Endoscopic Vein-Grafting Makes the Cut

Endoscopic Vein-Grafting Makes the Cut

A recent study published in the New England Journal of Medicine has raised a number of questions about the long term patency of endoscopically harvested saphenous veins that are collected and used for coronary artery bypass grafts. The study from Duke, based on a secondary analysis of the PREVENT IV data, concluded that endoscopic vein-graft harvesting is “independently associated with vein-graft failure and adverse clinical outcomes.”

Maquet, the maker of the popular Vasoview EVH system, has now fired back saying the study is “subject to a number of important limitations,” because it is based on a secondary data analysis. This is of course true, and we do need further randomized clinical tests to evaluate the safety and effectiveness of the endoscopic harvesting technique. But what we also need to realize is that one of the possible reasons that these grafts might be failing in the long term is because the vessels might be experiencing high degree of thermal trauma. Our own editors, in the course of their clinical practice, have seen many endoscopically harvested veins that showed burn marks. Albeit usually tiny in size, these burns probably come from the electrical cutting endoscopic scissors, that are routinely used to remove small side branches from the saphenous vein.

We don’t know whether burns play any negative long-term role in the lives of the grafts, or whether they are clinically insignificant. But we have a recommendation for Maquete and other manufacturers. To eliminate any questions about the technique, they should develop small endoscopic clip devices, that can be used to occlude side branches, as well as a regular endoscopic scissors that surgeon can use to cut vessels, once they’ve been occluded. Sure, this will make the technique more laborious, but it will surely eliminate the thermal factor altogether from the equation.

Despite a decrease in utilization rate during the last decade,1 more than 400 000 coronary artery bypass graft (CABG) surgery procedures were performed in 2009.2 It has been one of the most extensively studied major surgical procedures, with particular attention paid to mortality, morbidity, and quality of life. The majority of CABG surgeries use both arterial and saphenous vein grafts. The choice and quality of the conduit used for the bypass conduit plays a major role in short-term and long-term outcomes

When a patient needs a coronary artery bypass graft (CABG) to reroute his or her blood supply, surgeons typically harvest a section of that patient’s saphenous vein or radial artery. This has traditionally been accomplished through an “open” procedure involving a longitudinal incision, which can run as far as from the groin to the ankle. Endoscopic vein-grafting offers a minimally invasive alternative, requiring just one 2-3 cm incision or two even smaller cuts. However, in 2009 a study in the New England Journal of Medicine called into question the long-term viability of these endoscopically-harvested grafts. Our readers may recall the controversy and its coverage in Medgadget.

This month, however, some of the original researchers published a follow-up study in the Journal of the American Medical Association that concluded that “the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.” This is a victory for practitioners of endoscopic vessel harvesting (EVH) and companies that make equipment for the procedure, such as Maquet. In order to understand what the implications of the JAMA study are, we spoke to James Keuler (PA-C) of Milwaukee’s Aurora Medical Group, which has been performing EVH for the past 15 years. Keuler has been practicing for 29 years and also serves as President of Intervasc LLC., a medical consulting group in Wisconsin.

Shiv Gaglani, Medgadget: What do you see as the primary advantages and disadvantages of endoscopic vein grafting as opposed to open vein grafting?

James Keuler: Our group out of Wisconsin was actually one of the first groups to start endoscopic vein harvesting (EVH) back in 1997. At that time, I saw a huge difference between EVH and open vein harvesting (OVH), more from the standpoint of patient outcomes and patient satisfaction. I always like to describe it as – the open technique impacts the patient as if they had had a surgical procedure done on their legs as well as on their chest because they felt the surgery so much and experienced so many problems following the procedure. What EVH demonstrated at the beginning was that the patient felt as if there had been no surgery done whatsoever on their legs; the patients didn’t even know they had had any procedure done on their legs.

There were always some questions from the early days around whether the quality was as good with EVH, and that’s something that we always worked to demonstrate here in Milwaukee. Because we helped pioneer the original technique, when papers came out questioning EVH, we always worked at analyzing what exactly it is we’re doing to prove that we’re trying to improve outcomes with EVH.

Also here in Milwaukee, we offer an advanced course that meets once a week, where we look at EVH therapy from a higher level to research and learn new techniques. We’ve come up with a new way to perform EVH that we’re hoping will be better than OVH – we call it a “gentle technique” where there’s almost no touch during the removal of the vein.

Medgadget: Following the Lopes et. al., paper in NEJM in 2009, did you see a drop in endoscopic vein grafting? Was there pressure to stop using the procedure?

Keuler: Locally here in Milwaukee we didn’t abandon the technique or reduce usage – however, we did examine the technique very carefully following the 2009 NEJM publication. The paper raised a lot of questions, but it was a good time for us to take a look at what we were doing and analyze whether we were doing a good job. From those who were attending the advanced course that we offer, about 15 percent of them reverted back to OVH following that article, so there was some impact.

Medgadget: What do you find most interesting about the present study in JAMA? How will this change the field, if at all?

Keuler: I think it was very interesting that these JAMA findings came from the same group as the one that published the 2009 data in NEJM – and I think that was a good thing. I think it validated the findings even more because it showed that the same group looked at both techniques again more scientifically and came to the conclusion that there was, in fact, no difference between EVH and OVH. My group here in Milwaukee certainly felt that, from our background and experience, what this new JAMA study showed should have been the finding. This finally puts to rest any questions or doubts that a surgeon or harvester may have whether EVH is better than OVH.

For additional information here is a video demonstrating EVH:

Source ; http://jama.jamanetwork.com/article.aspx?articleid=1272994

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