DOI: 10.1111/jocs.

14153

REVIEW ARTICLE

Long saphenous vein harvesting techniques and their effect

on graft patency

Amer Harky MRCS, MSc1 | Beverly MacCarthy‐Ofosu MBBS2 |

Ciaran Grafton‐Clarke MBChB 3
| Dimitrios Pousios FRCS (CTh) 1
| Andrew D. Muir FRCS (CTh)1

1
Department of Cardiothoracic Surgery,
Liverpool Heart and Chest, Liverpool, UK
2
School of Medicine, University of Liverpool,
Liverpool, UK
3
School of Life Sciences, University of
Leicester, Leicester, UK
Correspondence
Amer Harky, MBChB, MSc, MRCS,
Department of Cardiothoracic Surgery,
Liverpool Heart and Chest Hospital, Thomas
drive, L14 3PE, Liverpool, UK.
Email: amer.harky@lhch.nhs.uk
Abstract
Coronary artery bypass grafting is a key cardiac surgery procedure and is the main
treatment for patients with multivessel coronary artery disease. The most frequently
used conduit for this procedure is the long saphenous vein (LSV). The technique of
harvesting the LSV has evolved over the last 30 years from total open harvesting to
endoscopic with minimal access technique. The most important determining factor
for success in coronary artery surgery is the graft patency rate. The literature
evidence behind each technique has been reported at different levels and there is an
ongoing debate about which technique can provide optimum vein patency over
the long term. This literature review aims to summarize the current evidence, the
implications involved with the use of each technique for harvesting LSV and the
patency rate at variable follow‐up intervals.

KEYWORDS
conduits, coronary artery bypass grafting, vein harvesting

1 | INTRODUCTION incidences of wound‐healing‐related issues, postoperative cellulitis,

The first saphenous vein harvesting approach, the conventional open
1
technique (COT), was developed in 1967 by Dr Rene Favaloro. The
inevitable vascular trauma associated with vein harvesting is thought
to contribute to graft failure, specifically through endothelial damage,
damage to the tunica media and adventitia, and the impact on the
vasa vasorum and vascular nerves.2 In response, a variety of
“atraumatic” or “no‐touch” (NT) techniques have been developed
with the aim of reducing or avoiding direct instrumentation of the
vein during harvesting. At present, the NT and “endoscopic vein
2
harvesting” (EVH) techniques represent the most studied alterna-
tives to the COT. The normal physiology of vein grafts exposes them
to damage upon handling; however, the extent of the damage
1
remains unclear. The COT, which is performed with the LSV under
direct vision, causes less damage to the endothelium of the vein when
compared with EVH.3 Despite this, the COT is associated with higher
and increased the length of hospital stay when compared with EVH
technique.3 In response, the NT technique was introduced to avoid
over‐handling of the LSV and the resultant denudation of the
protective adventitial layer and requirement for pharmacological
agents to mitigate against venospasm.2 In an NT technique, the LSV is
harvested together with a cushion of surrounding tissue without
provoking the vessel into spasm, thereby eliminating distension‐
induced damage and increasing preservation of normal vessel
morphology.4 In addition to the intraoperative protection afforded,
the perivascular tissue that remains in place acts as an external stent,
reducing the pulsatile pressure, altered flow, and tensile stress
inflicted upon the arterialized vein.2,4
The serious concerns relating to SVGs revolve around fast
atherosclerotic degeneration leading to graft patency failure.5 This is
evidenced by 15% to 20% graft occlusion at 1‐year follow‐up and
40% to 50% occlusion at 10 years. Graft‐attrition rate is 1% to 2%
per year in the first 6 years, and 4% in each subsequent year.5,6

Amer Harky, Beverly MacCarthy‐Ofosu, and Ciaran Grafton‐Clarke equally contributed to

