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Eur J Cardiothorac Surg 2006;29:324-333
© 2006 Elsevier Science NL

Review

Minimally invasive conduit harvesting: a systematic review

Omer Aziz, Thanos Athanasiou * , Ara Darzi

Department of Surgical Oncology and Technology, Imperial College of Science, Technology and Medicine, 10th Floor QEQM Building, St. Mary's Hospital, London W2 1NY, United Kingdom

Received 4 September 2005; received in revised form 30 October 2005; accepted 14 November 2005.

* Corresponding author. Tel.: +44 207 886 1310; fax: +44 207 886 1810. (Email: tathan5253{at}aol.com).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Minimally invasive conduit harvesting techniques for coronary artery bypass grafting have developed over the past decade, aiming to reduce the morbidity and recovery time associated with the procedure, whilst preserving the quality of the conduit. Two types of commonly harvested free conduits include the great saphenous vein and the radial artery. Although much research has focussed on comparing less invasive and conventional harvest techniques, there is at present no consensus on the areas where one technique is superior to the other. Aspects of conduits that deserve appreciation when comparing minimally invasive and open harvesting techniques include wound healing at the harvest site, the macroscopic, histological and functional quality of the conduit, but perhaps most importantly its long-term angiographic patency. This paper aims to review the literature comparing minimally invasive and conventional conduit harvesting techniques for coronary artery bypass grafting, with regard to the previously mentioned factors. A literature search of Medline, Ovid, Embase and Cochrane databases was used to identify comparative studies published between 1997 and 2005. Outcomes of interest included: wound infection, non-infective healing disturbances, post-operative pain, neurological disturbance, mobility, patient satisfaction, conduit quality (macroscopic, histological and functional) and long-term conduit patency. A scoring system was applied and used to grade the quality of the evidence, based on which a recommendation of it being ‘good’ (Grade A), ‘fair’ (Grade B), or ‘insufficient’ (Grade C) was made. Results showed that there was ‘good’ evidence to suggest that wound infection and non-infective complications are reduced with minimally invasive harvest as compared to conventional vein harvest. The evidence suggesting that post-operative pain and mobilisation is reduced after minimally invasive vein harvest and that once harvested, the conduits are macroscopically comparable to conventional ones, is only ‘fair’. Finally, although initial reports are encouraging, there is at present insufficient evidence to comment on whether minimally invasive radial artery harvesting is better than that of conventional open surgery. Wounds from minimally invasively harvested venous conduits appear to be less prone to complications although more comparative evidence on conduit quality and long-term patency is eagerly awaited.

Key Words: Coronary artery bypass • Conduit • Minimally invasive • Endoscopic


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Minimally invasive conduit harvesting techniques for coronary artery bypass grafting (CABG) have developed over the past decade [1], aiming to reduce the morbidity and recovery time associated with the procedure, whilst preserving the quality of the conduit. Conventional great saphenous vein harvest (CVH) involves an open incision extending from the medial malleolus, along the medial aspect of the knee to the groin, whilst in conventional radial artery harvest (CRH) the incision runs from just below the anticubital fossa to the wrist, along the medial border of the brachioradialis muscle. Minimally invasive vein harvest (MIVH) and radial artery harvest (MIRH) aim to reduce the length of the skin incision although the length of the subcutaneous tunnel is still the same with both techniques.

There are several aspects of conduit harvesting that deserve appreciation when comparing minimally invasive and open conduit surgery, first of which is wound healing at the harvest site. Wound infection, non-infective wound healing disturbances, post-operative pain and poor mobility all account for a large part of the morbidity associated with conduit harvest wounds and, therefore must be considered when comparing minimally invasive and conventional techniques [2,3]. Wound healing has an impact on post-operative pain, length of post-operative stay and cost of the procedure, and ultimately affects patient satisfaction with the procedure. Cosmetic outcome (risk of hypertrophic scarring), quality of life following surgery, and particularly in the case of radial artery harvesting, neurological deficit as a result of damage to the superficial radial or lateral antebrachial cutaneous nerves are all important components of this [4].

The quality of the harvested conduit, which includes macroscopic, histological and functional aspects, is another very important aspect to consider when comparing harvesting techniques, as this ultimately determines long-term patency and survival following CABG. Macroscopic quality may be assessed by comparing conduit length, number of injuries (such as side branch avulsions or tears) and the number of repairs required before grafting can take place [5]. Attempts to quantify this quality have ranged from the use of grading systems such as ‘good’, ‘fair’ or ‘poor’ [6], to numerical scoring systems based on the calibre of the conduit, presence of varicosities, its wall thickness and the number of tears requiring repair [7].

