Endoskopische Venenentnahme der V. saphena in der koronaren Bypasschirurgie - Aktuelle Datenlage - Dr. med. Stefanie Reutter

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1 Endoskopische Venenentnahme der V. saphena in der koronaren Bypasschirurgie - Aktuelle Datenlage - Dr. med. Stefanie Reutter

2 Endoskopische Venenentnahme (EVH) - Einführung 1979 Tevaearai und Kollegen haben als erstes die MIVH Technik bei 30 Patienten durchgeführt unter Verwendung des MiniHarvest System (US Surgical Corporation, Norwalk, Conn) 1996 Lumsden und Kollegen haben als erstes die EVH bei 30 Patienten durchgeführt und beschrieben (Georgia, USA) 1.Tevaearai HT et al. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg. 1997;63(6): Lumsden AB et al. Subcutaneous, veideo-assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg. 1996; 4(6): 771-6

3 EVH Einsatz und Verbreitung in den USA 1 90% 92% 93% 0,8 0,6 65% 70% 76% 55% 82% 62% 71% 73% 76% 46% 0,4 0,2 0 2% 7% 15% 20% 28% 36% * E USER ADOPTION (% of hospitals using EVH) PENETRATION (% of CABG cases using EVH)

4 EVH in den USA und Europa

5 EVH Vorteile vs. OVH Geringeres chirurgisches Trauma Inzisionslänge, Blutverlust, Schmerzen, postoperative Immunfunktion schnellere Rekonvaleszenz geringere postop. Wundheilungsstörungen befriedigenderes kosmetisches Ergebnis (Kostenreduktion) Patientenzufriedenheit

6 EVH vs. OVH Kosmetisches Resultat offen endoskopisch

7 EVH vs. OVH Wundheilung 2-25%

8 EVH Patientenauswahl Keine Adipositas permagna Keine extrem oberflächliche Vena saphena Keine Seitenastvarikosis Keine Gerinnungsauffälligkeiten Keine Notfälle Nur selektiertes Patientengut

9 EVH Nachteile vs. OVH Bypass-Versagen Fehlende Langzeitergebnisse Längere Operationszeiten Kostenerhöhung

10 EVH vs. OVH aktuelle Datenlage Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Meta-Analysis of Randomized Trials and Controlled Trials Innovations 2005 Objective: EVH improves clinical and resource outcomes compared with OVH in adults undergoing CABG Methods: Comprehensive literature search (Medline, Embase ) to identify all randomized and nonrandomized trials of EVH vs. OVH up to April 2005 Primary outcome: wound complications Secondary outrcomes: any other clinical morbidity and resource utilization Results: 36 trials of patients 13 randomized (1.319 patients) 23 nonrandomized (8.313 patients) 3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery Innovations. 2005; 1:51-60.

11 EVH vs. OVH aktuelle Datenlage Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Meta-Analysis of Randomized Trials and Controlled Trials Innovations 2005 Results: Risk of wound complications Risk of wound infections Need for surgical wound intervention significantly reduced by EVH vs. OVH Incidence of pain, neurolgia, patient satisfaction improved with EVH vs. OVH Postop. MI, stroke, reintervention, AP quality of graft not significantly different betw. EVH vs. OVH Operative time significantly increased by EVH 3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery Innovations. 2005; 1:51-60.

12 EVH vs. OVH aktuelle Datenlage 2005 The International Society for Minimally Invasive Cardiac Surgery (ISMICS) Consensus Conference suggest: Innovations 2005 EVH is recommended to reduce wound related complications, improve patient satisfaction, and decrease postop. pain, hospital LOS, and outpatient wound management resources when compared to OVH (Class I; Level A) Based on quality of conduit harvested, either EVH or OVH technique may be used (Class IIa; Level B) Based on major adverse cardiac events and angiographic patency at 6 months, either EVH or OVH technique may be used (Class IIa; Level A) Conclusion: EVH should be considered the standard of care for patients who require saphenous vein grafts for coronary bypass surgery 3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery Innovations. 2005; 1:51-60.

