Review

Angiology
2016, Vol. 67(2) 121-132
Endoscopic Versus No-Touch Saphenous The Author(s) 2015
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Vein Harvesting for Coronary Artery DOI: 10.1177/0003319715584126
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Bypass Grafting: A Trade-Off Between
Wound Healing and Graft Patency

Tomislav Kopjar, MD, PhD1 and Michael R. Dashwood, PhD2

Abstract
The advantage in terms of wound infection, wound healing, and scarring has resulted in the recent adoption of endoscopic vein
harvesting (EVH) as a standard of care for coronary artery bypass grafting in some centers. However, concerns regarding the
quality of these grafts have been raised after recent evidence of decreased graft patency, increased reoperation rate, and
myocardial infarct, problems that are associated with vascular trauma caused when using this technique. Simultaneously, an
atraumatic, no-touch technique for harvesting the saphenous vein was developed producing grafts with improved patency
comparable to the internal thoracic artery. However, wound complications remain a problem using this technique. This review
outlines the need to consider the poor graft quality that may result from EVH and raises the question what is likely to be the best
practice principle in saphenous vein harvesting?

Keywords
coronary artery bypass grafting, no-touch vein harvesting, endoscopic vein harvesting, saphenous vein patency, vascular damage

Introduction An atraumatic, no-touch technique of harvesting the

The great saphenous vein is the most commonly used conduit
for coronary artery bypass surgery (CABG) since its introduc-
tion by Favaloro in 1969.1 However, the patency of the saphe-
nous vein is inferior to the internal thoracic artery (ITA),2 with
the radial artery recently being the second conduit of choice for
many cardiac surgeons.3 Minimally invasive endoscopic vein
harvesting (EVH) introduced in 19964 reduces leg wound com-
plications, infection rate, and pain and improves cosmetic
results. It is used in many centers worldwide and in the majority
of CABG in the United States.5 Extensive skin incisions in
open vein harvesting (OVH) allow a harvest with minimal sur-
gical trauma to the conduit but at the risk of higher local wound
complications and postoperative pain. In either technique, the
vein should not be grasped with forceps, stretched, or overdis-
tended, since patency may be related to endothelial damage
during harvest and graft preparation. Although the benefits of
EVH and improved wound healing are well accepted, there are
conflicting reports regarding the patency of saphenous vein
grafts prepared by this method. At best, it appears that the
patency of EVH grafts is comparable to those prepared by
OVH.6,7 Although EVH is minimally invasive in terms of
vessel exposure, wound healing, and scarring, manipulation
by instruments and insufflation causes considerable vascular
trauma and damages the vein, impacting on its function as a
bypass graft.8,9
saphenous vein (NTVH) provides a superior graft with a
patency comparable to the ITA.10 Although no-touch saphe-
nous vein grafts (NTSVGs) are prepared by OVH via a long
superficial incision, they are removed complete with cushion
of surrounding tissue intact, minimizing surgical trauma, pre-
venting spasm, and obviating the need for intraluminal saline
distension, thus preserving the veins normal architecture.11
So far, there have been no sufficiently powered multicenter
randomized trials comparing hard clinical outcome to favor
NTVH over EVH. A number of studies into the improved per-
formance of NTSVGs have identified various features underly-
ing its success, from the advantages of reducing vascular
damage to preservation of tissue factors beneficial to the main-
tenance of a healthy graft.12,13
1
University of Zagreb School of Medicine, Department of Cardiac Surgery,
University Hospital Centre Zagreb, Zagreb, Croatia
2
Surgical and Interventional Sciences, Royal Free Hospital Campus, University
College Medical School, London, United Kingdom
Corresponding Author:
Michael R. Dashwood, Surgical and Interventional Sciences, Royal Free Hospital
Campus, University College Medical School, Surgical and Interventional
Sciences, Pond Street, London NW3 2QG, United Kingdom.
Emails: m.dashwood@ucl.ac.uk; mickeydash@hotmail.com
122
Figure 1. Examples of EVH and OVH saphenous vein harvesting. Top, Diagrams showing superficial skin incisions for EVH (left) and OVH
(right). Lower panels show wound healing/scarring in patients after receiving EVH (left) and OVH (right) grafts. (Top Maquet Cardiovascular LLC
2014. All rights reserved. Leftrepublished with permission from Allen KB et al., 1998.70 Copyright Elsevier, 1998. Rightfrom Kopjar) EVH
indicates endoscopic vein harvesting; OVH, open vein harvesting.
Here we have an interesting paradox whereby wound com-
plications are reduced when saphenous veins are prepared by
EVH, but grafts have a similar patency to those prepared by
conventional OVH; while wound complications persist where
saphenous veins are harvested by the no-touch technique, the
patency is superior to the other harvesting techniques. Unfortu-
nately, the difficulty related to visualization and maneuvrabil-
ity inherent to EVH has inhibited the development of a
technique that would produce a NTSVG through EVH. Efforts
to obtain such a graft by EVH are ongoing. Although EVH is
commonly used in the United States5 and other countries, it was
not recommended in the United Kingdom.14 The question
arises, is wound healing and cosmetic outcome more important
than graft performance and potentially the survival of patients
undergoing CABG?
Saphenous Vein Structure
Like the majority of blood vessels, the saphenous vein is char-
acterized by the following 3 layers: the intima, consisting of lit-
tle more than a thin basement membrane and its endothelial
lining; the media, containing vascular smooth muscle cells
separated by collagen in which the vasa vasorum is located; and
the adventitia, which is the thickest layer composed of collagen
fibers and fibroblasts merging with the surrounding connective
tissue. Within the adventitia, are the vascular nerves and vasa
Angiology 67(2)
vasorum. Surrounding the adventitia is a cushion of perivascu-
lar fat. The inner border of the media and intima is divided by
the internal elastic lamina and thrown into folds, features only
seen in normal, nondistended, sections and not truly repre-
sented in those published examples that have been perfusion
fixed. The media and adventitia are separated by the external
elastic lamina, which is less distinct in veins than arteries. Vas-
cular, autonomic nerves located in the adventitia penetrate the
media as does the vasa vasorum, a microvascular network that
may also extend into the vessel lumen.
Methods of Harvesting the Saphenous Vein
Conventional OVH
In conventional CABG, the great saphenous vein is harvested
by open surgery. Exposure is made by a longitudinal incision,
overlying the vein and extended directly over its trajectory
(Figure 1). Sharp dissection is then used to free the vein from
the surrounding tissue and the saphenous nerve (Figure 2). Dur-
ing this process, perivascular fat and adventitia are stripped off,
contributing to the traumatic stimulus. The side branches are
ligated and divided in situ. Once dissection is completed, the
vein is ligated and divided proximally and distally. A blunt-
tipped cannula is placed in the distal end. Generally, veins are
then flushed and manually distended with saline to check for
Kopjar and Dashwood 123

