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Anderson D, Kiaii B, Catrip J. The Current Status of Minimally Invasive Conduit Harvesting for Coronary Artery Bypass Grafting. J Cardiovasc Dev Dis 2024; 11:188. [PMID: 39057610 PMCID: PMC11276993 DOI: 10.3390/jcdd11070188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/18/2024] [Accepted: 06/20/2024] [Indexed: 07/28/2024] Open
Abstract
The harvesting of conduits for coronary artery bypass surgery has evolved over the last decade to include endoscopic approaches to access the saphenous vein, radial artery, and internal mammary artery. These minimally invasive techniques reduce the morbidity associated with open procedures by decreasing pain and recovery time and increasing mobility post operatively. This review highlights the differences in morbidity, quality, and patency between the most common conduits that are harvested minimally invasively for coronary artery bypass grafting surgery.
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Affiliation(s)
- Devon Anderson
- Division of Cardiac Surgery, Department of Surgery, University of California Davis Medical Center, Sacramento, CA 95817, USA; (B.K.); (J.C.)
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Emmert MY, Bonatti J, Caliskan E, Gaudino M, Grabenwöger M, Grapow MT, Heinisch PP, Kieser-Prieur T, Kim KB, Kiss A, Mouriquhe F, Mach M, Margariti A, Pepper J, Perrault LP, Podesser BK, Puskas J, Taggart DP, Yadava OP, Winkler B. Consensus statement-graft treatment in cardiovascular bypass graft surgery. Front Cardiovasc Med 2024; 11:1285685. [PMID: 38476377 PMCID: PMC10927966 DOI: 10.3389/fcvm.2024.1285685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 01/15/2024] [Indexed: 03/14/2024] Open
Abstract
Coronary artery bypass grafting (CABG) is and continues to be the preferred revascularization strategy in patients with multivessel disease. Graft selection has been shown to influence the outcomes following CABG. During the last almost 60 years saphenous vein grafts (SVG) together with the internal mammary artery have become the standard of care for patients undergoing CABG surgery. While there is little doubt about the benefits, the patency rates are constantly under debate. Despite its acknowledged limitations in terms of long-term patency due to intimal hyperplasia, the saphenous vein is still the most often used graft. Although reendothelialization occurs early postoperatively, the process of intimal hyperplasia remains irreversible. This is due in part to the persistence of high shear forces, the chronic localized inflammatory response, and the partial dysfunctionality of the regenerated endothelium. "No-Touch" harvesting techniques, specific storage solutions, pressure controlled graft flushing and external stenting are important and established methods aiming to overcome the process of intimal hyperplasia at different time levels. Still despite the known evidence these methods are not standard everywhere. The use of arterial grafts is another strategy to address the inferior SVG patency rates and to perform CABG with total arterial revascularization. Composite grafting, pharmacological agents as well as latest minimal invasive techniques aim in the same direction. To give guide and set standards all graft related topics for CABG are presented in this expert opinion document on graft treatment.
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Affiliation(s)
- Maximilian Y. Emmert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
- Institute for Regenerative Medicine (IREM), University of Zurich, Zurich, Switzerland
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, UPMC Heart and Vascular Institute, University of Pittsburgh, Pittsburgh, PA, United States
| | - Etem Caliskan
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charite (DHZC), Berlin, Germany
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, United States
| | - Martin Grabenwöger
- Sigmund Freud Private University, Vienna, Austria
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
| | | | - Paul Phillip Heinisch
- German Heart Center Munich, Technical University of Munich, School of Medicine, Munich, Germany
| | - Teresa Kieser-Prieur
- LIBIN Cardiovascular Institute of Alberta, University of Calgary, Calgary, AB, Canada
| | - Ki-Bong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Attila Kiss
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | | | - Markus Mach
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | - Adrianna Margariti
- The Wellcome-Wolfson Institute of Experimental Medicine, Belfast, United Kingdom
| | - John Pepper
- Cardiology and Aortic Centre, Royal Brompton Hospital, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | | | - Bruno K. Podesser
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
| | - John Puskas
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, United States
| | - David P. Taggart
- Nuffield Dept Surgical Sciences, Oxford University, Oxford, United Kingdom
| | | | - Bernhard Winkler
- Department of Cardiovascular Surgery KFL, Vienna Health Network, Vienna, Austria
- Ludwig Boltzmann Institute at the Center for Biomedical Research, Medical University of Vienna, Vienna, Austria
- Karld Landsteiner Institute for Cardiovascular Research Clinic Floridsdorf, Vienna, Austria