An appreciation of the antithrombogenic properties of vascular endothelium and its integrity in the conduit is important, particularly as vasospasm, occlusive intimal hyperplasia and accelerated arteriosclerosis have all been shown to occur as a result of endothelial injury [8]. Histological evidence of endothelial damage may be detected using light microscopy (LM) to quantify the extent of the damage, and scanning electron microscopy (SEM) to evaluate endothelial cell separation, oedema, detachment, basement membrane quality and collagen exposure [9]. Numerical scoring has also been used to grade the degree of endothelial coverage of the conduit using SEM, with grades ranging from ‘1’ for veins with a completely confluent endothelial layer to ‘5’ for veins with no endothelium [10]. Functional properties of harvested conduits and their endothelium have been assessed by measuring in vitro vasoreactivity [8,11], functional imaging [12], measurement of inflammatory response [13,14] and immunocytochemical assessment [15,16].

Finally, although long-term patency is a measure of paramount importance when comparing conduits, data for endoscopically harvested conduits are scarce mainly due to the cost and invasiveness of coronary angiography. The increasing use of imaging techniques such as contrast-enhanced electron beam computer tomography [17] and magnetic resonance angiography [18] however, means that conduit patency may now be evaluated in a non-invasive manner. Until more of this type of information is made available, measures such as the incidence of post-operative myocardial infarction may be the only way of indirectly measuring conduit patency.

We aim to review the literature with regard to the above-mentioned patient and conduit-related outcomes, comparing minimally invasive conduit harvest (MIVH and MIRH) to conventional harvest procedures.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
2.1 Literature search
A literature search was performed using Medline, Ovid, Embase and Cochrane databases. All studies published between 1997 and 2005 comparing minimally invasive to conventional vein harvest techniques for CABG were included. With regard to radial artery harvest, both comparative studies of minimally invasive (MIRH) and conventional (CRH) harvest as well as observational series were included. CVH and CRH were defined as harvest of the great saphenous vein or radial artery with a continuous skin incision, whereas MIVH and MIRH were defined as harvest of the vein or artery using endoscopic or non-endoscopic instruments. The following mesh headings were used: ‘comparative study’, ‘coronary artery bypass’, ‘surgical procedures, minimally invasive’, ‘endoscopy’, ‘conduits’, ‘outcome’, ‘quality’ and ‘patency’. The ‘related articles’ function was utilised to broaden the search, and all abstracts, studies and citations were scanned and reviewed. In the case of minimally invasive radial artery harvesting, non-comparative observational series were also included in this review due to the scarcity of comparative evidence.

2.2 Outcomes of interest
The following outcomes were used to compare minimally invasive and conventional conduit harvesting: wound infection, non-infective wound healing disturbances, post-operative pain, post-operative mobility, quality of life following surgery, neurological disturbance, operative time, post-operative length of stay, cost, conduit quality (macroscopic, histological and functional) and patency.

2.3 Data extraction and validation of studies
Two reviewers (O.A. and T.A.) independently extracted the following data from each study: first author, year of publication, study population characteristics, study design, number of subjects operated on with each technique, equipments used and the outcomes of interest mentioned above. Comparative evidence on the above-mentioned outcomes of interest was reviewed and a recommendation on the validity of this evidence was given. This was done by taking into consideration the source and the strength of the evidence and using the grading system of the US Preventive Services Task Force [19]; a recommendation was made on the strength of evidence. Accordingly, Grade A was awarded for strength of evidence when there was ‘good evidence to support the recommendation’, Grade B when there was ‘fair evidence’, and Grade C when there was ‘insufficient evidence for or against’.

2.4 Inclusion and exclusion criteria
In order to enter our review, studies had to report on at least one of the outcome measures mentioned above, and clearly document the term ‘minimally invasive’ as either endoscopic or non-endoscopic conduit harvest. When two studies were reported by the same institution, we included either the one of better quality (randomised) or the most recent publication.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
3.1 Studies included
The literature search identified 52 studies and three meta-analyses comparing MIVH and CVH, with regard to the previously mentioned outcomes. For MIRH, our literature search identified two prospective non-randomised studies comparing it to CRH and nine observational series reporting its use in a series of patients. An overview of the studies that were included in this review is shown in Fig. 1 . Table 1 shows the demographics and results of the studies reporting on MIRH (both endoscopic and non-endoscopic).