Figure 2. The NTSVG, OVH, and EVH conduits from patients undergoing coronary artery bypass surgery (CABG). Top left, A NTSVG that has
been removed complete with its cushion of surrounding perivascular fat (kindly provided by Dr. Domingos Savio Ramos de Souza). Middle,
Conventional, OVH, graft that has been stripped of its surrounding tissue, much of which is perivascular fat (kindly provided by Dr. Domingos
Savio Ramos de Souza). Right, EVH graft that has been stripped of its surrounding tissue. (Kindly provided by Drs Bhatnagar and Poston.) Scale
bar 3 mm. Bottom, Intraoperative photographs of saphenous vein harvesting matching the grafts from the upper panel. (Left and middle
republished with permission from Souza et al.15 Copyright Oxford University Press, 2009. RightKopjar) EVH indicates endoscopic vein
harvesting; NTSVG, no-touch saphenous vein graft; OVH, open vein harvesting.

leakage, often at high pressures reaching or exceeding 400 mm
Hg to overcome the spasm that occurs due to surgical trauma.16
The conduit is then stored in a heparinized saline solution at a
variable time frame.
Endoscopic Vein Harvest
Techniques described for EVH are usually aided with insuffla-
tion of carbon dioxide, while others require physical retraction.
A 2.5- to 3.0-cm skin incision is made (usually) above the knee
(Figure 1) and a small space created for introduction of the
endoscope (Figure 2). Harvesting is directed toward the groin
and the ankle if necessary. Carbon dioxide is insufflated into
the subcutaneous tunnel to a maximum pressure of 15 mm
Hg allowing for an easier separation from surrounding tissue,
reducing bleeding, and facilitating visualization. Carbon
dioxide embolism and consequent hemodynamic instability
have been reported.17 Bipolar scissors or ligaclips are used for
side branches. Once the dissection is completed and after
removing the vein from the leg, side branches are ligated with
4-0 silk ties. The vein is flushed and distended, again at high
pressure, to visualize side branches and leakage. Avulsed
branches are repaired with 6-0 polypropylene sutures. The
EVH requires forces to be applied to the vein that are usually
avoided in OVH or NTVH, including traction, adventitial strip-
ping, and venous compression. For an example of EVH saphe-
nous vein see Figure 2.
No-touch vein harvest has previously been described in
detail.15 Briefly, the preserved pedicle of tissue protects the
vein from spasm obviating the need for distension (Figure 2).
Side branches are ligated at the edge of the pedicle. The adven-
titia and the structures contained within the pedicle possess
124 Angiology 67(2)