Accordingly, at 10‐year postvenous grafting, more than 10% of
this work. patients require further intervention to alleviate symptoms arising
J Card Surg. 2019;1-8. wileyonlinelibrary.com/journal/jocs © 2019 Wiley Periodicals, Inc. | 1
2 |
from graft occlusion or progression of the native disease.7 Within the
first month following implantation technical failures such as catching
the back wall of the coronary, purse stringing of the anastomosis,
multiple over sewing of bleeding points between the conduit and the
graft walls are among key points that contribute to early graft failure.
However, endothelial disruption and cell loss caused by trauma
associated with harvesting, preparation, and execution of bypass
8
grafting can lead to graft thrombosis and failure. Endothelial injury
is perpetuated by hemodynamic stress inflicted on the vein walls as a
result of arterial pressure and pulsatile flow, for which vein walls
demonstrate poor elastic recoil and increased stiffness.9 Graft failure
occurring after 1‐month postinsertion is largely due to organisation
of thrombotic material into fibrotic tissue, resulting in intimal
hyperplasia and the development of atherosclerotic plaques.5
Plaques in SVGs are known to be diffuse, poorly calcified, and
characterized by fibroadenomas with large necrotic cores rich in
inflammatory and foam cells.5 The thin fibro‐lipidic layer encapsulat-
ing the formed plaque is highly susceptible to rupture, paving the way
5,10,11
for graft failure via thrombosis.
2 | CONVENTIONAL OPEN VEIN
HA RV ESTING TEC HN IQU E
Traditionally, the LSV was harvested by creating a long continuous
incision starting from the ankle, over its anatomical course.1,12 The
length of the incision made depends on how much venous conduit is
required to perform the coronary bypasses.12 A bridging technique,
which involves making several smaller “skip incisions,” was identified
as an effective solution in reducing wound complications in
11
comparison with the long incision approach. The conventional
saphenectomy approach involves the longitudinal opening of the
fascial canal surrounding the vein, formed predominantly by adipose
tissue.13 In doing so, the adventitial layer is invariably damaged,
leading to saphenous vein venospasm.13 The high distension
pressures required to overcome venospasm and to check for vascular
leaks before graft implantation induces substantial damage to the
vein at an ultrastructural level.14 The endothelial cells appear
deformed, flattened and polymorphic, with adventitial damage
14
accompanied by a reduction in the number of vasa vasorum. The
occlusion rate with this approach is extremely high, with 15% to 30%
14
failing within the first 12 months, and more than 50% requiring
regrafting within 10 years.14
3 | THE NO ‐T O U C H TE C HN IQ U E
The NT technique was first reported by Souza in 1996.15 It is also an
open technique and therefore an incision is made similar to that of
the COT. Since the LSV is surrounded by adherent tissue and fat, it is
harvested from its bed with a pedicle of the perivascular tissue and
16,17
fat. No significant venospasm is encountered with this technique
as neither the native perivascular tissue nor the vessel itself is
HARKY ET AL.
directly in contact with the surgical instruments.16 Practically
speaking, no mechanical distension or pharmacological vasodilators
are required to reverse venospasm or to assess the quality of the
conduit.4 During harvesting, sponges containing pure saline solution
are used to cover the vessel. After harvesting, the vessel is then
stored in blood retrieved from the patient.15
In 2002, Tsui et al17 undertook a cohort study comparing nitric
oxide synthase (NOS) preservation between 10 patient undergoing
CABG with the NT and conventional techniques. Samples were also
taken from segments that were stripped of surrounding tissue but
not distended. Segments harvested by the NT technique expressed
35% more NOS than with COT (P < .05).17 Similar outcomes were
reported by Dashwood et al in 2005,18 in which NOS expression
between 19 LSVs harvested by conventional and NT techniques were
analyzed. The injury was noted in the conventional group, specifically
to the endothelium and tunica adventitia. This injury was accom-
panied by an absence of endothelial NOS at regions of endothelial
denudation in stripped areas (P < .05) and lower tissue NO release
(P < .05) in the veins harvested by COT.
In 2006, Souza et al19 reported a longitudinal randomized trial
comparing graft patency in 104 patients undergoing CABG surgery.
Patients were split into two arms: conventional, where the vein was
stripped, distended, and stored in saline; and NT, where the vein was
removed with surrounding tissue, not distended, and stored in
heparinized blood. Participants were assessed angiographically at 18
months (short‐term) and 8.5 years (long‐term) postoperatively. No
difference was noted in patency rates between the NT (95%) and
COT (89%) groups at 18 months (P = .10). After 8.5 years, the NT
group (90%) demonstrated significantly superior patency compared
with the COT group (76%) (P = .01). Multivariate analysis revealed
surgical technique to be the most important factor determining graft
patency (odds ratio 3.7; P = .007) for the NT vs the COT, followed by
vein quality before implantation (odds ratio 3.2; P = .007) for veins
that were of good quality. In 2008, Rueda et al20 published a
prospective randomized study of 156 patients, analyzing angio-
graphic patency, endothelial structure and levels, and activity of
eNOS. Using angiography at 18‐month postharvesting, graft patency
rates were significantly superior in the NT group in comparison with
the COT group (95.4% vs 88.9%; P = .025), a contrary finding to that
observed by Souza et al19 As with previously discussed studies on
this topic, Rueda et al20 revealed enhanced endothelial structure, an
intact adventitial collagen layer, as well as eNOS activity throughout
the entire thickness of the vessel wall of the NT group as compared
with the COT group (P < .05) (20 2).
A cohort study of 26 patients undergoing CABG using veins
prepared with and without perivascular tissue, as reported by
Dashwood et al.4 Distension‐induced morphological damage and
expression of eNOS were compared in participants undergoing LSV
harvesting with an NT approach compared with a COT. Using vessel
wall thickness as a marker of vessel damage, the nondistended
conduits in the NT cohort‐maintained wall thickness vs the distended
conduits of the COT group (P = .022). High‐pressure distension led to
significant endothelial damage and reduced eNOS activity (P = .0009),
HARKY ET AL.
thus reinforcing the principle that retention of perivascular tissue
protects against distension‐induced damage, preserves vessel mor-
phology, and maintains eNOS activity.4
Johansson et al21 conducted a randomized controlled trial of 104
patients with LSV grafts harvested by either a COT or NT technique.
The primary outcome measures were graft patency rates, intimal
thickness and degree of intimal hyperplasia at 18 months (short‐
term) and 8.5 years (long‐term) postoperatively, with a focus on
cineangiographic‐evaluated stenosis. At 18 months, the incidence of
stenosis was lower in the NT group compared with the COT group
(11.0% vs 25%; P = .006). Similarly, at 18 months the NT approach
was associated with a decreased intimal thickness (0.43 mm vs
0.52 mm; P = .03) and fewer grafts with considerable (>0.9 mm)
intimal hyperplasia (25% vs 100%; P = .07). At 8.5‐year follow‐up,
there was no difference in the number of grafts with significant
stenosis between NT and COT (7.7% vs 15.6%; P = .14). Similarly,
intravascular ultrasonography revealed fewer grafts containing
multiple plaques (14.8% vs 50.0%; P = .008), reduced plaque thick-
ness (1.04 mm vs 1.32 mm; P = .02), and larger lumen volumes
21
(P = .03) in the NT group.
A further cohort study as reported by Dashwood et al in 201122
assessed leptin levels and leptin localization in the fat cushion
surrounding NT harvested saphenous veins used in 15 patients
undergoing CABG surgery. Increased levels and activity of leptin
were detected in veins harvested by means of an NT technique. It
was concluded that leptins located in the perivascular tissue have a
potent vasodilatory effect on NT harvested LSV grafts. Therefore,
longer‐term patency is observed in such cohorts and the practice of
22
NT LSV harvesting should be observed.
Dreifaldt et al23 studied nine patients by analysing paired
segments of LSV harvested by COT and NT techniques. Analysis of
vessel wall characteristics by morphometric and ultrastructural
analysis using electron microscopy revealed a significantly reduced
vasa vasorum in the media (P = .007) and adventitia (P = .014) of COT
harvested veins; thus, the superiority of NT existed.
While the evidence supporting an NT approach over the COT is
compelling, there is a small body of research highlighting a number of
important patient‐focused considerations. The PATENT saphenous
vein graft randomized‐controlled trial24 comparing vascular injury
markers between pedicled NT to the COT revealed leg assessment
scores to be worse in the NT legs at 3‐month postsurgery (general leg
discomfort: 2 v 0; P = .0005). While this had equilibrated at 12‐month
postsurgery (general leg discomfort: 1 vs 1; P = .13), this is an area
requiring further research input. Of note, at 3‐month post‐CABG,
there were four harvest site infections with NT, in comparison with
zero in the conventional group (P = .13).24
In response to the structural and functional limitations associated
with saphenous vein grafting, composite grafts based on the in‐situ
LIMA have been investigated as an alternative to improve conduit
patency.25-27 The study, as conducted by Kim et al25, identified that
SV grafts harvested with an NT technique further improved the early
and 1‐year patency of SV composite grafts as harvested using
minimal manipulation techniques. While this advancement
| 3
represents an exciting opportunity to improve graft patency,
midterm, and long‐term angiographic follow‐up is required to
demonstrate the superiority of NT composite grafts. A minimally
manipulative surgical strategy in harvesting the SV for use in a Y‐
composite graft based on the LIMA has been shown to preserve
endothelial structure when compared with manual dilatation of
harvested dilated SV.26 The theoretical advantages of using the SV as
part of a composite graft include less exposure to pressure trauma
from the ascending aorta and reduced propensity for atherosclerotic
progression due to the constant exposure of nitric oxide produced by
the LIMA.27 Further efforts to improve patency of the SV continue to
be trialed; of which external stent support28 and intraoperative gene
therapy represent two examples.29 An external vein graft support
with mesh tubing has been shown to reduce intimal and medial layer
thickening and cell proliferation in composite vein grafts.28 An
expandable SV graft external support system has been shown to
reduce nonuniform dilatation and neointimal formation in an animal
model post‐CABG, representing a novel technology with the
potential to improve SV graft patency rates.29 The VEST IV trial30
evaluated failure rates and degree of intimal hyperplasia between
nonstented and externally‐stented saphenous vein grafts. External
stenting was found to mitigate against saphenous vein graft
remodeling and significantly reduce diffuse intimal hyperplasia and
the development of lumen irregularities 4.5 years following CABG.
The results of the VEST III trial are eagerly awaited, a large
randomized trial that sets out to address the issues relating to the
learning curve effects of both the technology and implantation
technique.31
Table 1 summarises the key evidence behind the use of NT
technique in harvesting LSVs in the context of CABG surgery.
4 | ENDOSCOPIC HARVESTING
Since its inception in 1997, EVH has grown in popularity with efforts
to reduce the pain and risk of infection associated with LSV
harvesting.32 The Society of Thoracic National Cardiac Database
reported more than 70% of CABG procedures utilized EVH
approaches across the United States.33 EVH has gained prevalence
over COT in that its less invasive approach favors wound healing and
is associated with decreased wound morbidity, improved cosmetic
results, and enhanced patient satisfaction.32
In 2016, the International Society for Minimally Invasive
Cardiothoracic Surgery published a consensus statement recom-
mending endoscopic saphenous vein harvesting as the standard of
care for patients requiring conduits for coronary revascularization.34
This consensus statement, based on the appraisal of 76 studies
involving 281 459 participants, compared EVH with COT across a
variety of domains. The odds of wound complications (seroma,
drainage, necrosis, leg oedema, infection, cellulitis, abscess, and
dehiscence) were significantly reduced by 71% with EVH compared
with COT (OR = 0.29; P < .00001).34 EVH was not found to be
associated with an increase in myocardial infarction over COT at 30
 4
|