Figure 1
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  		Fig. 1. Outline of studies included in this review.

 

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  		Table 1. Summary of studies reporting outcomes from minimally invasive radial artery harvest
 
3.2 Minimally invasive great saphenous vein harvesting technique
Non-endoscopic MIVH techniques involve a bridging technique with [20] or without [7] the use of a specially adapted retractor. As in CVH, the saphenous vein is identified either at the medial malleolus or at the saphenofemoral junction in the groin, and dissected aiding the identification and clipping of its side branches. Once the vein is dissected, as far as possible, the next incision is created along the line of the vein, and the process is continued until an adequate length is obtained. Equipments used for non-endoscopic MIVH include: (a) Mini-Harvest System (Autosuture, USSC, Norwalk, CT, USA), (b) SaphLITE System (Genzyme Surgical Products, Cambridge, MA, USA), (c) Aesculap Retractor (Aesculap AGCoKG, Tutligen, Germany) and (d) Mayo Vein Stripper (Johnson and Johnson, Somerville, NJ, USA).

Endoscopic great saphenous vein harvest (EVH) usually involves making a 2–3 cm incision at or above the knee to identify and isolate the great saphenous vein. A space is then dissected over the vein for the introduction of a subcutaneous retractor and/or endoscope. The endoscope is subsequently introduced into the subcutaneous tissue and advanced towards either the groin or down towards the medial malleolus, identifying and clipping venous side branches. Additional incisions are used as required either at the groin or the ankle, although most groups describe being able to perform the harvest through a single incision using a ligation loop once adequate experience has been gained [21,22]. The use of carbon dioxide insufflation to improve the visualisation of the vein during harvest is dependent on the equipment used [5], and the use of bipolar diathermy for the harvest down to the preference of the surgeon [23]. Equipments used for endoscopic MIVH include: (a) Ethicon Endo-Surgery Vein Harvest Equipment (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA), (b) VasoView Endoscopic Vessel Harvesting System® (Guidant Medsystems Inc., Menlo Park, CA, USA), (c) Karl Storz Endoskope (Karl Storz, Tuttlingen, Germany), (d) Clearglide Accel (Cardiovations, Edinburgh, Scotland) and (e) a combination of these instruments. Fig. 2 illustrates the cosmetic result of endoscopic MIVH and MIRH on the same patient.


Figure 2
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  		Fig. 2. A picture of the arm and leg wounds of the same patient following endoscopic great saphenous vein and radial artery harvest procedures.

 
It is important to note that there is a learning curve associated with both endoscopic and non-endoscopic MIVH techniques, as illustrated by the finding that veins harvested with MIVH technique require a significantly greater number of repairs as compared to CVH [24]. The exact nature of this curve is uncertain at present, although some findings suggest a training period of approximately 30 patients as appropriate [25]. Conversion rates documented for endoscopic MIVH range from 0% [26] to 22% [27].

3.3 Minimally invasive radial artery harvesting technique
The growing popularity of endoscopic venous conduit harvest for CABG has led to the modification of this technique to also harvest the radial artery. Equipments that have been described in the literature include: (a) VasoView Endoscopic Vessel Harvesting System® (Guidant Medsystems Inc.), (b) Ultraretractor (Cardiovations, Johnson and Johnson), Ethicon Endosurgery Endoscopic Radial Artery kit with or without the use of harmonic scalpel shears (Ethicon Endo-surgery Inc.) and (c) Tsukuba-West Virginia Endoscopic Radial Artery: TW-ERA series, Takumi Cardio Co., Chiba, Japan). Minimally invasive (non-endoscopic) radial artery harvest has been described using bridging skin incisions [28] as well as using a modified retractor (RadLITE System, Genzyme Biosurgery, Cambridge, MA, USA) [29,30].

The endoscopic radial artery harvest (ERH) technique commonly involves making a 3–4 cm longitudinal incision 1 cm cephalad to a point lying halfway between the tendon of flexor carpi radialis and the radial styloid process. The subcutaneous tissues and fascia overlying the radial artery are divided longitudinally with the distal part of the radial artery identified under direct vision, with any visible side branches clipped, and care is taken to separate the radial artery from the superficial radial nerve, which is one of the two nerves that can be damaged during radial artery harvest [31]. This nerve has been noted to be most commonly encountered during the distal dissection in the forearm, and supplies sensory innervation to the volar and dorsal part of the first two fingers. The lateral antebrachial cutaneous nerve runs above the brachioradialis muscle, providing sensory innervation to the lateral volar aspect of the forearm, and may also be damaged during the harvest. Next, a space is created around the incision using blunt dissection and a retractor [4], cannula [32] or appropriate endoscopic instrument is inserted and pushed forward into the subcutaneous tissue just anterior to the fascia overlying the radial artery. Carbon dioxide insufflation has been used by many authors to help improve visualisation of the radial artery and aid the dissection [32,33]. As exposure is gained, the longitudinal fascial incision is continued proximally, with side branches ligated using clips or a Harmonic Scalpel (Ultracision harmonic scalpel; Ethicon Endo-surgery Inc.). This technique has been used to gradually free the radial artery which is usually harvested together with the two satellite veins. Once the conduit is completely dissected, the proximal radial artery is either clipped or ligated with an endoloop suture, and divided with long-curved endoscopic scissors. Although a 2-cm incision in the anticubital space is sometimes used to help in the identification and ligation of the distal radial artery, it is possible to safely deliver the radial artery through only one incision. Some authors have described the use of a tourniquet on the upper arm, which is inflated to 250 mmHg once the radial artery has been identified at the distal (wrist) incision [32]. Once this is done, the arm is wrapped in a sterile bandage to empty it of venous blood, the tourniquet inflated and the bandage removed, with proximal endoscopic dissection continued. The minimally invasive radial artery harvest technique involves making either multiple incisions with tunnelling in between and then using a tissue retractor [28] or harvesting the radial artery through a single incision midway up the forearm through which the radial artery can be harvested both proximally and distally under direct vision [29,30].

Little is known about the learning curve associated with endoscopic radial artery harvesting although some authors have suggested that it takes about 15 cases to become comfortable with the procedure [4]. Others have suggested that 50–75 endoscopic vein harvests and 10–20 open radial artery harvests should be successfully undertaken before attempting endoscopic radial artery harvesting [33]. Conversion rates reported for ERH were very favourable, ranging from 0% to 1.9% as demonstrated in Table 1.

3.4 Does minimally invasive conduit harvesting result in reduced rate of wound infection?
3.4.1 Saphenous vein: MIVH versus CVH (evidence Grade A)
A meta-analysis of 14 randomised controlled trials comparing the incidence of leg wound infection in 801 patients undergoing MIVH as compared to 726 patients undergoing CVH has demonstrated a significantly lower rate of wound infection following the less invasive technique (3% vs 13%), which was also the case when only endoscopic MIVH was considered (3% vs 14%) [2]. The calculated absolute risk reduction of 7.2% means that for MIVH, every 14 patients that undergo the minimally invasive procedure prevent one patient having a leg wound infection. Authors note that in patients with a high risk of wound infection (obese, diabetic and peripheral vascular disease) this number would be smaller. A recently published randomised controlled trial comparing 106 MIVH and 119 CVH patients has also shown a significantly lower leg wound infection rate with minimally invasive surgery (8.5% vs 29.4%) [34].

3.4.2 Radial artery: MIRH versus CRH (evidence Grade C)
The incidence of wound infection following endoscopic radial artery harvest ranges from 0% to 2.7% as demonstrated by three non-comparative observational studies of endoscopic MIRH [35–37]. There is at present only one prospective non-randomised study comparing the incidence of post-operative wound infection in 200 patients following endoscopic MIRH as compared to CRH, showing a significantly reduced incidence of wound infection after the less invasive technique (1% vs 7%) [33].

3.5 Does minimally invasive conduit harvesting result in reduced rate of other non-infective wound healing disturbances?
3.5.1 Saphenous vein: MIVH versus CVH (evidence Grade A)
A meta-analysis of 27 studies including 4953 patients suggests that non-infective wound healing disturbances of haematoma, oedema, skin necrosis, wound dehiscence, drainage and seroma were all significantly reduced with the minimally invasive technique [3]. These findings were re-confirmed when only the 12 randomised studies reporting on these complications were considered. The number of patients needed to treat to prevent one of these complications was only two for leg wound oedema, but was higher at 13 for the other complications. This meta-analysis has also shown a significantly reduced length of hospital stay in the patients undergoing minimally invasive harvest as compared to conventional vein harvest. The factors of reduced wound infection, and other non-infective wound complications such as haematoma, seroma and oedema are all likely to contribute to this earlier discharge from hospital.