Figure 3. Scanning electron micrographs of NTSVG, OVH, and EVH saphenous veins. Appearance of luminal surface of veins showing regions of
endothelial denudation and endothelial cell shape change as well as platelet adhesion in EVH and OVH compared with undamaged NTSVG. The
arrow shows a termination of the vasa vasorum in the lumen of a NTSVG. The NTSVG and OVHrepublished with permission from Vasilakis
et al.19 Copyright Bentham Science Publishers Ltd (2004). The EVHrepublished with permission from Alrawi et al, 2001.71 Copyright The
Heart Surgery Forum (2001). EVH indicates endoscopic vein harvesting; NTSVG, no-touch saphenous vein graft; OVH, open vein harvesting.

properties that protect the vein. Timing of heparin administra-
tion, a crucial step during a standard CABG, is dictated by var-
ious factors not directly related to saphenous vein harvesting.
An experienced surgeon can easily complete vein harvesting
prior to the moment of mandatory heparinization. The impor-
tance of leaving the vein in situ and covered with moistened
swabs at least until a few minutes after heparinization, as advo-
cated in NTVH, has been proven to be beneficial when using
other harvesting techniques.9 This eliminates the need for rin-
sing or flushing.9,18 After removal, the vein is stored in hepar-
inized blood. Manual distension using a syringe is avoided,
thus preventing pressure-induced trauma to the endothelium and
vessel wall.
Harvesting Technique and Vascular Damage
Endothelium
A number of histological studies have reported the effect of
both EVH and OVH on the endothelium (Figure 3) with con-
flicting results. Reports comparing EVH to traditional, OVH,
preparation showed no detrimental effect on vein morphology,
endothelial structure, or function;20,21 better preservation;22,23
or no difference24,25 in endothelial integrity between these
grafts. However, Rousou et al showed that there is damage to
the endothelium of EVH saphenous vein grafts and that cellular
metabolic activity, viability, and membrane damage to the
endothelium is less in OVH compared with EVH grafts.8 Also,
this is accompanied by attenuated cell viability and extensive
membrane damage in intimal/medial layers of EVH compared
with OVH vein grafts. Consistent with these data, using optical
coherence tomography (OCT), Kiani and Poston described
regions of endothelial denudation in EVH saphenous veins and
also abnormalities within the intima and deeper layers of these
grafts18 (Figure 4). Interestingly, the histological examples in
this article also show marked damage to the adventitia of
EVH saphenous vein grafts, a factor that seems to have been
previously ignored. There are scant data regarding the func-
tional consequences of the vascular damage described previ-
ously. However, an in vitro study comparing the effect of
dilator and constrictor compounds on OVH versus NTSVG
showed that the vasodilator response of SVGs was signifi-
cantly higher in NTSVG when compared with OVH. Conver-
sely, the constrictor responses were significantly higher in
OVH versus NTSVG. On the basis of these results it was con-
cluded, no-touch harvesting technique of SVGs may
decrease early graft failure and also reduce postoperative
morbidity and mortality rate, contributing to improved graft
patency rate in the long-term.26, p. 510
Although EVH decreases local wound complications and
improves cosmetic results, several authors have demonstrated
that the time required for completing the harvest and the need
to convert to an open technique or place external repair stitches
were higher, especially during early adoption of EVH, with the
reported rate of conversion to OVH ranging from 5% to 7%.27
Despite an increased number of defects requiring suture repair
with EVH, patency rates up to 6 months appeared similar to
OVH in prospective randomized studies.6,7,28
Distension in OVH is performed using saline even though
many reports emphasize its negative effect on endothelial
integrity and graft performance.29 Overdistension has long
been proven to have an adverse effect on graft patency, and the
amount of time the saphenous vein is distended during harvest-
ing is directly correlated with an upregulation of innate inflam-
matory biomarkers in conduits used in CABG.30 Data suggest
that vein graft failure is a multifactorial process involving
neointimal hyperplasia and inflammation, although immediate
vein graft failure is partially attributed to defects that originate
from intraoperative technical errors.31 Early graft failure may
be attributed to endothelial damage and the involvement of
inflammatory cytokines, whereas late failure (>1 year after
CABG) may be attributed to neointimal hyperplasia. However,
the underlying cause of both processes is quite likely exacer-
bated by high-pressure distension.
Kopjar and Dashwood 125

Figure 4. Structural damage to conventional OVH and EVH saphenous vein. Transverse sections of saphenous veins used in coronary artery
bypass surgery (CABG). No-touch saphenous vein graft (NTSVG): undamaged saphenous vein harvested by the no-touch technique with
adventitia and surrounding perivascular fat intact. The OVH: conventional, OVH, vein harvested with adventitia damaged or removed (Dash-
wood unpublished). The EVH: endoscopically harvested vein with adventitia damaged or removed. Republished with permission from Kiani and
Poston.18 Copyright Wolters Kluwer Health (2011). Large arrow indicates intimal tearing. Small arrows indicate position of the adventitia. Scale
bar 2 mm. EVH indicates endoscopic vein harvesting; OVH, open vein harvesting.

