST III trial. Other factors intrinsic to the endoscopic harvest technique that result in poorer patency include the thermal diathermy injury of the conduit or more traumatic handling/stretch of the conduit that translates into histological evidence of trauma [2]. A strength of the paper is the within-patient randomized that mitigated the potential effect of variability in saphenous vein preparation on graft patency. For example, an open no-touch technique or the distending pressure used on the vein for leaks check are known determinants of angiographic graft patency [3] and graft wall remodelling [4].