T A B L E 1 Best evidence papers comparing open technique versus no‐touch technique

Author Date Study type Level of evidence Summary of key findings
4
Dashwood et al 2009 Observational study 3 Surrounding perivascular tissue in NT harvesting guards against distension‐induced damage, preserved vessel structure,
and maintains eNOS activity
Tsui et al17 2002 Observational study 3 NT LSV harvesting avoids the damage of NOS sources and as such causes an increase in NO production. Increased NO
contributes to long term patency of the graft
Dashwood et al18 2005 Observational study 3 Open technique caused damage to the graft vessel wall and decrease to eNOS and nitric oxide release.
NT harvesting delivers improved patency and performance
Souza et al19 2006 Randomized controlled trial 2 Perivascular tissue of NT harvested grafts leads to high patency in both long and short‐term which are similar to that of
LIMA
Rueda et al20 2008 Prospective randomized trial 2 NT graft harvesting causes less damage to the endothelium as well as maintaining higher eNOS activity as compared with
COT. Perivascular tissue in NT harvesting gives mechanical cushioning which guards against twisting, ischemia, and
spasm. NO as a vessel relaxant and antithrombotic to increase LSV patency.
Johansson et al21 2010 Randomized controlled trial 2 Lower levels and progression of atherosclerosis when NT is used in graft harvesting as compared with COT leads to
improved long‐term patency
Dashwood et al22 2011 Observational study 3 Perivascular fat retained in NT harvesting contains leptin which promotes long‐term patency in LSV grafts
23
Dreifaldt et al 2011 Observational study 3 The vasa vasorum is maintained in NT harvesting. This may provide a possible explanation for the improved patency levels
seen in LSV grafts
Abbreviations: COT, conventional open technique; eNOS, endothelial nitric oxide synthase; LITA, left internal thoracic artery; LSV, long saphenous vein; NO, nitric oxide; NT, no‐touch technique.
Level of evidence
2 ‐ Prospective cohort studies, low‐quality RCTs, systematic reviews of level 2 study
3 ‐ Retrospective cohort study, case‐control study
HARKY
ET AL.
HARKY ET AL.
days (OR = 0.89; P = .35) or at 1‐year follow‐up (OR = 0.60; P = .53).34
The odds of all‐cause mortality at 30 days were significantly reduced
by 27% with EVH compared with COT at 30 days (OR = 0.73;
P = .001) (34). The 7% difference in all‐cause mortality at 4‐year
follow‐up in favor of EVH was not found to be significant (OR = 0.93;
P = .44). The consensus group report that few of the included trials
reported on angiographic outcomes.34 Pooled analysis showed the
odds of angiographic occlusion at 6‐month follow‐up were not
increased in EVH patients compared with COT patients (OR = 1.15;
P = .66). Similarly, with follow‐up data greater than 1 year, the odds
of angiographic graft failure or occlusion were nonsignificantly
increased in EVH compared with COT patients (OR, 1.58;
P = .10).34 The odds of moderate to severe pain in the postoperative
period were significantly reduced by 81% in patients undergoing EVH
compared with OVH (OR = 0.19; P < .00001) and by 90% at 6‐month
follow‐up (OR = 0.10; P = .0005).34 Similarly, the odds of mobility
disturbance at discharge were reduced by 69% with EVH compared
with COT (OR = 0.31; P = .002). While EVH is noninferior to COT in
terms of major adverse cardiac events and angiographic patency, its
use is associated with a reduced incidence of wound complications,
greater postoperative pain control, and improved levels of mobility.32
Despite evidence demonstrating noninferior short‐term patency
34
rates and superior wound‐related outcomes, observational studies
on the long‐term patency rates of LSV harvested by EVH are
conflicting and remains ill‐defined. It is important to recognize that
the literature contains a paucity of studies employing angiographic
follow‐up of graft patency with a common failure to design
prospectively designed trials. The long‐term patency rates at 12
months and beyond appear to favor the COT. This represents the
major limitation of the endoscopic approach.
35
The PREVENT IV trial reported an increased rate of vein graft
failure at 12 to 18‐month postharvesting in the EVH cohort
compared with the COT cohort (46.7% vs 38.0%; P < .001). The
ROOBY trial,36 reporting on outcomes at 1‐year post‐CABG,
concluded that in comparison with COT, EVH was associated with
a higher rate of graft failure (25.5% vs 14.8%; P < .001) and repeat
revascularization (6.7% vs 3.4%; P < .05). Similarly, data from the
EPIC trial37 demonstrated lower graft patency at 9‐month follow‐up
in EVH compared with COT (79.2% vs 90.8%). It is worth mentioning
that the findings from these trials are subject to unadjusted
confounders and bias as none were specifically designed to compare
the safety and/or efficacy of EVH vs COT. Therefore, the results of
these trials should be interpreted with caution.
35-37
Three independent studies with a combined total of more
than 16 000 CABG patients reported that EVH was not associated
with reduced survival or the need for repeat revascularization
procedures. These studies were undertaken in high‐volume centers
that have been performing the EVH technique since its early days;
therefore, the operators were highly skilled and effective practi-
tioners. As such, the findings of noninferiority relating to the EVH
technique may be related to technical skill and experience, rather
than the technique itself. A meta‐analysis, with a particular focus on
the long‐term effects of graft patency, was tabulated, revealing
| 5
better long‐term patency in favor of COT in comparison with EVH
(odds ratio = 1.26; P = .00039), with no significant bias or hetero-
geneity demonstrated.38
Endovascular harvesting of veins ultimately involves traction,
adventitial stripping, and compression being applied to the vein.39
These forces are seldom required in COT. The degree to which the
practitioner is experienced in performing the harvest has been shown to
impact on perioperative and postoperative outcomes.40 A prospective
study as reported by Desai et al.41 found that novice practitioners (<100
cases) reported nearly 50% more injuries than that of experienced
practitioners (>900 cases) following endovascular harvesting.41 In
addition, it was also identified that the number of vessels with a
positive remodeling response was found to be reduced in novice
practitioners, compared with their experienced et al.42 Novice harvest-
ers are more likely to apply excessive force to the vein to gain increased
endoscopic vision and exposure.42 This, may represent a causative
factor in graft quality difference between experienced and less‐
experienced practitioners.1,2 The open NT technique does not require
such manipulations to be applied.43 A number of the studies
demonstrating adverse outcome following endovascular harvesting
were carried out whilst the technique was in its infancy, without the
practitioners gaining a high level of competence which is demonstrated
in todayʼs practice. As such, the results of historical studies should be
interpreted with caution considering the steep learning curve involved
in gaining endoscopic competence.42,43 The difference in graft patency
between EVH and COT may decrease with time if the only explanation
for the difference is inexperience. As many centers continue to train
novice practitioners to perform this technique, the inevitability of
inexperience will continue to contribute to poor graft patency seen with
endovascular harvesting. Therefore, in as much as an explanation could
be provided for the conflicting findings of different groups for the
effectiveness of EVH with regard to graft patency, there still remains
some degree of uncertainty which will require further research work to
clarify. However, there is evidence to support that when EVH is
performed by highly experienced harvesters, the physical damage to the
vein is similar to that of open harvest. Therefore, it is hypothesized that
EVH and COT carry similar patency rates when performed by highly
experienced harvesters if all other factors are equalized.44 Table 2
contains a summary of the key studies comparing COT vs EVH.
In addition to conduit choice and technique of vein harvesting,
the role of storage solution has been implicated as an important
contributing factor to venous graft failure.47 In the hours following
surgery, saphenous venous grafts are exposed to ischaemic reperfu-
sion injuries, with reduced levels of NO production leading to
proinflammatory states.47,48 The standard of practice has been to
store the products of harvesting in heparinized 0.9% normal saline
(NS) before implantation. NS has been shown to alter the functional
integrity of the endothelial layer and reduce vascular wall tension.48
Autologous heparinized blood has been shown to minimize endothe-
lial damage; however, comparative studies have yielded conflicting
results.48 Buffered solutions have been shown to ensure a more
physiological pH during saphenous vein graft (SVG) preparation, an
important consideration when endothelial integrity is crucial in
6 | HARKY ET AL.