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Wang Z, Gu R, Wang J, Gai Y, Lin H, Zhang Y, Li Q, Sun T, Wei L. Effectiveness of a Game-Based Mobile App for Educating Intensive Critical Care Specialist Nurses in Extracorporeal Membrane Oxygenation Pipeline Preflushing: Quasi-Experimental Trial. JMIR Serious Games 2023; 11:e43181. [PMID: 38062643 PMCID: PMC10723763 DOI: 10.2196/43181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 10/30/2023] [Accepted: 11/06/2023] [Indexed: 12/17/2023] Open
Abstract
Background In the context of training specialist nurses and nursing education, a game-based mobile app was used as a simulation to teach intensive critical care specialist nurses the knowledge and skills of extracorporeal membrane oxygenation (ECMO) pipeline preflushing. Objective This study aimed to evaluate the impact of a game-based mobile app on improving ECMO pipeline preflushing skills in intensive critical care specialist nurses. Methods A total of 86 intensive critical care specialist nurses who were learning ECMO for the first time were included in this study. The nurses were divided into 2 groups: a control group (n=43) and an experimental group (n=43). Participants in the experimental group used a game-based mobile app for simulation exercises; the control group received no additional intervention. All participants took a theoretical test and a skill operation test at the beginning of the study and 1 week later. The differences in scores between the 2 groups were compared, and the learning curve of the experimental group was observed. Results The final theoretical test scores (88.44 and 85.02) and skill operation test scores (89.42 and 86.33) of the experimental group and control group, respectively, were significantly higher than those of the initial tests (theoretical test scores: 75.88 and 74.42; skill operation test scores: 75.44 and 75.93; all P<.001). The scores of the final theoretical test (88.44) and the final skill operation test (89.42) in the experimental group were higher than the scores of the control group (85.02; P<.001 and 86.33; P<.001, respectively). Learning curve analysis showed that the experimental group needed an average of 17 operations to master the skill. Conclusions This study suggests that a game-based mobile app may be more effective for intensive critical care specialist nurses in ECMO pipeline preflushing education than traditional Chinese lecture-practice education.
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Affiliation(s)
- Zihan Wang
- School of Nursing, Qingdao University, Qingdao, China
| | - Ruting Gu
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jingyuan Wang
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yubiao Gai
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Hui Lin
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yan Zhang
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qianqian Li
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Tong Sun
- Population Monitoring and Family Development Department, Qingdao Licang Municipal Health Commission, Qingdao, China
| | - Lili Wei
- Nursing Department, The Affiliated Hospital of Qingdao University, Qingdao, China
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Zivkovic I, Krasic S, Stankovic M, Milacic P, Milutinovic A, Zdravkovic D, Tabakovic Z, Peric M, Krstic M, Bojic M, Milic D, Micovic S. Influence of Three Different Surgical Techniques on Microscopic Damage of Saphenous Vein Grafts-A Randomized Study. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59020217. [PMID: 36837419 PMCID: PMC9962261 DOI: 10.3390/medicina59020217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/27/2022] [Indexed: 01/25/2023]
Abstract
Background and Objectives: The saphenous vein is one of the most common used grafts (SVG) for surgical revascularization. The mechanism of the SVGs occlusion is still unknown. Surgical preparation techniques have an important role in the early and late graft occlusion. Our study analyzed the influence of the three different surgical techniques on the histological and immunohistochemical characteristics of the vein grafts. Methods: Between June 2019 and December 2020, 83 patients who underwent surgical revascularization were prospectively randomly assigned to one of the three groups, according to saphenous vein graft harvesting (conventional (CVH), no-touch (NT) and endoscopic (EVH)) technique. The vein graft samples were sent on the histological (hematoxylin-eosin staining) and immunohistochemical (CD31, Factor VIII, Caveolin and eNOS) examinations. Results: The CVH, NT, and EVH groups included 27 patients (mean age 67.66 ± 5.6), 31 patients (mean age 66.5 ± 7.4) and 25 patients (mean age 66 ± 5.5), respectively. Hematoxylin-eosin staining revealed a lower grade of microstructural vein damage in the NT group (2, IQR 1-2) in comparison with CVH and EVH (3, IQR 2-4), (4, IQR 2-4) respectively (p < 0.001). Immunohistochemical examination revealed a high grade of staining in the NT group compared to the CVH and EVH group (CD 31 antibody p = 0.02, FVIII, p < 0.001, Caveolin, p = 0.001, and eNOS, p = 0.003). Conclusion: The best preservation of the structural vein integrity was in the NT group, while the lowest rate of leg wound complication was in the EVH group. These facts increase the interest in developing and implementing the endoscopic no-touch technique.
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Affiliation(s)
- Igor Zivkovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Correspondence: ; Tel.: +381-6-2100-9619
| | - Stasa Krasic
- Cardiology Department, Mother and Child Health Care Institute, 11000 Belgrade, Serbia
| | - Milica Stankovic
- Center for Pathology and Pathological Anatomy, Clinical Center of Niš, 18000 Niš, Serbia
| | - Petar Milacic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | | | - Djordje Zdravkovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Zoran Tabakovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Miodrag Peric
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Miljan Krstic
- Center for Pathology and Pathological Anatomy, Clinical Center of Niš, 18000 Niš, Serbia
- Faculty of Medicine, University of Niš, 18000 Niš, Serbia
| | - Milovan Bojic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Dragan Milic
- Faculty of Medicine, University of Niš, 18000 Niš, Serbia
- Cardiac Surgery Department, Clinical Center of Niš, 18000 Niš, Serbia
| | - Slobodan Micovic
- Cardiac Surgery Department, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- School of Medicine, University of Belgrade, 11000 Belgrade, Serbia
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Siddiqui S, Whooley J, Miceli A, Bartolozzi F, Soo A. Endoscopic vein harvesting: a guide for approaching difficult cases and assessing patients preoperatively. Interact Cardiovasc Thorac Surg 2022; 35:6595113. [PMID: 35640590 PMCID: PMC9486924 DOI: 10.1093/icvts/ivac142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 04/25/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
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.
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Affiliation(s)
- Sadiq Siddiqui
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Jack Whooley
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Antonio Miceli
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
- Instituto Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato , Milan, Italy
| | - Fabio Bartolozzi
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
| | - Alan Soo
- Department of Cardiothoracic Surgery, University Hospital Galway , Galway, Ireland
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Gu R, Wang J, Zhang Y, Li Q, Wang S, Sun T, Wei L. Effectiveness of a game-based mobile application in educating nursing students on flushing and locking venous catheters with pre-filled saline syringes: A randomized controlled trial. Nurse Educ Pract 2021; 58:103260. [PMID: 34864483 DOI: 10.1016/j.nepr.2021.103260] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/18/2021] [Accepted: 11/19/2021] [Indexed: 01/22/2023]
Abstract
AIM This study aimed to determine the effect of a game-based mobile application on the skill levels of nursing students in respect of flushing and locking of venous catheters with pre-filled saline syringes. BACKGROUND In the context of the education of nursing students, a game-based mobile application was used as a motivational aid to improve nursing students' skills in flushing and locking of venous catheters. DESIGN A single-blind randomized controlled trial was conducted from August 2020, in a university-affiliated hospital in China. METHODS A total of 154 nursing students were divided randomly into two groups: a control group (n = 77) and an experimental group (n = 77). All the participants received a 30-min theoretical interpretation, 30-min demonstration, and one opportunity to practice. For the next seven days, the participants in the experimental group used a game-based mobile application as a motivational aid to practice their skills in flushing and locking of venous catheters; the control group received no additional intervention. We observed the skill performance and the incidence of errors in the procedural steps of the participants in the two groups at first and seven days later, along with the learning curve of the skills of the experimental group in respect of flushing and locking of venous catheters. RESULTS The final skill performance scores of the nursing students in the experimental group were higher than the average scores of the nursing students in the control group (p = 0.003); The incidence of errors in material preparation rate, hand hygiene, and flushing and locking in the experimental group were lower than that in the control group (p = 0.027, p = 0.035, p = 0.045). Analysis of the learning curve revealed that the experimental group needed an average of 11 repeat practices sessions to master the skills. CONCLUSIONS In the short term, the game-based mobile application was effective in improving the skills of nursing students in flushing and locking venous catheters with pre-filled saline syringes. It is an effective complement to existing training methods.
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Affiliation(s)
- Ruting Gu
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
| | - Jingyuan Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
| | - Yan Zhang
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
| | - Qianqian Li
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
| | - Siyao Wang
- Department of Respiratory and Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
| | - Tong Sun
- School of Nursing, Qingdao University, Qingdao 266000, Shangdong, China.
| | - Lili Wei
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao 266000, Shangdong, China.
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Learning process and results in endoscopic saphenous vein harvesting technique. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.969519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Krishnamoorthy B, Zacharias J, Critchley WR, Rochon M, Stalpinskaya I, Rajai A, Venkateswaran RV, Raja SG, Bahrami T. A multicentre review comparing long term outcomes of endoscopic vein harvesting versus open vein harvesting for coronary artery bypass surgery. NIHR OPEN RESEARCH 2021; 1:11. [PMID: 35098131 PMCID: PMC7612280 DOI: 10.3310/nihropenres.13215.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/24/2021] [Indexed: 11/22/2022]
Abstract
Background Utilisation of the Endoscopic Vein Harvesting (EVH) technique has been increasing for coronary artery bypass grafting (CABG) for the last two decades. Some surgeons remain concerned about the long-term patency of the long saphenous vein harvested endoscopically compared to traditional Open Vein Harvesting (OVH). The aim of this study was to perform a retrospective analysis of the outcomes between EVH and OVH from three UK centres with 10 years follow-up. Methods 27,024 patients underwent CABG with long saphenous vein harvested by EVH (n=13,794) or OVH (n=13,230) in three UK centres between 2007 and 2019. Propensity modelling was used to calculate the Inverse Probability of Treatment Weights (IPTW). The primary endpoint was mortality from all causes and secondary endpoints were length of hospital stay, postoperative complications, and incidence of repeat coronary re-vascularisation for symptomatic patients. IPTW was used to balance the two intervention groups for baseline and preoperative co-morbidities. Results Median follow-up time was 4.54 years for EVH and 6.00 years for OVH. Death from any cause occurred in 13.8% of the EVH group versus 20.8% in the OVH group over the follow-up period. The hazard ratio of death (EVH to OVH) was 0.823 (95% CI: 0.767, 0.884). Length of hospital stay was similar between the groups (p=0.86). Post-operative pulmonary complications were more common in EVH vs OVH (14.7% vs. 12.8%, p<0.001), but repeat coronary re-vascularisation was similar between the groups. Conclusions This large retrospective multicentre analysis indicates that EVH has a lower risk of mortality compared with OVH during the follow-up period of the study. The observed benefits of EVH may outweigh the risks but should be considered on a case-by-case basis. We hope this review gives confidence to other cardiac centres that offering an EVH approach to conduit harvesting does not affect long term patient outcomes.
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Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- Department of Cardiovascular Sciences, Faculty of Health, Biology and Medicine, The University of Manchester, Manchester, UK
- Department of Allied Health Professions, Faculty of Health and Social Service, Edge hill University, Ormskirk, UK
- Department of Cardiothoracic surgery, Manchester Foundation Trust, Wythenshawe Hospital, Manchester, UK
| | - Joesph Zacharias
- Department of Cardiothoracic surgery, Blackpool Victoria NHS trust, Blackpool, UK
| | - William R. Critchley
- Endothelial Cell Biology, School of Molecular Medicine, University of Leeds, Leeds, England, UK
| | - Melissa Rochon
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
| | - Iryna Stalpinskaya
- Department of Cardiothoracic surgery, Blackpool Victoria NHS trust, Blackpool, UK
| | - Azita Rajai
- Centre for Biostatitics, Division of Population Health, University of Manchester, Manchester, UK
| | - Rajamiyer V. Venkateswaran
- Department of Allied Health Professions, Faculty of Health and Social Service, Edge hill University, Ormskirk, UK
| | - Shahzad G. Raja
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
| | - Toufan Bahrami
- Department of Cardiothoracic surgery, Royal Brompton & Harefield NHS Trust, London, UK
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Taggart DP, Gavrilov Y, Krasopoulos G, Rajakaruna C, Zacharias J, De Silva R, Channon KM, Gehrig T, Donovan TJ, Friedrich I. External stenting and disease progression in saphenous vein grafts two years after coronary artery bypass grafting: A multicenter randomized trial. J Thorac Cardiovasc Surg 2021; 164:1532-1541.e2. [PMID: 34024615 DOI: 10.1016/j.jtcvs.2021.03.120] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 03/28/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Little data exist regarding the potential of external stents to mitigate long-term disease progression in saphenous vein grafts. We investigated the effect of external stents on the progression of saphenous vein graft disease. METHODS A total of 184 patients undergoing isolated coronary artery bypass grafting, using an internal thoracic artery graft and at least 2 additional saphenous vein grafts, were enrolled in 14 European centers. One saphenous vein graft was randomized to an external stent, and 1 nonstented saphenous vein graft served as the control. The primary end point was the saphenous vein graft Fitzgibbon patency scale assessed by angiography, and the secondary end point was saphenous vein graft intimal hyperplasia assessed by intravascular ultrasound in a prespecified subgroup at 2 years. RESULTS Angiography was completed in 128 patients and intravascular ultrasound in the entire prespecified cohort (n = 51) at 2 years. Overall patency rates were similar between stented and nonstented saphenous vein grafts (78.3% vs 82.2%, P = .43). However, the Fitzgibbon patency scale was significantly improved in stented versus nonstented saphenous vein grafts, with Fitzgibbon patency scale I, II, and III rates of 66.7% versus 54.9%, 27.8% versus 34.3%, and 5.5% versus 10.8%, respectively (odds ratio, 2.02; P = .03). Fitzgibbon patency scale was inversely related to saphenous vein graft minimal lumen diameter, with Fitzgibbon patency scale I, II, and III saphenous vein grafts having an average minimal lumen diameter of 2.62 mm, 1.98 mm, and 1.32 mm, respectively (P < .05). Externally stented saphenous vein grafts also showed significant reductions in mean intimal hyperplasia area (22.5%; P < .001) and thickness (23.5%; P < .001). CONCLUSIONS Two years after coronary artery bypass grafting, external stenting improves Fitzgibbon patency scales of saphenous vein grafts and significantly reduces intimal hyperplasia area and thickness. Whether this will eventually lead to improved long-term patency is still unknown.
