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Clinical Advantages of

Endoscopic Vessel Harvesting

Improving Patient Outcomes through Endoscopic Vessel Harvesting

Endoscopic Vessel Harvesting (EVH) was first introduced in the 1990s as an alternative surgical approach to the traditional Open Vessel Harvesting (OVH) for Coronary Artery Bypass Grafting (CABG) procedures1.

The adoption journey of the technique has been marked by pioneering studies demonstrating the safety of the technique versus OVH, as well as significant improvements in wound complication rates, surgical reintervention rates, hospital length of stay and readmission rates2,3, but was slowed down in 2009, when a study with 3,000 patients raised major concerns regarding the vein graft patency of endoscopically harvested veins, resulting in an increase in major adverse cardiac events (MACE)4.

However, since then, various large registries and randomized controlled trials were able to prove again, that when comparing EVH to OVH, no significant differences in mortality, repeat revascularization, or myocardial infarction rates can be observed5-10. 

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Benefits of EVH

Clinical studies highlight the substantial benefits of EVH over OVH, showing that it provides significant patient advantages and cost savings without compromising conduit quality or long-term clinical outcomes.

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Equivalent Conduit Quality and Graft Patency compared to Open Vessel Harvesting (OVH)

With EVH, there are no significant differences in mortality, repeat revascularization, or myocardial infarction rates compared to OVH5-10.

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Reduced Risk of Infections and Wound Complications

Due to the smaller incision, EVH significantly reduces the incidence of wound complications compared OVH and bridging techniques1,9,11,12.

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Faster Recovery and Lower Readmission Rates

Lower rates of wound complications lead to reduced post-operative care needs, shorter hospital length of stay and lower readmission rates for follow-up treatments1,13,14.

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Improvements in Patient Comfort and Satisfaction

Patients generally benefit from less post-operative pain, earlier mobility and quicker return to normal activities, improved cosmetic outcomes as well as an enhanced overall experience 1,11,13,15-17.

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Overall Cost Savings

EVH has the potential to reduce overall treatment costs, as lower costs further down in the treatment pathway outweigh the initial higher investment for the EVH equipment. Multiple studies have shown that EVH is cost-effective compared to OVH9,13,18-22.

Societal Guidelines

The various clinical advantages of EVH have also been recognized in the guideline recommendations of several scientific institutes, further solidifying the technique's position in clinical practice:  

2018 ESC/EACTS Guideline on Myocardial Revascularization23

Recommendations on procedural aspects of coronary artery bypass grafting: Class IIa, Level A recommendation for performing EVH to reduce incidence of wound complications, if performed by experience surgeons (https://pubmed.ncbi.nlm.nih.gov/30165437/).

 

2014 National Institute for Health and Care Excellence (NICE) Guidance24

Current evidence on the efficacy and safety of endoscopic saphenous vein harvest (EVH) for coronary artery bypass grafting (CABG) is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit (https://www.nice.org.uk/guidance/ipg494).

 

2016 International Society for Minimally Invasive Cardiac Surgery (ISMICS)  Consensus Statement25

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 (https://pubmed.ncbi.nlm.nih.gov/29028651/).

 

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Harvester Training and Experience is key!

Harvester experience is crucial for optimal outcomes. Studies show that lack of proficiency with EVH can compromise intra-operative results, making it essential for EVH to be performed by qualified and well-trained clinicians16,17,26,27.

References

1.Ferdinand FD, MacDonald JK, Balkhy HH, et al. Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery: An ISMICS Systematic Review and Consensus Conference Statements. Innovations (Phila). 2017;12(5):301-319.

2.Athanasiou T, Aziz O, Skapinakis P, et al. Leg wound infection after coronary artery bypass grafting: a meta-analysis comparing minimally invasive versus conventional vein harvesting. Ann Thorac Surg 2003;76:2141-6.

3.Cheng D, Allen K, Cohn W, et al. Endoscopic vascular harvest in coronary artery bypass grafting surgery: a meta-analysis of randomized trials and controlled trials. Innovations (Phila) 2005;1:61-74.

4.Lopes RD, Hafley GE, Allen KB, et al. Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery. N Engl J Med. 2009;361(3):235-244. 

5.Kirmani BH, Barnard JB, Mourad F, et al. Mid-term outcomes for Endoscopic versus Open Vein Harvest: a case control study. J Cardiothorac Surg 2010;5:44.

6.Ouzounian M, Hassan A, Buth KJ, et al. Impact of Endoscopic Versus Open Saphenous Vein Harvest Techniques on Outcomes After Coronary Artery Bypass Grafting. Ann Thorac Surg 2010;89:403-8.