3.5.2 Radial artery: MIRH versus CRH (evidence Grade C)
Post-operative haematoma has been reported by five observational [4,29,35–37] and two prospective non-randomised studies [28,33], with a reported incidence ranging from 0% to 6.7%. When just endoscopic MIRH was considered, the highest reported incidence of haematoma was 3.7% [4]. With radial artery harvesting, it is important to note that hand ischaemia has not been noted to occur following ERH, however, this is more likely due to careful patient selection with Allen's testing and Doppler ultrasonography rather than minimally invasive surgery.

3.6 Are post-operative pain, sensory disturbances and mobility affected by the mode of harvest?
3.6.1 Saphenous vein: wound pain following MIVH and CVH (evidence Grade B)
In an attempt to quantify the post-operative pain experienced by patients following MIVH as compared to CVH, several groups have developed scoring systems to grade pain according to its severity (‘light’, ‘moderate’ and ‘severe’) [6,38,39]. The main limitation of these scoring systems is the difficulty in comparing results between studies. The use of a numerical 0–10 pain scale (increasing numerical values correspond to increasing pain) has made results more comparable, with Table 2 showing the results of eight comparative studies reporting on post-operative leg wound pain at discharge and at two or more weeks post-operatively [5,20,21,26,40–43]. Four out of six studies found significantly reduced pain score at discharge following MIVH, whereas none found a difference between MIVH and CVH extending two weeks or more following surgery. This reduction in pain is likely to be an important factor in potential differences in post-operative mobilisation between the two techniques.


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  		Table 2. Studies comparing MIVH and CVH with regard to post-operative pain using a numerical (0–10) scoring system
 
3.6.2 Saphenous vein: sensory disturbance following MIVH and CVH (evidence Grade C)
The incidence of sensory disturbances such as saphenous nerve parasthaesia and neuralgia in the leg three or more months following great saphenous vein harvest was as high as 11% with MIVH as compared to 32% following CVH [26]. In a prospective randomised study of 60 patients (30 EVH and 30 CVH), Bonde et al. [5] found a significantly reduced incidence of saphenous neuralgia (3.3%) following endoscopic as compared to conventional harvest (26.7%). This benefit was maintained at six weeks following surgery when none of the EVH group complained of saphenous neuralgia, whereas 16.7% of CVH patients still had symptoms (p = 0.026).

3.6.3 Saphenous vein: post-operative mobilisation after MIVH and CVH (evidence Grade B)
Several groups have attempted to score mobility in the post-operative period with MIVH as compared to CVH. In a randomised controlled trial of 144 patients, Kiaii et al. [26] used a combination of subjective scoring by the patient and objective scoring by research nursing staff, and found that although the patient's subjective ability to mobilise was significantly greater at discharge with MIVH; this was not matched by the nursing assessment. In addition, there was no significant difference between MIVH and CVH groups in subjective and objective mobility score at six weeks post-operatively [26]. Bonde et al. [5] also used a scoring system to compare the two techniques, finding that MIVH patients mobilised significantly earlier in the first five post-operative days as compared to CVH. Of note, in contrast to these studies, Lutz et al. [39] found that although there was no significant difference in early mobilisation, at one month following surgery 1.3% of MIVH patients had a ‘severe’ mobility disturbance as compared to 18% of CVH patients (p = 0.002). Finally, although authors have used ‘days to ambulation’ as a measure, no significant difference has been identified when considering this outcome in MIVH versus CVH patients [40,44,45].

3.6.4 Radial artery: sensory disturbance following MIRH versus CRH (evidence Grade C)
The incidence of various sensory and neurological complications reported from conventional radial artery harvest has been as high as 30% [46] to 67% [47]. Although it is unclear from the literature which of the two nerves are more commonly affected after open surgery, most neurological deficits and symptoms of paraesthesia are thought to be temporary, self limiting and clinically insignificant [4]. The endoscopic radial artery harvesting technique avoids the lateral antebrachial cutaneous nerve as the operative tunnel lies below the brachioradialis muscle [4], although the superficial radial nerve is still susceptible. The incidence of transient neurological complaints with minimally invasive radial artery harvest range from 2% [28] to 84% [37], although the highest reported incidence of permanent neurological impairment is 7.4% [4]. These figures are comparable to conventional harvest techniques but it has been suggested that the incidence of neurological complications may be minimised by directly visualising the two nerves using ERH as well as staying as close to the radial artery as possible during the dissection, only dividing side branches under direct vision [4]. There is little evidence comparing MIRH and CRH with regard to post-operative pain and mobilisation of the operated arm.

