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).