When a patient needs a coronary artery bypass graft (CABG) to reroute his or her blood supply, surgeons typically harvest a section of that patient’s saphenous vein or radial artery. This has traditionally been accomplished through an “open” procedure involving a longitudinal incision, which can run as far as from the groin to the ankle. Endoscopic vein-grafting offers a minimally invasive alternative, requiring just one 2-3 cm incision or two even smaller cuts. However, in 2009 a study in the New England Journal of Medicine called into question the long-term viability of these endoscopically-harvested grafts. Our readers may recall the controversy and its coverage in Medgadget.
This month, however, some of the original researchers published a follow-up study in the Journal of the American Medical Association that concluded that “the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.” This is a victory for practitioners of endoscopic vessel harvesting (EVH) and companies that make equipment for the procedure, such as Maquet. In order to understand what the implications of the JAMA study are, we spoke to James Keuler (PA-C) of Milwaukee’s Aurora Medical Group, which has been performing EVH for the past 15 years. Keuler has been practicing for 29 years and also serves as President of Intervasc LLC., a medical consulting group in Wisconsin.
Shiv Gaglani, Medgadget: What do you see as the primary advantages and disadvantages of endoscopic vein grafting as opposed to open vein grafting?
James Keuler: Our group out of Wisconsin was actually one of the first groups to start endoscopic vein harvesting (EVH) back in 1997. At that time, I saw a huge difference between EVH and open vein harvesting (OVH), more from the standpoint of patient outcomes and patient satisfaction. I always like to describe it as – the open technique impacts the patient as if they had had a surgical procedure done on their legs as well as on their chest because they felt the surgery so much and experienced so many problems following the procedure. What EVH demonstrated at the beginning was that the patient felt as if there had been no surgery done whatsoever on their legs; the patients didn’t even know they had had any procedure done on their legs.
There were always some questions from the early days around whether the quality was as good with EVH, and that’s something that we always worked to demonstrate here in Milwaukee. Because we helped pioneer the original technique, when papers came out questioning EVH, we always worked at analyzing what exactly it is we’re doing to prove that we’re trying to improve outcomes with EVH.
Also here in Milwaukee, we offer an advanced course that meets once a week, where we look at EVH therapy from a higher level to research and learn new techniques. We’ve come up with a new way to perform EVH that we’re hoping will be better than OVH – we call it a “gentle technique” where there’s almost no touch during the removal of the vein.
Medgadget: Following the Lopes et. al., paper in NEJM in 2009, did you see a drop in endoscopic vein grafting? Was there pressure to stop using the procedure?
Keuler: Locally here in Milwaukee we didn’t abandon the technique or reduce usage – however, we did examine the technique very carefully following the 2009 NEJM publication. The paper raised a lot of questions, but it was a good time for us to take a look at what we were doing and analyze whether we were doing a good job. From those who were attending the advanced course that we offer, about 15 percent of them reverted back to OVH following that article, so there was some impact.
Medgadget: What do you find most interesting about the present study in JAMA? How will this change the field, if at all?
Keuler: I think it was very interesting that these JAMA findings came from the same group as the one that published the 2009 data in NEJM – and I think that was a good thing. I think it validated the findings even more because it showed that the same group looked at both techniques again more scientifically and came to the conclusion that there was, in fact, no difference between EVH and OVH. My group here in Milwaukee certainly felt that, from our background and experience, what this new JAMA study showed should have been the finding. This finally puts to rest any questions or doubts that a surgeon or harvester may have whether EVH is better than OVH.
For additional information here is a video demonstrating EVH: