EVH vs. OVH - Herzzentrum

Endoskopische Venenentnahme der V. saphena in
der koronaren Bypasschirurgie
- Aktuelle Datenlage Dr. med. Stefanie Reutter
Endoskopische Venenentnahme (EVH) - Einführung
1979
Tevaearai und Kollegen haben als erstes die MIVH Technik bei 30 Patienten durchgeführt
unter Verwendung des MiniHarvest System (US Surgical Corporation, Norwalk, Conn)
1996
Lumsden und Kollegen haben als erstes die EVH bei 30 Patienten durchgeführt und
beschrieben (Georgia, USA)
1.Tevaearai HT et al. Minimally invasive harvest of the saphenous vein for coronary artery bypass grafting. Ann Thorac Surg. 1997;63(6):119-121
2.Lumsden AB et al. Subcutaneous, veideo-assisted saphenous vein harvest: report of the first 30 cases. Cardiovasc Surg. 1996; 4(6): 771-6
EVH – Einsatz und Verbreitung in den USA
1
90%
0,8
65%
70%
76%
92%
82%
71%
73%
93%
76%
62%
55%
0,6
46%
36%
0,4
28%
15%
0,2
2%
20%
7%
0
1997
1998
1999
2000
2001* 2002
2003
2004
2005
2006
USER ADOPTION (% of hospitals using EVH)
PENETRATION (% of CABG cases using EVH)
2007 2008E
EVH in den USA und Europa
EVH – Vorteile vs. OVH
¾
Geringeres chirurgisches Trauma
Inzisionslänge, Blutverlust, Schmerzen, postoperative Immunfunktion
¾
schnellere Rekonvaleszenz
¾
geringere postop. Wundheilungsstörungen
¾
befriedigenderes kosmetisches Ergebnis
¾
(Kostenreduktion)
Patientenzufriedenheit
EVH vs. OVH – Kosmetisches Resultat
offen
endoskopisch
EVH vs. OVH – Wundheilung
2-25%
EVH – Patientenauswahl
¾
Keine Adipositas permagna
¾
Keine extrem oberflächliche Vena saphena
¾
Keine Seitenastvarikosis
¾
Keine Gerinnungsauffälligkeiten
¾
Keine Notfälle
Nur
selektiertes Patientengut
EVH – Nachteile vs. OVH
¾
Bypass-Versagen
¾
Fehlende Langzeitergebnisse
¾
Längere Operationszeiten
¾
Kostenerhöhung
EVH vs. OVH – aktuelle Datenlage
Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery:
A Meta-Analysis of Randomized Trials and Controlled Trials Innovations 2005
¾
Objective:
EVH improves clinical and resource outcomes compared with OVH in adults undergoing
CABG
¾
Methods:
Comprehensive literature search (Medline, Embase…) to identify all randomized and
nonrandomized trials of EVH vs. OVH up to April 2005
Primary outcome: wound complications
Secondary outrcomes: any other clinical morbidity and resource utilization
¾
Results:
36 trials of 9.632 patients
13 randomized (1.319 patients)
23 nonrandomized (8.313 patients)
3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of
Minimally Invasive Cardiothoracic Surgery 2005. Innovations. 2005; 1:51-60.
EVH vs. OVH – aktuelle Datenlage
Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery:
A Meta-Analysis of Randomized Trials and Controlled Trials Innovations 2005
¾
Results: Risk of wound complications
Risk of wound infections
significantly reduced by EVH vs. OVH
Need for surgical wound intervention
Incidence of pain, neurolgia,
improved with EVH vs. OVH
patient satisfaction
Postop. MI, stroke, reintervention, AP
quality of graft
Operative time
not significantly different betw. EVH vs. OVH
significantly increased by EVH
3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of
Minimally Invasive Cardiothoracic Surgery 2005. Innovations. 2005; 1:51-60.
EVH vs. OVH – aktuelle Datenlage
2005 The International Society for Minimally Invasive Cardiac Surgery (ISMICS)
Consensus Conference suggest:
Innovations 2005
¾
EVH is recommended to reduce wound related complications, improve patient satisfaction, and
decrease postop. pain, hospital LOS, and outpatient wound management resources when compared
to OVH (Class I; Level A)
¾
Based on quality of conduit harvested, either EVH or OVH technique may be used
(Class IIa; Level B)
¾
Based on major adverse cardiac events and angiographic patency at 6 months, either EVH or OVH
technique may be used (Class IIa; Level A)
Conclusion:
EVH should be considered the standard of care for patients who require
saphenous vein grafts for coronary bypass surgery
3. Allen K, Cheng D, Cohn W, et al. Endoscopic Vascular Harvest in Coronary Artery Bypass Graft Surgery: A Consensus Statement of the International Society of
Minimally Invasive Cardiothoracic Surgery 2005. Innovations. 2005; 1:51-60.
EVH vs. OVH – aktuelle Datenlage
Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery
N Engl J Med 2009
¾
Objective:
Effect of EVH on vein-graft failure as assessed by angiography 12 to 18 months and on
long-term clinical outcomes
¾
Methods:
3.000 patients undergoing CABG (1.753 EVH; 1247 OVH); randomized, 107 centers
Primary outcome: vein-graft failure (defined as >75% stenosis of graft on angio.)