13 EVH vs. OVH aktuelle Datenlage Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery N Engl J Med 2009 Objective: Effect of EVH on vein-graft failure as assessed by angiography 12 to 18 months and on long-term clinical outcomes Methods: patients undergoing CABG (1.753 EVH; 1247 OVH); randomized, 107 centers Primary outcome: vein-graft failure (defined as >75% stenosis of graft on angio.) Clinical outcomes: death, MI, repeat revascularization (3 year follow-up period) Results: EVH significantly higher rates of vein-graft failure at 12 to 18 months than OVH (46.7% vs. 38.0%, P<0.001) EVH associated with higher rates of death, MI, or repeat revascularization after 3 y (20.2% vs. 17.4%, P=0.04) A 4. Lopes RD, Hafley GE, Allen KB et al. Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery: N Engl J Med. 2009; 361(3):

14 EVH vs. OVH aktuelle Datenlage Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting Objective: Assess the effect of EVH on short-term and midterm outcomes after CABG Ann Thorac Surg 2010 Methods: at a single center (Canada); data prospectively collected patients undergoing first time isolated CABG and combined valve/cabg (34.4%) patients EVH; (65.6%) patients OVH (continuous/bridging) Short-term outcomes: Midterm outcomes: leg infections, in-hospital mortality, all-cause mortality, readmission to hospital for cardiac catheterization, repeat revascularization, unstable angina, MI, heart failure median follow-up 2.6 years 5. Ouzounian M et al. Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting: Ann Thorac Surg. 2010; 89(2): A

15 EVH vs. OVH aktuelle Datenlage Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting Ann Thorac Surg 2010 Results: EVH associated with reduced rates of leg infection (1.1% vs. 2.2%, p=0.003) EVH similar rates of in-hospital mortality compared with OVH (3.2% vs. 4.0%, p=0.16) EVH no association with midterm adverse outcomes (hazard ratio 0.93, p=0.22) EVH and OVH similar freedom from death or readmission to hospital for cardiac cause EVH associated with reduced rate of readmission to hospital for unstable angina (hazard ratio 0.74), but not for MI Conclusion: EVH is not an independent predictor of in-hospital or midterm adverse outcomes 5. Ouzounian M et al. Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting: Ann Thorac Surg. 2010; 89(2): 403-8

16 A EVH vs. OVH aktuelle Datenlage Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting Objective: Explore use of EVH and influence on perioperative and long-term outcomes Circulation 2011 Methods: at a 8 centers (north. New Engl.); data prospectively collected patients undergoing first time isolated CABG (excluded: <30y, emergency surgery, life-threatening malignancy, TAR, radial artery) (52.5%) patients EVH; (47.5%) patients OVH (continuous incision) Short-term outcomes: Long-term outcomes: in-hospital morbidity and mortality mortality and repeat revascularization (CABG or PCI) follow-up 4 years 6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2):

17 EVH vs. OVH aktuelle Datenlage Results: Long-term outcome: Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting Circulation 2011 mortality Figure 1. Adjusted risk of mortality by vein harvesting approach (2001 to 2004). The HR is for EVH relative to OVH related to mortality. Adjusted for age, sex, EF, vascular disease, DM, BMI 6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2):

18 EVH vs. OVH aktuelle Datenlage Results: Long-term outcome: Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting Circulation 2011 repeat revascularization Figure 2. Adjusted risk of repeat revasculariztaion by vein harvesting approach (2001 to 2004). The HR is for EVH relative to OVH related to risk of repeat revascularization. Adjusted for age, sex, EF, vascular disease, DM, BMI, 6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2):

19 EVH vs. OVH aktuelle Datenlage Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting Circulation 2011 Results: In-Hospital outcomes: Use of OVH associated with an increased postop. leg wound infection (P<0.001) EVH associated with an increase in return to operating room for bleeding (P=0.03) Long-Term outcomes: EVH significantly associated with a reduced risk of mortality EVH associated with an insignificant increased risk of repeat revascularization Conclusion: EVH is a safe and viable technique for obtaining saphenous vein conduit for CABG Additional studies are warranted to improve understanding of mechanism by which EVH influences long-term outcomes, as well as how clinical teams can maximize the utility of this technique 6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2):

20 EVH - Schlussfolgerung Sicheres und praktikables Verfahren Datenlage zeigt durchweg geringere Wundkomplikationsraten Sehr gutes kosmetisches Ergebnis erhöhte Patientenzufriedenheit Prospektiv-randomisierte Studien Langzeitergebnisse nach EVH (EVH vs. MIVH) Kostenanalyse