Perivascular Tissue remains intact, representing another mechanism underlying the

Apart from preserving the endothelium of saphenous vein
grafts in patients with CABG, there is evidence that veins har-
vested complete with surrounding cushion of tissue results in
improved graft performance. The NTVH technique removes
the saphenous vein with its cushion of perivascular fat intact
and, using this procedure, the vein does not go into spasm,
high-pressure saline distension is not required, and the vein
maintains its normal architecture (Figure 4).10,11,13 Short-term
patency of NTSVG is improved compared with conventionally
prepared grafts that have been stripped of surrounding tissue and
distended.32 Mid-33 and long-term10 follow-up studies have
shown a dramatic improvement in NTSVG over conventional
grafts with a resulting patency rate comparable to the ITA.
Various mechanisms have been described underlying the
success of NTSVGs. Of particular relevance to OVH versus
EVH preparations is the suggestion that the pronounced cush-
ion surrounding the vein when using NTVH plays an important
mechanical role that protects the vein, not just at harvesting,
but once implanted, where it buffers against arterial hemody-
namics. In support of this are data showing that the external
cushion protects against high pressure-induced damage to both
vascular smooth muscle and endothelial cells as observed in
conventional vein grafts.11,12,19,34,35 Importantly, the outer
cushion possesses mechanical properties where it prevents
kinking of grafts of excessive length.15 Also, by preserving the
cushion of perivascular surrounding tissue, the vasa vasorum
improved patency of these grafts.36 Apart from the obvious dif-
ferences in the appearance of EVH, OVH, and NTVH, the pro-
tective properties of the saphenous veins outer cushion are
striking when compared by both light (Figures 4 and 5) and
electron microscopy.19,34 Histologically, EVH and conven-
tional OVH saphenous veins look very different than those pre-
pared by the no-touch technique (Figures 4 and 5). These
differences are not only seen at the light microscope level but
also obvious at the ultrastructural level (Figure 3).
Perivascular Fat
Adipose tissue is accepted as a source of inflammatory media-
tors associated with coronary artery disease (CAD), such as
interleukin 6 and tumor necrosis factor a. Regarding the coron-
ary circulation, epicardial adipose tissue may represent a
source of adipocyte-derived factors with cardioprotective prop-
erties but also those associated with various aspects of CAD.37
Although the outer layers of OVH and EVH saphenous veins
are removed or damaged, NTVH veins are harvested with a
pronounced cushion of perivascular adipose tissue (PVAT)
intact (Figures 2, 4, and 5). The PVAT, surrounding most blood
vessels, is no longer thought of as merely having a support-
ing role but is now recognized as a source of factors that
potentially influences vascular tone and structure. There is
experimental evidence that PVAT influences vascular tone38
via so-called adipocyte-derived relaxing factor (ADRF).39,40
126 Angiology 67(2)

Figure 5. Damaged vasa vasorum: no-touch saphenous vein graft (NTSVG) versus conventional OVH and EVH veins. Dark CD34 immu-
nostaining identifies endothelial cells lining the lumen (L) and the vasa vasorum. Left, Part of a transverse section of a no-touch harvested vein
with adventitia and vasa vasorum intact. Middle, Conventional OVH vein with adventitia and vasa vasorum damaged (both from Dashwood
unpublished). Right, Damaged adventitia and vasa vasorum in an EVH vein. Republished with permission from Nowicki et al.22 Copyright Elsevier
(2004). Large arrows adventitia; small arrows indicate vasa vasorum. Scale bar 0.5 mm. EVH indicates endoscopic vein harvesting; L, lumen;
OVH, open vein harvesting; PVAT, perivascular adipose tissue.

