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Randomized Trial of Endoscopic or Open Vein-Graft Harvesting for Coronary-Artery Bypass

Thursday, November 15, 2018

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Source Name: The New England Journal of Medicine


Marco A. Zenati, Deepak L. Bhatt, Faisal G. Bakaeen, Eileen M. Stock, Kousick Biswas, J. Michael Gaziano, Rosemary F. Kelly, Elaine E. Tseng, Jerene Bitondo, Jacquelyn A. Quin, G. Hossein Almassi, Miguel Haime, Brack Hattler, Ellen DeMatt, Alexandra Scrymgeour, Grant D. Huang, for the REGROUP Trial Investigators

An interesting randomized controlled trial asserting robustly that endoscopic harvesting of saphenous vein is: (1) better for leg dehiscence and (2) at least noninferior for MACE compared to the conventional open "full touch" method. Somewhat puzzling are the high mortalities and revascularization rates in both arms, across a median follow up less than three years. The requisite hour or more to harvest the vein(s) openly also seems a bit long for experienced operators, even if we include closure of the incision.


While I understand there has been a few surgeons who feel endoscopic vein harvesting is a bad thing and there has been some weak data in that regard, few believe that patients truly benefit from having 2-3 foot long incisions in their legs - remember how common wound problems were back then? However, my major issue with this paper, which I admit is biased by my being a veteran, is that is was wrong to conduct this study in VA hospitals with a captive, vulnerable population. Routine open vein harvest is not the prevailing standard anymore for CABG in the US. Likely could not have done this study in civilian hospitals: most civilian insured patients would not go for it. Veterans are not lab rats they are heroes who served so others including the investigators can enjoy freedom and security and I think this was wrong to do this study.
There are multiple problems with this manuscript. First, operative mortality is prohibitively high. How do these results compare to the VA or STS database estimated operative mortality? It appears that the individuals who harvested the being were inexperienced, given the length of time required. It appears that these results, although randomized and prospective, do not appear to be valid outside of the Veterans Administration. One could make a case for moving heart surgery out of the VA given these results.

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