Endoscopic Vein Harvesting Research Articles

Does the experience of the endoscopic vein harvester matter to the quality of the vein conduit: A critical thematic literature review.

Coronary artery bypass graft surgery remains the golden standard surgical option for multiple vessel disease. Harvesting the long saphenous vein using endoscopic vein harvesting requires advanced surgical skills dexterity, but the lack of a national standardised training programme allows for variance in the learning curve and the quality of the vein during the learning cycle is unknown. A search of bibliographic databases: CINHAL Plus, Embase, Pubmed and the Cochrane register for randomised controlled trials identified 11 articles eligible for review. The themes emerging were learning curve-associated injuries to the long saphenous vein, intimal wall remodelling of the long saphenous vein and incidence of graft patency rates. Harvesting practitioners with less than 100 cases of experience inflict more conduit injuries leading to endothelial remodelling and narrowed vein grafts at the six-month point resulting in lumen loss. Practitioners with more than 100 cases demonstrated reduced learning curve-related injuries on the conduit. Adopting a formalised structured training programme such as the Manchester Endoscopic Learning Tool has shown to reduce endothelial injury to the long saphenous vein minimising early vein graft failure during the learning cycle.

A histology and immunochemistry study comparing open versus close and open-method endoscopic saphenous vein harvesting.

The introduction of endoscopic saphenous vein harvesting (ESVH) has been reported to reduce wound pain and infection, compared with open saphenous vein harvesting (OSVH) techniques. There are still controversies regarding this technique. The aim of our study is to investigate the endothelial preservation of saphenous vein (SV) grafts harvested by different techniques. Further observations were made for harvesting and closure time, incision length and effect of pressure distension of the veins to the vein endothelium. Prospective observational study of sixty human saphenous vein grafts was performed to evaluate endothelial preservation by haematoxylin-eosin and Cluster of Differentiation 31 (CD 31) staining. Saphenous vein was harvested endoscopically either by closed CO2 (carbon dioxide) ESVH, open CO2 ESVH or OSVH harvesting technique. Demographic data and intra-operative data were collected. Two saphenous vein samples were collected from each patient to compare differences before and after distension of the veins. Both haematoxylin-eosin and immunohistochemistry slides were imaged by a high-resolution slide scanning system. Open CO2 ESVH group showed the highest number of endothelial detachments. Mean scoring of the immunohistochemistry method using the CD31 antibody was much lower in the open CO2 ESVH group (33.25% ± 28.71, P < 0.0003). This represents a more poorly preserved endothelial cells in the Open CO2 ESVH than the closed CO2 ESVH. Closure time and incision lengths were significantly shorter in both ESVH groups compared to the OSVH group. Significant low scores of immunohistochemistry for samples were seen in distended veins (39.0% ± 30.08, p = 0.004). The OSVH in random sample B, which represents the conduit that will be used, had a far better endothelium preservation and less endothelial detachment when compared to ESVH. We observed more endothelial detachment in the open CO2 ESVH group, due to lack of subcutaneous tissue separation, poor visualization and traction stress across the wall of the saphenous vein. The closed CO2 ESVH group had more endothelial cells preserved, but the OSVH group fared the best with the least number of endothelial cell detachment and a higher score of CD31 antibody. The online version contains supplementary material available at 10.1007/s12055-024-01752-3.

Chronic total occlusions and coronary artery bypass grafting outcomes

ObjectiveTo investigate the association between the presence and grafting of chronic total occlusions (CTOs) and coronary artery bypass grafting (CABG) outcomes. MethodsThis was a post hoc analysis of the Randomized Endograft vs Open Prospective (REGROUP) trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified on the basis of the presence of at least 1 CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months) and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. ResultsAt least 1 CTO was present in 453 of 1149 patients (39.4%). Over a median follow-up of 4.7 years (interquartile range, 3.84-5.45), MACE rates were 23.4% versus 22.2% for the CTO versus no CTO group, respectively (adjusted hazard ratio [aHR], 0.92; 95% confidence interval [CI], 0.70-1.20). MACE rates for patients with complete CTO grafting versus not were 23.1% versus 25.0%, respectively (aHR, 0.95; 95% CI, 0.57-1.57). In patients with right coronary dominance undergoing left anterior descending artery grafting, bypassing a right coronary artery CTO was associated with significantly lower rates of all-cause mortality (aHR, 0.38; 95% CI, 0.17-0.83). ConclusionsIn this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels was associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside left anterior descending artery grafting warrants additional study.