3.7 What is the difference in patient satisfaction with the procedure?
3.7.1 Saphenous vein: MIVH versus CVH (evidence Grade C)
Numerical Likert-type visual scales (0–10) have been used to evaluate and compare patient satisfaction with cosmesis following MIVH as compared to CVH, with results not surprisingly showing a statistically significant patient preference for the procedure with the smaller scar at discharge, although interestingly at six weeks following discharge this difference was no longer significant [26]. In order to assess quality of life following MIVH as compared to CVH, scoring systems such as the ‘Short Form 36’ [21] and ‘Short Form 12’ [48] questionnaires have been employed with no significant difference identified between groups.

3.7.2 Radial artery: MIRH versus CRH (evidence Grade C)
Evidence on quality of life following CRH suggests that patients report positively on their experience, with no association between quality of life and the presence or absence of symptoms related to radial artery harvest, with some patients volunteering a ‘preference’ for the radial artery harvest site as compared to the long saphenous vein [47].

3.8 Comparing minimally invasive and conventional techniques with regard to cost
3.8.1 Saphenous vein: MIVH versus CVH (evidence Grade C)
The operative cost of MIVH is greater than that of CVH due to the equipment required to perform the procedure as well as the increased operative time needed to harvest the conduit. In addition to this, the endoscopic MIVH techniques require more expensive equipments than non-endoscopic ones [6]. The total cost of hospital stay following CABG with endoscopic MIVH in one institution has been quantified at $38,639 as compared to $37,169 following CVH [21]. The cost of re-admission for wound complications (mainly leg wound infection) has also been estimated at $171 per patient [49]. Despite this, the cost of MIVH looks to be higher than CVH.

3.8.2 Radial artery: MIRH versus CRH (evidence Grade C)
Although there is little evidence comparing the overall cost of endoscopic and open radial artery harvest, the former is likely to be significantly greater due to the equipment needed. Factors such as wound infection, pain, and subsequent mobilisation all have the potential to reduce the cost of hospital stay, although this is more the case for minimally invasive saphenous vein harvest where the wounds are greater. Cosmesis and patient satisfaction may end up being the main justification for the increased expenditure of ERH. For techniques where the same equipment used for both endoscopic radial and vein harvest, the equipment cost of harvesting the radial artery is of course not increased [33]. In this case, the same disposable instruments can be used to harvest both arterial and venous conduits.

3.9 Is the quality of the minimally invasively harvested conduit macroscopically comparable?
3.9.1 Saphenous vein: MIVH versus CVH (evidence Grade A)
Surgeon-assessed macroscopic quality of the harvested vein just prior to CABG is an important factor to appreciate, as it is often used to decide whether the conduit is used for grafting or not. A recent meta-analysis of 32 studies has identified vein length, the proportion of veins requiring repair, the number of repairs per vein and macroscopic quality score (‘good’, ‘fair’ or ‘poor’) as important factors when considering the saphenous vein's macroscopic appearance [24]. Although vein length, proportion of veins requiring repair and macroscopic score of vein quality were not found to be significantly different following MIVH as compared to CVH, the number of repairs to the harvested vein was significantly greater following MIVH. This may be due to the increased incidence of traction injury during the minimally invasive procedure, which may be reduced with endoscopic MIVH where the harvest takes place under direct vision.

3.9.2 Radial artery: MIRH versus CRH (evidence Grade C)
The proportion of radial arteries harvested endoscopically that were subsequently used for CABG has been reported to range from 83% to 100% as demonstrated in Table 1. The degree of atheromatous calcification or a diameter of less than 1.8 mm has been suggested as being important in ensuring radial conduit quality, and careful selection of radial arteries prior to harvest using ultrasonography has been advised to reduce the number of unsuitable radial arteries harvested [36]. With regard to thermal injury due to diathermy or harmonic scalpel, there is one report of an endoscopically harvested radial artery that appeared to be mildly damaged macroscopically, but in this case, subsequent sectioning and microscopic examination did not reveal any luminal irregularity [36].

3.10 Is the minimally invasively harvested conduit histologically comparable?
3.10.1 Saphenous vein: MIVH versus CVH (evidence Grade C)
Light and scanning electron microscopy have been used to histologically assess the degree of endothelial damage either documenting the degree of this damage or numerically grading it as shown in Table 3 . Light microscopy was used to compare the histological quality of the venous conduit with MIVH versus CVH in 12 studies, of which 10 used subjective pathologist assessment [5,18,26,50–56], finding no significant difference between veins harvested using the two techniques. The remaining two studies used numerically graded histological assessment [7,57], as demonstrated in the prospective randomised study of 92 patients by Fabricius et al. [57], who compared the morphology of two ‘ring’ segments of vein from three groups: endoscopic MIVH, non-endoscopic MIVH and CVH. The conduits were graded from 1 to 6 according to the degree of endothelial denudation (Grade 1 < 1%, Grade 6 > 90%). Both these studies also did not find any significant difference between the techniques. It is difficult to compare the results of studies reporting this outcome because of the absence of a standardised objective measure of histological quality.


