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

Benefits and Outcomes of Endoscopic Vessel Harvesting in Coronary Artery Bypass Grafting

Endoscopic vessel harvesting (EVH) is recommended for patients at risk of wound complications during CABG procedures, as it significantly reduces wound morbidity while maintaining comparable clinical outcomes to traditional open vessel harvesting techniques. 1, 2

Advantages of Endoscopic Vessel Harvesting

Reduced Wound Complications

• EVH significantly decreases leg wound morbidity compared to open vessel harvesting (OVH)
  • Overall wound complication rates: 3% with EVH vs 27% with OVH 3
  • Purulent infection rates: 0% with EVH vs 11% with OVH 3
  • Reduced cellulitis, dehiscence, and skin necrosis 3, 4

Improved Patient Experience

• Decreased postoperative pain, particularly after the first week 5
• Better cosmetic results due to smaller incisions 3, 4
• Higher patient satisfaction scores 4
• Reduced need for post-discharge wound care 3

Efficiency Considerations

• EVH can be quicker than OVH when harvesting vein for multiple grafts 4
• Does not significantly prolong overall operative time 4

Clinical Outcomes and Safety Considerations

Mortality and Major Adverse Events

• No significant difference in:
  • All-cause mortality 6, 7
  • In-hospital mortality (0.9% EVH vs 1.1% OVH) 7
  • Major adverse cardiac events (MACE) 6, 7
  • Recurrence of angina (6.1% EVH vs 4% OVH) 5

Graft Quality and Patency

• Historical concerns exist regarding potential conduit damage with EVH
  • The 2010 European guidelines initially cautioned against EVH due to concerns about vein graft failure 1
  • More recent evidence shows comparable endothelium integrity between EVH and OVH techniques (EVH: 70.7% vs OVH: 68.3% after distension) 5
  • One-year graft patency rates show no significant difference (EVH: 11.6% occlusion vs OVH: 9.8% occlusion) 5

Technical Considerations

• Conversion rate from EVH to OVH: approximately 14% 3
• Proper conduit handling is essential to maintain graft quality 2

Implementation Recommendations

Patient Selection

• EVH is particularly beneficial for patients with:
  • Diabetes mellitus
  • Peripheral vascular disease
  • Advanced age
  • Risk factors for poor wound healing 3, 4

Best Practices for EVH

• The 2021 ACC/AHA/SCAI guidelines specifically recommend using EVH in patients at risk of wound complications 1, 2
• Careful inspection of the conduit is essential to ensure quality 2
• Proper training and experience are necessary to minimize potential graft injuries 6

Caveats and Pitfalls

• Learning curve effect: Outcomes may be influenced by operator experience 6
• Potential for increased graft injuries during the harvesting process 6
• Conversion to open technique may be necessary in some cases 3
• Long-term data beyond 2 years is still evolving 7

Conclusion

EVH represents an important advancement in CABG techniques that can significantly improve patient recovery and satisfaction while maintaining comparable clinical outcomes to traditional methods. The technique is particularly valuable for patients at higher risk of wound complications, and its benefits in reducing wound morbidity are well-established. While historical concerns about graft quality existed, more recent evidence suggests comparable outcomes when performed by experienced operators with proper technique.