Contemporary outcomes after endoscopic vein harvesting for lower extremity bypass in a multicenter subspecialty practice

BackgroundEndoscopic vein harvesting (EVH) is considered the standard of care for coronary bypass procedures given the lower early morbidity from surgical wound complications. However, the use of EVH for lower extremity (LE) bypass remains controversial owing to concerns about decreased graft patency. In 2022, the BEST-CLI Trial (Best Endovascular vs. Best Surgical Therapy in Patients With Critical Limb Ischemia) demonstrated patients undergoing surgical bypass with adequate great saphenous vein quality experienced a lower incidence of major adverse limb events and mortality than those who underwent endovascular repair. Despite these results, wound complications from large harvest site incisions remain a significant barrier preventing surgical bypass as being the preferred initial treatment. To mitigate wound complications, our practice has adopted EVH as the standard approach for harvesting bypass conduit. Here, we report our recent 5-year experience using EVH for LE bypass. MethodsOne hundred sixty-eight LE bypasses with EVH were evaluated from 2017 to 2022. The cohort included 14 vascular surgeons in 8 hospitals. The primary end point was 30-day surgical wound complications. Secondary end points included bypass patency, need for major amputation, 30-day morbidity and mortality, length of operation, and length of hospitalization. Wound complications were measured using Szilagyi's method, with class I characterized by erythema necessitating antibiotics, class II having drainage or superficial dehiscence, and class III threatening graft integrity and requiring surgical intervention. ResultsA total of 168 LE bypasses with EVH were performed on 166 patients. Of these, 65.48% were male with a median age of 68.4 ± 9.7 years. There were no wound complications related to saphenectomy. Surgical site infections occurred in 22 patients (13.10%). Seven patients (4.17%) had class I complications, 12 (7.14%) had class II complications, and 3 (1.79%) had class III complications. Primary patency at 30 days was 96.10% and 86.84% at 1 year). Seven patients (4.17%) required major amputation at 30 days. The 1-year amputation-free survival was 89.39%. The 30-day postoperative stroke, myocardial infarction, and death rates were 0.60%, 0.60%, and 2.38%, respectively. The median operative time was 3.30 ± 1.18 hours. The median length of hospitalization was 3.00 ± 3.56 days. ConclusionsEVH minimizes saphenectomy wound complications without compromising patency and limb salvage rates. Older studies suggesting lower patency rates after EVH may have been limited by older technology and inexperienced operators. Whether EVH should be the standard of care for LE bypass warrants further investigation.

Endoscopic Vein Harvesting - How Do We Do It?

The saphenous vein graft (SVG) remains the most used conduit as a second graft in Coronary Artery Bypass Grafting (CABG).1 Traditionally, surgeons harvest SVG with an open approach, making a long incision along the medial part of the leg or thigh. This procedure can potentially result in important complications, such as delayed wound healing, postoperative pain and infection.2 Thus, less invasive techniques for vessel harvesting have grown in popularity. Endoscopic vein harvesting (EVH) is a minimally invasive harvesting procedure, which only requires a short incision, leading to less wound complications and a faster return to normal daily activities. This article intends to describe how we do EVH technique in our centre, from the preparation of the patient to the postoperative period and share some tips and tricks from our experience.

