What are the benefits of using endoscopic vessel harvesting (EVH) in coronary artery bypass grafting (CABG) procedures?

Benefits of Endoscopic Vessel Harvesting in Coronary Artery Bypass Grafting

Endoscopic vessel harvesting (EVH) significantly reduces wound complications and postoperative pain compared to traditional open vessel harvesting, while maintaining comparable graft patency rates in coronary artery bypass grafting procedures.

Clinical Benefits of EVH

Reduced Wound Complications

• EVH dramatically decreases wound-related morbidity compared to open harvesting techniques:
  • Wound complication rates: 3-7.4% with EVH versus 13-19.4% with open technique 1, 2
  • Purulent infection rates: 0% with EVH versus 11% with open technique 3
  • Overall leg wound morbidity (cellulitis, infection, dehiscence, skin necrosis): 3% with EVH versus 27% with open technique 3

Decreased Postoperative Pain

• Patients experience significantly less pain with EVH compared to open harvesting:
  • Pain scores: 0.52±0.95 for EVH versus 1.02±1.51 for open technique (p=0.03) 2
  • This reduced pain contributes to improved patient satisfaction and potentially faster recovery

Improved Cosmetic Results

• Better cosmetic outcomes due to smaller incisions 3
• Higher patient satisfaction scores due to improved cosmesis 1

Reduced Length of Hospital Stay

• Multiple studies show shorter hospital stays with EVH compared to open harvesting:
  • Weighted mean difference of -1.04 to -0.85 days (p=0.02) 2

Operational Efficiency

• EVH can be quicker to perform when multiple vein grafts are needed (p<0.01) 1
• Does not significantly prolong overall operative time when performed by experienced personnel 4

Potential Concerns and Limitations

Graft Patency Considerations

• The 2010 European guidelines cautioned that endoscopic vein-graft harvesting could not be recommended at that time due to concerns about vein-graft failure 5
• Some studies have reported higher occlusion rates with EVH:
  • Six-month occlusion rates: 21.7% for EVH versus 17.6% for open technique 2
  • At 12-18 months: 46.7% versus 38.0% (p<0.001) 2

Learning Curve and Technical Considerations

• EVH requires specialized training and equipment
• Conversion rate from EVH to open technique: approximately 14% 3
• Technique is most effective when performed by experienced personnel 4

Evolution of EVH Techniques

Expanded Applications

• Initially applied to saphenous vein harvesting, now also used for radial artery harvesting 6
• Can be incorporated into hybrid revascularization procedures 5

Integration with Modern CABG Approaches

• EVH aligns with the trend toward minimally invasive cardiac surgery
• Complements other advancements in CABG such as arterial grafting and off-pump techniques 5

Best Practices for EVH Implementation

Patient Selection

• Particularly beneficial for patients at higher risk of wound complications:
  • Diabetic patients
  • Patients with peripheral vascular disease
  • Elderly patients 1

Technical Recommendations

• For saphenous vein harvesting, endoscopic technique should be used in patients at risk of wound complications 5
• When harvesting the internal mammary artery, skeletonization technique reduces risk of sternal wound complications 5

Conclusion

EVH represents a significant advancement in CABG technique that reduces morbidity while maintaining surgical efficacy. The reduced wound complications, decreased pain, and improved cosmetic results make it an attractive option for patients undergoing CABG, particularly those at higher risk for wound complications.