T A B L E 2 Best evidence papers comparing open harvesting technique versus endoscopic technique
Level of
Author Date Study type evidence Summary of findings
35
Hess et al 2014 Observational study 2 EVH was associated with decreased patency of LSV at both
patient and graft level
Kim et al42 2015 Observational study 2 No difference in patency rates of LSV in the immediate
postoperative period and at 6 mo
Sastry et al45 2013 Meta‐analysis 1 All studies
● 2 Prospective randomised EVH was associated with decreased patency rates
controlled trials
● 2 Nonrandomized studies RCTs only
No significant difference in patency rates between EVH
and OVH
VGF
46
Andreasen et al 2015 Randomised controlled trial 1 EVH was associated with decreased patency rates
Abbreviations: EVH, endoscopic vessel harvesting; LSV, long saphenous vein; OVH, open vein harvesting; RCT, Randomised controlled trial.
Level of evidence
1 ‐ Systematic review and meta‐analysis of RCTs, individual RCTs
2 ‐ Prospective cohort studies, low‐quality RCTs, systematic reviews of level 2 study

maintaining a grafts ability to adapt to hemodynamic forces and
shear stress in a high‐pressure and pulsatile arterial system.49 At
present, there is no clear consensus on the most protective solution;
however, buffered solutions appear to represent the best opportu-
nity to prevent graft failure.50,51 Clinical trials, adequately powered,
with graft patency as a primary endpoint are required to determine
the most optimal intraoperative storage solution.
5 | CONC LU SION
The current evidence remains controversial with debate remaining
regarding the superiority of any technique to provide long‐term patency.
Conventional and EVH outcomes are equivocal depending on iatrogenic
vein damages and operator experience, respectively. The NT technique is
relatively free from such traumatic events; however, the conduit quality is
not clear until the time of anastomosis. A larger randomized trial is
required to identify the optimum technique that can provide the best
long‐term graft patency.
CO NFLICT OF I NTERE STS
The authors declare that there is no conflict of interests.
OR CID
Amer Harky http://orcid.org/0000-0001-5507-5841
REFERENC ES
1. Favaloro RG. Saphenous vein autograft replacement of severe
segmental coronary artery occlusion: operative technique. Ann
Thorac Surg. 1968;5(4):334‐339.
2. Tsui J, Dashwood M. Recent strategies to reduce vein graft occlusion:
a need to limit the effect of vascular damage. Eur J Vasc Endovasc
Surg. 2002;23(3):202‐208.
3. Harky A, Balmforth D, Shipolini A, Uppal R. Is endoscopic long
saphenous vein harvesting equivalent to open harvesting technique
in terms of graft patency? Interact Cardiovasc Thorac Surg.
2017;25(2):323‐326.
4. Dashwood MR, Savage K, Tsui JCS, et al. Retaining perivascular tissue
of human saphenous vein grafts protects against surgical and
distension‐induced damage and preserves endothelial nitric oxide
synthase and nitric oxide synthase activity. J Thorac Cardiovasc Surg.
2009;138(2):334‐340.
5. Windecker S, Kolh P, Alfonso F, et al. 2014 ESC/EACTS guidelines on
myocardial revascularization. Eur Heart J. 2014;35(37):2541‐2619.
6. Mehta D, Izzat MB, Bryan AJ, Angelini GD. Towards the prevention
of vein graft failure. Int J Cardiol. 1997;62(Suppl 1):S55‐S63.
7. Weintraub WS, Jones EL, Craver JM, Guyton RA. Frequency of
repeat coronary bypass or coronary angioplasty after coronary artery
bypass surgery using saphenous venous grafts. Am J Cardiol.
1994;73(2):103‐112.
8. Cox JL, Chiasson DA, Gotlieb AI. Stranger in a strange land: the
pathogenesis of saphenous vein graft stenosis with emphasis on
structural and functional differences between veins and arteries. Prog
Cardiovasc Dis. 1991;34(1):45‐68.
9. Canham PB, Finlay HM, Boughner DR. Contrasting structure of the
saphenous vein and internal mammary artery used as coronary
bypass vessels. Cardiovasc Res. 1997;34(3):557‐567.
10. Cuminetti G, Gelsomino S, Curello S, Lorusso R, Maessen JG,
Hoorntje JCA. Contemporary use of arterial and venous conduits in