These factors are of particular interest in vessels used as con-
duits in CABG such as the ITA41 and saphenous vein.42
Regarding the saphenous vein, we have shown that the PVAT
surrounding NTSVG exhibits immunostaining for endothelial
nitric oxide (eNOS) as well as NOS activity.43 In addition, lep-
tin expression and staining have been identified in PVAT of
NTVH veins.44 Since PVAT is in direct contact with the adven-
titia and possesses ADRF activity, there is the potential for this
layer to influence vessel structure and tone. Also, within the
PVAT is a network of capillaries that connect to the vasa
vasorum, microvessels providing the vessel wall with oxygen
and nutrients that are implicated in the superior patency rate
in NTSVG.36,45 The presence of ADRFs surrounding this capil-
lary network that connects to the vasa vasorum suggests that
ADRFs may play a role in preserving a healthy graft by
maintaining blood flow through the vessel wall after its implan-
tation into the coronary circulation. Apart from influencing
vascular tone ADRFs may also affect vessel structure, since
many may possess direct growth factor properties.
Perivascular Innervation
In addition to the ADRFs mentioned previously, the autonomic
innervation of fat should be considered. A recent review
describes the interaction between autonomic nerves and
PVAT.46 Here, the authors describe the expression of adreno-
ceptors, purinoceptors, and receptors for neuropeptide Y,
receptors that can modulate both lipolysis and lipogenesis. A
mechanism is proposed whereby sympathetic neurotransmis-
sion can simultaneously activate smooth muscle cells in the
tunica media to cause vasoconstriction and alter free fatty acid
content and release from adjacent adipocytes in PVAT that can
then influence endothelial function. The authors hypothesize a
strong link between PVAT and autonomic fibers, suggesting
that this poorly understood relationship is important for normal
vascular function and warrants further detailed studies.
These reports are of particular relevance to the saphenous
vein when used in CABG, since removal of the perivascular
cushion of fat would be expected to affect graft performance.
Since preservation of PVAT improves graft performance in
NTSVG the question arises, might perivascular damage to the
saphenous vein (as in OVH and EVH) influence certain
receptor-mediated effects? For example, removal of PVAT and
subsequent loss of ADRFs (eg, adiponectin, leptin, and NO)
might be associated with vasospasm and early occlusion rates
that often occur in OVH47 and EVH vein grafts. Also, does
adventitial damage and removal of PVAT affect autonomic
control of the saphenous vein as well as PVAT-derived
ADRFs? If reduced ADRF levels are associated with vein graft
failure, their receptors may represent potential therapeutic tar-
gets in CABG patients.
The saphenous vein is under the influence of many neuro-
transmitters and neuropeptides that, apart from affecting vascu-
lar tone, possess mitogenic properties that may contribute to
morphological changes caused by vascular injury. Such neuro-
vascular actions may play a role in the altered vein reactivity
and structure involved in graft failure.48 The sympathetic inner-
vation of NTSVG has been studied at both the light microscope
and the ultrastructural level. Here, adrenergic nerves were iden-
tified using tyrosine hydroxylase immunohistochemistry,
where nerve plexi were located in the adventitia, many being
associated with microvessels (vasa vasorum). In conventional
preparations of SV that had been stripped and distended,
degenerating tyrosine hydroxylase-positive axons were identi-
fied as well varicosities with prominent swollen mitochondria
and other signs of nerve damage.49
Clearly, when harvesting the saphenous vein in patients
undergoing CABG, any nerve fibers in the NTSVG will be
Kopjar and Dashwood
separated from their respective cell bodies and thus not be under
full autonomic control. As far as we are aware, there are no data
to show whether, postimplantation, these fibers remain discon-
nected or are reconnected. However, neural reorganization year, Zenati et al published the results of 1471 Veteran Admin-
has been previously described in a porcine saphenous veincar-
otid artery interposition grafting model using NF200 immunos-
taining (a nerve marker). Here, a significant time-dependent
(1 and 6 months) reduction in perivascular nerves located in
the media was observed. In contrast, there was a highly signifi-
cant increase in paravascular nerves in the adventitia accom-
panied by the appearance of large paravascular nerve bundles
at 1 month that diminished at 6 months. Based on these findings,
it was concluded that there is a reorganization of neural tissue in
this porcine vein graft model. Whether these alterations consti-
tute an adaptation to arterial conditions and grafting per se or
whether they influence graft thickening and subsequent patholo-
gical consequences remains to be established.50
Graft Patency: OVH Versus EVH
Dacey et al recently reported on the increasing use of EVH in
the United States (34% in 2001, 75% in 2004, and 80% by