7.Williams JB, Peterson ED, Brennan JM, Sedrakyan A, Tavris D, Alexander JH, et al. Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308:475-84.

8.Sastry P, Rivinius R, Harvey R, et al. The influence of endoscopic vein harvesting on outcomes after coronary bypass grafting: a meta-analysis of 267,525 patients. Eur J Cardiothorac Surg 2013;44:980-9.

9.Zenati MA, Bhatt DL, Bakaeen FG, et al. Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass. New England Journal of Medicine. 2018; 380(2): 132-141.

10.Zenati MA, Bhatt DL, Stock EM, et al. Intermediate-Term Outcomes of Endoscopic or Open Vein Harvesting for Coronary Artery Bypass Grafting: The REGROUP Randomized Clinical Trial. JAMA Network Open. 2021; 4(3): e211439-e211439.

11.Sastry P, Rivinius R, Harvey R, et al. The influence of endoscopic vein harvesting on outcomes after coronary bypass grafting: a meta-analysis of 267,525 patients. Eur J Cardiothorac Surg 2013;44:980-9.

12.Williams JB, Peterson ED, Brennan JM, Sedrakyan A, Tavris D, Alexander JH, et al. Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery. JAMA. 2012;308:475-84.

13.Luckraz H, Kaur P, Bhabra M, et al. Endoscopic vein harvest in patients at high risk for leg wound complications: a cost-benefit analysis of an initial experience. Am J Infect Control. 2016;44:1606-1610. Rao C, Aziz O, Deeba S, et al. Is minimally invasive harvesting of the great saphenous vein for coronary artery bypass surgery a cost-effective technique? J Thorac Cardiovasc Surg. 2008;135:809-815.

14.Gulack BC et al. Secondary surgical-site infection after coronary artery bypass grafting: A multi-institutional prospective cohort study. J Thorac Cardiovasc Surg. 2018 Apr;155(4):1555-1562.

15.Chernyavskiy et al. Comparative results of endoscopic and open methods of vein harvesting for coronary artery bypass grafting: a prospective randomized parallel-group triaJournal of Cardiothoracic Surgery (2015) 10:163.

16.Akowuah E, Burns D, Zacharias J, Kirmani BH. Endoscopic vein harvesting. Journal of Thoracic Disease. 2021; 13: 1899-1908.

17.Krishnamoorthy B, Critchley WR, Thompson AJ, et al. Study Comparing Vein Integrity and Clinical Outcomes in Open Vein Harvesting and 2 Types of Endoscopic Vein Harvesting for Coronary Artery Bypass Grafting. Circulation 2017;136(18):1688-1702.

18.Oddershede L, Andreasen JJ. Long-term cost-effectiveness of endoscopic vs open vein harvest for coronary artery bypass grafting. J Cardiovasc Dis Diagn. 2015;3:3.

19.Rao C, Aziz O, Deeba S, et al. Is minimally invasive harvesting of the great saphenous vein for coronary artery bypass surgery a cost-effective technique? J Thorac Cardiovasc Surg. 2008;135:809-815.

20.García-Altés A, Peiró S. A Systematic Review of Cost-effectiveness Evidence of Endoscopic Saphenous Vein Harvesting: Is it Efficient? European Journal of Vascular and Endovascular Surgery. 2011; 41(6): 831-836.

21.Illig KA, Rhodes JM, Sternbach Y et al. Financial impact of endoscopic vein harvest for infrainguinal bypass. Journal of vascular surgery. 2003; 37(2).

22.Eckey et al. Economic Evaluation of Endoscopic vs Open Vein Harvesting. Ann Thorac Surg. 2022. 115(6):1144-1150.

23.2018 ESC/EACTS Guidelines on myocardial revascularization. European Heart Journal 2019. 2019; 40(2): 87–165.

24.National Institute for Health and Care Excellence. Endoscopic saphenous vein harvest for coronary artery bypass grafting Interventional procedures guidance [IPG494] Published date: June 2014.

25.Ferdinand FD et al. Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery: An ISMICS Systematic Review and Consensus Conference Statements. Innovations (Phila). 2017 Sep/Oct;12(5):301-319.

26.Lucchese G, Jarral OA. Endoscopic vein harvest: benefits beyond (a) reasonable doubt? Journal of thoracic disease. 2019;11(Suppl 9):1342-S1345.

27.Li G, Zhang Y, Wu Z, et al. Mid-term and long-term outcomes of endoscopic versus open vein harvesting for coronary artery bypass: A systematic review and meta-analysis. International Journal of Surgery. 2019; 72: 167-173.