Endoscopic Approach For Bypass Graft Surgery
There have been questions regarding the safety and durability of endoscopic vein graft harvest for coronary artery bypass graft (CABG) surgery. However, an analysis of data from more than 200,000 patients who underwent CABG surgery found no evidence of a long-term increased risk of death with endoscopic vein graft harvesting when compared to open vein-graft harvesting, according to a study in the August 1 issue of JAMA. The authors did find that the endoscopic technique was associated with a significant reduction in wound complications.
"In the mid-1990s, surgeons began using endoscopic vein-graft harvesting techniques as an alternative to large, incision-based open vein-graft harvesting to improve post-operative discomfort and incision-site complications," according to background information in the article. "The perceived advantages of endoscopic vein-graft harvesting led to wide-spread adoption of the technique, and the devices have been used in the majority of the more than 400,000 CABG surgery procedures performed at U.S. surgical centers each year." In 2009, a study that included 3,000 patients called into question the safety of the endoscopic vein-graft harvesting technique, finding that patients who received this procedure had higher three-year mortality than those receiving an open vein-graft harvesting technique.
Judson B. Williams, M.D., M.H.S., of Duke University Medical Center, and colleagues, conducted a study to assess use of the endoscopic vein-graft harvesting technique in CABG surgery and the risk of death, heart attack, and repeat revascularization. Based on Medicare Part B coding, 52 percent of patients received endoscopic vein-graft harvesting during CABG surgery. The researchers found no significant differences between the cumulative incidence rate for mortality through three years for the endoscopic (13.2 percent) and open (13.4 percent) vein-graft harvest groups. There were also no significant differences between the cumulative incidence through three years for the composite of death, heart attack or revascularization among the endoscopic versus open vein-graft harvest groups (19.5 percent vs. 19.7 percent).
Endoscopic vein-graft harvesting was associated with lower harvest site wound complications relative to open vein-graft harvesting (3.0 percent vs. 3.6 percent). "Our study found that endoscopic vein-graft harvesting was the most commonly used technique for vein-graft harvesting, with approximately 70 percent of CABG surgery cases in the STS Adult Cardiac Surgery Database using this technique in 2008, the most recent year examined. After adjustment for baseline clinical factors, no evidence was found of increased long-term mortality or the composite of death, myocardial infarction, or revascularization associated with endoscopic vs. open vein-graft harvesting in isolated patients undergoing CABG surgery. Consistent with previous randomized comparisons, use of endoscopic vein-graft harvesting was associated with a significant reduction in wound complications relative to the open procedures," the authors conclude.
In an accompanying editorial, Lawrence J. Dacey, M.D., M.S., of the Dartmouth-Hitchcock Medical Center, Lebanon, NH, comments on the findings of this study.
"Physicians tend to do what is best for their patients. Patient satisfaction is markedly better with endoscopic vein-graft harvesting. Patients who have had both an endoscopic and open vein-graft harvest marvel at the difference in reduced pain and time of healing with endoscopic vein-graft harvesting. This conclusive study by Williams, et. al. provides information to say with certainty that the benefits of endoscopic vein-graft harvesting in short-term patient-centered outcomes are not associated with an increased risk of important adverse long-term outcomes. And that is something to be thankful for."