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      The use of minimally invasive videoscopic technique in large vessel and cardiac surgery. Does the potentially increased difficulty bring benefits to the patient?

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          Abstract

          We present the clinical case of a 63-year-old patient who underwent in the Department of Cardiac Surgery implantation of an aorto-bifemoral graft prosthesis and coronary artery bypass revascularization with application of less invasive off-pump technique. Graft selection (arterial grafts, venous grafts) is very important during qualification for coronary artery bypass revascularization. Minimally invasive saphenous vein harvesting was performed during the presented case. The endoscopic technique of vein harvesting is a relatively rarely applied technique during myocardial revascularization surgery. The concept of minimally invasive videoscopic technique is presented. There is a discussion on why the team decided to prolong duration of the case consisting of two major operations performed simultaneously. Minimally invasive videoscopic technique may have a significant positive impact on postoperative outcome in a selected group of patients.

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          Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery.

          Nicholas Kouchoukos, G Hafley, Karen Peterson … (2009)
          Vein-graft harvesting with the use of endoscopy (endoscopic harvesting) is a technique that is widely used to reduce postoperative wound complications after coronary-artery bypass grafting (CABG), but the long-term effects on the rate of vein-graft failure and on clinical outcomes are unknown. We studied the outcomes in patients who underwent endoscopic harvesting (1753 patients) as compared with those who underwent graft harvesting under direct vision, termed open harvesting (1247 patients), in a secondary analysis of 3000 patients undergoing CABG. The method of graft harvesting was determined by the surgeon. Vein-graft failure was defined as stenosis of at least 75% of the diameter of the graft on angiography 12 to 18 months after surgery (data were available in an angiographic subgroup of 1817 patients and 4290 grafts). Clinical outcomes included death, myocardial infarction, and repeat revascularization. Generalized estimating equations were used to adjust for baseline covariates associated with vein-graft failure and to account for the potential correlation between grafts within a patient. Cox proportional-hazards modeling was used to assess long-term clinical outcomes. The baseline characteristics were similar between patients who underwent endoscopic harvesting and those who underwent open harvesting. Patients who underwent endoscopic harvesting had higher rates of vein-graft failure at 12 to 18 months than patients who underwent open harvesting (46.7% vs. 38.0%, P<0.001). At 3 years, endoscopic harvesting was also associated with higher rates of death, myocardial infarction, or repeat revascularization (20.2% vs. 17.4%; adjusted hazard ratio, 1.22; 95% confidence interval [CI], 1.01 to 1.47; P=0.04), death or myocardial infarction (9.3% vs. 7.6%; adjusted hazard ratio, 1.38; 95% CI, 1.07 to 1.77; P=0.01), and death (7.4% vs. 5.8%; adjusted hazard ratio, 1.52; 95% CI, 1.13 to 2.04; P=0.005). Endoscopic vein-graft harvesting is independently associated with vein-graft failure and adverse clinical outcomes. Randomized clinical trials are needed to further evaluate the safety and effectiveness of this harvesting technique. 2009 Massachusetts Medical Society
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            Endoscopic venous harvesting by inexperienced operators compromises venous graft remodeling.

            Soroosh Kiani, Pranjal H Desai, Nannan Thirumvalavan … (2012)
            Endoscopic vein harvesting (EVH) is the standard of care for coronary artery bypass grafting (CABG) in the United States, but recent comparisons with open harvesting suggest that conduit quality and outcomes may be compromised in EVH. To test the hypothesis that problems with EVH may relate to its learning curve and conduit quality, we analyzed the quality and early function of conduits procured by technicians with varying experience in EVH. Experienced (more than 900 cases, n=55 patients) and novice (less than 100 cases, n=30 patients) technicians performed EVH during CABG. Subsequently, optical coherence tomography (OCT) was used to examine the conduits for vascular injury, with segments identified as injured being further examined for gene expression with an array of genes related to tissue injury. Conduit diameter was measured intra- and postoperatively (day 5 and 6 months, respectively) with OCT and computed tomographic angiography. Endoscopic vein harvesting by novice harvesters resulted in a greater number of discrete graft injuries and greater expression of tissue-injury genes than EVH done by experienced harvesters. Regression analysis revealed an association between shear stress and early dilation of engrafted vessels (positive remodeling) (R2=0.48, p<0.01). Injured veins showed blunted positive remodeling at 5 days after harvesting and a greater degree of late lumen loss at 6 months. Under normal conditions, intraluminal shear stress leads to positive remodeling of vein grafts during the first postoperative week. Injury to conduits, a frequent sequela of the learning curve for EVH, was a predictor of early graft failure and of blunted positive remodeling and greater negative remodeling of endoscopically harvested vein grafts. Given the current annual volume of cases in which EVH is used, rigorous monitoring of the learning curve for this procedure represents an important and unrecognized issue in public health. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
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              Is endoscopic harvesting bad for saphenous vein graft patency in coronary surgery?

