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December 28, 2021
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In a study published in 2019, VA researchers found that a form of vein removal used in heart bypass surgery, called endoscopic vein harvesting, is as safe as open vein harvesting when it’s performed by surgeons who are expert in vein removal. Their work has influenced current clinical guidelines concerning bypass procedures.
Vein harvesting is a surgical technique often used in conjunction with heart bypass surgery. To improve blood flow and oxygen to the heart, patients with coronary artery disease may be offered a bypass to reroute blood around blocked arteries and improve blood flow and oxygen to the heart.
To create the bypass graft, surgeons remove or “harvest” healthy blood vessels from another part of the body, often the leg or the arm. This vessel becomes a graft, with one end attaching to a blood source above and the other end below the blocked area, creating a new blood flow connection.
Both endoscopic and open vein harvesting call for removal of the greater saphenous vein in the leg for use in coronary artery bypass grafting, the most common type of open-heart surgery. Endoscopic vein removal requires only a small incision at the knee to insert a lighted, flexible instrument called an endoscope before the saphenous vein is removed. In open vein removal, surgeons make either a long incision or many small ones to remove the vein.
Endoscopic vein removal requires greater skill, and is much more complex than the open vein approach. However, it’s used in more than 90% of cases because it reduces the rate of leg infections after surgery. Open vein removal increases the risk of infection, and can cause pain, numbness, bleeding, and other complications.
Much depends on skill, experience levels of surgeons
Clinicians have been concerned about the safety of endoscopic vein removal, according to Dr. Marco Zenati, chief of thoracic and cardiovascular surgery at the VA Boston Healthcare System. Dr. Zenati led VA’s study, called the REGROUP trial. The trial’s difference from previous studies of this kind is that only operations done by surgeons known as expert vein harvesters were included. Those harvesters, essentially heart surgeons, had completed at least 100 cases of endoscopic vein removal and used open harvesting less than 5% of the time over the previous two years.
The trial looked at surgeries involving 1,100 patients, and found no major differences in the ability of the two leg vein removal techniques to prevent cardiac events. The combined rate of deaths from all causes, heart attacks, and the need to repeat the procedure was 14% for endoscopic removal and 16% for open removal over nearly three years. The report challenges the conclusions of a previous large study, published in 2009 by non-VA researchers, which questioned the safety of endoscopic vein removal.
“My conclusion is that endoscopic is the way to go when it’s in the hands of experienced medical personnel,” Zenati said. “Endoscopic vein removal has a steep learning curve, and inexperienced harvesters may damage the conduit, leading to early graft failure and heart problems. If the harvester is inexperienced, open harvesting is likely to be preferred.” In 2021, the American College of Cardiology and the American Heart Association published guidelines for surgeons that agreed with Dr. Zenati’s statement.
Principal investigator: Dr. Marco Zenati, VA Boston Healthcare System
Selected publications:
Randomized trial of endoscopic or open vein-graft harvesting for coronary-artery bypass. Zenati MA, Bhatt DL, Bakaeen FG, Stock EM, Biswas K, Gaziano JM, Kelly RF et al. N Engl J Med. 2019 Jan 10;380(2):132-141.
Endoscopic versus open vein-graft harvesting in coronary-artery bypass surgery. Lopes RD, Hafley GE, Allen KB, Ferguson TB, Peterson ED, Harrington RA, Mehta RH et al. N Engl J Med. 2009 Jul 16;361(3):235-44.
Trial confirms safety of vein-removal technique used in open-heart surgery. VA Research Currents, Nov. 28, 2018