Mid-term outcomes of endoscopic vein harvesting in coronary artery bypass grafting: a retrospective cohort study

ObjectivesEndoscopic vein harvesting (EVH) is an alternative technique to obtain the saphenous vein for coronary artery bypass grafting (CABG) surgery. We aimed to evaluate the early and mid-term outcomes of patients with EVH in CABG.MethodsThis cohort study included consecutive isolated CABG patients in Nanjing First Hospital from July 2020 to December 2022 using propensity score matching methods. Patients were classified to EVH group and open vein harvesting (OVH) group according to the vein harvesting methods. The primary outcome was the all-cause death, and the secondary outcomes were major adverse cardiovascular events (MACEs) including cardiovascular death, heart failure, myocardial infarction and revascularization and asymptomatic survival in the follow-up.ResultsTotally 1247 patients were included in the study with 849 in OVH group and 398 in EVH group. Patients with EVH were more female, diabetes, higher body mass index, more multi-vessel and left main diseases. 308 pairs were formed after the matching. There was no significant difference in the rates of in-hospital death (EVH vs. OVH, 2.3% vs. 1.3%, P = 0.543). During the 3 years follow-up, EVH grafts were considered not inferior to OVH grafts, no differences were found in all-cause death [8.5% vs. 5.0%, hazard ratio (HR) 1.565, 95% confidence interval (CI): 0.77–3.17, P = 0.21], MACEs (8.1% vs. 7.1%, HR 1.165, 95CI: 0.51–2.69, P = 0.71) and asymptomatic survival (66.7% vs. 72.5%, HR 1.117, 95%CI: 0.65–1.92, P = 0.68).ConclusionsEVH grafts were considered comparable to OVH grafts in patients following CABG in the 3 years follow-up.

Endoscopic Vein Harvest and its Effect on Lower Extremity Arterial Bypass Patency

Endoscopic Vein Harvest and its Effect on Lower Extremity Arterial Bypass Patency

Abstract 1152: Hydrodissection Facilitates Endoscopic Vein Harvesting Of The Great Saphenous Vein For Coronary Artery Bypass Grafting

Coronary Artery Disease is the primary cause of mortality in the United States (US), ranking as the third leading cause of death globally. Coronary Artery Bypass Grafting (CABG) with left internal mammary artery to the left anterior descending artery is the gold standard for CABG with a patency rate of 90% at 15 years. The great saphenous vein (GSV) harvested by endoscopic vein harvesting (EVH) is the second most common vascular conduit used for CABG in the US. This is despite the poor long-term patency of this conduit due to vein graft failure (VGF). VGF is the number one technical problem associated with CABG, with 15-year patency rates of only 30 to 50%. While the "no touch" harvesting technique avoids VGF, with 15-year patency rates of 86%, it is technically demanding and results in increased leg wound healing, and not widely used. With this in mind, we developed the Minimally Invasive No Touch (MINT) technique that incorporates the best features of EVH and no touch. This procedure employs hydro dissection, a process that utilizes fluid pressure to gently harvest the GSV with minimal trauma. This approach effectively addresses two significant issues associated with using the GSV in CABG, namely VGF resulting from impaired endothelial function and excessive trauma to the GSV during the extended learning curve needed to master EVH. To evaluate this, harvesting was conducted by a PA, with over 2,000 standard EVH procedures. Our preliminary studies looked to evaluate the quality of GSVs harvested from patients using 1) standard EVH, 2) “no touch” harvesting techniques or 3) the MINT harvesting procedure, focused on evaluating the quality of the vessels by measuring the endothelial nitric oxide synthase (eNOS) activity and nitric oxide (NO) bioavailability. eNOS activity assays across harvested GSVs revealed a 3.4-fold increase in NO generation across MINT harvested samples compared to EVH and “no touch” samples, respectively. This data suggests that the GSVs harvested by the MINT procedure result in a structurally intact vein with elevated eNOS activity and NO bioavailability consistent with a functionally intact endothelium. Additional studies are necessary to uncover the array of vascular benefits associated with MINT GSV harvesting for CABG procedures.

Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes.

