Vascular Trauma and Grafting Techniques

The provided assignments cover various aspects of vascular trauma and grafting techniques. The first article discusses prosthetic grafts in complex military vascular trauma, while the second focuses on randomized trials comparing bilateral vs single internal mammary artery bypass grafting. Another article explores coronary atherosclerosis imaging by CT angiography. Additionally, there are articles on arterial revascularization trial results, limb salvage strategies using prosthetic grafts, and associations between endoscopic vs open vein-graft harvesting and CABG surgery outcomes.

SCHOOL OF HEALTHCARE SCIENCES
ASSIGNMENT SUBMIT FORM
Student number:
Course: BSc (Hons) in intra & perioperative Practice
Module code and name: HC3076 DISSERTATION
Assignment title: A review of autologous venous harvesting
Coronary Artery Bypass Graft
Declared word count: 9993
A review of autologous venous harvesting Coronary Artery Bypass
Graft
A project submitted in partial fulfillment of the
BSc (Hons) Degree in Intra and Perioperative Practice
yasir almuzaini
C165028
May 2018
Perioperative Practice Programme,
School of Healthcare Studies
Cardiff University
Cardiff CF14 4XN
Perioperative Practice Programme,
Cardiff University
B Sc (Hons) Dissertation
1

Acknowledgment
I would like to take this opportunity to express my sincere gratitude and
deep appreciation to my supervisor Paul Hennessey and Fiona Morgan for
their invaluable insight, timely advice, continual guidance, constant
supervision, encouragement and moral support throughout this project.
2

Abstract
Coronary artery disease affects the major proportion of the world population. Coronary
artery bypass grafting is a proven technique which provides a long-term survival rate of
patients. The current scope of study evaluates the effectiveness of endoscopic
autologous vein harvesting process as compared to the traditional or open vein
harvesting methods for the purpose of reducing long-term complications. A
methodology to analyze various literature article has been used as the search strategy
to understand the better CABG technique. Review of articles is conducted in
accordance with the PICO procedure to develop research questions. Findings from
secondary sources reveal that EVH has various associated complications that arise
post operations. However, the complications are cases of open harvesting is
considerably lower, therefore selecting EVH as an alternative requires considerable
evaluation.
3

Table of Contents
Acknowledgment 3
Abstract...................................................................................................................... 4
Table of Contents............................................................................................................ 5
Introduction................................................................................................................ 6
Methods.................................................................................................................... 14
Search Strategy, Justification for Review...............................................................14
Results with Prisma chart......................................................................................... 16
Discussion................................................................................................................ 19
Limitations................................................................................................................ 33
Recommendations.................................................................................................... 34
Conclusion................................................................................................................ 34
Reference................................................................................................................. 35
Introduction
Coronary artery disease is the most fundamental reason for mortality in the
industrialized nations all over the world (Owens, 2010). It has been estimated that
yearly in excess of one million people in the world suffer from coronary atherosclerosis
disease. Coronary Artery Bypass Grafting (CABG) was first used in the 1960s. From the
middle of 1990s cardiac surgeons made use of endoscopic vein-graft harvesting (EVH)
techniques as opposed to large, incision-based open vein harvesting such that patient
postoperative discomfort and incision-site complications could be improvised. EVH
4

applies devices that are certified by the Food and Drug Administration (FDA) on the
basis of considerably applied procedures. There are a wide variety of advantages of
EVH which convinced its widespread adoption(Stone, Maehara, Lansky, de Bruyne,
Cristea, Mintz, Mehran, McPherson, Farhat, Marso & Parise, 2011). Data reveals that
EVH has been used in more than 400,000 coronary artery bypass grafting (CABG)
procedures that were conducted in the U.S. surgical centers.The current scope of study
examines EVH and OVH to evaluate the better one amongst the two. The introduction
covers a brief description along with understanding post-operative complications of the
procedures.
The long saphenous vein (LSV) is the most preferred conduit for coronary artery bypass
grafting (CABG) procedures in spite of increasing usage benefits of multiple arterial
grafting. In open vein harvesting (OVH) LSV is harvested by means of an incision in the
lower limb. A recent procedure to reduce the pain along with the risk of infection in post-
operative cases is depicted by (EVH). The EVH method is used in 70% CABG
procedures in the year 2008 as per data provided by the Society of Thoracic Surgeons’
National Cardiac Database (Hassantash, Bikdeli, Kalantarian, Sadeghian & Afshar,
2008). EVH has been shown to decrease the postoperative risk of leg wound morbidity
with improved cosmetic results, along with enhanced patient satisfaction according to
evidence obtained. EVH has several potential detrimental impacts on vein graft patency
as per clinical outcomes in spite of the several benefits remaining. This review article
comprehensively deals with the technical aspects, outcomes, concerns, and
controversies associated with EVH (Nissen, Nicholls, Wolski, Nesto, Kupfer, Perez,
Jure, De Larochellière, Staniloae, Mavromatis & Saw, 2008).
Patients affected with the coronary artery disease are treated with coronary artery
bypass graft surgery or CABG, as being the most acceptable form of cure. The
condition affecting narrowing of coronary arteries by building up of the plaques in the
arterial walls hinders blood flow thus leading to further cardiac complications. This
reduces oxygen rich blood from entering the heart muscle affecting its functions. The
blocked portion of the arteries is bypassed by replacing the narrowed artery with
another piece of grafts. There is a varied process for vein grafting such as open vein
5

