Research review
Endoscopic vein harvesting for coronary artery bypass grafting: a systematic review with meta-analysis of 27,789 patients

https://doi.org/10.1016/j.jss.2012.11.013Get rights and content

Abstract

Background

To determine the current strength of evidence for or against endoscopic vein harvesting (EVH) in patients undergoing coronary artery bypass grafting (CABG).

Materials and Methods

A meta-analysis of randomized controlled trials (RCT) and observational trials (OT) was performed that reported the impact of EVH on adverse clinical outcomes after CABG. Analyzed postoperative outcomes included wound infection, postoperative pain, myocardial infarction (MI), vein graft failure, length of hospital stay, and mortality. Pooled treatment effects (OR or weighted mean difference (WMD), 95%CI) were assessed using a fixed or random effects model.

Results

A total of 27,789 patients from 43 studies (16 RCT, 27 OT) were identified who underwent saphenectomy by endoscopic (46%; n = 12,822) or conventional technique (54%; n = 14,967). Pooled effect estimates revealed a reduced incidence (P < 0.001) for wound infections (OR 0.27; 95% CI 0.22 to 0.32), pain (WMD −1.26, 95% CI −2.07 to −0.44; P = 0.0026), and length of hospital stay (WMD −0.6 d, 95% CI −1.08 to −0.12; P = 0.0152). EVH was associated to an increase of the odds for vein graft failure (OR 1.38; 95% CI 1.01 to 1.88; P = 0.0433), a finding that lost statistical difference after pooled analysis of RCT and studies with high methodological quality. Similarly, graft-related endpoints, including mortality and MI, did not differ between the harvesting techniques.

Conclusion

The present systematic review underscores the safety of EVH in patients undergoing CABG. EVH reduces leg wound infections without increasing the midterm risk for vein graft failure, MI, or mortality.

Introduction

Coronary artery bypass grafting (CABG) remains the gold standard in the treatment of multi-vessel coronary artery disease (CAD) [1]. Although complete arterial revascularization is increasingly propagated, the great saphenous vein still remains the most frequently used conduit for CABG. Following a long leg incision, conventional vein harvesting (CVH) is performed under direct visualization using a no-touch technique. The invasiveness of the open harvesting technique is associated with postoperative pain and leg wound infection that may prolong hospitalization of patients [2], [3]. The recent introduction of total endoscopic vein harvesting (EVH) has been associated with a substantial decrease in postoperative leg wound healing disorders after CABG [2], [3]. Consequently, a consensus statement published in 2005 by the International Society for Minimally Invasive Cardiothoracic Surgery recommends the use of EVH for CABG [4], and data from US registries confirm the wide adoption of EVH in up to 75% of performed CABG procedures [5], [6].

Previous systematic reviews uniformly document the superiority of minimal invasive over conventional harvesting techniques in terms postoperative associated leg wound morbidity [2], [3], [7], [8]. However, accumulating evidence from recently published reports raise serious concerns with regard to the quality and midterm patency of grafts after EVH and fundamentally questions its value for CABG [9], [10]. Post-hoc analysis from the PREVENT-IV study (Project of Ex-Vivo Vein Graft Engineering Via Transfection IV) [9] and the ROOBY trial (Randomized On/Off Bypass) [10] revealed decreased graft patency rates after EVH compared with CVH that were associated to inferior clinical outcomes. Although the underlying reasons remain unclear, increased surgical manipulation of the VSM during EVH resulting in endothelial injury has been reported by some investigators as a causal role for vein graft failure compared with the conventional techniques [11]. Others have failed to demonstrate a difference with regard to endothelial damage among harvesting techniques [12].

In view of the limited clarity of available data, the present meta-analysis assessed the strength of evidence of EVH use for CABG with special focus on graft-related outcome, including vein graft failure, myocardial infarction (MI), and mortality.

Section snippets

Selection criteria and search strategy

This systematic review of the literature was performed according to the guidelines for Quality of Reporting of Meta-Analysis [13]. Randomized controlled (RCT) and observational trials (OT) published between 1966 and April 2011 that reported the effects of EVH on postoperative outcomes in adult patients undergoing CABG were identified and analyzed with respect to the a priori defined inclusion criteria: (1) use of any commercially available endoscopic device for saphenous vein harvesting during

Selection and characteristics of included studies

The search of the literature retrieved 1119 studies. Following the de-duplication, 613 trials (91%) were excluded after initial abstract review for reasons explained in Figure 1. Of the remaining 60 studies, 17 studies were excluded after full-text evaluation either since they missed the inclusion criteria (n = 8 no EVH use; n = 1 no CABG), for not reporting desired endpoints (n = 4), due to inclusion of the same patient population in more than one publication (n = 3), or additional employment

Discussion

The present systematic review represents the largest meta-analysis to date that evaluates the strength of evidence for the use of EVH for CABG. The analyzed clinical endpoints were separated into two main aspects: on the one hand, the directly procedure-related results of EVH on operative variables and wound healing complications, and on the other hand, the potential impact of EVH on graft-related outcomes including vein graft failure, MI, and mortality.

Primarily, our results indicate a

Limitations

Our review has several important limitations that need to be considered for accurate interpretation of the reported treatment effects. First, our analysis revealed an unequal distribution of potential confounding factors among treatment groups, with patients in the EVH group being more obese and having a higher prevalence of diabetes, peripheral vascular disease, and aspirin therapy before surgery. Thus, the definite impact of this treatment bias and unequal distribution of risk factors on the

Acknowledgments

The authors declare that they have no conflict of interest.

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      In this present study, a significantly higher rate of leg wound complications was observed in the OVH group compared with the EVH group. The results of the present study are comparable with those of previous publications on leg wound complications after EVH.1,7,9,11 Another strength of the present study is that no selection criteria were used in the selection of patients for EVH or OVH.

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    1

    These authors contributed equally to this work.

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