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45 Executive Briefing: Endoscopic Vessel Harvesting Sponsored by: E ndoscopic vessel harvesting (EVH) is a minimally invasive procedure performed right before coronary artery bypass grafting, or bypass surgery. A physicians' assistant (PA) typically performs the procedure, taking healthy blood vessels from other parts of the body and using them to bypass a block- age to the arteries of the heart. In many operating rooms, the PAs efficiently and safely per- form endoscopic vessel harvesting in preparation for the by- pass surgery. "It doesn't matter if the surgeon or the PA is performing the endoscopic vessel harvesting, as long as they've been trained to do the procedure and perform it on a regular basis," says Saurabh Ashier, a physicians assistant based in Los Angeles. "It takes skill and there is a learning curve. But after the PAs are comfortable with it, they can safely perform the procedure." Vessel harvesting was traditionally performed with an open technique. The conventional open vein harvesting technique requires a long incision from the groin to the ankle. The patient often experiences pain and the wound is prone to healing com- plications. "The open technique covers a large area with a big incision for harvesting," says Mr. Ashier. "The endoscopic technique is done with a one-inch incision. This is aesthetically pleasing to the pa- tient, but the biggest advantage for the patient is the reduced pain. The healing is faster with the endoscopic procedure." The endoscopic technique is becoming increasingly popular. It was developed in 1995 and utilization accelerated in 2005 when the International Society for Minimally Invasive Cardiotho- racic Surgery (ISMICS) concluded it was the standard of care. This less invasive technique requires a single, small incision across the leg or forearm, as opposed to a large open incision. There are several key advantages for the endoscopic technique: 1. Patients undergoing EVH report less leg pain and scarring after the procedure than after open vessel harvesting. 1 2. The endoscopic vessel harvesting procedure significantly reduces wound complications and infection. 2 3. The patients who undergo the endoscopic procedure have a shorter length of stay on average than after the open procedure. 3 4. EVH is associated with lower hospital readmission rates 4 and fewer outpatient office visits. 5 5. Endoscopic vessel harvesting has not been shown to compromise long-term patient outcomes or safety. 6 "The patients are able to recover more quickly from endoscopic vessel harvesting, and they like that better," says Mr. Ashier. "The shorter length of stay coupled with the reduced complication and infection risk, adds a cost-benefit to endoscopic vessel har- vesting over the open technique." In European Journal of Vascular & Endovascular Surgery an ar- ticle titled "A Systematic Review of Cost-effectiveness Evidence of Endoscopic Saphenous Vein Harvesting: Is it Efficient?" found evidence suggesting lower costs for endoscopic harvesting. Physicians and PAs at almost all hospitals across the United States perform endoscopic vessel harvesting; around 76 per- cent of the coronary artery bypass grafting surgery cases used endoscopic vessel harvesting in the United States in 2008. Since 1996 the procedure has been performed more than 2 million times worldwide with Maquet Medical Systems' VASOVIEW En- doscopic Vessel Harvesting System. "We've been able to improve the technology so much that do- ing anything else deviates from the standard of care," says Mr. Ashier. "In most places, endoscopic vessel harvesting is be- coming the standard of care. However, there are a few patients where this isn't the ideal situation. EVH may not be the best procedure for patients with very small vessels, particularly if the harvester is not very experienced." Obese patients and patients at greater risk for developing leg wound complications are ideal candidates for endoscopic ves- sel harvesting. High-risk patients are undergoing bypass sur- gery at a higher rate today than in the past. 7 "There have been some articles trying to sway providers to perform the procedure one way or another based on the fact Endoscopic Vessel Harvesting: Key Thoughts on Benefits for Patients By Laura Dyrda