What is the recommended technique for saphenous vein (SV) harvesting in Coronary Artery Bypass Grafting (CABG), reversed or non-reversed?

Saphenous Vein Harvesting Techniques for CABG: No-Touch Technique is Recommended

For saphenous vein (SV) harvesting in Coronary Artery Bypass Grafting (CABG), the no-touch technique is recommended over conventional reversed or non-reversed techniques in patients at low risk of wound complications to improve graft patency and reduce the need for repeat angiography. 1, 2

Saphenous Vein Harvesting Techniques Overview

No-Touch Technique

• Recommended in patients at low risk of wound complications 1
• Associated with significantly lower rates of graft failure compared to both conventional open vein harvesting (OVH) and endoscopic vein harvesting (EVH) 2
• Demonstrates improved patency rates and could potentially lead to better clinical outcomes 3
• Patients who received no-touch vein grafts had 46% lower risk of graft failure compared to conventional open harvesting 2

Endoscopic Technique

• Recommended in patients at higher risk of wound complications 1
• Associated with significantly lower rates of leg wound infections (52% reduction) compared to open harvesting 4
• Demonstrates lower all-cause mortality compared to open harvesting in some studies 2
• Takes longer to perform than traditional open harvesting (45 min vs. 31 min) 5
• Results in fewer local infections, bleeding complications, and better cosmetic outcomes 5

Conventional Open Technique

• Associated with higher rates of wound complications (18% vs. 0% for endoscopic) 5
• Higher rates of readmission for wound debridement 5
• More postoperative pain and less satisfactory cosmetic results 5

Clinical Decision-Making Algorithm for SV Harvesting Technique

1. First, assess patient's risk for wound complications:

   • If patient has high risk for wound complications (diabetes, obesity, peripheral vascular disease):

     • Use endoscopic vein harvesting technique 1

   • If patient has low risk for wound complications:

     • Use no-touch vein harvesting technique 1

2. Consider operator experience:

   • Endoscopic technique requires specific training and experience 5
   • No-touch technique also requires proper training for optimal results 3

Long-term Outcomes by Technique

• No-Touch Technique:

  • 24% lower risk of requiring repeat angiography 3
  • Lower rates of failed grafts at angiography (43.2% vs. 53.6% for conventional technique) 3
  • Improved long-term patency rates 2, 3

• Endoscopic Technique:

  • 26% reduction in repeat angiography compared to open harvesting 4
  • 23% lower all-cause mortality compared to conventional open harvesting 2
  • 26% lower readmission rate for unstable angina 4

Important Caveats and Considerations

• The orientation of the vein (reversed vs. non-reversed) is less important than the harvesting technique itself 2, 3
• Proper handling of the vein graft is critical regardless of technique to minimize endothelial damage 1
• Saphenous vein grafts have historically lower patency rates compared to arterial grafts (internal mammary artery, radial artery) 1
• When possible, radial artery is recommended over saphenous vein for grafting the second most important non-LAD vessel 1
• Perioperative antiplatelet therapy improves early and 1-year SVG patency 1

Special Considerations

• In patients undergoing combined valve and CABG procedures, the same principles apply for conduit selection 1
• Patients with respiratory insufficiency may experience greater impairment in pulmonary function with internal mammary artery harvesting compared to saphenous vein harvesting 6
• The decision between reversed and non-reversed orientation should be based on anatomical considerations and surgeon preference, as current guidelines do not specifically address this aspect 1