Performance of a technically sound left internal thoracic artery to left anterior descending artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We used prospectively collected data from the multicentre, randomized REGROUP (Randomized Endograft Vein Perspective) trial to investigate CABG outcomes based on whether a resident or an attending surgeon performed the LITA-LAD anastomosis. This was a post hoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest from 2014 through 2017. The primary end point was major cardiac adverse events, defined as the composite of all-cause deaths, nonfatal myocardial infarctions or repeat revascularizations. Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%), by attending surgeons. Residents (compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs 37.4%, P < 0.001), performed fewer multiarterial CABGs (5.2% vs 14.6%, P < 0.001) and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs 10.9%, P < 0.001) and non-calcified landing zones (25.1% vs 21.6%, P < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), major cardiac adverse events occurred in 77 patients (22.4%) in the group treated by residents and 169 patients (22.8%) in the group treated by attendings (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; P = 0.99). Outcomes persisted on adjusted analyses. Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by the residents yielded clinical outcomes similar to those of the attendings.

Endoscopic Pedicle Saphenous Vein Graft Harvesting.

The excellent long-term patency of no-touch (NT) saphenous vein grafts (SVGs) makes the grafts very attractive for coronary artery bypass grafting; however, NT-SVG harvesting has a greater incidence of wound complications than conventional methods. Since 2009, we have performed endoscopic vein harvesting (EVH) in our department with very few major wound complications. Because NT-SVG harvesting is expected to provide long-term patency, if performed with EVH, the incidence of wound complications will be reduced. Thus, we began performing endoscopic pedicle SVG harvesting (Pedicle-EVH) in March 2019. Herein, we report the early results obtained using our current Pedicle-EVH procedure. No major wound complications were reported, and the early results, including patency, were satisfactory. To harvest the pedicle SVG, however, we used a different method than the NT-SVG procedure, so careful monitoring will be needed to assess long-term outcomes.

Early Results of Endoscopic Versus Open Saphenous Vein Harvesting in Coronary Artery Bypass Grafting: A Single Blinded Randomized Controlled Trial

Background: The great saphenous vein (GSV) remains the most commonly used conduit worldwide for the majority of coronary artery bypass surgery (CABG) procedures, despite concerns regarding the long-term patency of arterial revascularization. Therefore, our aim is to assess and demonstrate the impact of harvesting techniques on patient quality of life and early post-operative outcomes.&#x0D; Methods: This prospective, single-blinded randomized controlled study enrolled patients with ischemic heart disease indicated for CABG. The study was conducted at the Cardiothoracic and Vascular Surgery Center (CVSC) at Mansoura University, Mansoura, and El-Galaa Military Hospital, Cairo, involving 32 patients. Patients were categorized into two groups: Group I comprised sixteen patients where the GSV was harvested using the open vein harvesting technique (OVH), and Group II included sixteen patients where the GSV was harvested using the endoscopic vein harvesting technique (EVH).&#x0D; Results: Multivariate regression analysis evaluating the effect of the endoscopic technique revealed a significant correlation with postoperative outcomes, particularly in terms of leg wound complications assessed by the ASEPSIS score (p &lt; 0.001) and the prediction of postoperative NRS values for leg pain (p 0.001). Additionally, the impact on patients' quality of life across all subclinical categories was assessed using the Euro-Qol 5D (p &lt; 0.001).&#x0D; Conclusion: EVH presents itself as a viable minimally invasive alternative to traditional OVH techniques. It offers greater patient comfort, improved cosmetic satisfaction, a reduced incidence of postoperative leg wound complications, and lower levels of pain. Moreover, there is a statistically significant association between performing EVH techniques and enhanced quality of life, as well as a decrease in total ASEPSIS scores.