2005).5 Although many studies support the use of EVH,5,51
other studies show that saphenous veins prepared by EVH
provide a graft with inferior patency to those harvested by
OVH.52-54 Protagonists of EVH raise the benefits of this tech-
nique being reduced local wound complications, infection rate,
and pain and improved cosmetic outcome while those favoring
OVH highlight the reduced patency rate of EVH veins compared
with those harvested conventionally by OVH.52-54
Previous guidance in the United Kingdom advised that EVH
should only be used with special arrangements (NICE Interven-
tional procedures guidance 343, Issued: May 2010).14 This
decision was based on data from the Project of Ex Vivo Vein
Graft Engineering via Transfection IV (PREVENT IV) trial
undergoing protocol-mandated follow-up angiography 12- to
18-month post-CABG or earlier clinically driven angiography,
where EVH grafts showed higher failure rates than OVH grafts
and, at 3 years, a higher death rate, myocardial infarction, or
revascularization in EVH versus OVH grafts.52 This landmark
study by Lopes et al52 showed that EVH is independently
associated with graft failure and adverse clinical outcomes
in a secondary analysis of 3000 patients undergoing CABG
(EVH: 1753 patients and OVH: 1247 patients). The finding
of this study resulted in a debate and apprehension among sur-
geons to use EVH grafts for coronary artery surgery. More
recently, yet another post hoc analysis of the PREVENT IV
trial revealed a high prevalence of vein graft failure following
CABG (12.1%-63.6%) and multiple patient- and surgery-
specific factors associated with vein graft failure, including
EVH.55
Data published subsequently to the study by Lopes et al in
2009 provided more definitive answers regarding hard clinical
outcome of patients undergoing EVH for CABG. In 2011,
Dacey et al published a retrospective analysis of 8542 patients
in Northern New England, in which about a half of the patients
127
had EVH.5 Patients who had EVH had about 20% reduced risk
of mortality at 4 years and a nonsignificant increased risk of
repeat revascularization when compared to OVH.5 In the same
istration patients and found no significant differences in 1-year
mortality, although EVH patency was lower and repeat revas-
cularization rate was significantly higher (Table 1).53 And
finally, following on the safety concerns of EVH, the US Food
and Drug Administration issued a request to analyze the Soci-
ety of Thoracic Surgeons Adult Cardiac Surgery Database for
EVH- and OVH-related outcomes. A retrospective analysis
of 235 394 Medicare patients who underwent isolated CABG
surgery in 934 centers between 2003 and 2008 were exam-
ined and published in 2012 by Williams et al51 where 52%
of patients received EVH. In a propensity score-adjusted
analysis, there were no significant differences in 3-year mor-
tality, or a composite of death, myocardial infarction, and
revascularization. The EVH was associated with a 13% lower
harvest wound infection rate.
Considering these new data and the number of patients
included in the subsequent analyses, the NICE interventional
procedure guidance Committee judged that current evidence
on the efficacy and safety of EVH for CABG is adequate to
support the use of this procedure, although the importance of
training and regular experience for any clinician doing this pro-
cedure was noted (NICE interventional procedure guidance
494, issued June 2014).
The difference between the findings from more recent
studies,5,51 and the study by Lopes et al,52 regarding increased
risk of death and adverse cardiac events highlights the poten-
tial bias from unaccounted confounding variables, since the
vein-harvesting technique was not the basis for randomiza-
tion. In this era of percutaneous coronary stenting, it is diffi-
cult to explain how impaired saphenous vein patency might
lead to mortality, particularly when veins are frequently used
for bypassing worse targets, while the second arterial graft is
placed on the better target after the left anterior descending
territory. From a recent review regarding graft quality,64 it
appears that suture repairs of saphenous vein grafts are more
often necessary in EVH than OVH, presumably since EVH
veins are subjected to greater vascular trauma than those pre-
pared by OVH.
Overall patency rate does not solely depend on harvesting
method but on target and vein-related variables and patient
characteristics.55 So far, there are only a few short- and mid-
term follow-up trials (listed in Table 1) comparing EVH and
OVH patency, with the general consensus being that patency
of EVH grafts is, at best, comparable to OVH grafts. Lack of
long-term follow-up EVH patency data forces one to draw con-
clusions about contemporary saphenous vein patency from
trials comparing it with arterial conduits. It seems difficult to
justify EVH use in favor of NTVH, given the potential benefit
to patients with CABG. It is interesting that, while 1 major
advantage of EVH is cosmetic outcome, differences in
appreciation of scarring are mostly notable during the early
postoperative period whereas, after 6 weeks, cosmetic outcome
128 Angiology 67(2)

