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Endoscopic vein harvesting (EVH) is a minimally invasive technique used to retrieve the greater saphenous vein (GSV) for use as a conduit in coronary artery bypass grafting and other vascular surgeries. EVH provides significant advantages over traditional open harvesting methods, including reduced postoperative pain, shorter recovery times, and fewer wound complications. The procedure utilizes an endoscope and carbon dioxide insufflation to create a subcutaneous tunnel, allowing for precise vein dissection while minimizing trauma to the vein and surrounding tissues. This technique is associated with lower infection rates, hematoma, and seroma, making it the preferred method for GSV harvesting in many centers. Clinicians participating in this course gain an in-depth understanding of the EVH technique, including the necessary skills, equipment, and surgical strategy for successful vein harvesting. They also learn about the potential complications, such as vessel injury and nerve damage, and how to manage these issues to optimize graft patency and minimize patient discomfort. This course emphasizes the importance of interprofessional collaboration, highlighting the roles of surgeons, nurses, anesthesiologists, and other healthcare professionals in improving patient outcomes and safety during EVH. Additionally, participants explore best practices for training and developing expertise in EVH. Objectives: Identify appropriate patients for endoscopic vein harvesting based on clinical indications and vein quality assessments. Apply saphenous vein anatomy and physiology knowledge to enhance procedural success and minimize vascular injury. Implement safe and effective endoscopic vein harvesting techniques to minimize patient morbidity and optimize conduit quality. Collaborate with nursing staff, radiologists, and other specialists within the interprofessional healthcare team to ensure comprehensive care and optimal patient outcomes during the endoscopic vein harvesting procedure. Access free multiple choice questions on this topic.

Over the last decade, endoscopic vein harvesting (EVH) has been the method of choice to harvest the greater saphenous vein (GSV), which is the most widely used conduit in coronary artery bypass graft (CABG) surgery. The saphenous veins are often used for their ease of harvesting and length. The global demand for CABG surgery and the increasing need for patients to require multiple coronary artery bypasses in the same procedure have increased the demand for more and better conduits.[1] In the past, the conventional open technique of GSV harvesting involved a long skin incision, which often carries a higher incidence of wound complications and pain. This is often coupled with increased length of hospital stay and decreased patient satisfaction. The EVH technique has evolved and developed to improve the above-mentioned drawbacks of the open procedure.[2] Results from a recent review of approximately 28,000 patients from 22 studies found that the mid- and long-term patency of vein conduits harvested using the endoscopic technique was lower than that of the open technique. However, this study was limited to 1 year. The researchers concluded that growing surgical experience in the EVH might be associated with better outcomes.[3] Although the long-term patency of harvested conduits by EVH has been questioned, many studies show that the patency of vein grafts harvested by the EVH technique is similar to that reported using the conventional method.[4]

EVH is a minimally invasive technique that significantly reduces complications compared to traditional open harvesting methods. EVH is associated with a markedly lower incidence of leg wound infections, hematomas, seromas, and wound dehiscence, leading to faster recovery and improved patient outcomes. Wound infection remains the most common complication, although its occurrence is significantly lower than in conventional open techniques.[13] Most cases of hematoma, dehiscence, and infection can be managed conservatively, though surgical intervention may be required in severe cases.[14][15] Saphenous nerve injury is another important consideration in EVH. This can result in postoperative pain, paresthesias, or hyperalgesia along the medial aspect of the lower limb, particularly above the harvest site. While these symptoms are often temporary, they can lead to more postoperative leg pain than sternal discomfort in some patients. Careful surgical technique is necessary to avoid mechanical trauma or heat-related nerve damage, especially in the lower leg, where the saphenous nerve is near the GSV.[16] Another potential complication arises from using carbon dioxide insufflation to maintain tunnel patency. This technique can lead to pneumoperitoneum, subcutaneous extravasation, or air embolism. In such cases, the primary treatment involves halting insufflation and providing hemodynamic support until the carbon dioxide is absorbed.[17] While EVH has largely addressed many complications of open vein harvesting, initial concerns about its impact on vein graft integrity and long-term patency were raised. Early observational studies, including a posthoc analysis of the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial, provided results suggesting higher rates of midterm graft failure, myocardial infarction, repeat revascularization, and mortality with EVH.[18] Similarly, results from a meta-analysis of 22 observational and randomized studies indicated that EVH may have lower midterm and long-term graft patency than open harvesting.[19]

While EVH has largely addressed many complications of open vein harvesting, initial concerns about its impact on vein graft integrity and long-term patency were raised. Early observational studies, including a posthoc analysis of the Project of Ex-vivo Vein Graft Engineering via Transfection IV (PREVENT IV) trial, provided results suggesting higher rates of midterm graft failure, myocardial infarction, repeat revascularization, and mortality with EVH.[18] Similarly, results from a meta-analysis of 22 observational and randomized studies indicated that EVH may have lower midterm and long-term graft patency than open harvesting.[19] However, more recent randomized controlled trials have shown no significant differences in long-term clinical outcomes between EVH and traditional techniques, aside from the clear benefits of reduced leg wound complications and postoperative pain. With a 4.7-year follow-up, the REGROUP trial confirmed that EVH provides comparable long-term clinical outcomes to the open approach.[20][21] Additionally, results from a retrospective analysis of the REGROUP trial found no significant difference in the overall costs of CABG surgeries and follow-up care between EVH and open vein harvesting.[22][23] Consequently, EVH has become the standard approach for saphenous vein harvesting in the United States.[2]

Successful endoscopic vein harvesting (EVH) requires a multidisciplinary approach, where advanced clinicians, nurses, pharmacists, and other healthcare professionals work together to optimize patient outcomes and safety. Surgeons and advanced clinicians must have technical proficiency in EVH, ensuring precise dissection, minimal trauma, and preservation of vein integrity to maximize graft patency. Anesthesia teams are critical in maintaining hemodynamic stability, managing patient positioning, and minimizing complications such as carbon dioxide embolism. Nurses and surgical technologists are essential in preparing equipment, assisting intraoperatively, and monitoring patients postoperatively for wound complications, hematomas, or neuropathic pain. Effective interprofessional communication and care coordination are vital to reducing errors and improving outcomes. Preoperative collaboration with radiologists ensures accurate venous mapping, identifying the best conduit for harvest and avoiding unnecessary complications. Pharmacists contribute by ensuring appropriate anticoagulation protocols and managing postoperative pain and infection prophylaxis. Postoperatively, coordinated follow-up with vascular teams, physical therapists, and wound care specialists enhances patient recovery, mobility, and long-term graft viability. Regular team briefings, structured training, and standardized protocols help improve efficiency, patient safety, and overall team performance, leading to better surgical outcomes and patient satisfaction in EVH.