coronary artery bypass grafting: anatomical, functional, and clinical
aspects. Neth Heart J. 2017;25(1):4‐13.
11. Hijazi EM. Comparative study of traditional long incision vein
harvesting and multiple incisions with small skin bridges in patients
with coronary artery bypass grafting at King Abdullah University
Hospital—Jordan. Rev Bras Cir Cardiovasc. 2010;25(2):197‐201.
12. Papadopoulos NJ, Sherif MF, Albert EN. A fascial canal for the great
saphenous vein: gross and microanatomical observations. J Anat.
1981;132(Pt 3):321‐329.
13. Sen O, Gonca S, Solakoglu S, Dalcik H, Dalcik C, Ozkara A.
Comparison of conventional and no‐touch techniques in harvesting
HARKY ET AL.
saphenous vein for coronary artery bypass grafting in view of
endothelial damage. Heart Surg Forum. 2013;16(4):177.
14. Manninen HI, Jaakkola P, Suhonen M, Rehnberg S, Vuorenniemi R,
Matsi PJ. Angiographic predictors of graft patency and disease
progression after coronary artery bypass grafting with arterial and
venous grafts. Ann Thorac Surg. 1998;66(4):1289‐1294.
15. Souza D. A new no‐touch preparation technique. Technical notes.
Scand J Thorac Cardiovasc Surg. 1996;30(1):41‐44.
16. Souza DS, Bomfim V, Skoglund H, et al. High early patency of
saphenous vein graft for coronary artery bypass harvested with
surrounding tissue. Ann Thorac Surg. 2001;71(3):797‐800.
17. Tsui JCS, Souza DSR, Filbey D, Karlsson MG, Dashwood MR.
Localization of nitric oxide synthase in saphenous vein grafts
harvested with a novel “no‐touch” technique: potential role of nitric
oxide contribution to improved early graft patency rates. J Vasc Surg.
2002;35(2):356‐362.
18. Dashwood MR, Savage K, Dooley A, Shi‐Wen X, Abraham DJ, Souza
DSR. Effect of vein graft harvesting on endothelial nitric oxide
synthase and nitric oxide production. Ann Thorac Surg. 2005;80(3):
939‐944.
19. Souza DSR, Johansson B, Bojö L, et al. Harvesting the saphenous vein
with surrounding tissue for CABG provides long‐term graft patency
comparable to the left internal thoracic artery: results of a
randomized longitudinal trial. J Thorac Cardiovasc Surg. 2006;132(2):
373‐378.e5.
20. Rueda F, de, Souza D, Lima R, et al. Novel no‐touch technique of
harvesting the saphenous vein for coronary artery bypass grafting.
Arq Bras Cardiol. 2008;90(6):356‐362.
21. Johansson BL, Souza DSR, Bodin L, et al. Slower progression of
atherosclerosis in vein grafts harvested with ‘no touch’ technique
compared with conventional harvesting technique in coronary artery
bypass grafting: an angiographic and intravascular ultrasound study.
Eur J Cardio‐Thoracic Surg. 2010;38(4):414‐419.
22. Dashwood M, Dooley A, Shi‐Wen X, Abraham D, Dreifaldt M, Souza
D. Perivascular fat‐derived leptin: a potential role in improved vein
graft performance in coronary artery bypass surgery. Interact
Cardiovasc Thorac Surg. 2011;12:170‐173.
23. Dreifaldt M, Souza D, Loesch A. The ‘no‐touch’ harvesting technique
for vein grafts in coronary artery bypass surgery preserves an intact
vasa vasorum. J Thorac Cardiovasc Surg. 2011;141:145‐150.
24. Verma S, Lovren F, Pan Y, et al. Pedicled no‐touch saphenous vein
graft harvest limits vascular smooth muscle cell activation: the
PATENT saphenous vein graft study. Eur J Cardiothorac Surg.
2014;45(4):717‐725.
25. Kim JS, Hwang HY, Kim K‐B. Angiographic equivalency of off‐pump
saphenous vein and arterial composite grafts at one year. Ann Thorac
Surg. 2010;90(2):516‐521.
26. Hwang HY, Kim M‐A, Seo JW, Kim K‐B. Endothelial preservation of
the minimally manipulated saphenous vein composite graft: histologic
and immunohistochemical study. J Thorac Cardiovasc Surg.
2012;144(3):690‐696.
27. Kim YH, Oh HC, Choi JW, Hwang HY, Kim K‐B. No‐touch saphenous
vein harvesting may improve further the patency of saphenous vein
composite grafts: early outcomes and 1‐year angiographic results.
Ann Thorac Surg. 2017;103(5):1489‐1497.
28. Krejca M, Skarysz J, Szmagala P, et al. A new outside stent—does it
prevent vein graft intimal proliferation? Eur J Cardiothorac Surg.
2002;22(6):898‐903.
29. Ben‐Gal Y, Taggart DP, Williams MR, et al. Expandable external
support device to improve saphenous vein graft patency after CABG.
J Cardiothorac Surg. 2013;8(1):122.
30. Taggart DP, Webb CM, Desouza A, et al. Long‐term performance of
an external stent for saphenous vein grafts: the VEST IV trial. J
Cardiothorac Surg. 2018;13(1):117.
| 7
31. Raja SG, Haider Z, Ahmad M, Zaman H. Saphenous vein grafts: to use
or not to use? Heart Lung Circ. 2004;13(4):403‐409.
32. Ouzounian M, Hassan A, Buth KJ, et al. Impact of endoscopic versus
open saphenous vein harvest techniques on outcomes after coronary
artery bypass grafting. Ann Thorac Surg. 2010;89(2):403‐408.
33. Ferdinand FD, MacDonald JK, Balkhy HH, et al. Endoscopic conduit
harvest in coronary artery bypass grafting surgery. Innov Technol
tech cardiothorac. Vasc Surg [Internet]. 2017;12(5):301‐319 [cited
2019 Apr 22].
34. Lopes RD, Hafley GE, Allen KB, et al. Endoscopic versus open
vein‐graft harvesting in coronary‐artery bypass surgery. N Engl J
Med [Internet]. 2009;361(3):235‐244. https://doi.org/10.1056/
NEJMoa0900708, Jul 16 [cited 2019 Apr 22]. Available from:
http://www.nejm.org/doi/abs
35. Hess CN, Lopes RD, Gibson CM, et al. Saphenous vein graft failure
after coronary artery bypass surgery: insights from PREVENT IV.
Circulation. 2014;130:1445‐1451.
36. Zenati MA, Shroyer AL, Collins JF, et al. Impact of endoscopic versus
open saphenous vein harvest technique on late coronary artery
bypass grafting patient outcomes in the ROOBY (Randomized On/Off
Bypass) Trial. J Thorac Cardiovasc Surg [Internet]. 2011;141(2):338‐
344, [cited 2019 Apr 22]. Available from. http://www.ncbi.nlm.nih.
gov/pubmed/21130476
37. Puskas JD, Halkos ME, Balkhy H, et al. Evaluation of the PAS‐port
proximal anastomosis system in coronary artery bypass surgery (the
EPIC trial). J Thorac Cardiovasc Surg. 2009;138(1):125‐132, [cited
2019 Apr 22] Available from http://www.ncbi.nlm.nih.gov/pubmed/
19577069
38. Markar SR, Kutty R, Edmonds L, Sadat U, Nair S. A meta‐analysis of
minimally invasive versus traditional open vein harvest technique for
coronary artery bypass graft surgery. Interact Cardiovasc Thorac Surg.
2010;10(2):266‐270.
39. Yun KL, Wu Y, Aharonian V, et al. Randomized trial of endoscopic
versus open vein harvest for coronary artery bypass grafting: six‐
month patency rates. J Thorac Cardiovasc Surg. 2005;129(3):496‐503,
[cited 2019 Apr 22] Available from http://www.ncbi.nlm.nih.gov/
pubmed/15746730
40. Kiaii B, Moon BC, Massel D, et al. A prospective randomized trial of
endoscopic versus conventional harvesting of the saphenous vein
in coronary artery bypass surgery. J Thorac Cardiovasc Surg.
2002;123(2):204‐212 [cited 2019 Apr 22] Available from http://
www.ncbi.nlm.nih.gov/pubmed/11828277
41. Desai P, Kiani S, Thiruvanthan N, et al. Impact of the learning curve
for endoscopic vein harvest on conduit quality and early graft
patency. Ann Thorac Surg. 2011;91(5):1385‐1392.
42. Kim DY, Song H, Kim HW, Jo GH, Kang J. Early outcomes of
endoscopic vein harvesting during the initial learning period. Korean J
Thorac Cardiovasc Surg. 2015;48(3):174‐179.
43. Allen KB, Heimansohn DA, Robison RJ, Schier JJ, Griffith GL,
Fitzgerald EB. Influence of endoscopic versus traditional saphenect-
omy on event‐free survival: five‐year follow‐up of a prospective
randomized trial. Heart Surg Forum. 2003;6(6):E143‐E145.
44. Khaleel MS, Dorheim TA, Duryee MJ, et al. High‐pressure distention
of the saphenous vein during preparation results in increased
markers of inflammation: a potential mechanism for graft failure.
Ann Thorac Surg. 2012;93(2):552‐558.
45. Sastry P, Rivinius R, Harvey R, et al. The influence of endoscopic vein
harvesting on outcomes after coronary bypass grafting: a meta‐
analysis of 267,525 patients. Eur J Cardiothorac Surg. 2013;44:980‐
989.
46. Andreasen JJ, Vadmann H, Oddershede L, Tilsted HH, Frokjaer JB,
Jensen SE. Decreased patency rates following endoscopic vein
harvest in coronary artery bypass surgery. Scand Cardiovasc J.
2015;49:286‐292.
8 | HARKY ET AL.