Table 1. Early Saphenous Vein Graft Patency to Non-left Anterior Descending Territory.

Author, Year, Graft No. Patency

Reference, Study F/u, Study Size F/u (EVH, OVH, or Failure P Patency or
Type Months (Patients) Angio, % NTVH, RA) Rate, % Value Failure Definition Comment

Perrault et al, 3 40 80.0 32, 27, 0, 0 84.4, 85.2 .99 No graft Standard EVH and OVH
2004,7 RCT occlusion intraoperative graft management
Yun et al, 2005,6 6 200 72.0 166, 170, 0, 0 68.1, 70.0 .58 <50% stenosis All veins were gently distended
RCT with autologous heparinized
blood
Zenati et al, 12 1471 60.8 689, 1118, 0, 0 74.5, 85.2 .00 FitzGibbon A, B Prior to 2003, the SV harvesting
2011,53 R technique was not noted
Goldman et al, 12 733 72.7 51, 218, 0, 266 78.4, 91.3 .01a Opacification of SV was dilated with heparinized
2011,54 RCT 88.8, 89.5 .82b distal target by cold (4 C) saline solution and
graft injection stored in this cold solution until
used
Lopes et al, 13 2400 75.7 2321, 1969, 0, 0 27.2, 22.6 .00 >75% stenosis SV were treated with edifoligide or
2009,52 R placebo in a pressure-mediated
system
Souza et al, 18 156 84.6 0, 107, 109, 0 88.9, 95.4 .03 No graft SV harvested by NTVH or the
2002,32RCT occlusion conventional OVH as described
Mannion et al, 15 210 9.5 22, 0, 16, 00 27.3, 93.8 .02 <80% stenosis SV harvested by NTVH or the
2014,65 R standard EVH as described
Dreifaldt et al, 36 108 91.7 0, 0, 99, 99 93.9, 81.8 .01 <70% stenosis RA grafts were prepared with
2013,33 RCT similar technique as the NTVH
grafts
Abbreviations: EVH, endoscopic vein harvesting; F/u, mean follow-up duration; F/u angio, follow-up angiography completion; NTVH, no-touch vein harvesting;
OVH, open vein harvesting; R, retrospective observational trial; RA, radial artery; RCT, randomized controlled trial; SV, saphenous vein.
a
EVH versus OVH.
b
EVH OVH versus RA.

Table 2. Beyond 5-Year Saphenous Vein Graft Patency to Non-left Anterior Descending Territory.

Author, Year, Graft No. Patency Patency

Reference, Study F/u, Study Size F/u (EVH, OVH, or Failure P or Failure
Type Months (Patients) Angio, % NTVH, RA) Rate, % Value Definition Comment

