Editorial Comment: Endoscopic vein harvest: standard of care?

We read with interest the meta-analysis by Sastry et al. [1] comparing outcomes with open vs endoscopically harvested saphenous veins in coronary artery bypass grafting (CABG) surgery. The authors should be commended for their meticulous work collecting and analysing data on this highly nuanced and controversial topic. After selecting 44 studies, they offer thoughtful and balanced conclusions regarding the most pertinent outcome relating to saphenous vein grafting. Their conclusions echo the perception of endoscopic vein harvest (EVH) advocates, with an early benefit with regard to leg wound pain and complications, and no adverse effects on graft failure, repeat revascularization or survival up to 3 years. Similar findings were reported by an earlier meta-analysis published in 2005, although it included far fewer patients [2]. Unfortunately, the Achilles heel of the EVH literature remains the lack of long-term clinical results and only scattered reports on angiographic follow-up. We published one of the earliest randomized trials comparing open vein harvest (OVH) with EVH and found no difference in outcomes to 30 days [3]. This study was performed early on in our experience, which may explain the neutral results compared with more recent trials that have shown a benefit with EVH with regard to wound complications over the same 30-day period. When reviewing the contemporary literature, there is little doubt regarding the benefits of EVH on local wound pain and complications. Sastry et al. demonstrate this nicely in the meta-analysis, with a combined analysis of all studies reporting on pain (n = 12) and infections (n = 31) favouring EVH. Interestingly, the differences in pain were only significant in studies using the Vasoview system (Maquet, Wayne, NJ, USA). This is the system that we currently use at our institution; however, it may be that this variability is related to the subjectivity inherent in self-reporting of pain rather than an advantage with one system over another. With a clear benefit with respect to harvest site complications and patient preference towards a ‘less-invasive’ approach, the question remains how endoscopically harvested grafts will perform over time and how many ‘patency percentage points’ we are willing to exchange for advantages in short-term comfort and cosmesis. Vein graft quality is measured either by angiographic patency, or by surrogates such as myocardial infarction, recurrent angina, repeat revascularization and survival. All of these variables were challenged by the post hoc analysis of the PREVENT IV trial published in the NEJM by Lopes et al. [4], and the safety of EVH was questioned by many surgeons worldwide. In contrast, the present meta-analysis, which included the Lopes article among the randomized and non-randomized trials, showed no advantage of OVH in any of these outcomes. In randomized trials, repeat revascularization was neither different up to 2.6 years, nor was there a difference in myocardial infarction over a similar time frame. Furthermore, a recent study by Williams et al. [5] reviewed over 230 000 Medicare patients from across the USA, showing fewer harvest site complications and no increase in mortality with EVH at 3 years. This highlights the danger of considering a single non-randomized study when making important clinical decisions. In addition to the inherent biases of the PREVENT IV post hoc analysis, the significant interinstitutional variability and overall low graft patency rates suggest that differences in both equipment and technique may have contributed to poorer outcomes with EVH. While it is reassuring to have data showing that EVH performs well up to 3 years, intimal damage can predispose patients to late complications, such as intimal hyperplasia, with potentially decreased long-term graft patency. This shortcoming of the literature is well presented by the authors who, due to limited data, are forced to state that a comparison of mid-term mortality is inconclusive. Significant operator variability also complicates EVH reporting. Although difficult to study, it is intuitive that operator experience and diligence in conduit procurement will influence graft patency and clinical outcomes [6]. To maximize graft quality, it important not only to focus on overcoming the learning curve, but also to maintain a ‘handle with care’ attitude throughout. We continue to offer EVH as a standard of care for all patients requiring saphenous vein grafts in our institution because of the short-term benefits and the lack of evidence for long-term drawbacks. However, we also recognize that the saphenous vein is an imperfect conduit, regardless of the method of procurement, and we advocate total arterial revascularization whenever possible [7, 8]. The reality of today’s world is that patients will choose procedures with smaller scars and shorter recovery times in the absence of a conclusively demonstrated decrement in long-term survival. There is a valid concern that patients may be more likely to undergo percutaneous coronary intervention procedures in clinical scenarios outside established guidelines if surgeons cannot offer ‘less invasive’, aesthetically pleasing operations. EVH is one of the innovations making CABG surgery more acceptable to both patients and referring cardiologists. With the current literature showing clear early benefits and no