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  		Table 3. Studies reporting histological and functional qualities of the conduit
 
Electron microscopy was used to assess histological quality in four studies [9,10,57,58]. Lancey et al. [58], in a prospective non-randomised study of 156 patients, did not find any significant difference between MIVH and CVH veins in the degree of intimal disruption and thrombus formation. In another prospective non-randomised trial of 90 patients, Alrawi et al. [9] used two rings of tissue from MIVH and CVH conduits to score the degree of endothelial damage seen on scanning and transmission electron microscopy (TEM), from 0 (no damage) to 4 (>50% damage). No significant difference was found between the two techniques. Finally, a prospective randomised study by Lamm et al. [10] compared endothelial integrity scores between endoscopic MIVH and CVH groups undergoing continuous perfusion with autologous blood, compared to storage in a crystalloid solution. Although they did not find a significant difference between endoscopic MIVH and CVH veins, they did find a significantly better endothelial integrity in veins that were kept perfused as compared to those stored in crystalloid solution.

3.11 Do minimally invasively harvested conduits display the same functional characteristics as those conventionally harvested?
3.11.1 Saphenous vein: MIVH versus CVH (evidence Grade C)
Table 3 shows the characteristics of studies reporting on functional characteristics of veins harvested using MIVH and CVH. Two of these studies used cytokine (IL-1, -2 and -10) levels [13,59], and one study used the expression of intercellular and vascular cell adhesion molecules (ICAM-1 and VCAM-1) by the conduit as a measure of inflammation from conduit trauma [5]. None of these identified any significant difference between the two techniques.

Vascular reactivity of the harvested conduit was measured by five studies, measuring contraction on exposure to phenylephyrine, potassium chloride, noradrenaline, 5-hydroxytryptamine and relaxation on exposure to acetylcholine and SNP [18,53,60–62]. Although Cook et al. [62] found significantly impaired acetylcholine-mediated endothelium-dependent relaxation in vein segments isolated using MIVH techniques, as compared to CVH, the remaining studies reported no significant difference in vascular reactivity between MIVH and CVH veins.

Endothelial cell viability was used as a measure of conduit quality in one prospective non-randomised study, with no significant difference identified between the two groups [16]. Finally, in a prospective randomised study of 200 patients, immunocytochemical staining using anti-CD 31 antibodies and anti-nitric oxide synthase antibodies was used to assess endothelial integrity, which was found to be better preserved in MIVH veins [15].

3.12 What is the evidence on long-term survival and angiographic patency of minimally invasively harvested conduits?
3.12.1 MIVH versus CVH (evidence Grade C)
In a prospective non-randomised study of 17 patients undergoing endoscopic MIVH versus 15 patients undergoing CVH, Perrault et al. [63] used quantitative coronary angiography to assess early graft patency at a mean of three months following CABG. They did not find any significant difference in graft stenosis (>50% of internal graft diameter) MIVH versus CVH groups. In a separate prospective randomised study, Allen et al. [64] assessed long-term angiographic patency (over a five-year follow-up period) in 10 selected patients (5 MIVH and 5 CVH). In each group four out of five patients had saphenous vein graft closures, with stenoses of greater than 50% being found in 60% of MIVH and 40% of CVH patients. This sample size was very small, and the difference therefore was not statistically significant. Finally, magnetic resonance angiography and thallium scanning were used by O’Regan et al. [18] to assess graft patency one year following CABG in nine patients undergoing both non-endoscopic MIVH and CVH. Saphenous vein graft patency was identified as 89% using thallium scanning and 92% using MRA, rates that the authors concluded were comparable to CVH grafts.

3.12.2 Radial artery: MIRH versus CRH (no evidence available)
Very little is known about the long-term angiographic patency of the endoscopically harvested radial artery and how this compares to results with open surgery. The advent of CT angiography is likely to increase the amount of angiographic patency data available with time.