grafting, and endoscopic vein harvesting(Lopes, Williams, Mehta, Reyes, Hafley, Allen,
Mack, Peterson, Harrington, Gibson & Califf, 2012). Open vein grafting procedure is a
traditional approach as against EVH. While there remains a debate on the efficacy of
both methods, surgeons make a selection on the basis of post-operative complications
in patients. EVH method has lesser post-operative complications as compared to the
traditional approach. Research conducted in the past reflects that open surgery has
increased rate of complications, with an increased hospital stay, leg pain, and so on. In
the EVH method, there is associated considerable risk of injury that might undermine
the vein graft patency.
The short-term safety along with efficacy of EVH was evident in most studies that were
conducted however the studies did not evaluate the long-term outcomes from
randomized controlled (Menasché, Alfieri, Janssens, McKenna, Reichenspurner,
Trinquart, Vilquin, Marolleau, Seymour, Larghero & Lake, 2008). There have been
conducted a number of an observational study in 2009 that could question the safety of
endoscopic vein-graft harvesting. as being the replacement of open surgery. Studies
depicted that those receiving EVH faced a higher risk from higher 3-year mortality and
1-year angiographic vein graft failure as compared to those who were receiving open
harvesting. This was concluded from a study that examined 3000 CABG patients who
were in the PREVENT IV trial. The importance of venous stasis at the time harvest
creates a pressurized subcutaneous tunnel, along with larger caliber segments for a
harvested vein in EVH procedure, as biological mechanisms in EVH harm extends
greater vessel manipulation (Harskamp, Lopes, Baisden, de Winter & Alexander, 2013).
The confirmation regarding EVH findings from one regional studyof PREVENT IV was
not undertaken.EVH systems with and without carbon dioxide insufflation are used in
disposable systems and reusable in nature. The location of the vein in EVH is identified
by the operator by means of gentle “milking” of the vein after appropriate positioning of
the patient. Ultrasound machine can be applied for localizing the point of care in case
the operator is not able to palpate the vein, portable or osseous landmarks. A 35 cm of
the thigh leg LSV might be harvested from a three cm incision above the medical
condition of the knee. In order to start the harvesting process a 2 to 3 cm on the medial
malleolus part is done, a post which a second incision on the knee for harvesting the
6

vein on the groin is done.In case the whole 70 cm length of vein is required, the
changes will need to repeat the processby the same incision towards the other direction
(Khalafi, Bradford & Wilson, 2008). A balloon tip trocar is injected into the incision post
identification of the vein and with the tunnel being inflated with carbon dioxide. On the
anterior surface of the vein examined under videoscopic, the conical dissection cone is
introduced in the direction of the groin. Any clots within the vein are flushed for
removing any clots which might have accumulated. A redivac drain is positioned post
the wound closure and the leg is wrapped along with a compression bandage for a
period of 48 hours and then the tunnel is evacuated from any residual blood(Erbel,
Möhlenkamp, Moebus, Schmermund, Lehmann, Stang, Dragano, Grönemeyer, Seibel, Kälsch
& Bröcker-Preuss, 2010).
Recognizes the complications in the LSV light, Brown and co-workers use optical tomography
(OCT) to study the effects of preheparinization and sealed CO2. Initial Preheparinization prior to
EVH (5000 IU bolus or full dose heparin for activated coagulation time> 300 seconds) in
coagulation fractions and coagulation volume. CO2 insufficient CO2 system is not observed in
the EVH system with an open CO2 insufflation system without preheating.An open CO2 system
can be achieved using the EGF system. There is no difference in low dose and (II) full dose
dosing and (III) in an open CO2 insufflation system without pretreatment (Serruys, Morice,
Kappetein, Colombo, Holmes, Mack, Ståhle, Feldman, van den Brand, Bass & Van
Dyck, 2009).
. Although this study will not be implemented in the future, it is not possible to reduce
the load of a blood clot. The largest saphenous vein (GVS) is the most collected
revascularization channel during coronary artery surgery (CABG). Some studies have
shown that the OVH procedure indicates postoperative disease, delayed hospitalization,
and extension. Therefore, a minimally invasive method of reducing surgical damage
associated with OVH has developed over the past decade(Desai, Seifalian & Hamilton,
2011). There are postoperative infections, illness, impaired mobility, and hospitalization
length. In early studies, there was no significant difference in OVH and EVH procedures
within six months after surgery. However, new studies indicate that EVH can be
attributed to reduced pain. From a histopathological point of view, EVH is very similar to
OVH techniques. However, some studies of endothelial cell transmissions do not match
7