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Affiliation(s)
- David P Taggart
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | | | - George Krasopoulos
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Cha Rajakaruna
- Department of Cardiothoracic Surgery, University Hospitals Bristol, Bristol, United Kingdom
| | - Joseph Zacharias
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, United Kingdom
| | - Ravi De Silva
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, United Kingdom
| | - Keith M Channon
- Department of Cardiovascular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Thomas Gehrig
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany
| | | | - Ivar Friedrich
- Herzzentrum Trier, Krankenhaus der Barmherzigen Bruder, Trier, Germany.
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Zenati MA, Bhatt DL, Stock EM, Hattler B, Wagner TH, Bakaeen FG, Biswas K. Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial. JAMA Netw Open 2021; 4:e211439. [PMID: 33720367 PMCID: PMC7961312 DOI: 10.1001/jamanetworkopen.2021.1439] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
This randomized clinical trial examines intermediate-term outcomes of endoscopic vs open vein harvesting for coronary artery bypass grafting as part of the Randomized Endo-Vein Graft Perspective (REGROUP) trial.
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Affiliation(s)
- Marco A. Zenati
- Division of Cardiac Surgery, Department of Surgery, Veterans Affairs Boston Healthcare System, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eileen M. Stock
- Cooperative Studies Program, Perry Point/Baltimore Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
| | | | - Todd H. Wagner
- VA Health Economics Resource Center, Department of Surgery, Stanford University, Palo Alto, California
| | | | - Kousick Biswas
- Perry Point Cooperative Studies Program Coordinating Center, Office of Research and Development, US Department of Veterans Affairs, Perry Point, Maryland
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore
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Abstract
Coronary artery bypass grafting is the most common cardiac surgical procedure performed worldwide and the long saphenous vein the most common conduit for this. When performed as an open vein harvest (OVH), the incision on each leg can be up to 85cm long, making it the longest incision of any routine procedure. This confers a high degree of morbidity to the procedure. Endoscopic vein harvest (EVH) methods were popularised over two decades ago, demonstrating significant benefits over OVH in terms of leg wound complications including surgical site infections. They also appeared to hasten return to usual activities and wound healing and became popular particularly in North America. Subgroup analyses of two trials designed for other purposes created a period of uncertainty between 2009–2013 while the impact of endoscopic vein harvesting on vein graft patency and major adverse cardiac events was scrutinised. Large observational studies debunked the findings of increased mortality in the short-term, allowing practitioners and governing bodies to regain some confidence in the procedure. A well designed, adequately powered, randomised controlled trial published in 2019 also definitively demonstrated that there was no increase in death, myocardial infarction or repeat revascularisation with endoscopic vein harvest. Endoscopic vein harvest is a Class IIa indication in European Association of Cardio-Thoracic Surgery (EACTS) and a Class I indication in International Society of Minimally Invasive Cardiac Surgery (ISMICS) guidelines.
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Affiliation(s)
- Enoch Akowuah
- Department of Cardiac Surgery, James Cook University Hospital, South Tees NHS, Foundation Trust, Middlesbrough, UK
| | - Daniel Burns
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Joseph Zacharias
- Department of Cardiothoracic Surgery, Blackpool Victoria Hospital, Blackpool, UK
| | - Bilal H Kirmani
- Department of Cardiac Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Tamim M, Alexiou C, Al-Hassan D, Al-Faraidy K. Prospective randomized trial of endoscopic vs open radial artery harvest for CABG: Clinical outcome, patient satisfaction, and midterm RA graft patency. J Card Surg 2020; 35:2147-2154. [PMID: 32652684 DOI: 10.1111/jocs.14706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Endoscopic radial artery (RA) harvest (ERAH) is an alternative to open RA harvest (ORAH) technique. Our aim was to ascertain clinical outcomes, patent satisfaction, and 1-year angiographic patency rates after ERAH and ORAH. PATIENTS AND METHODS A total of 50 patients undergoing coronary artery bypass grafting were prospectively randomized to two groups. In the ERAH group (25 patients) the RA was harvested endoscopically and in the ORAH group (25 patients) openly. RESULTS There were not differences between the groups in preoperative characteristics. Length of skin incision was shorter in ERAH (P < .001) but there were not differences in the length of RA, harvest time, blood flow, and pulsatility index after ERAH and ORAH. Wound healing was uniformly smooth in ERAH and there were two hematomas and one infection in ORAH. Postoperatively, major neuralgias were present in five patients in ORAH and none in ERAH and minor neuralgias in 11 and 3 patients (P = .02) respectively. Twenty-four patients in ERAH and four in ORAH graded their experience as excellent (P < .001). One-year angiographic RA patency was 90% without intergroup difference. Target vessel stenosis less than 90% adversely affected RA patency (P < .0001). CONCLUSIONS In expert center, ERAH does not appear to have negative impact on the time harvest, the length, and quality of RA conduit, the wound healing, and the occurrence of hand and forearm complications. In addition, provides excellent cosmetic result and patient satisfaction. RA graft patency is gratifying when placed to a target coronary artery vessel with stenosis greater than 90%.
