Endoscopic saphenous vein harvest for coronary artery bypass grafting

# Recommendations
This document replaces previous guidance on endoscopic saphenous vein harvest for coronary artery bypass grafting (interventional procedure guidance 343).
Current evidence on the efficacy and safety of endoscopic saphenous vein harvest for coronary artery bypass grafting (CABG) is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit.
Clinicians should enter details of all patients undergoing endoscopic saphenous vein harvest for CABG onto the UK Central Cardiac Audit Database.# Indications and current treatments
Coronary artery disease refers to hardening and narrowing of the coronary arteries as a result of atherosclerosis. This can cause angina and myocardial infarction, and result in heart failure. One treatment option for coronary artery disease is coronary artery bypass grafting, which is normally done using autologous vein or arterial grafts. Vein grafts are most commonly done using the great saphenous vein.
The conventional method of harvesting the saphenous vein is an 'open' technique using 1 or more incisions in the leg. This technique may result in local complications including wound infection, dehiscence and persistent pain. Endoscopic saphenous vein harvest aims to reduce these problems by using much smaller incisions.# The procedure
The procedure is carried out with the patient under general anaesthesia, at the same time as coronary artery bypass grafting. An endoscope is usually inserted through a short incision near the knee, to visualise the subcutaneous plane in which the great saphenous vein lies. Carbon dioxide insufflation may be used to open this space. The vein is mobilised by blunt dissection and its tributaries are clipped and divided before removing the dissected segment of vein. The subcutaneous tunnel may be packed with an antibiotic-soaked swab, which is removed before wound closure. A compression bandage is applied to the leg to minimise haematoma.# Efficacy
This section describes efficacy outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
A systematic review and meta-analysis of 44 studies including 269,474 patients reported no statistically significant difference in mid-term mortality between patients treated by endoscopic or open saphenous vein harvest for coronary artery bypass grafting (CABG) (log-relative risk 0.90, 95% confidence interval  0.79 to 1.03, p=0.12, median follow-up 22.5 months). A non-randomised comparative study of 4709 patients treated by endoscopic or open saphenous vein harvest reported that there was no difference between the groups for the main outcome measure of mid-term mortality, repeat revascularisation and myocardial infarction combined (hazard ratio  1.15, 95% CI 0.76 to 1.74, p=0.51) in 2665 propensity-matched patients (533 versus 2132). A non-randomised comparative study of 1988 patients treated by endoscopic or open saphenous vein harvest reported overall rates of revascularisation, death and myocardial infarction of 6% and 7% respectively (p=0.18) with a mean follow-up of 22 months.
The systematic review of 44 studies reported an increased incidence of vein graft stenosis in the endoscopic group compared with the open group (3 studies, n=3229, log-rate ratio 1.19, 95% CI 1.05 to 1.34, p=0.005). In 2 of the studies reporting this outcome, angiography was done at 3 and 6 months; in the third study, angiograms were done at a median of 12.6 months. Neither of the randomised controlled trials included in this analysis showed any statistically significant difference between the groups.
The systematic review of 44 studies reported less postoperative pain in patients following endoscopic saphenous vein harvesting than after open saphenous vein harvest (12 studies, n=663, unstandardised mean difference 1.48, 95% CI 2.38 to 0.59, p=0.001, I2=98% ). A similar result was obtained when the analysis was limited to randomised controlled trials only (unstandardised mean difference 1.75, 95% CI 3.17 to 0.32, p=0.02). Significant heterogeneity was observed in both analyses, partly because of differences in the device system used across studies.
The specialist advisers listed key efficacy outcomes as reduced hospital stay, reduced risk of leg wound infections, early mobility, early rehabilitation and return to normal activities after CABG, reduced rate of readmissions, freedom from myocardial infarction, freedom from re-intervention, and patient satisfaction.# Safety
This section describes safety outcomes from the published literature that the Committee considered as part of the evidence about this procedure. For more detailed information on the evidence, see the interventional procedure overview.
The systematic review and meta-analysis of 44 studies reported a lower incidence of 30day mortality in patients treated by endoscopic saphenous vein harvest than in patients who had open saphenous vein harvest (log-relative risk 0.71, 95% CI 0.56 to 0.90, p=0.005). This difference was no longer statistically significant when only randomised controlled trials were analysed (log-relative risk 0.75, 95% CI 0.27 to 2.11, p=0.58). In-hospital mortality was 1% after both endoscopic and open saphenous vein harvest in the non-randomised comparative study of 4709 patients (2665 propensity-matched patients ). Mortality within 30 days occurred in 2% of patients treated by endoscopic saphenous vein harvest and 4% of patients treated by open saphenous vein harvest in the non-randomised comparative study of 1988 patients (478 propensity-matched patients, p=0.26).
Wound infection was reported in a lower proportion of patients treated by endovascular vein harvest than in patients treated by open saphenous vein harvest in the systematic review of 44 studies (log-relative risk 0.31, 95% CI 0.23 to 0.42, p<0.0001, I2=43%). A similar result was reported from the analysis of randomised controlled trials only (log-relative risk 0.26, 95% CI 0.15 to 0.44, p<0.0001). Wound infection was reported in less than 1% of patients treated by endoscopic saphenous vein harvest and 2% of patients treated by open saphenous vein harvest in the non-randomised comparative study of 1988 patients (p=0.03).
Severe leg wound complications needing surgical revision were reported in 1% and 2% of patients treated by endoscopic and open saphenous vein harvest respectively (p=not significant) in the non-randomised comparative study of 885 patients.
Necrotising fasciitis was reported in 1 patient in a case report. The patient developed symptoms 3 weeks after the procedure, and surgical exploration of the wound showed extensive necrosis. Treatment included radical debridement, intravenous antibiotics followed by oral antibiotics, and a split-thickness skin graft.
Compartment syndrome was reported in 1 patient in a case report. Symptoms of leg tightness, swelling and tenderness occurred 4 days after the procedure. A fasciotomy was performed to decompress all 4 compartments of the lower leg. By 3 months, the patient had recovered without any neurological sequelae.
Massive carbon dioxide (CO2) embolisation was reported in 2 patients in a case series of 405 patients: 1 patient was successfully treated pharmacologically and the other needed emergency cardiopulmonary bypass support to complete the coronary artery bypass graft surgery.
A case report described scrotal distension due to CO2 and signs of cellulitis in 1 patient following endoscopic saphenous vein harvesting. The patient was treated with antibiotics and discharged after 14 days.
Pneumoperitoneum was reported in 1 patient in a case report. Postoperative chest Xray showed a complete resorption of CO2.
The specialist advisers described the possibility that endoscopic saphenous vein harvest might result in damage to the vein, which could decrease patency and lead to increased rates of postoperative myocardial infarction, mid-term myocardial infarction, mid-term mortality, recurrence of angina, repeat revascularisation rates and decreased survival over the long term.# Further information
For related NICE guidance see the NICE website.

# Information for patients
NICE has produced information on this procedure for patients and carers (Information for the public). It explains the nature of the procedure and the guidance issued by NICE, and has been written with patient consent in mind.# About this guidance
NICE interventional procedures guidance makes recommendations on the safety and efficacy of the procedure. It does not cover whether or not the NHS should fund a procedure. Funding decisions are taken by local NHS bodies after considering the clinical effectiveness of the procedure and whether it represents value for money for the NHS.
This guidance was developed using the NICE interventional procedures guidance process.
It updates and replaces NICE interventional procedure guidance 343.
We have produced a summary of this guidance for patients and carers. Information about the evidence the guidance is based on is also available.
NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services.  We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland.  Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.
Your responsibility
    This guidance represents the views of NICE and was arrived at after careful consideration of the available evidence. Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. This guidance does not, however, override the individual responsibility of healthcare professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Implementation of this guidance is the responsibility of local commissioners and/or providers. Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity and foster good relations. Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.
Copyright
     National Institute for Health and Care Excellence 2014. All rights reserved. NICE copyright material can be downloaded for private research and study, and may be reproduced for educational and not-for-profit purposes. No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
ISBN 978-1-4731-0617-8