              Soroosh Kiani, R P Poston (2011)
              Endoscopic vein harvest (EVH) has quickly been adopted as the standard-of-care for coronary artery bypass grafting (CABG). Despite clear advantages in terms of wound morbidity, healing, pain, and patient satisfaction, data from recent large clinical trials have called the safety of this technique into question. Post-hoc analyses of a variety of prospective trials have suggested EVH is associated with decreased graft patency, higher rates of cardiovascular complications (e.g. myocardial infarction, need for repeat revascularization) and mortality. Imaging studies of veins procured by EVH have revealed retained clot and vascular injury, particularly during the 'learning curve' of the technician. These findings may alter the quality of the conduit and, therefore, the outcome of the bypass graft. Elucidating the mechanisms that underlie any differences in results produced by the open and endoscopic procedures would help better inform clinical practice and the development of targeted strategies to improve EVH. Clear clinical advantages over traditional open vein harvest have allowed EVH to rapidly become the standard-of-care for harvesting of one or more vein grafts during CABG. The quality of these conduits, suggested to be equivalent by early studies, has come into question as groups with varying levels of experience have adopted the endoscopic technique. Elucidating the principles of 'best practice' for vein harvest will likely help shorten the learning curve and improve the safety of EVH.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Wideochir Inne Tech Malo Inwazyjne
                Journal ID (iso-abbrev): Wideochir Inne Tech Malo Inwazyjne
                Journal ID (publisher-id): WIITM
                Title: Videosurgery and other Miniinvasive Techniques
                Publisher: Termedia Publishing House
                ISSN (Print): 1895-4588
                ISSN (Electronic): 2299-0054
                Publication date (Electronic): 06 November 2012
                Publication date (Print): March 2013
                Volume: 8
                Issue: 1
                Pages: 86-89
                Affiliations
                [1 ]Department and Clinic of Cardiac Surgery, Medical University of Wrocław, Poland
                [2 ]Department and Clinic of Vascular, General and Transplantation Surgery, Medical University of Wrocław, Poland
                [3 ]Department of Anaesthesiology and Intensive Therapy, Medical University of Wrocław, Poland
                Author notes
                Address for correspondence: Maciej Rachwalik MD, PhD, Department and Clinic of Cardiac Surgery, Medical University of Wrocław, 213 Borowska St, 50-556 Wroclaw, Poland. phone: 609 051 961. fax: +48 71 736 41 00. e-mail: mrach@ 123456wp.pl
                Article
                Publisher ID: 19697
                DOI: 10.5114/wiitm.2011.31596
                PMC ID: 3627157
                PubMed ID: 23630560
                SO-VID: 63664eeb-e8d5-46ec-88b9-41a04619c9d9
                Copyright © Copyright © 2013 Sekcja Wideochirurgii TChP
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution-Noncommercial 3.0 Unported License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 22 April 2012
                Date revision received : 28 May 2012
                Date accepted : 07 July 2012
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Surgery
                Keywords: endoscopic vein harvesting,coronary artery bypass grafting,“y” prosthesis,cardiac surgery,vascular surgery
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: endoscopic vein harvesting, coronary artery bypass grafting, “y” prosthesis, cardiac surgery, vascular surgery

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