When surgeons need veins to replace clogged vessels in the heart, they often use a minimally invasive technique to remove veins from the patient's legs. But a new study suggests that so-called "keyhole surgery" may lead to a worse outcome for bypass surgery patients.
Three years after surgery, patients whose surgeons harvested leg veins using keyhole, or endoscopic, techniques had a higher risk of heart attacks, repeat surgeries and death than patients who underwent traditional "open" surgery to remove leg veins, according to a study by Dr. John Alexander of Duke University, published in the July 16 issue of the New England Journal of Medicine.
Alexander said his results suggest that open harvesting may be the best procedure for removing veins because the process is less damaging to the veins.
"If you've ever seen one of these [endoscopic] procedures, there's clearly more tugging on the vein and more rough handling of the vein when it's harvested," Alexander said.
The National Center for Health Statistics estimates that in 2006, 448,000 coronary artery bypass procedures were performed on 253,000 patients in the United States, and endoscopic harvesting of vein has become the standard technique.
The analysis took a look at 1,753 bypass patients who had endoscopic harvesting and 1,247 who had graft harvesting under direct vision. A year to a year and a half after surgery, the rate of vein-graft failure resulting in repeat surgery, heart attack, or death was 47 percent among the patients who received endoscopically harvested veins versus only 38 percent in the open surgery group.
In recent years, minimally invasive methods have largely become the standard of care because of advantages such as less pain, shorter hospital stays and substantially smaller scars.
However, the studies that formed the basis for the popularity of minimally invasive vein harvesting had short-term follow-up and other problems that led to little knowledge of long-term effects.
This may explain the difference in findings, as the separation in outcomes in Alexander's analysis did not become apparent until almost one year after these patients underwent bypass surgery.
Still, Alexander cautioned against a dramatic shift in practice back to open harvesting, stressing instead the need to discuss these potential long-term risks with patients.
Likewise, Dr. Timothy Gardner, president of the American Heart Association and a heart surgeon, wasn't ready to abandon endoscopic methods on the basis of this one study, though he agreed that more care is warranted.
"I'm sure that surgeons that use this technique will be much more careful, will take extra steps to avoid trauma to the vein while it's being harvested, and will probably be more inclined to add an extra incision if they find themselves in a situation where it's hard to get the vein out," he said.
The focus should be on ways to improve endoscopic vein harvesting techniques "to reduce the trauma associated with it and allow patients to get both the short-term benefits and avoid the long-term risks," Alexander said.
Additonal studies with long-term follow-up are now needed to settle the issue, Alexander's group explained.