the results. In recent studies, EVH is associated with increased mortality, myocardial
infarction in first-year surgery after surgery.
Since post-operative theoretical investigations were not systematically performed,
planned CABGenders was decided upon, not on pumps to make their own decisions in
accordance with these procedures (Locker, Schaff, Dearani, Joyce, Park, Burkhart,
Suri, Greason, Stulak, Li & Daly, 2012). OVH and EVH in the coronary bypass method.
In addition to clinical and pathological results, there is a comparison for the EVH and
OVH layers.In recent years, there has been much evidence to focus on ATTH EVH
accompanied by low morbidity legs, better cosmetic results, and improved patient
satisfaction. For all this, despite the benefits of the benefits, there is still some concern
about these potential benefits of this technology on endothelial integrity (McLean,
Nazarian, Gluckman, Schulman, Thiemann, Shapiro, Conte, Thompson, Shafique,
McNicholas & Villines, 2011). However, the results of our study did not show any
negative EVH clinical outcomes and patients had pain in the OVH group. This study
was a post-pain pain after six weeks. The monitoring of the EVH Group has shortened
the period significantly compared to the OVH Group. With the degree of pain (23.1% by
volume 6.7%), neuralgia (24.3% by volume 7.1%) and patient satisfaction (49% V 75%)
it can be assumed that EVH is better in the OVH Group.
One of the other is an infection of complications of venous seizures in the incision. Over
eleven EVH ACE technique associated with SV significantly reduced the rate of
infection site OVH recipients (OR = 0.22, P <0.00001) (Domanski, Mahaffey,
Hasselblad, Brener, Smith, Hillis, Engoren, Alexander, Levy, Chaitman, & Broderick,
2011). Sv Another meta-analysis of 35 studies, including the king of the EVH group, the
infection rate (p <0.0001) is maintained. In another study by Raja et al. 2013 where 411
CABG expects the level of infection at the logging site to be four years. The fact that
EVH's technique virtually eliminated the risk that the technique warns the site of
infection, the HVO (13.1% versus 1.3%, p <0.001). The reason may be the result of a
smaller incision and the safe transfer of this tissue to the surgical procedure. Another
important aspect of the primary outcome is tissue perfusion, which preserves one of the
least likely viable tissue valves(Shahian, O'brien, Filardo, Ferraris, Haan, Rich,
8

Normand, DeLong, Shewan, Dokholyan & Peterson, 2009). The infection has always
been a big problem, related to the quality of harvested vein complications transported to
close the graft can cause serious complications in other organs. In this study, two
groups of HART complications, renal and cerebrovascular diseases were compared
during hospitalization and there was no significant difference. Myocardial Infarction (MI)
Analysis The main complication is the opening up of transplantation indicators
(Sareyyupoglu, Schaff, Ucar, Sundt, Dearani & Park, 2009).
Investigation of short, medium and long-term mortality is another important factor in
assessing the safety of a given technology. There was found no difference in mortality
during hospitalization and between six groups of six weeks of follow-up. This is also
reported in some comparative meta-analyses performed by EVH and OVH. But more
research is needed on this subject to obtain more precise results, especially in the short
and medium term. Another important aspect of this study is the cost of treatment, higher
in the HLE group than in the OVH group(Albert, Elena, Nicole, Süleyman, Ralph,
Richard & Udo, 2015). This mainly affects the cost of the technology itself. Few studies
that have examined this problem have shown that a reduced response time and
reduced injuries reduce hospitalization and reduce the costs of medical care in the EVH
Group. However, there were no significant differences between the two patients studied
in their hospital. Despite the awareness of the benefits of EVH, the quality of the
corrected vein is a major problem because endothelial lesions affect the opening of the
graft by the PAC. This study has controversial results; Hussain et al. did not reveal the
difference between the structural and functional viability of the intravenous vein of EVH
and the OVH endothelium but demonstrated that vasomotor activity would decrease.
Wang et al. had similar results were also published(Ahmadi, Nabavi, