Comparative results of endoscopic and open methods of vein harvesting for coronary artery bypass grafting: a prospective randomized parallel-group trial

Saphenous vein harvesting techniques for coronary artery bypass grafting: a systematic review and meta-analysis

The great saphenous vein (GSV) graft remains a frequently used conduit for coronary artery bypass graft (CABG) surgery. The optimal technique for GSV harvesting has been the subject of on-going controversy. We therefore sought to conduct a systematic review and meta-analysis of all available GSV harvesting techniques in CABG. A systematic search of 12 electronic databases was performed to identify all randomized controlled trials (RCTs) of any GSV harvesting technique, including conventional vein harvesting (CVH), no-touch, standard bridging technique (SBT) and endoscopic vein harvesting (EVH) techniques. We investigated safety and long-term efficacy outcomes. All outcomes were analyzed using the frequentist network meta-analysis. A total of 6480 patients from 34 RCTs were included. For safety outcomes, EVH reduced 91% and 77% risk of wound infection compared to no-touch and CVH, respectively. EVH and SBT also significantly reduced the risk of sensibility disorder and postoperative pain. The techniques were not significantly different regarding long-term efficacy outcomes, including mortality, myocardial infarction and graft patency. For GSV harvesting for CABG, EVH techniques are the most favorable, but in case of using an open technique, no-touch is more recommended than CVH. More effective and safer procedures should be investigated for GSV harvesting in CABG.

PCI and CABG for Treating Stable Coronary Artery Disease: JACC Review Topic of the Week

Percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) are considered revascularization procedures, but only CABG can prolong life in stable coronary artery disease. Thus, PCI and CABG mechanisms may differ. Viability and/or ischemia detection to guide revascularization have been unable to accurately predict treatment effects of CABG or PCI, questioning a revascularization mechanism for improving survival. By contrast, preventing myocardial infarction may save lives. However, the majority of infarcts are generated by non-flow-limiting stenoses, but PCI is solely focused on treating flow-limiting lesions. Thus, PCI cannot be expected to significantly limit new infarcts, but CABG may do so through providing flow distal to vessel occlusions. All comparisons of CABG to PCI or medical therapy that demonstrate survival effects with CABG also demonstrate infarct reduction. Thus, CABG may differ from PCI by providing "surgical collateralization," prolonging life by preventing myocardial infarctions. The evidence is reviewed here.

A Prospective Randomized Study of Endoscopic Versus Conventional Harvesting of the Radial Artery

OBJECTIVE

The aims of the study were to determine whether endoscopic harvesting of the radial artery (RA) reduces morbidity due to pain, infection, and disability with improvement in satisfaction and cosmesis compared to the conventional technique and (2) to compare the 6-month angiographic patency of the RA harvested conventionally and endoscopically.

METHODS

In a prospective randomized study, 119 patients undergoing coronary artery bypass grafting using the RA were randomized to have RA harvested either conventionally (n = 59) or endoscopically (n = 60).

RESULTS

Radial artery harvest time (open wound time) was significantly reduced in the endoscopic group (36.5 ± 9.4 vs 57.7 ± 9.4 minutes, P < 0.001). Only one patient developed wound infection (1.6%) in the endoscopic group compared with six patients (10.2%), P = 0.061, in the conventional group. Although this was not statistically significant, clinically this was relevant in terms of reduction in postoperative morbidity. Postoperative pain in the arm incision was significantly lower in the endoscopic group at postoperative day 2 (P < 0.001) and at discharge (P < 0.001) and similar to the conventional open group at 6 weeks' follow-up (P = 0.103). Overall patient satisfaction and cosmesis were significantly better in the endoscopic group at postoperative day 2 (P < 0.001), at discharge (P < 0.001), and at 6 weeks' follow-up (P < 0.001). There was no difference in the arm disability postoperatively (P = 0.505) between the two groups. Six-month angiographic assessment of 23 patients (12 endoscopic and 11 open) revealed no difference in the patency rate (10/12 in endoscopic and 9/11 in open group).

CONCLUSIONS

Endoscopic RA harvesting reduced the incidence of postoperative wound infection and wound pain and improved patient satisfaction and cosmesis compared with conventional harvesting technique. There was no difference in the 6-month angiographic patency of the RA harvested conventionally and endoscopically.

Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery

Objective

The purpose of this consensus conference was to develop and update evidence-informed consensus statements and recommendations on harvesting saphenous vein and radial artery via an open as compared with endoscopic technique by systematically reviewing and performing a meta-analysis of randomized and nonrandomized clinical trials.

Methods

All randomized controlled trials and nonrandomized controlled trials included in the first the International Society for Minimally Invasive Cardiothoracic Surgery Consensus Conference and Statements,1,2 in 2005 up to November 30, 2015, were included in a systematic review and meta-analysis. Based on the resultant, 76 studies (23 randomized controlled trials and 53 nonrandomized controlled trials) on 281,459 patients analyzed, consensus statements, and recommendations were generated comparing the risks and benefits of endoscopic versus open conduit harvesting for patients undergoing coronary artery bypass grafting.

Results

Compared with open vein harvest, it is reasonable to perform endoscopic vein harvest of saphenous vein to reduce wound-related complications, postoperative length of stay, and outpatient wound management resources and to increase patient satisfaction (class I, level A). Based on the quality of the conduit and major adverse cardiac events as well as 6-month angiographic patency, endoscopic vein harvest was noninferior to open harvest. It is reasonable to perform endoscopic radial artery harvest to reduce wound-related complication and to increase patient satisfaction (class I, level B-R and B-NR, respectively) with reduction in major adverse cardiac events and noninferior patency rate at 1 and 3 to 5 years (class III, level B-R).

Conclusions

Based on the consensus statements, the consensus panel recommends (class I, level B) that endoscopic saphenous vein and radial artery harvesting should be the standard of care for patients who require these conduits for coronary revascularization.

Study Comparing Vein Integrity and Clinical Outcomes in Open Vein Harvesting and 2 Types of Endoscopic Vein Harvesting for Coronary Artery Bypass Grafting: The VICO Randomized Clinical Trial (Vein Integrity and Clinical Outcomes)

BACKGROUND

Current consensus statements maintain that endoscopic vein harvesting (EVH) should be standard care in coronary artery bypass graft surgery, but vein quality and clinical outcomes have been questioned. The VICO trial (Vein Integrity and Clinical Outcomes) was designed to assess the impact of different vein harvesting methods on vessel damage and whether this contributes to clinical outcomes after coronary artery bypass grafting.

METHODS

In this single-center, randomized clinical trial, patients undergoing coronary artery bypass grafting with an internal mammary artery and with 1 to 4 vein grafts were recruited. All veins were harvested by a single experienced practitioner. We randomly allocated 300 patients into closed tunnel CO₂ EVH (n=100), open tunnel CO₂ EVH (n=100), and traditional open vein harvesting (n=100) groups. The primary end point was endothelial integrity and muscular damage of the harvested vein. Secondary end points included clinical outcomes (major adverse cardiac events), use of healthcare resources, and impact on health status (quality-adjusted life-years).

RESULTS

The open vein harvesting group demonstrated marginally better endothelial integrity in random samples (85% versus 88% versus 93% for closed tunnel EVH, open tunnel EVH, and open vein harvesting; P<0.001). Closed tunnel EVH displayed the lowest longitudinal hypertrophy (1% versus 13.5% versus 3%; P=0.001). However, no differences in endothelial stretching were observed between groups (37% versus 37% versus 31%; P=0.62). Secondary clinical outcomes demonstrated no significant differences in composite major adverse cardiac event scores at each time point up to 48 months. The quality-adjusted life-year gain per patient was 0.11 (P<0.001) for closed tunnel EVH and 0.07 (P=0.003) for open tunnel EVH compared with open vein harvesting. The likelihood of being cost-effective, at a predefined threshold of £20 000 per quality-adjusted life-year gained, was 75% for closed tunnel EVH, 19% for open tunnel EVH, and 6% for open vein harvesting.

CONCLUSIONS

Our study demonstrates that harvesting techniques affect the integrity of different vein layers, albeit only slightly. Secondary outcomes suggest that histological findings do not directly contribute to major adverse cardiac event outcomes. Gains in health status were observed, and cost-effectiveness was better with closed tunnel EVH. High-level experience with endoscopic harvesting performed by a dedicated specialist practitioner gives optimal results comparable to those of open vein harvesting.

CLINICAL TRIAL REGISTRATION

URL: https://www.isrctn.com. International Standard Randomised Controlled Trial Registry Number: 91485426.