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The National Institute for Health and Clinical Excellence (NICE) has produced new guidance in relation to the endoscopic harvesting of saphenous veins for coronary artery bypass graft (CABG) surgery, advising that this procedure should only be used with special arrangements for clinical governance, consent and audit or research.1 NICE have been moved to make these recommendations in the light of recent evidence that has cast a shadow over the vein graft patency in patients who have had venous conduit dissected by the endoscopic technique.2 The paper in question is the offshoot of a large north American phase III, multicentre, randomised double-blind placebo controlled trial of the ex-vivo treatment of autologous vein grafts with Edifoglide in patients undergoing initial CABG surgery (PREVENT IV). The study was not designed to test the differences between endoscopic and open vein harvested vein graft patency, and involved 107 different surgical centres, at least two different endoscopic devices, no randomisation of patients to the two techniques, no record of the experience of the surgical operator and no record of the calibre of the vein or the level of the leg from which it was dissected. NICE reports that vein grafts harvested by the keyhole procedure had a higher rate of failure (narrowing or blockage; 47%) compared with the veins harvested by the open procedure (38%) after 1 year. These statistics are misleading. The figures they give are actually the percentage of patients carrying a stenosed or occluded graft, whereas the actual vein graft failure rates were 27.2% and 22.6%, respectively, with 22.6% and 19.4% of the overall veins actually being occluded in a patient cohort of 1817. The OR of vein graft failure for patients who had the endoscopic harvest technique compared with the open technique was 1.34 (95% CI 1.14 to 1.59; p<0.001) …
Competing interests None.
Provenance and peer review Commissioned; externally peer reviewed.
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