A Comparative Analysis on Surgical Outcomes and Complications of Endoscopic and Open Vein Harvesting Techniques

A Comparative Analysis on Surgical Outcomes and Complications of Endoscopic and Open Vein Harvesting Techniques

Interpretation on Expert systematic review on the choice of conduits for coronary artery bypass grafting endorsed by the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons in 2023

Expert systematic review on the choice of conduits for coronary artery bypass grafting: endorsed by the European Association for Cardio-Thoracic Surgery and the Society of Thoracic Surgeons published in 2023 made recommendations for the selection of bypass vessels. The left internal thoracic artery-anterior descending branch anastomosis represents the accepted gold standard. Radial artery could achieve a better long-term patency rate and a reduction in adverse cardiac events compared to the great saphenous vein. Radial artery graft using an open harvesting method should be chosen to graft the target vessel with low competitive coronary flow, with the use of vasodilators for the first year. There was no clear evidence of better patency for the right internal thoracic artery compared to the great saphenous vein. The bilateral internal thoracic artery had better long-term survival compared to great saphenous vein but may be associated with a higher risk of deep sternal wound infection and should be avoided in high-risk patients. The impact of skeletonization of the internal thoracic artery on graft patency and cardiovascular outcomes was unclear. Endoscopic vein harvest reduced the risk of leg wound complications and was associated with reduced long-term patency. The patency of the no-touch great saphenous vein was significantly better than that of conventional great saphenous vein. A significantly higher risk of complications at the harvesting site and no clear evidence of better long-term clinical outcomes were found in the no-touch great saphenous vein compared to the conventional. There was limited data on the use of right gastroepiploic artery and skeletonized harvesting, which should be used to bypass target vessels in patients with low competitive flow.

Midterm outcomes of endoscopic-assisted brachial-basilic arteriovenous fistula creation

Endoscopic vein harvest remains underused in single-stage brachial-basilic arteriovenous fistula creation. We analyzed our results with the use of this technique in a cohort of predominantly obese (body mass index ≥30 kg/m2) patients. Demographics, intraoperative details, and outcomes for all consecutive patients who underwent single-stage endoscopic-assisted brachial-basilic arteriovenous fistula creation between 2020 and 2022 at a single institute were analyzed retrospectively. The primary outcomes were technical success, fistula maturation, and primary assisted and secondary patency rates. Of the 11 patients (7 men; mean age, 62 ± 11.6 years), 7 (64%) already required dialysis at referral. The mean body mass index was 34 ± 7 kg/m2, 64% were obese, and an additional 27% were overweight. The medical comorbidities included hypertension in 11 patients (100%), diabetes in 7 (64%), and smoking in 8 (73%). Technical success was 100%, with no intraoperative complications. The median procedural length was 231 minutes (range, 183-302 minutes). Early complications in two patients (18%) included bleeding of the venous side branch requiring ligation and the loss of thrill requiring division of a tethering bridge of a large tributary. The maturation rate was 100%, and the brachial-basilic arteriovenous fistula was successfully accessed in all patients who required dialysis. At 12 months, the primary assisted and secondary patency rates were 90% ± 10% and 100%, respectively. Reintervention in seven patients (64%) included successful angioplasty in four, thrombectomy in two, and aneurysm resection with an interposition graft in one patient. Endoscopic vein harvest can be used for single-stage brachial-basilic arteriovenous fistula creation with good technical success and favorable maturation and patency rates, even for obese patients.

Impact of Oral Anticoagulation on Clinical Outcomes in Postoperative Atrial Fibrillation

IntroductionThe impact of postoperative oral anticoagulation (OAC) with warfarin on postoperative atrial fibrillation (POAF) after coronary artery bypass grafting (CABG) was the focus of this examination of patients from the randomized endo-vein graft prospective (REGROUP) Trial. Material and methodsREGROUP was a prospective randomized Veterans Affairs cooperative study comparing endoscopic versus open vein harvest in elective CABG patients (March 2014-April 2017) at 16 Veterans Affairs facilities. This study compared new-onset POAF patients who were treated with warfarin versus no-warfarin. Outcomes included stroke during active follow-up and a major adverse cardiac event composite of mortality, acute myocardial infarction, and repeat revascularization during active and passive follow-up. ResultsOf the 316/1103 (28.6%) of REGROUP patients who developed new-onset POAF, 45 patients were excluded - mainly for preoperative warfarin use. Of the remaining 269 patients, 85 received OAC with warfarin (OAC group); 184 did not (no-OAC group). Stroke rates during active follow-up (32 [IQR 24-38] mo) were 3.5% OAC group versus 5.4% no-OAC group (P = 0.76); major adverse cardiac eventrates were 20% OAC versus 11.4% no-OAC (P = 0.06). On longer follow-up of (median 4.61 [IQR 3.9-5.1] y), discharge OAC use was associated with all-cause mortality after adjusting for Society of Thoracic Surgeons mortality risk (20.0% versus 11.4% no-OAC use; HR = 2.00, 95% CI: 1.05-3.81, P = 0.035). ConclusionsREGROUP patients with POAF treated with OAC had similar stroke and higher mortality rates versus no-OAC patients. Further investigation of the risk-benefit ratio of OAC in post-CABG patients and which POAF patient subgroups might derive the most benefit with anticoagulation appears warranted.