47. Ben Ali W, Bouhout I, Perrault LP. The effect of storage solutions, 51. Harky A, Bithas C. Total arterial revascularization and the future of
gene therapy, and antiproliferative agents on endothelial function long saphenous vein. Biomed J Sci & Tech Res. 2019;15(5BJSTR).
and saphenous vein graft patency. J Card Surg. 2018;33(5):235‐242. MS.ID.002776. https://doi.org/10.26717 BJSTR.2019.15.002776
48. Schaeffer U, Tanner B, Strohschneider T, Stadtmüller A, Hannekum A.
Damage to arterial and venous endothelial cells in bypass grafts
induced by several solutions used in bypass surgery. Thorac
Cardiovasc Surg. 1997;45(04):168‐171. How to cite this article: Harky A, MacCarthy‐Ofosu B,
49. Hinokiyama K, Valen G, Tokuno S, Vedin JB, Vaage J. Vein graft Grafton‐Clarke C, Pousios D, Muir AD. Long saphenous vein
harvesting induces inflammation and impairs vessel reactivity. Ann harvesting techniques and their effect on graft patency. J Card
Thorac Surg. 2006;82(4):1458‐1464.
Surg. 2019;1‐8. https://doi.org/10.1111/jocs.14153
50. Owens CD, Gasper WJ, Rahman AS, Conte MS. Vein graft failure. J
Vasc Surg. 2015;61(1):203‐216.