Clinical outcomes: death, MI, repeat revascularization (3 year follow-up period)
¾
Results:
EVH significantly higher rates of vein-graft failure at 12 to 18 months than OVH
(46.7% vs. 38.0%, P<0.001)
EVH associated with higher rates of death, MI, or repeat revascularization after 3 y
(20.2% vs. 17.4%, P=0.04)
A
4. Lopes RD, Hafley GE, Allen KB et al. Endoscopic versus Open Vein-Graft Harvesting in Coronary-Artery Bypass Surgery: N Engl J Med. 2009; 361(3): 235-44
EVH vs. OVH – aktuelle Datenlage
Impact of endoscopic versus open saphenous vein harvest techniques
on outcomes after coronary artery bypass grafting
Ann Thorac Surg 2010
¾
Objective:
Assess the effect of EVH on short-term and midterm outcomes after CABG
¾
Methods:
1998 - 2007 at a single center (Canada); data prospectively collected
5.825 patients undergoing first time isolated CABG and combined valve/CABG
→
2.004 (34.4%) patients EVH;
→
3.821 (65.6%) patients OVH (continuous/bridging)
Short-term outcomes: leg infections, in-hospital mortality,
Midterm outcomes:
all-cause mortality, readmission to hospital for cardiac
catheterization, repeat revascularization, unstable angina,
MI, heart failure
median follow-up 2.6 years
5. Ouzounian M et al. Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting: Ann Thorac Surg.
2010; 89(2): 403-8
A
EVH vs. OVH – aktuelle Datenlage
Impact of endoscopic versus open saphenous vein harvest techniques
on outcomes after coronary artery bypass grafting
Ann Thorac Surg 2010
¾
Results:
EVH associated with reduced rates of leg infection (1.1% vs. 2.2%, p=0.003)
EVH similar rates of in-hospital mortality compared with OVH (3.2% vs. 4.0%, p=0.16)
EVH no association with midterm adverse outcomes (hazard ratio 0.93, p=0.22)
→
EVH and OVH similar freedom from death or readmission to hospital
for cardiac cause
→
¾
EVH associated with reduced rate of readmission to hospital for
unstable angina (hazard ratio 0.74), but not for MI
Conclusion: EVH is not an independent predictor of in-hospital or midterm adverse outcomes
5. Ouzounian M et al. Impact of endoscopic versus open saphenous vein harvest techniques on outcomes after coronary artery bypass grafting: Ann Thorac Surg.
2010; 89(2): 403-8
EVH vs. OVH – aktuelle Datenlage
Long-Term Outcomes of Endoscopic Vein Harvesting After
Coronary Artery Bypass Grafting
Circulation 2011
¾
Objective:
Explore use of EVH and influence on perioperative and long-term outcomes
¾
Methods:
2001 - 2004 at a 8 centers (north. New Engl.); data prospectively collected
8.542 patients undergoing first time isolated CABG
(excluded: <30y, emergency surgery, life-threatening malignancy, TAR, radial artery)
→
4.480 (52.5%) patients EVH;
→
4.062 (47.5%) patients OVH (continuous incision)
Short-term outcomes: in-hospital morbidity and mortality
Long-term outcomes: mortality and repeat revascularization (CABG or PCI)
follow-up 4 years
6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2): 147-53
A
EVH vs. OVH – aktuelle Datenlage
Long-Term Outcomes of Endoscopic Vein Harvesting After
Coronary Artery Bypass Grafting
Circulation 2011
¾
Results:
Long-term outcome:
mortality
Figure 1. Adjusted risk of mortality by
vein harvesting approach (2001 to 2004).
The HR is for EVH relative to OVH
related to mortality. Adjusted for age,
sex, EF, vascular disease, DM, BMI…
6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2): 147-53
A
EVH vs. OVH – aktuelle Datenlage
Long-Term Outcomes of Endoscopic Vein Harvesting After
Coronary Artery Bypass Grafting
Circulation 2011
¾
Results:
Long-term outcome:
repeat revascularization
Figure 2. Adjusted risk of repeat revasculariztaion
by vein harvesting approach (2001 to 2004).
The HR is for EVH relative to OVH related to
risk of repeat revascularization. Adjusted for age,
sex, EF, vascular disease, DM, BMI, …
6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2): 147-53
A
EVH vs. OVH – aktuelle Datenlage
Long-Term Outcomes of Endoscopic Vein Harvesting After
Coronary Artery Bypass Grafting
Circulation 2011
¾
Results:
In-Hospital outcomes:
Use of OVH associated with an increased postop. leg wound infection (P<0.001)
EVH associated with an increase in return to operating room for bleeding (P=0.03)
Long-Term outcomes:
EVH significantly associated with a reduced risk of mortality
EVH associated with an insignificant increased risk of repeat revascularization
¾
Conclusion: EVH is a safe and viable technique for obtaining saphenous vein conduit for CABG
Additional studies are warranted to improve understanding of mechanism by which
EVH influences long-term outcomes, as well as how clinical teams can maximize
the utility of this technique
6. Dacey LJ et al. Long-Term Outcomes of Endoscopic Vein Harvesting After Coronary Artery Bypass Grafting: Circulation. 2011; 123(2): 147-53
EVH - Schlussfolgerung
¾
Sicheres und praktikables Verfahren
¾
Datenlage zeigt durchweg geringere Wundkomplikationsraten
¾
Sehr gutes kosmetisches Ergebnis → erhöhte Patientenzufriedenheit
¾
Prospektiv-randomisierte Studien → Langzeitergebnisse nach EVH
(EVH vs. MIVH)
¾
Kostenanalyse