Endoscopic vein harvesting: just a promised land?

Lopes et al1 recently published in The New England Journal of Medicine the results of a comparative study between open and endoscopic vein harvesting (EVH) in coronary artery bypass surgery. This study did not pass unnoticed. An impressive record of 1000 patients per arm, 1800 angiographies at 12 to 18 months, and a clinical 3-year follow-up were analyzed. Surprisingly, the results of the 4000 studied graft showed a disappointing high incidence of graft failure in EVH group. Lopes et al also found an increased incidence of combined rate of myocardial infarct and repeat revascularization in the EVH group at 3-year follow-up, ultimately resulting in a statistically higher incidence of death in this group. A plausible explanation for these adverse events at follow-up could be that a more traumatic harvesting due to endoscopic technique might lead to accelerated atherosclerosis, resulting in a worse long-term patency and therefore in a worse clinical outcome. Remarkably, adverse angiographic and clinical events in the EVH group became apparent from 12-month follow-up. Previous studies with shorter follow-up failed to detect differences between the two techniques.2 Nevertheless, a recent retrospective study showed a nonsignificant increase in repeat revascularization and survival after EVH even at long-term follow-up.3 However, the study of Lopes et al has some limitations. The major limitation of the study is its not randomized nature. Another major limitation is the fact that two different devices were used for endoscopic harvesting, and the study does not provide information over the experience level and the volume of procedures performed by operators. Regardless of the conflicting evidence about EVH reported in several studies, there is currently enough consensus about the fact that EVH can reduce wound-related complications when compared with open vein technique. In fact, several studies demonstrated that EVH statistically reduces the level of pain and the incidence of mobility and sensory disorders at discharge. According to Likert scale, the score of esthetic satisfaction and pain is significantly better after EVH at discharge.2,4 On the other hand, 6 weeks after surgery, patients undergoing open vein harvesting experience a significant improvement in the scale of pain and cosmetic results. This improvement drastically reduces the initial advantage of EVH. In other words, we have to keep in mind that the initial benefits of EVH can disappear after 6 weeks.2,4 Another interesting issue about EVH is cost management. In fact, although EVH can reduce postoperative length of stay and outpatient wound management resources, the cost of EVH due to equipment needed should be also considered and related to the specific reimbursement system of each country.5 Finally, looking purely at histologic and functional characteristics of the harvested conduit, either open or EVH might be equivalent, because no significant differences have been demonstrated until now.2,6,7