A Novel Technique of No-Touch Endoscopic Saphenous Vein Harvesting.

No-touch saphenous vein harvesting is considered an ideal procedure for harvesting good-quality veins, whereas endoscopic vein harvesting (EVH) is considered ideal for decreasing wound complications. The no-touch EVH (NT-EVH) technique, which was developed in 2018, is one of the best vein-harvesting procedures. We have improved this method in several aspects since our initial experience. Herein, we present the details of this technique.

Vein Morphology in Endoscopic Vein Harvesting: 15-Year Outcomes.

Long-term outcomes of vein morphologies in the endoscopic vein harvesting setting are lacking. We analyzed 15-year follow-up for endoscopic versus open vein harvesting and associated vein morphology outcomes in coronary artery bypass grafting at a single center. This single-center, prospectively collected, retrospective, observational study evaluated 15-year major adverse cardiovascular events (MACE) of endoscopic versus open vein harvesting and associated vein morphologies. Among 729 patients, no differences were found between endoscopic and open vein harvesting in MACE hazard ratios despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Asian and Filipino patients had more thin-walled veins and Asian and multirace patients had more vasovasoral branches than White patients. Bifid veins were associated with increased risk of cardiac catheterization. Varicose veins were associated with myocardial infarction, congestive heart failure, and death. Thick-walled veins were associated with revascularization and dense adhesions with cardiac catheterization and revascularization. Fifteen-year adjusted MACE was similar between endoscopic and open vein harvesting in small coronary targets despite increased risks with native Hawai'ian, Pacific Islander, and Filipino patients. Bifid, varicose, thick-walled veins, and dense adhesions had worse MACE.

Long Saphenous Vein Harvesting: Reviewing Various Techniques.

Ischemic heart disease is the leading cause of mortality and morbidity in the Western world. Thus, coronary artery bypass graft is the most common cardiac procedure performed as it remains the gold standard for multiple vessel disease and left main disease. Long saphenous vein is the conduit of choice for coronary artery bypass graft as it is accessible and easy to harvest. Over the previous 4 decades, several techniques have emerged to optimize harvesting and reducing adverse clinical outcomes. The most cited techniques are open vein harvesting, no-touch technique, endoscopic vein harvesting, and standard bridging technique. In this literature review, we aim to summarize current literature for each of the 4 techniques in terms of: (A) graft patency and attrition, (B) myocardial infarction and revascularization, (C) wound infections, (D) postoperative pain, and (E) patient satisfaction.

Vein Harvesting Techniques in Coronary Artery Bypass Grafting: A Prospective Comparative Observational Study

Despite well-established recommendations for endoscopic vein harvesting (EVH) internationally, open vein harvesting (OVH) is still the main harvesting technique for the great saphenous vein in coronary artery bypass graft (CABG) surgery in Australia. At the Alfred Hospital, EVH is currently being performed by perioperative nurse surgical assistants (PNSA) on patients who are high risk for postoperative leg wound complications. This study aimed to compare and evaluate postoperative leg wound complications of both EVH and OVH at the Alfred Hospital.

Comparing Early Wound Outcomes Following Endoscopic Vein Harvesting Using “No Touch” and Skeletonised Techniques

This study aimed to compare the clinical and functional state of the lower limb after endoscopic vein harvesting in a flap and with a skeletonised technique.