What are the recommendations for performing endoscopic vessel harvest?

Recommendations for Endoscopic Vessel Harvest in Coronary Artery Bypass Grafting

Endoscopic saphenous vein harvesting should be the standard of care for patients requiring saphenous vein conduits for coronary revascularization, particularly in those at risk of wound complications. 1

Indications and Benefits

Endoscopic vessel harvest (EVH) offers several significant advantages over traditional open harvesting techniques:

• Reduced wound-related complications: EVH significantly decreases wound healing issues compared to open harvesting 1, 2
• Shorter postoperative hospital stay: Patients undergoing EVH typically experience shorter lengths of stay 1
• Decreased postoperative pain: EVH results in less pain both immediately after surgery and up to 4 weeks postoperatively 3, 2
• Higher patient satisfaction: Patients report greater satisfaction with the cosmetic results and overall experience 1
• Fewer outpatient wound management resources: EVH reduces the need for wound care visits after discharge 3

Patient Selection

EVH is particularly beneficial for patients with risk factors for poor wound healing:

• Diabetes mellitus
• Obesity
• Peripheral vascular disease
• Advanced age
• Immunocompromised states

According to the 2021 ACC/AHA/SCAI guidelines for coronary artery revascularization, "Use an endoscopic saphenous vein harvest technique in patients at risk of wound complications." 4

Technical Considerations

Preoperative Assessment

• Evaluate venous anatomy before harvesting
• Identify and mark the course of the saphenous vein
• Assess for anatomical variants or previous venous procedures

Procedural Approach

1. Make a small 2-3 cm incision, typically at the knee level
2. Create a tunnel around the vein using specialized endoscopic equipment
3. Dissect the vein from surrounding tissues under endoscopic visualization
4. Ligate and divide branches with endoscopic clips or energy devices
5. Extract the vein through the small incision

Potential Challenges

• Previous venous surgery or procedures
• Significant varicosities
• Anatomical variations
• Obesity (may require modified techniques)
• Previous leg trauma or surgery

Quality Considerations

While EVH offers clear advantages in terms of wound complications, there have been concerns about conduit quality:

• The 2013 European Heart Journal guidelines noted concerns about vein graft failure and adverse clinical outcomes with EVH 4
• However, more recent evidence from the 2017 ISMICS systematic review showed that EVH was non-inferior to open harvest regarding conduit quality and major adverse cardiac events 1

To optimize conduit quality:

• Use atraumatic handling techniques
• Minimize vein manipulation
• Avoid excessive traction
• Maintain proper hydration of the conduit
• Perform careful inspection for any damage

Special Considerations for Radial Artery Harvest

For radial artery harvesting:

• Endoscopic radial artery harvest is reasonable to reduce wound complications and increase patient satisfaction 1
• Preoperative assessment should include Allen's test to confirm adequate ulnar collateral circulation
• The technique shows non-inferior patency rates at 1 and 3-5 years compared to open harvesting 1

Anticoagulation Management After EVH

For patients requiring anticoagulation after EVH:

• Resume anticoagulation 24-72 hours after the procedure, depending on bleeding and thrombotic risks 5
• Patients with high thrombotic risk should resume anticoagulation at the earlier timeframe (24 hours) if hemostasis is adequate 5
• Patients with low thrombotic risk can resume anticoagulation at the later timeframe (48 hours) 5
• Monitor for signs of delayed bleeding for 2 weeks after resuming anticoagulation 5

Conclusion

EVH represents an important advancement in coronary artery bypass grafting, offering significant benefits in terms of reduced wound complications and improved patient comfort. The technique should be considered the standard of care for patients requiring saphenous vein conduits, particularly those at risk for wound complications, while ensuring proper attention to conduit quality and handling.