Recent progress in minimally invasive conduit harvesting.

Wound-related morbidity frequently encountered after open-incision harvesting of vessel conduits for coronary artery bypass grafting (CABG) is invariably recognized as an obstacle impeding the patient's path towards complete postoperative recovery. The endoscopic approach provides surgical access to the intended conduit vessel while affording an appreciably lower incidence of traumatic injury to the surrounding tissues. For this reason, the minimally invasive endoscopic dissection of vessel conduits is steadily gaining acceptance as a preferable alternative to the standard open-incision technique. Endoscopic systems, originally developed for general surgical procedures in the early 1990s, and readily adapted to saphenous vein harvesting by mid-decade, are now also being applied to minimally invasive radial artery harvesting. The growth of this surgical modality has paralleled the rapid development of remote access minimally invasive endoscopic devices and technologies and therefore remains an evolving body of knowledge. As experience and refinements in instrumentation progress, the endoscopic approach will undoubtedly become the procedure of choice for harvesting vessel conduits. This article provides a practical primer, based on the benefit of our serial experience with endoscopic vein and radial artery dissections, for those considering the minimally invasive endoscopic approach in harvesting vessels for CABG.

Optical coherence tomography imaging as a quality assurance tool for evaluating endoscopic harvest of the radial artery.

BACKGROUND: Concerns about intimal disruption and spasm have limited enthusiasm for endoscopic radial artery harvest (ERAH), although the risk of these problems after this procedure remains uncertain. Radial artery conduits were screened intraoperatively before and after ERAH vs open harvest using catheter-based high-resolution optical coherence tomography (OCT) imaging. METHODS: Twenty-four cadavers and 60 coronary artery bypass graft (CABG) patients scheduled to receive a RA graft underwent OCT imaging before (in situ) and after (ex vivo) open harvest or ERAH. Spasm was quantified by the percentage change in luminal volume between images. Intimal disruption was classified as minor or severe depending on whether the defect was confined to branch ostia or involved the luminal surface. Histology was used to confirm OCT findings. RESULTS: Luminal volume significantly declined after harvest in all RAs from CABG patients, but there was no difference between groups: -43% +/- 29% vs -35% +/- 38% change after ERAH (n = 21) vs open harvest (n = 39; p = 0.342). Significantly more intimal injury was noted after ERAH vs open harvest (34/41 vs 9/43, intimal tears/total evaluated RAs, p < 0.0001). Most intimal injury was minor: only 2 tears involved the luminal surface of the RA (both after ERAH). Serial imaging in cadavers revealed that 86% of ostial tears occur in ERAH during the initial blunt dissection step using the endoscope. CONCLUSIONS: Although branch injury is a pitfall of ERAH, OCT imaging documented that the quality of RA procured is acceptable and comparable with open harvest. Catheter-based OCT provides an important quality assurance tool for RA harvest.

Endoscopic vascular harvest in coronary artery bypass grafting surgery: a meta-analysis of randomized trials and controlled trials.

OBJECTIVE: : This meta-analysis sought to determine whether endoscopic vascular graft harvesting (EVH) improves clinical and resource outcomes compared with conventional open graft harvesting (OVH) in adults undergoing coronary artery bypass surgery. METHODS: : A comprehensive search was undertaken to identify all randomized and nonrandomized trials of EVH versus OVH up to April 2005. The primary outcome was wound complications. Secondary outcomes included any other clinical morbidity and resource utilization. Odds ratios (OR), weighted mean differences (WMD), or standardized mean differences (SMD) and their 95% confidence intervals (95% CI) were analyzed. RESULTS: : Thirty-six trials of 9,632 patients undergoing saphenous vein harvest met the inclusion criteria (13 randomized; 23 nonrandomized). Risk of wound complications was significantly reduced by EVH compared with OVH (OR 0.31, 95% CI 0.23-0.41). Similarly, the risk of wound infections was significantly reduced (OR 0.23, 95% CI 0.20-0.53; P < 0.0001). Need for surgical wound intervention was also significantly reduced (OR 0.16, 95% CI 0.08-0.29). The incidence of pain, neuralgia, and patient satisfaction was improved with EVH compared with OVH. Postoperative myocardial infarction, stroke, reintervention for ischemia or angina recurrence, and mortality were not significantly different. Operative time was significantly increased (WMD 15.26 minutes; 95% CI 0.01, 30.51), hospital length of stay was reduced (WMD -0.85 days; 95% CI -1.55, -0.15), and readmissions were reduced (OR 0.53, 95% CI 0.29-0.98). Costs were insufficiently reported to allow for aggregate analysis. CONCLUSIONS: : Endoscopic vascular graft harvesting of the saphenous vein reduces wound complications and improves patient satisfaction and resource utilization. Further research is required to determine the incremental cost-effectiveness of EVH versus OVH.

Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) 2005.

OBJECTIVE: : This purpose of this consensus statement was to compare endoscopic vascular graft harvesting (EVH) with conventional open vascular harvesting (OVH) in adults undergoing coronary artery bypass grafting (CABG) surgery and to determine which resulted in improved clinical and resource outcomes. METHODS: : Before the consensus conference, the consensus panel reviewed the best available evidence, whereby systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of importance. Evidence-based statements were created, and consensus processes were used to determine the ensuing statements. The AHA/ACC system was used to label the level of evidence and class of recommendation. RESULTS: : The consensus panel agreed upon the following statements: CONCLUSIONS: : Given these evidence-based statements, the consensus panel stated that EVH should be the standard of care for patients who require saphenous vein grafts for coronary revascularization (Class I, Level B). Future research should address long-term safety, cost-effectiveness, and endoarterial harvest.