DISCUSSION
This prospective randomized clinical trial shows that in experienced
centre endoscopically harvested RA is safe and provides excellent early
and mid-term clinical and angiographic outcomes bearing some advantages
over the open harvest technique.
The aim of less invasive techniques is to minimize the trauma inflicted
upon the patient without compromising the quality of work and the
clinical outcome. Open RA harvest is a straightforward procedure that
can be readily taught to an average surgeon (12). On the other hand,
endoscopic RAH technique requires different set of skills, time
consuming training and perseverance and is linked with a significant
learning curve (22, 23).
In our unit, the program of endoscopic vein harvest (EVH) was started
first in 2010 and after accumulation of large experience in EVH we
proceeded to ERAH. A senior surgeon and a surgical assistant were
involved in both programs from their outset acquiring in-depth knowledge
and expertise, which they now pass to younger colleagues. As already
mentioned, all ERAH procedures in the study were carried out by the same
surgical assistant.
In this study, wrist skin incision was 2.4cm in ERAH compared to 24.8 in
ORAH, yet the harvest time and the length of the RA graft were similar.
Published data on time harvest for ERAH vs ORAH differs widely. In
accordance with our findings (harvest time 31 vs 28min for ERAH and
ORAH, p=ns), Patel et al reported in their case series similar harvest
time for both groups (26 vs 22min) (15). On the other hand, Fouly in a
retrospectively analyzed cohort of consecutive patients (16) and Kiaii
et al in their prospectively randomized study (24) described
significantly shorter harvest time for ERAH (40 vs 49min,
p<0.001) and ORAH (36.5 vs 57.5min, p<0.001)
respectively. Nonetheless, it should be noted that the ORAH times
reported by Fouly (16) and Kiaii (24) (49min and 57min respectively)
were much longer than those reported for ORAH by us and by Patel et al
(15). In contrast, Rahouma et al in their meta-analysis found a longer
harvest time after ERAH with a steep learning curve in inexperienced
hands (22). Wound healing after ERAH was smooth and uncomplicated in all
patients in this study echoing previously published work, which
uniformly describes superior wound healing after ERAH, the obvious
explanation for this being the shorter skin incision and the smaller
dissection planes that are required compared to ORAH (15,16,22,24,25).
We recorded significantly less neuralgias after endoscopic harvest of RA
in the early postoperative period, which could be attributed to smaller
incision resulting in less cutaneous nerves being damaged, and the
efforts made by the experienced surgical assistant to apply a RA
“non-touch” harvest technique. Our findings are in agreement with
those previously reported in prospectively randomized (24), propensity
score matched (25) and case series (15) studies that reported fewer
neurological complications after ERAH. On the contrary, in his
retrospective study Fouly (16) recorded more cases of superficial radial
nerve injury and hand numbness after ERAH vs ORAH (20% vs 5.2%,
P=0.05) and ascribed this to his limited experience in endoscopically
harvesting the RA.
Our data show that, performed in experienced center by expert operator,
ERAH leads to better patient satisfaction than ORAH, which can be
credited to smooth wound healing, lack of neurovascular complications
and the excellent cosmetic result afforded by the endoscopic harvest
technique (24).
The overall RA patency rate of 90% at 1-year angiographic follow up
(without intergroup differences) in this study is comparable to previous
reports addressing this topic (26-28). Although we examined a possible
effect of several preoperative, intraoperative and postoperative
parameters on RA graft patency, native coronary artery stenosis of
< 90% emerged as the only significant factor adversely
affecting RA graft patency (p<0.00001). This finding is in
line with the results of the large angiographic study by Tatoulis et al
who demonstrated that aorto-coronary RA graft patency is significantly
improved when anastomosed to a coronary artery with a luminal narrowing
of at least 80% (28).