Vein Harvesting Research Articles

Use of Endoscopic Vein Harvest Yields Improved Outcomes in Popliteal Artery Aneurysm Repair

There is growing literature showing that endoscopic vein harvest (EVH) is safe, with excellent patency rates and decreased wound complications when treating infrainguinal occlusive disease. Our institution has performed EVH since 2003 with a dedicated team of providers specializing in endoscopic vein harvest. The purpose of this study was to evaluate major outcomes of EVH as an adjunct to standard, open operative repair of popliteal artery aneurysms. We performed a 12-year retrospective single-institution chart review from January 2005 to December 2017, identifying all patients undergoing popliteal artery aneurysm repair with EVH. Primary outcomes were procedural technical success, operative time, wound complication, major morbidity, and freedom from amputation. A total 37 limbs (in 31 patients) received EVH popliteal artery aneurysm repair at an average age of 65.2±10years; 65% of the patients presented without symptoms or with claudication and 35% with rest pain or tissue loss. Coexisting aneurysm was present in 68% of patients: 49% had contralateral popliteal artery aneurysms and 19% had concurrent aortic aneurysms. Of 37 limbs, 33 (89%) were treated through a medial approach with aneurysm ligation, and 4 patients (11%) were treated through a posterior approach. The average vein size was 4.4±1.1mm, with 86% harvested by the ipsilateral great saphenous vein. Average operative time was 3.89±0.82hr, with a median hospitalization of 2days and a median of 1day of intravenous narcotics use. Only 2 patients (5.4%) had Szilagyi class-2 surgical site infections remedied with debridement and antibiotics. Kaplan-Meier data showed a 5-year primary patency of 82.3% and primary-assisted patency of 88.2%. Additionally, 30-day primary patency was 89.2% and primary-assisted patency of 97.3%. EVH for popliteal aneurysmal disease provides a safe and efficacious means of popliteal artery aneurysm repair with shorter hospitalization, lower wound complication rates, and excellent long-term patency compared to standard open technique.

The Effect of Aloe Vera Gel on Saphenous Vein Harvest Wound Healing and Local Pain in Non-diabetic Patients Undergoing CABG Surgery: A Clinical Trial

Background: Coronary artery bypass graft (CABG) is a common surgical procedure in patients with heart disease associated with pain and problems with great saphenous veins (GSVs) wound healing. Objectives: We aimed to determine the effect of aloe vera gel on pain intensity, and GSVs wound healing in non-diabetic patients undergoing CABG. Methods: In this clinical trial, 35 CABG candidate patients fulfilling admission criteria were selected by convenience sampling, and their lower limbs were randomly assigned to the intervention or control group. The wound care for both groups was the same except for using aloe vera gel for the intervention group from the first to the fourth days after surgery. Pain intensity and GSVs wound healing data were collected by Redness, Edema, Ecchymosis, Discharge, and Approximation (REEDA) scale and Visual Analog Scale (VAS) questionnaires on the first, fourth, seventh, and fourteenth days and analyzed by SPSS software. Results: On the seventh day, the mean pain intensity in the intervention group was significantly lower (P = 0.01). The mean scores of wound healing in the intervention limb decreased faster; however, the wound healing score was not significantly different between the two groups at any time (P > 0.05). Using aloe vera gel reduced ecchymosis on the seventh and fourteenth days and reduced pain on the seventh day compared to the control limb (P < 0.001). Conclusions: Aloe vera gel can effectively reduce GSVs' pain intensity and ecchymosis from the seventh day. The topical application of this herb can have various degrees of effectiveness in decreasing pain and speeding up the healing of surgical wounds.

Saphenous vein harvesting with endoscopy versus no-touch technique: short-term results

Saphenous vein harvesting with endoscopy versus no-touch technique: short-term results

Surgical outcome after using negative pressure therapy in infected leg wounds in coronary bypass grafting surgery

BackgroundInfection of leg wounds is a common complication following great saphenous vein harvesting (GSV) for coronary bypass grafting (CABG). This complication can result in increased risk of patient morbidity and mortality by causing septicemia, and gangrene, subjecting the patients to amputation. This study aimed to assess the efficacy of negative pressure wound therapy (NPWT) compared to conventional wound care in infected leg wounds following GSV harvesting for myocardial revascularization.ResultsThe NPWT group had a significantly lower rate of deep vein thrombosis (p = 0.013), osteomyelitis (p < 0.001), bed sores (p < 0.001), shorter duration of tissue edema (p < 0.001), and lesser discharge (p < 0.001). Also, the length of hospital stay was significantly shorter in the NPWT group (p < 0.001). Multivariable analysis revealed that traditional wound care (without NPWT, p < 0.001) and wound stage IV (p = 0.001) significantly and independently prolonged the length of hospital stay.ConclusionsThe use of NPWT in advanced complicated infected leg wounds could improve patients’ outcomes and satisfaction by decreasing the rate of complications and the length of hospital stay.

Patients’ experiences regarding severe leg wound infection associated with coronary artery bypass grafting: A qualitative study

IntroductionCoronary artery bypass grafting (CABG) is the most common cardiac surgery throughout the world. The most commonly used graft is the saphenous vein. Wound healing complications related to saphenous vein harvesting are common, with reported surgical site infection rates ranging from 2% to 20%. Surgical site infection can be long-lasting, and the wound healing can be difficult and also presumably troublesome for the patient. CABG patients’ experiences of severe infection in the harvesting site have not been studied before. Aim: The aim of this study was to describe patients’ experiences associated with acquiring a severe infection in the harvesting site after CABG. MethodA qualitative study with descriptive design was conducted at the department of vascular and cardiothoracic surgery in a Swedish university hospital from May to December 2018. Patients diagnosed with a severe surgical site infection in the harvesting site following CABG were included. Data from 16 face-to-face interviews were analysed with inductive qualitative content analysis. ResultThe main category, varying impact on body and mind, was the core of the patients’ experiences of severe wound infection in the harvesting site after CABG. Two generic categories were identified: physical impact and thoughts about the complication. The patients described experiencing different degrees of pain, anxiety, and limitation in daily life. ConclusionThese findings indicate that a severe infection in the harvesting site after CABG was experienced as an important issue with varying impact. Overall, the participants experienced pain, anxiety, and limitations in daily life. However, most of them were satisfied with the outcome after the wound had healed. Patients should be advised to seek care at an early stage if symptoms of infection occur. Improved individual pain management is needed for those with severe pain, and varied experiences imply a need for person-centred care.

Current practice of saphenous vein graft harvesting in coronary artery bypass graft surgery: an Indian survey.

The treatment of occluded saphenous vein graft (SVG) is challenging, and thus preventing the graft occlusion is of utmost importance. However, despite its recognized importance, a paucity of data exists regarding howSVGsare handled and preserved. Hence, this survey was conducted to document the techniques ofveingraftpreservation and handling among cardiac surgeons in India. The survey had 26 questions regarding vein graft usage, harvesting, handling, and preservation techniques. Three hundred cardiac surgeons across India participated in this survey between March 2019 and July 2019. Responses were received from 215 (71.6%) surgeons across 13 states. Around 87% of respondents reported that ≥ 76% of veins were harvested by the open technique. Among the respondents, around 67% used one SVG in ≥ 96% of their patients, 45% used two SVGs in ≥ 86% of their patients, and 38% used ≥ 3 SVGs in < 25% of their patients, respectively. Around 54%, 27%, 9%, and 9% of respondents used autologous whole blood, saline solution, pH-buffered solution, and other solutions, respectively. In addition, 96.74% of respondents heparinized their vein graft preservation solutions, and 98.14% preserved the solution at room temperature. 34.88% and 83.26% of respondents used dual antiplatelet therapy (DAPT) before and after surgery in ≥ 76% of their patients, respectively. 63.26% of the surgeons reported that the patients received DAPT for > 12months. There is a significant variance in the process of vein harvesting, preservation, handling, and antiplatelet therapy protocols among various cardiac surgeons across India. Therefore, there is a need for standardization in the practice of vein harvesting.

159. Antibiotic and diagnostic stewardship surrounding pre-operative testing in patients undergoing cardiac surgery

Abstract Background Despite national guidelines from the US Preventative Services Task Force and the Infectious Diseases Society of America that recommend against screening for asymptomatic bacteriuria (ASB, defined as &amp;gt; 105 CFU of an organism) in most circumstances, pre-operative screening urine culture (UCx) continues. Detection and treatment of ASB leads to antibiotic exposure and risk of antibiotic-associated adverse events like drug reactions, Clostridioides difficile infection (CDI), and colonization by drug-resistant organisms. We describe the implementation of eliminating pre-operative screening for ASB in patients undergoing cardiac surgery. Figure 1Pre-operative checklist for cardiac surgery prior to intervention Methods This was a pre-post study of practice change involving removing ASB screening as part of the pre-cardiac surgery checklist (Figure 1). The pre-intervention period was 08/18/21 – 11/17/21, the post intervention period was 12/1/21 – 3/1/22. We identified all patients who underwent a cardiac arterial bypass graft procedure with or without vein harvesting. We reviewed pre-operative UCx, test indication, antibiotic administration pre-operatively due to culture growth, and post-operative CDI and CAUTI within 30 days post procedure identified through routine infection prevention and control surveillance. Results Pre-intervention, 117/128 (91.4%) patients undergoing cardiac surgery had a UCx collected. Of the UCx, 100% were ordered as part of the pre-operative checklist and not for symptoms. Five patients pre-intervention had ASB detected. Four patients received antibiotics to treat ASB. A fifth patient received antibiotics for bacteriuria which did not meet ASB count threshold. Post-intervention, 15/123 had a UCx (12.3%). Of these, 12/15 were ordered as part of the pre-operative checklist (80%), and the remaining three had symptoms documented. Post-intervention, one patient had ASB detected and did not receive antibiotics. Pre- and post-intervention there were 2 cases of CDI (2/128, 1.6% and 2/123, 1.6%, respectively). There were no CAUTIs either pre- or post-intervention. Conclusion Standard pre-operative UCx is known to be a low-value test and is not recommended by national guidelines. In this single-center diagnostic stewardship intervention, screening was reduced by 87.2%. There was no change in infectious outcomes. Disclosures All Authors: No reported disclosures.

Impact of saphenous vein harvesting on graft diameter: Supporting the no-touch technique.

In a recent study published in the Journal, Kurazumi and colleagues1 compare the effect of conventional (CV) versus no-touch (NT) saphenous vein (SV) harvesting on graft diameter pre- and postimplantation. Here, ultrasound imaging and electrocardiogram-gated enhanced computed tomography showed that preoperative versus postoperative SV graft diameter was significantly distended in the CV group (P < .0001) but not changed in the NT group (P = .33). Also, the diameter mismatch was significantly smaller in the NT versus the CV group (P < .0001).

Ten-year experience of infrainguinal bypass with endoscopic vein harvest.

There is conflicting data comparing minimally invasive vein harvest (MIVH) using endoscopic technique and open vein harvest (OVH) in terms of bypass patency, wound infection incidence, and patient morbidity. Our institution has performed MIVH since 2003 for peripheral bypass procedures with a consistent team of specialized endoscopic vein harvesters. This study reviewed the major outcomes of MIVH infrainguinal bypass at our institution given a predominant cohort of critical limb ischemia. We performed a 10-year, retrospective, single-institution review from January 2005 to December 2014, identifying all patients undergoing MIVH for obstructive infrainguinal disease. Primary outcomes were primary patency, operative time, intraoperative complications, surgical site infection (SSI), and freedom from amputation. A total of 289 patients (70% male) underwent MIVH infrainguinal bypass at an average age of 68 ± 12years old, an obesity prevalence of 28%, and with critical limb ischemia in 81% of the patient cohort (20% rest pain, 61% tissue loss/gangrene). Ninety-four percent of patients had no intraoperative complications, 2.5% had adverse cardiac or technical complications, and 4.2% of patients required transfusion. Average operative time was 4.2h. Femoral-popliteal TASC classification C and D constituted 80% of our patient cohort. At the last follow-up, toe pressures had increased from 30 ± 30 to 62 ± 40mmHg (p < 0.0001). Primary bypass patency in the first 30days was 95%. SSI incidence requiring surgical treatment was only 6%. Our median length of stay was 4.0days, with median intravenous narcotic use of 1day. In addition, 77% of patients returned to their baseline mobility at first follow-up (median 19days), and 83% of patients had freedom from amputation at last follow-up (median 820days). In a center with experience in MIVH and a consistent group of experienced endoscopic vein harvesters, MIVH bypass has excellent patency, low surgical site infection, short length of stay, and prompt return to baseline mobility.

Abstract 9602: Higher Anatomical Syntax Score is Associated With Lower Survival After CABG in the REGROUP Trial

Introduction: The SYNergy between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) score quantifies complexity of coronary artery disease (CAD) using angiographic data to objectively guide mode of revascularization. Recent studies evaluating complexity of CAD by the anatomical SYNTAX score (SS1) and impact on clinical outcomes following CABG have been inconclusive. Hypothesis: We sought to investigate the prognostic value of SS1 in predicting survival and incidence of major adverse cardiac events (MACE) following CABG in the REGROUP trial (ClinicalTrials.gov number NCT01850082.) Methods: This was a pre-planned sub-analysis of the REGROUP trial which randomized patients undergoing isolated CABG to endoscopic versus open vein harvest at 16 U. S. Veterans Affairs Medical Centers between 2014-2017; The median follow-up was 4.7 years (interquartile range 3.84-5.45). SS1 was extracted for all patients and stratified by terciles. Time-to-event survival analysis was performed for MACE defined as death from any cause, nonfatal myocardial infarction, or repeat revascularization over the study follow-up. Results: The mean SS1 for this cohort (N=1,145) was 28.5±11.5 (median 27). Mean age was 66.4±6.90 years, 50.2% were diabetics and 99.5% were males reflecting the Veterans population. According to SS1 terciles, low (&lt;23), intermediate (23-32) and high (&gt;32) SS1 groups comprised 383, 393 and 369 patients, respectively. Over study follow-up, SS1 terciles were associated with all-cause death (log-rank, p=0.012), which occurred in 8.6%, 14.2% and 15.2% of patients respectively (p=0.013). However, SS1 was not associated with higher rates of the composite MACE which occurred in 20.4%, 22.6% and 25.5% of patients (p=0.247). Conclusions: Over the REGROUP study follow-up, complexity of CAD evaluated by the SS1 is significantly associated with all-cause death, but not MACE.

Cost Effectiveness of Endoscopic Vein Harvest for CABG

Cost Effectiveness of Endoscopic Vein Harvest for CABG

Intimal hyperplasia, saphenous vein graft disease, and clinical outcomes: Insights from the CTSN VEST randomized trial

BackgroundDiffuse intimal hyperplasia and graft irregularity adversely affect the long-term patency of saphenous vein grafts (SVGs) and clinical outcomes of patients undergoing coronary artery bypass grafting (CABG). The VEST trial evaluated the efficacy of external graft support in limiting the development of intimal hyperplasia (IH) at 1 year postsurgery. In the present secondary analysis, we explored the associations between graft disease and IH and clinical events. We also examined risk factors for early graft occlusion. MethodsVEST is a within-patient randomized, multicenter trial that enrolled 224 patients with multivessel coronary disease undergoing CABG surgery, of whom 203 were evaluated by 1 year postsurgery. Intimal hyperplasia, lumen uniformity, graft stenosis, and graft perfusion were measured by intravascular ultrasound and angiography. Major cardiac and cerebrovascular events (MACCE; including death, myocardial infarction, stroke, and revascularization) were recorded over a median follow-up of 3 years. ResultsWorse lumen uniformity, greater stenosis, and worse graft perfusion were associated with higher IH values and an increased incidence of clinical events. Consistent with previous findings, we identified endoscopic vein harvesting, female sex, and transit time flow measurement of pulsatility index and flow as risk factors for SVG occlusion during the first year postsurgery. ConclusionsIn this secondary analysis of the VEST trial, we observed an association between intimal hyperplasia area and clinical measures of SVG disease at 1 year postsurgery. More severe SVG disease and larger areas of IH were associated with a higher incidence of 3-year MACCE. Ongoing follow-up to 5 years will further elucidate the impact of SVG disease on long-term clinical outcomes of CABG.

Endoscopic Saphenous Vein Harvesting and Surgical Site Infections after Coronary Artery Bypass Surgery (CABG)

Introduction: Coronary artery bypass grafting (CABG) surgery remains the most common procedure in adult cardiac surgery for coronary artery disease. Objectives: The main objective of the study is to find the infection in open vs endoscopic saphenous vein harvest for patients undergoing CABG surgery. Material and method: This comparative analysis was conducted at Rawalpindi Institute of Cardiology, Armed Forces Institute of Cardiology, Rawalpindi and Shifa International Hospital, Islamabad from October 2019 to 2021. The data was collected with the permission of the ethical committee of hospital. The data was collected with the permission of the ethical committee of the hospital. Patients undergoing CABG or combined valve/CABG with EVH and OVH were differentiated from each other in the MHCCSR as of the start of the study period. The OVH was performed by either a continuous, longitudinal incision or through multiple smaller incisions. Results: The data were collected from 122 patients, from these 22 patients were not extubated and none of them survived. The most common indication for surgery was myocardial revascularization (30.6%), followed by valve replacement (22.7%) and thoracic aortic aneurysm repair. Practical implication: EVH is now considered not to be the best method in CABG surgery. Conclusion: It is concluded that, patients undergoing CABG surgery with EVH presented with worse systolic function and more recent myocardial infarction. Keywords: CABG, Procedure, EVH, Systolic, Myocardial infarction, Endoscopic

Economic Evaluation of Endoscopic vs Open Vein Harvesting

BackgroundEndoscopic vein harvesting is an alternative to open vein harvesting during coronary artery bypass grafting. Although endoscopic vein harvesting includes significant clinical benefits, few long-term cost-effectiveness studies have been performed, limiting its use in the United Kingdom. In this study, we assessed the cost-effectiveness of endoscopic vein harvesting compared with open vein harvesting from the United Kingdom’s National Health Service perspective. MethodsA Markov model was developed to estimate the cost-effectiveness of endoscopic vein harvesting vs open vein harvesting by investigating the incremental lifetime costs per quality-adjusted life-year gained. A scoping literature review was conducted to inform the development of the model. One-way and probabilistic sensitivity analyses examined the robustness of the results. ResultsCompared with open vein harvesting, endoscopic vein harvesting leads to cost savings of £68.46 and quality-adjusted life-year gains of 0.206 per patient over a lifetime perspective. Thus, endoscopic vein harvesting is a dominant treatment option over open vein harvesting (net monetary benefit: £6248.46). In the scenario analysis, which accounted for a high-risk population with respect to leg wound infections, the net monetary benefit was £7341.47. The probabilistic sensitivity analysis showed that endoscopic vein harvesting has a 62.3% probability of being cost-effective at a threshold of £30,000 per quality-adjusted life-year, highlighting uncertainties resulting from follow-up event rates. ConclusionsEndoscopic vein harvesting is a cost-effective method of harvesting a saphenous vein graft. Further clinical data beyond 5 years of follow-up are required to confirm the long-term cost-effectiveness.

Uniportal Endoscopic Vein Harvest Using the Three-Step Haemostatic Technique—A Modified Approach

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.

Endoscopic Versus Conventional Vein Harvest Technique: Histological and Immunohistochemical Evaluation of Venous Wall Integrity.

The introduction of endoscopic saphenous vein graft harvesting has been known for two decades. It offers benefits related to decreased rate of donner site complications. Debates related to its safety in terms of trauma to the wall of the venous graft and long-term graft patency have been raised, but few studies had investigated this point. Our aim is to compare the endoscopic saphenous vein harvest and conventional harvest techniques, in terms of the integrity of the wall of the vein graft. A prospective study in which we examined 80 samples of saphenous vein from 80 patients to whom coronary artery bypass grafting was done. Patients randomly were assigned to either technique. Vein samples were taken from patients having the conventional technique (group 1, 40 patients) and from patients having endoscopic vein harvest (group 2, 40 patients). Vein samples were stained with Hematoxylin & Eosin, Masson's trichrome, and immunohistochemical stain for CD 31 and then examined by light microscopy. The degree of intimal staining was graded from 0% to 100%, which is directly related to the degree of intimal preservation (the least injury, the more the staining score) and vein media changes were reported. Patient characteristics were comparable in the groups. Group 1 (conventional group) was better than group 2 (endoscopic group), regarding endothelial integrity and medial changes although it was statistically not significant. Both the conventional and endoscopic techniques are comparable, regarding the intimal preservation of the venous graft.

Costs of Endoscopic vs Open Vein Harvesting for Coronary Artery Bypass Grafting

Value-based purchasing creates pressure to examine whether newer technologies and care processes, including new surgical techniques, yield any economic advantage. To compare health care costs and utilization between participants randomized to receive endoscopic vein harvesting (EVH) or open vein harvesting (OVH) during a coronary artery bypass grafting (CABG) procedure. This secondary economic analysis was conducted alongside the 16-site Randomized Endo-Vein Graft Prospective (REGROUP) clinical trial funded by the Department of Veterans Affairs (VA) Cooperative Studies Program. Adults scheduled for urgent or elective bypass involving a vein graft were eligible. The first participant was enrolled in September 2013, with most sites completing enrollment by March 2014. The last participant was enrolled in April 2017. A total of 1150 participants were randomized, with 574 participants receiving OVH and 576 receiving EVH. For this secondary analysis, cost and utilization data were extracted through September 30, 2020. Participants were linked to administrative data in the VA Corporate Data Warehouse and activity-based cost data starting with the index procedure. EVH vs OVH, with comparisons based on intention to treat. Discharge costs for the index procedure as well as follow-up costs (including intended and unintended events; mean [SD] follow-up time, 33.0 [19.9] months) were analyzed, with results from different statistical models compared to test for robustness (ie, lack of variation across models). All costs represented care provided or paid by the VA, standardized to 2020 US dollars. Among 1150 participants, the mean (SD) age was 66.4 (6.9) years; most participants (1144 [99.5%] were male. With regard to race and ethnicity, 6 participants (0.5%) self-reported as American Indian or Alaska Native, 10 (0.9%) as Asian or Pacific Islander, 91 (7.9%) as Black, 62 (5.4%) as Hispanic, 974 (84.7%) as non-Hispanic White, and 6 (0.5%) as other race and/or ethnicity; data were missing for 1 participant (0.1%). The unadjusted mean (SD) costs for the index CABG procedure were $76 607 ($43 883) among patients who received EVH and $75 368 ($45 900) among those who received OVH, including facility costs, insurance costs, and physician-related costs (commonly referred to as provider costs in Centers for Medicare and Medicaid and insurance data). No significant differences were found in follow-up costs; per 90-day follow-up period, EVH was associated with a mean (SE) added cost of $302 ($225) per patient. The results were highly robust to the statistical model. In this study, EVH was not associated with a reduction in costs for the index CABG procedure or follow-up care. Therefore, the choice to provide EVH may be based on surgeon and patient preferences. ClinicalTrials.gov Identifier: NCT01850082.

What is the benefit of venous mapping in saphenous vein harvesting?

What is the benefit of venous mapping in saphenous vein harvesting?

P11: Endoscopic Procurement of Saphenous Vein: a Hydraulic Conductivity and Microscopic Assessment

Background: Endoscopic saphenous vein harvest (ESVH) technique is an alternate and widely used conduit in coronary artery bypass grafting CABG in leu of the internal mammary artery (IMA). Unfortunately, multiple studies have shown low-patency rate in saphenous vein (SV) than IMA and prone to early atherosclerotic changes leading to obstruction. Thus, our goal was to explore the effects of physical distention on the endothelial integrity of SV by using hydraulic conductivity (HC) and scanning electron microscopy (SEM). Method: Saphenous vein conduits were collected intra-operatively from consented patients and procured at 37 °C. Vessel wall filtration rate was determined over 30-minute period at 100 mm Hg pressure and compared with baseline and negative control by using dialysis tubing, and isolated fresh swine carotid arteries. Conduits were stored in saline after harvest. Longitudinal sections of IMAs were fixed and dehydrated in various ethanol concentrations in deionized water for 15-minutes. Samples were then analyzed under SEM imaging. Result: Hydraulic conductivity of ESHV is tenfold higher than the pig carotid and dialysis tubing. Furthermore, SEM analyses of ESHV showed intimal injuries on the luminal surface. Conclusion: ESHV technique may increase the risk of traumatic handling by creating physical gaps in endothelial barrier. Alteration in vascular integrity may impact on permeability of larger molecules enhancing pathologic occlusive state and graft failure.

Endoscopic vein harvesting: a guide for approaching difficult cases and assessing patients preoperatively.

Coronary artery bypass grafting remains the most commonly performed cardiac surgical procedure worldwide. The long saphenous vein still presides as the first choice conduit as a second graft in multivessel coronary artery bypass grafting surgery. Traditionally, the long saphenous vein has been harvested with an open approach which can potentially result in significant wound complications in certain circumstances. Endoscopic vein harvesting is a minimally invasive vein harvesting technique, which requires a single 2–3 cm incision and is associated with a quicker return to normal daily activities, decreased wound complications and better quality of life in the longer term. There is a learning curve associated with endoscopic vein harvesting adoption and there are certain patient factors that can prove to be challenging when adopting an endoscopic approach. This commentary aims to provide a concise guide of certain challenging patient factors that operators may encounter during endoscopic vein harvesting, and how to approach these patients in both the preoperative and intraoperative settings. We suggest that with appropriate planning and awareness of the challenging patient factors and problematic venous anatomy that exists, the operator can consistently formulate a strategy for ensuring a successful endoscopic harvest.