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Affiliation(s)
- Muhammed Tamim
- Department of Cardiac Surgery, King Fahd Military Medical Complex, Dhahran, KSA
| | - Christos Alexiou
- Department of Cardiac Surgery, King Fahd Military Medical Complex, Dhahran, KSA
| | - Donya Al-Hassan
- Department of Radiology, King Fahd Military Medical Complex, Dhahran, KSA
| | - Khalid Al-Faraidy
- Department of Cardiology, King Fahd Military Medical Complex, Dhahran, KSA
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Kroeze VJ, Lam KY, van Straten AH, Houterman S, Soliman-Hamad MA. Benefits of Endoscopic Vein Harvesting in Coronary Artery Bypass Grafting. Ann Thorac Surg 2019; 108:1793-1799. [DOI: 10.1016/j.athoracsur.2019.04.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/14/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022]
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Szczechowicz MP, Easo J, Zhigalov K, Mashhour A, Mkalaluh S, Weymann A. Training of Residents in Cardiac Surgery-Does It Have Impact on the Outcome? Thorac Cardiovasc Surg 2019; 69:13-18. [PMID: 31770776 DOI: 10.1055/s-0039-3400263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES In many centers, training in cardiac surgery is considered to increase perioperative risk. This study aims to test whether a resident working as the main operator is a genuine risk factor. METHODS We analyzed patients who underwent elective isolated aortic valve replacement, elective isolated coronary artery bypass grafting, or both, in our institution, from 2008 to 2016. Redo- and off-pump surgery, ejection fraction < 30%, and other concomitant procedures were the exclusion criteria. After this selection, we included 3,077 patients in our study. Within this group, 357 (11.6%) had been operated by residents and 2,720 (88.4%) by senior surgeons. We performed propensity score matching using the nearest neighbor method with a ratio of 1:2, considering the most important preoperative conditions. In this way, the 357 patients operated by residents were matched with the 714 patients who were operated by senior surgeons. The standardized mean differences were highly reduced after matching, so both groups had similar risk profiles. We compared surgical data, postoperative adverse events, and the 30-day mortality between the two groups. RESULTS The times of surgery, cardiopulmonary bypass, and cross-clamp were longer if residents operated (p < 0.001). There were no differences regarding postoperative adverse events, time of mechanical ventilation, and the intensive care unit length of stay. The 30-day mortality rates of the two groups were very similar (p = 0.75, power = 0.8). CONCLUSION Training in cardiac surgery is safe, and carefully selected patients can be operated by residents without increased risk of perioperative mortality and complications.
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Affiliation(s)
- Marcin Piotr Szczechowicz
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Jerry Easo
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Konstantin Zhigalov
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Sabreen Mkalaluh
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
| | - Alexander Weymann
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg, Groningen, Oldenburg, Germany
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Soni MK, Williams L, Raja SG. Use of endoscopic vein harvesting (EVH) during coronary artery bypass grafting in United Kingdom: The EVH survey. Int J Surg 2019; 69:146-151. [PMID: 31398455 DOI: 10.1016/j.ijsu.2019.07.037] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/07/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Manish K Soni
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Luke Williams
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
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Filip T, Schröther F, Haase R, Rudolph N, Claus T, Albes JM. Patient Satisfaction and Clinical Complications after Endoscopic or Surgical Saphenous Vein Harvesting. Thorac Cardiovasc Surg 2019; 68:700-705. [PMID: 30947354 DOI: 10.1055/s-0039-1683901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Endoscopic saphenous vein harvesting (EVH) for coronary artery bypass grafting (CABG) has been developed to reduce leg wound problems. This study was undertaken to evaluate postoperative complications and patient's subjective satisfaction comparing EVH and surgical vein harvesting (SVH). METHODS From January to December 2017, patients undergoing elective cardiac surgery (CABG, CABG + Valve repair or replacement) underwent saphenous vein graft harvesting either by EVH (n = 136) or SVH (n = 104). Clinical follow-up was scheduled for day 7 and > 45 days after surgery. Primary end points were divided into two subgroups. The first one included postoperative extent of subjective pain and satisfaction with the cosmetic results described by the patients themselves, while the second subgroup included objective postoperative complications including wound healing disturbances, hematoma, and neuropathy. Secondary end point was length of hospital stay. RESULTS At 7 days follow-up, EVH patients were more satisfied with the cosmetic results than those of the SVH group (p < 0.001) and expressed a significant tendency toward lower subjective pain compared with the SVH patients (p < 0.001), exhibited significantly lower cellulitis (p-0.002), neuropathy (p-0.005), and superficial wound healing disturbance (p-0.007). During further follow-up at > 45 days, patients with EVH were still more satisfied with the cosmetic results (p < 0.001) and expressed lower subjective pain (p < 0.001), while the other objective wound parameters did not show significant differences between both groups. Mean length of hospital stay of EVH patients was 0.7 days less compared with SVH patients. CONCLUSIONS Our findings demonstrate the noninferiority of EVH in the short term and in the early medium term.
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Affiliation(s)
- Tomas Filip
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
| | - Filip Schröther
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
| | - Robert Haase
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
| | - Nicol Rudolph
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
| | - Thomas Claus
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
| | - Johannes M Albes
- Department of Cardiovascular Surgery, Heart Centre Brandenburg, Brandenburg Medical School, Bernau bei Berlin, Germany
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Zenati MA, Bhatt DL, Bakaeen FG, Stock EM, Biswas K, Gaziano JM, Kelly RF, Tseng EE, Bitondo J, Quin JA, Almassi GH, Haime M, Hattler B, DeMatt E, Scrymgeour A, Huang GD. Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass. N Engl J Med 2019; 380:132-141. [PMID: 30417737 DOI: 10.1056/nejmoa1812390] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The saphenous-vein graft is the most common conduit for coronary-artery bypass grafting (CABG). The influence of the vein-graft harvesting technique on long-term clinical outcomes has not been well characterized. METHODS We randomly assigned patients undergoing CABG at 16 Veterans Affairs cardiac surgery centers to either open or endoscopic vein-graft harvesting. The primary outcome was a composite of major adverse cardiac events, including death from any cause, nonfatal myocardial infarction, and repeat revascularization. Leg-wound complications were also evaluated. RESULTS A total of 1150 patients underwent randomization. Over a median follow-up of 2.78 years, the primary outcome occurred in 89 patients (15.5%) in the open-harvest group and 80 patients (13.9%) in the endoscopic-harvest group (hazard ratio, 1.12; 95% confidence interval [CI], 0.83 to 1.51; P=0.47). A total of 46 patients (8.0%) in the open-harvest group and 37 patients (6.4%) in the endoscopic-harvest group died (hazard ratio, 1.25; 95% CI, 0.81 to 1.92); myocardial infarctions occurred in 34 patients (5.9%) in the open-harvest group and 27 patients (4.7%) in the endoscopic-harvest group (hazard ratio, 1.27; 95% CI, 0.77 to 2.11), and revascularization occurred in 35 patients (6.1%) in the open-harvest group and 31 patients (5.4%) in the endoscopic-harvest group (hazard ratio, 1.14; 95% CI, 0.70 to 1.85). Leg-wound infections occurred in 18 patients (3.1%) in the open-harvest group and in 8 patients (1.4%) in the endoscopic-harvest group (relative risk, 2.26; 95% CI, 0.99 to 5.15). CONCLUSIONS Among patients undergoing CABG, we did not find a significant difference between open vein-graft harvesting and endoscopic vein-graft harvesting in the risk of major adverse cardiac events. (Funded by the Cooperative Studies Program, Office of Research and Development, Department of Veterans Affairs; REGROUP ClinicalTrials.gov number, NCT01850082 .).
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Affiliation(s)
- Marco A Zenati
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Deepak L Bhatt
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Faisal G Bakaeen
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Eileen M Stock
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Kousick Biswas
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - J Michael Gaziano
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Rosemary F Kelly
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Elaine E Tseng
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Jerene Bitondo
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Jacquelyn A Quin
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - G Hossein Almassi
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Miguel Haime
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Brack Hattler
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Ellen DeMatt
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Alexandra Scrymgeour
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
| | - Grant D Huang
- From the Divisions of Cardiac Surgery (M.A.Z., J.A.Q., M.H.) and Cardiology (D.L.B., J.M.G.), Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, the Department of Surgery, Brigham and Women's Hospital and Harvard Medical School (M.A.Z., J.A.Q., M.H.), Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School (D.L.B.), and Massachusetts General Hospital (J.B.) - all in Boston; the Departments of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland (F.G.B.); the VA Pittsburgh Healthcare System, Pittsburgh (F.G.B.); the Cooperative Studies Program Coordinating Center, Office of Research and Development, Department of Veterans Affairs, Perry Point, MD (E.M.S., K.B., E.D.); Minneapolis VA Medical Center and University of Minnesota, Minneapolis (R.F.K.); San Francisco VA Medical Center and University of California, San Francisco, San Francisco (E.E.T.); Zablocki VA Medical Center and Medical College of Wisconsin, Milwaukee (G.H.A.); VA Eastern Colorado Healthcare System, Denver (B.H.); the Cooperative Studies Program Pharmacy Coordinating Center, Department of Veterans Affairs, Albuquerque, NM (A.S.); and the Cooperative Studies Program Central Office, Office of Research and Development, Department of Veterans Affairs, Washington, DC (G.D.H.)
