Endoscopic vessel harvesting: Key thoughts on benefits for patients

Endoscopic vessel harvesting (EVH) is a minimally invasive procedure performed right before coronary artery bypass grafting, or bypass surgery. A physicians' assistant (PA) typically performs the procedure, taking healthy blood vessels from other parts of the body and using them to bypass a blockage to the arteries of the heart.

In many operating rooms, the PAs efficiently and safely perform endoscopic vessel harvesting in preparation for the bypass surgery.

"It doesn't matter if the surgeon or the PA is performing the endoscopic vessel harvesting, as long as they've been trained to do the procedure and perform it on a regular basis," says Saurabh Ashier, a physicians assistant based in Los Angeles. "It takes skill and there is a learning curve. But after the PAs are comfortable with it, they can safely perform the procedure."

Vessel harvesting was traditionally performed with an open technique. The conventional open vein harvesting technique requires a long incision from the groin to the ankle. The patient often experiences pain and the wound is prone to healing complications.

"The open technique covers a large area with a big incision for harvesting," says Mr. Ashier. "The endoscopic technique is done with a one-inch incision. This is aesthetically pleasing to the patient, but the biggest advantage for the patient is the reduced pain. The healing is faster with the endoscopic procedure."

The endoscopic technique is becoming increasingly popular. It was developed in 1995 and utilization accelerated in 2005 when the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) concluded it was the standard of care. This less invasive technique requires a single, small incision across the leg or forearm, as opposed to a large open incision. There are several key advantages for the endoscopic technique:

1. Patients undergoing EVH report less leg pain and scarring after the procedure than after open vessel harvesting.1

2. The endoscopic vessel harvesting procedure significantly reduces wound complications and infection.2

3. The patients who undergo the endoscopic procedure have a shorter length of stay on average than after the open procedure.3

4. EVH is associated with lower hospital readmission rates4 and fewer outpatient office visits.5

5. Endoscopic vessel harvesting has not been shown to compromise long-term patient outcomes or safety.6

"The patients are able to recover more quickly from endoscopic vessel harvesting, and they like that better," says Mr. Ashier. "The shorter length of stay coupled with the reduced complication and infection risk, adds a cost-benefit to endoscopic vessel harvesting over the open technique."

In European Journal of Vascular & Endovascular Surgery an article titled "A Systematic Review of Cost-effectiveness Evidence of Endoscopic Saphenous Vein Harvesting: Is it Efficient?" found evidence suggesting lower costs for endoscopic harvesting.

Physicians and PAs at almost all hospitals across the United States perform endoscopic vessel harvesting; around 76 percent of the coronary artery bypass grafting surgery cases used endoscopic vessel harvesting in the Untied States in 2008. Since 1996 the procedure has been performed more than 2 million times worldwide with Maquet Medical Systems' VASOVIEW Endoscopic Vessel Harvesting System.

"We've been able to improve the technology so much that doing anything else deviates from the standard of care," says Mr. Ashier. "In most places, endoscopic vessel harvesting is becoming the standard of care. However, there are a few patients where this isn't the ideal situation. EVH may not be the best procedure for patients with very small vessels, particularly if the harvester is not very experienced."

Obese patients and patients at greater risk for developing leg wound complications are ideal candidates for endoscopic vessel harvesting. High-risk patients are undergoing bypass surgery at a higher rate today than in the past.7

"There have been some articles trying to sway providers to perform the procedure one way or another based on the fact that people believe the endoscopic method causes injury to the conduit," says Mr. Ashier. "But there have been articles published showing the new technology can improve outcomes in the hands of highly-skilled and experienced harvesters."

There is a slight learning curve — around 30 to 50 cases depending on the provider's hand-eye coordination. Maquet offers workshops to teach the procedure, and holds the dominant position in the market share today for endoscopic vessel harvesting.

"Most surgical training curriculums now involve some components of surgery that involve video-assisted procedures," says Mr. Ashier.

There are several published articles, including a 2012 JAMA article titled "Association Between Endoscopic vs. Open Vein Graft Harvesting and Mortality, Wound Complications, and Cardiovascular Events in Patients Undergoing CABG Surgery," comparing open vein and endoscopic graft harvesting for coronary artery bypass graft surgery. The researchers compared Medicare patients who underwent either the open procedure or endoscopic vessel harvesting between 2003 and 2008 with 934 surgical centers participating in the Society of Thoracic Surgeons national database.

The researchers found there wasn't significant difference between the long-term mortality rates and composite of death, myocardial infarction and revascularization. However, the endoscopic vein graft harvesting was associated with lower harvest site wound complications compared with open vein-graft harvesting.

In honor of National Physician Assistant Week, Oct. 6 to 12, physician assistants supporting cardiac surgeons dedicated time to educate the public on endoscopic vessel harvesting. The event commemorates the first anniversary of Duke University's physician assistant class on Oct. 6, 1967. Now, there are more than 75,000 PAs providing medical and surgical care in the United States. Each year more than 6,000 PAs enter the workforce and 78 percent of recent graduates are receiving multiple job offers.

"The big reason I participated in National Physician Assistant Week was to spread the word about endoscopic vessel harvesting and the important advancements in the field," said Mr. Ashier. "I want to make sure physicians and other practitioners are involved in bringing the endoscopic procedure to their practice and providing the best care options for their patients."

Endnotes:

1. "The Benefits of Endoscopic Vein Harvesting" The Heart Institute at Lawnwood Regional Medical Center. Lawnwoodmed.com/our-services/heart/endoscopic-vein-harvesting.dot

2. "Clinical benefits of endoscopic vein harvesting in patients with risk factors for saphenectomy wound infections undergoing coronary artery bypass grafting," Journal of Cardiovascular Surgery, January 2000. p. 69-75.

3. "Is it safe to perform endoscopic vein harvest?" Interactive Cardiovascular and Thoracic Surgery, Oxford Journals, 2010.

4. "Encouraging results with endoscopic vein harvest for infrainguinal bypass," Journal of Vascular Surgery, May 2005.

5. "Minimally Invasive Endoscopic Vessel Harvesting For Bypass Surgery," Health Awareness. www.napsnet.com/articles/71513.html

6. "Minimally Invasive Endoscopic Vessel Harvesting For Bypass Surgery," Health Awareness. www.napsnet.com/articles/71513.html

7. "Minimally Invasive Endoscopic Vessel Harvesting For Bypass Surgery," Health Awareness. www.napsnet.com/articles/71513.html

This article is sponsored by Maquet.

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