Tranbaugh et al, 60 1851 15.0 0, 364, 0, 420 47.0, 82.0 .00 <50% stenosis SV harvesting technique was not
2012,56 R described
Athanasiou et al, >60 1200 100 0, 848, 0, 309 75.2, 89.6 .00 <50% stenosis Moderate heterogeneity
2011,57 MA I2 25%, P .24
Hadinata et al, 65 416 61.3 0, 197, 0, 68 81.2, 86.9 .26 <70% stenosis SV harvesting was performed by OVH
2009,58 RCT with minimal conduit handling or
distention
Hayward et al, 66 225 50.2 0, 60, 0, 53 87.0, 90.0 .29 <80% stenosis 2008 AATS Meeting Dr Hayward: These
2010,59 RCT veins were all taken in a shamelessly
open no-touch manner.
Collins et al, 68 142 72.5 0, 44, 0, 59 86.4, 98.3 .04 No graft The SV was harvested in a routine fashion
2008,60 RCT occlusion and gently distended
Deb et al, 92 510 52.7 0, 234, 0, 234 19.7, 12.0 .03 TIMI 0-2 SV harvesting included OVH and EVH,62
2012,61 RCT although data not reported
Souza et al, 102 104 71.2 0, 101, 101, 0 76.2, 90.1 .01 No graft SV harvested by NTVH or the
2006,10 RCT occlusion conventional OVH as described
Goldman et al, 120 1254 29.4 56, 58a No graft Data from patients operated prior to the
2004,63 P occlusion introduction of EVH
Abbreviations: EVH, endoscopic vein harvesting; F/u, mean follow-up duration; F/u angio, follow-up angiography completion; MA, meta-analysis; NTVH, no-
touch vein harvesting; OVH, open vein harvesting; P, prospective observational trial; R, retrospective observational trial; RA, radial artery; RCT, randomized
controlled trial; SV, saphenous vein; TIMI, Thrombolysis In Myocardial Infarction flow grade.
a
Patency rates for OVH when bypassing the right (56%) and the circumflex (58%) coronary artery.
Kopjar and Dashwood
is equally appreciated.28 Long-term NTSVGs have a patency
rate of 90% compared with 76% for conventionally, OVH vein
grafts at mean time 8.5 years.10 These results were produced
from a single-center randomized longitudinal trial. Initially,
52 patients were enrolled in each group. Angiographic
follow-up was performed at 18 months and at 8.5 years when
37 patients in each group completed angiographic follow-up.
At 18 months, NTSVG patency was 95%, while conventional
OVH was 89%.32 Others have also emphasized the impor-
tance of no-touch graft handling on long-term saphenous vein
patency (eg, The Radial Artery Patency and Clinical Out-
comes [RAPCO] trial). Beyond 5 years, patency of conven-
tionally harvested vein grafts is about 75%, ranging from
47% to 87% in the most recent literature (Table 2). Since the
majority of studies suggest that saphenous veins prepared by
both EVH and OVH have similar patency rates, it seems rea-
sonable to assume that NTSVG would be superior to those
prepared by EVH.
Learning Curve
Using OCT it has been proven that technicians inexperienced
with EVH are more likely to cause deep vessel injury to the
saphenous vein graft than those with more experience.
Although prior studies suggest that only 20 cases of experience
are required to complete the learning curve of EVH, a more
recent study showed that performing even 100 cases is insuffi-
cient to attain the beneficial results of more experienced har-
vesters.18 Acquiring EVH experience and maintaining this
skill presents a more complex challenge than previously
assumed.66 Importantly, those CABG studies reporting adverse
outcomes after EVH had enrolled patients during the early
phase of its adoption. To date no studies have specifically eval-
uated the learning curve of NTVH. Considering that EVH,
when compared to OVH or NTVH, is mostly associated with
increased intrinsic difficulties, from a surgeons perspective
(Tomislav Kopjar), the learning curve for EVH is longer than
NTVH, which is comparable to that for OVH.
Cost-Effectiveness (Wound Infection)
Despite the saphenous vein being the most commonly used
graft in CABG and EVH, the preferred method in the United
States, data regarding cost-effectiveness are unclear. Wound
infection rate is a crucial factor when determining cost-
effectiveness of saphenous vein harvesting technique. Post-
operative costs show EVH not to be cost effective within 35
days whether effect is shown as purulent infections avoided
or as an estimate of quality-adjusted life years gained.67 How-
ever, results suggest that conclusions may shift when the
follow-up period is increased. Although it has been suggested
that EVH is the most cost-effective method of harvesting the
great saphenous vein and can significantly improve a patients
quality of life,68 the Consensus Statement of the International
Society of Minimally Invasive Cardiothoracic Surgery (ISMICS)
2005 concluded there was inadequate cost-effectiveness data to
129
allow recommendations on the resource implications of the 2
(OVH vs EVH) techniques.
To date, no studies have analyzed the cost-effectiveness of
the NTVH technique. If we consider the no-touch technique,
it is clear that there are no additional equipment costs when
compared to conventional OVH. Also, wound complication
and infection rates for NTSVH would be expected to be higher
than EVH but comparable with OVH. A very recent study,
focusing on vascular smooth muscle cell activation, showed
worse leg wound assessment scores at 3 months but similar
scores at 12 months when comparing NTVH with OVH.35 This
suggests that the cost-effectiveness of NTVH is more likely
comparable with conventional OVH than EVH.
Conclusion/Discussion
Despite the benefits shown to date, the use of NTVH in CABG is
limited to a few centers. Poor conduit quality, as a sequel of the
learning curve for EVH, is a predictor of early graft failure as well
as an underrecognized public health issue.18 Recent supporting
data have shown NTSVG patency rate to be comparable to ITA,
giving it the advantage in the battle for the graft of second choice
in CABG.33 When considering that EVH saphenous vein graft
patency is, at best, comparable to OVH, it seems reasonable to
assume that NTSVG would be superior to those prepared by
EVH, as confirmed by a recent small, short-term, study.65
It is surprising that while both EVH and NTVH techniques
were introduced almost 20 years ago, EVH was so readily
accepted, particularly in the United States.5 The improved cos-
metic outcome and patient satisfaction may explain one of
the main reasons for the large take-up rate of EVH, despite the
high initial equipment costs and lack of cost-effectiveness data.
A number of studies into mechanisms underlying the improved
performance of NTSVGs have identified various features con-
tributing to its success from the advantages of reducing vascu-
lar damage and preservation of the vasa vasorum to preserving
the perivascular fat and various tissue factors beneficial to the
maintenance of a healthy graft.12,13,36
Here, an opportunity for patient selection arises when con-
sidering the emerging data on the improved patency of NTSVG
and concerns over EVH graft quality. Based on risk factors for
harvest site wound morbidity, target characteristics, patient
age, and preference, one technique may be considered over the
other.69 The optimal principle for saphenous vein conduit har-
vesting is one causing minimal vascular trauma, as with
NTVH, and minimal wound complication rate, as with EVH.
Until such a technique is developed, NTVH can and should
be considered for those in whom the risk of harvest site wound
morbidity is justified and tolerable. Multicenter randomized
controlled clinical trials, such as the on-going Surgical and
Pharmacological Novel Interventions to Improve Overall
Results of Saphenous Vein Graft Patency in Coronary Artery
Bypass Grafting Surgery: An International Multi-Center Ran-
domized Controlled Clinical (SUPERIOR SVG) trial (clinical-
trials.gov identifier: NCT01047449), comparing graft patency
and hard clinical outcome of OVH/EVH versus NTVH are
130
required to inform and encourage trainee and established car-
diac surgeons to adopt what is likely to be the best practice
principle in saphenous vein harvesting.
Acknowledgments
We thank Dr Janice Tsui for comments on earlier versions of this
manuscript and Drs Sugam Bhatnagar and Robert Poston for the
example of an EVH saphenous vein graft shown in Figure 2.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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