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Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins Using 2 Types of Endoscopic and Open Vein Harvesting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:320-328. [PMID: 29016381 DOI: 10.1097/imi.0000000000000405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of the study was to assess whether the use of carbon dioxide insufflation has any impact on integrity of long saphenous vein comparing 2 types of endoscopic vein harvesting and traditional open vein harvesting. METHODS A total of 301 patients were prospectively randomized into 3 groups. Group 1 control arm of open vein harvesting (n = 101), group 2 closed tunnel (carbon dioxide) endoscopic vein harvesting (n = 100) and Group 3 open tunnel (carbon dioxide) endoscopic vein harvesting (open tunnel endoscopic vein harvesting) (n = 100). Each group was assessed to determine the systemic level of partial arterial carbon dioxide, end-tidal carbon dioxide, and pH. Three blood samples were obtained at baseline, 10 minutes after start of endoscopic vein harvesting, and 10 minutes after the vein was retrieved. Vein samples were taken immediately after vein harvesting without further surgical handling to measure the histological level of endothelial damage. A modified validated endothelial scoring system was used to compare the extent of endothelial stretching and detachment. RESULTS The level of end-tidal carbon dioxide was maintained in the open tunnel endoscopic vein harvesting and open vein harvesting groups but increased significantly in the closed tunnel endoscopic vein harvesting group (P = 0.451, P = 0.385, and P < 0.001). Interestingly, partial arterial carbon dioxide also did not differ over time in the open tunnel endoscopic vein harvesting group (P = 0.241), whereas partial arterial carbon dioxide reduced significantly over time in the open vein harvesting group (P = 0.001). A profound increase in partial arterial carbon dioxide was observed in the closed tunnel endoscopic vein harvesting group (P < 0.001). Consistent with these patterns, only the closed tunnel endoscopic vein harvesting group demonstrated a sudden drop in pH over time (P < 0.001), whereas pH remained stable for both open tunnel endoscopic vein harvesting and open vein harvesting groups (P = 0.105 and P = 0.869, respectively). Endothelial integrity was better preserved in the open vein harvesting group compared with open tunnel endoscopic vein harvesting or closed tunnel endoscopic vein harvesting groups (P = 0.012) and was not affected by changes in carbon dioxide or low pH. Significantly greater stretching of the endothelium was observed in the open tunnel endoscopic open tunnel endoscopic vein harvesting group compared with the other groups (P = 0.003). CONCLUSIONS This study demonstrated that the different vein harvesting techniques impact on endothelial integrity; however, this does not seem to be related to the increase in systemic absorption of carbon dioxide or to the pressurized endoscopic tunnel. The open tunnel endoscopic harvesting technique vein had more endothelial stretching compared with the closed tunnel endoscopic technique; this may be due to manual dissection of the vein. Further research is required to evaluate the long-term clinical outcome of these vein grafts.
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Krishnamoorthy B, Critchley WR, Nair J, Malagon I, Carey J, Barnard JB, Waterworth PD, Venkateswaran RV, Fildes JE, Caress AL, Yonan N. Randomized Study Comparing the Effect of Carbon Dioxide Insufflation on Veins using 2 Types of Endoscopic and Open Vein Harvesting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom
| | - William R. Critchley
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Janesh Nair
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Ignacio Malagon
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - John Carey
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - James B. Barnard
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Paul D. Waterworth
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - Rajamiyer V. Venkateswaran
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
| | - James E. Fildes
- Manchester Collaborative Centre for Inflammation Research, Faculty of Medical and Human Sciences, University of Manchester, Manchester, United Kingdom
| | - Ann L. Caress
- School of Nursing and Midwifery, The University of Manchester, Manchester, United Kingdom
| | - Nizar Yonan
- Department of Cardiothoracic Surgery, University Hospital of South Manchester NHS Foundation Trust, Manchester, United Kingdom
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Krishnamoorthy B, Critchley WR, Thompson AJ, Payne K, Morris J, Venkateswaran RV, Caress AL, Fildes JE, Yonan N. 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). Circulation 2017. [PMID: 28637880 DOI: 10.1161/circulationaha.117.028261] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Bhuvaneswari Krishnamoorthy
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.).
| | - William R Critchley
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Alexander J Thompson
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Katherine Payne
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Julie Morris
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Rajamiyer V Venkateswaran
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Ann L Caress
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - James E Fildes
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
| | - Nizar Yonan
- From Departments of Cardiothoracic Surgery (B.K., R.V.V., N.Y.) and Medical Statistics (J.M.), University Hospital of South Manchester NHS Foundation Trust, United Kingdom; Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (W.R.C., B.K.), Manchester Collaborative Centre for Inflammation Research, Faculty of Biology, Medicine and Health (J.E.F.), Manchester Centre for Health Economics (A.J.T., K.P.), and School of Nursing and Midwifery (A.L.C.), University of Manchester, United Kingdom; and Faculty of Health and Social Care, Edge Hill University, Ormskirk, Lancashire, United Kingdom(B.K.)
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