Circ: CABG open vein harvesting may be 'obsolete' soon

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The use of endoscopic vein harvesting during CABG was not associated with harm or decreased survival compared with open vein harvesting, based on a regional, five-year study published Jan. 10 in Circulation.

CABG surgery is commonly performed, with nearly 450,000 procedures completed during 2006 in the U.S.

The use of endoscopic saphenous vein harvesting has developed into a routine surgical approach at many cardiothoracic surgical centers in an effort to reduce the pain and risk of infection associated with the procedure, according to the authors, who added that the association between this technique and long-term morbidity and mortality “has recently been called into question.”

However, in the accompanying Circulation editorial, Sary F. Aranki, MD, and Barry Shopnick, PA-C, from the division of cardiac surgery at Brigham and Women’s Hospital in Boston, noted that 95 percent of veins at their facility are harvested endoscopically.

Currently, five of nine physician assistants in their unit have never performed open vein harvesting. These personal experiences, along with the current study, led them to conclude that endoscopic vein harvesting is “here to stay.”

For this study, Lawrence J. Dacey, MD, from the cardiothoracic surgery department at Dartmouth-Hitchcock Medical Center in Hanover, N.H., and colleagues assessed open versus endoscopic vein harvesting and risk of mortality and repeat revascularization in northern New England during a time period (2001 to 2004) in which both techniques were being performed.

From 2001 to 2004, 8,542 patients underwent isolated CABG procedures, 52.5 percent with endoscopic vein harvesting. Surgical discretion dictated the vein harvest approach. The main outcomes were death and repeat revascularization (PCI or CABG) within four years of the index admission.

The use of endoscopic vein harvesting increased from 34 percent in 2001 to 75 percent in 2004. By 2005, it approached 80 percent, "effectively becoming a routine surgical approach and thereby precluding inclusion of more current data in the present analysis,” the authors wrote. In general, patients undergoing endoscopic vein harvesting had greater disease burden.

Dacey and colleagues found that endoscopic vein harvesting was associated with an increased adjusted risk of bleeding requiring a return to the operating room (2.4 versus 1.7) but a decreased risk of leg wound infections (0.2 versus 1.1).

Also, the researchers found that the use of endoscopic vein harvesting was associated with a significant reduction in long-term mortality, but a nonsignificant increased risk of repeat revascularization.

Based on their findings, the authors could not identify any significant differences in five-year event-free (freedom from death, MI, recurrent angina) survival (75 percent for endoscopic vein harvesting versus 74 percent for open vein harvesting).

Aranki and Shopnick wrote that they “totally agree with the authors that endoscopic vein harvesting is a safe and viable technique. “More important, we also conclude from this study that endoscopic vein harvesting is not inferior to open vein harvesting.”

However, as always, cost considerations will enter the decision-making process. “It is evident that EVH [endoscopic vein harvesting] is considerably more expensive than OVH [open vein harvesting] by many hundreds of dollars,” Aranki and Shopnick wrote. “It is a complex issue in this era of healthcare constraints to justify this increased expense. However, the reduction in pain, leg wound infections and hospital stay may put both techniques at financial parity.”

Due to the preference of the younger generation of providers, along with the positive patient outcomes, Aranki and Shopnick concluded that open vein harvesting “will be obsolete in a few years.”