1. Endoscopic Vein harvesting: Is there a learning curve effect on patient outcomes?
Joseph Zacharias & Bilal Kirmani
Lancashire Cardiac Centre
Blackpool
England

2. Lancashire Cardiac Centre
2008: 950 cardiac cases Thoracic cases
2009: 1035 cardiac cases thoracic cases
2010: 1200 cardiac cases thoracic cases

3. Background
Endoscopic Vein harvesting has been developed over the past decade mainly in the US.
The short term benefits on leg wounds are impossible to deny
A recent sub group analysis of a randomised trial cast doubt on 2 year clinical outcomes.
In the UK with a high level of public scrutiny there is a concern in adoption of new technology due to its potential learning curve impact.

4. Methods Design Inclusion Criteria: Exclusion Criteria:
Review of prospectively collected data.
Consecutive first time CABG
Retrospective patient cohorts
Inclusion Criteria:
Two or more vessel disease
Operated on by a single surgeon
Exclusion Criteria:
Previous Cardiac surgery
Concomitant Valve surgery
Radial artery use
Routine use of aprotinin

5. Methods Primary outcome measures: Secondary outcome measures:
Mortality (Civil registry)
Secondary outcome measures:
Major Adverse coronary events (clinical MI, ACS, need for revascularisation)
Cardiac related readmissions
Freedom from angina, dyspnoea
New anti-anginals,
Wound pain,
Self reported health status

6. Technique CABG (EVH): Open vein Harvesting:
3 cases done off pump (no touch)
114 cases done on pump
Two stage Venous cannulation
Straight aortic cannulation
Centrifugal pump on bypass
Single cross clamp technique
Intermittent cold blood antegrade cardioplegia.
Open vein Harvesting:
Harvest by Surgical Care Practitioners or Registrars
CABG: Same technique as above.
5% Off Pump (no touch)

7. EVH technique EVH: Vasoview 6,7,Haemopro systems (Maquet Inc.)
Carbon dioxide insufflation (pressure controlled to <10mmHg)
2,500iu heparin prior to insufflation
Bipolar diathermy until Haemopro
Titanium clips to side branches

9. Patients undergoing CABG under JZ (n: 495)
Routine Aprotinin (n = 148)
Radial artery Conduit = (48)
Eligible = 299
EVH (n = 117)
OVH (n = 182)
Lost to follow up ( n = 21)
Lost to follow up ( n = 77)
Primary Endpoint analysis (n = 116)
Secondary Endpoint analysis (n =95)
Primary Endpoint analysis (n = 180)
Secondary Endpoint analysis (n = 103)

10. OVH (n=182) EVH (n=117) mean Age 67.5 66.5 No of grafts 3.5 3.2
EuroSCORE
3.4
3.3
Trainee Cases
42%
64%
Cross clamp Time 64 65
Bypass Time 81 84
CVA 1
In Hospital Deaths
2 (1.09%)
1 (0.85%)

11. Results: Leg Wound OVH EVH Leg wound problems 29 (28%) 5 (5%)
Leg wound pain
Mean +/- SD
1.0 +/- 2.3
1.3 +/- 1.4
Sternal wound pain
0.8 +/- 0.9
1.6 +/- 1.3

13. Major adverse Clinical events
Need for new anti-anginals
OVH: 13 (12%)
EVH : 9 (9%)
Further cardiac related admissions
OVH: 9 (9%)
EVH: 5 (5%)

14. Results: Quality of Life: Dyspnoea
NYHA class
OVH
(n=105)
EVH
(n=101)
Preop
1.9 +/- 0.8
2.1 +/- 0.8
Post op
0.5 +/- 0.9
0.8 +/- 0.9

15. Quality of Life : Angina
CCS status
OVH (105)
EVH (95)
Pre-op
2.1 +/- 1.1
2.2 +/- 1.0
Post-op
0.2 +/- 0.6
0.2 +/- 0.7

16. Self rated health status
Relative health:
Very Good or Excellent: % in OVH
61% in EVH
Much Better : % in OVH
90% in EVH

17. Results: Survival

18. Learning curve: Time Ann R Coll Surg Engl 2009; 91: 426–429
A prospective audit of endoscopic vein harvesting for coronary artery bypass surgery
ZAKARIYA WAQAR-UDDIN, MANOJ PUROHIT, NADENE BLAKEMAN, JOSEPH ZACHARIAS
Ann R Coll Surg Engl 2009; 91: 426–429

19. Learning curve: Conversion
Initial audit 25 patients
Conversion rate of 3 (12%)
Reasons:
Unable to find vein : 2
Poor caliber vein harvested: 1
In 117 patients:
Conversion rate < 8%
Poor vein caliber: >80%
Poor vein quality: <10%

20. Conclusion Our review suggests:
Endoscopic vein harvest can be introduced into every day practice without an obvious impact on patient outcomes
Despite the limitations of the size of the study at a median of 20 months we found,at least equivalent, survival and freedom from angina in patients at the start of our program.