3.13 Is there any difference between endoscopically and non-endoscopically harvested minimally invasive conduits?
3.13.1 Endoscopic MIVH versus non-endoscopic MIVH (insufficient evidence available)
Only three of the studies identified in this review compared both endoscopic and non-endoscopic MIVH with CVH [6,57,61]. None of these studies, however, aimed to directly compare endoscopic and non-endoscopic MIVH techniques, and reported on a total population of only 66 and 50 patients, respectively. This combined with the fact that each study focused different outcomes, makes conclusions difficult to draw.

3.13.2 Radial artery: endoscopic versus non-endoscopic MIRH (no evidence available)
There is at present no comparative evidence available reporting on the difference in conduit and wound-related outcomes between the two types of MIRH.


   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
This review article aims to evaluate and clarify outcomes from the previously published literature comparing the harvesting of arterial and venous conduits for CABG using minimally invasive (endoscopic and non-endoscopic) as compared to conventional techniques. It attempts to compare the wounds produced by the conduits not only in terms of infection and wound healing disturbances but also with regard to pain, mobility, patient satisfaction with cosmesis and quality of life. It has also attempted to compare conduits with regard to their macroscopic, histological, functional and patency characteristics. It is important to note that the comparison of endoscopic and non-endoscopic minimally invasive conduit harvesting techniques was not possible, as there are at present very few studies in the published literature that compare the two techniques. This review also does not attempt to debate the use of arterial versus venous and conduits for CABG.

With regard to great saphenous vein harvesting, there is good evidence suggesting that minimally invasive harvest produces a wound that is less likely to suffer infective and non-infective complications. There is reasonable evidence to suggest that leg wound pain and ambulation are better following MIVH as compared to CVH, all of which is likely to contribute to the finding that MIVH reduces the length of hospital stay. There is also reasonable evidence to suggest that in gross (macroscopic) appearance, the MIVH conduit is comparable to those harvested conventionally, although evidence of whether the conduits are histologically and functionally comparable is less clear. Increasing availability of procedures such as intra-operative saphenous vein duplex scanning to map and optimise vein site selection prior to harvest may further reduce morbidity and warrant further evaluation [65]. Finally, the fact that little is known about the long-term patency characteristics of the minimally invasively harvested venous conduit adds caution to findings that otherwise suggest MIVH as a more favourable mode of great saphenous vein harvest.

Although the learning curve for MIVH has been investigated, it is important to note that none of the articles provided a risk-adjusted multidimensional analysis of the learning curve in MIVH surgery based on surgeon and patient-specific outcomes. Particular emphasis should be given to the adjustment of potential confounding factors (patient case mix and procedural risk factors) that may affect the learning curve as well as the surgeon's experience (number and sequence of cases). It is important to appreciate that in some studies, conduits were harvested by technicians, who are often greatly experienced due to the volume of cases they perform, which is likely to result in better operative techniques and may translate into reduced wound-related morbidity and increased cost-effectiveness.

Minimally invasive radial artery harvest is clearly a much younger technique, and has been driven by the development and availability of MIVH equipment. Although the early evidence suggests that this procedure is likely to produce a similar benefit to the wound as MIVH, this review highlights the need for high quality, randomised research comparing MIRH to CRH. In addition to this, the high incidence of neurological complications following radial artery harvest means that this factor is particularly important to consider when considering patient satisfaction with the procedure. Also, with radial artery grafting, vasospasm is an important consideration and so any comparative MIRH and CRH research must standardise the handling of the conduit and the solution it is stored in from the time it is harvested to the time it is grafted.

An important limitation of most studies comparing harvest techniques is that they offer very poor comparison of overall procedural cost, particularly as they do not take account of the added cost of treating wound complications. This is mainly due to the fact that most studies have relatively short lengths of follow-up and are therefore unable to take account of re-admission to hospital and treatments such as oral or intravenous antibiotics. Until these factors are addressed, reducing the cost of minimally invasive conduit harvesting is likely to depend not only on making the actual instruments cheaper but also on making the procedure more cost-effective by opening one minimally invasive or endoscopic instrument kit and using this for both saphenous vein and radial artery harvest on the same occasion.

The evidence thus far suggests that wounds from minimally invasively harvested conduits are less prone to complications, pain, and result in an earlier mobilisation and better cosmetic result as compared to conventional surgery. The evidence on the quality if the minimally invasively harvested conduit, however, is less conclusive, and should therefore be the focus of further high quality, standardised research. Until then, patient preference for the smaller scar produced by minimally invasive surgery as well as the increasing availability of this new technology is likely to further drive its uptake.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

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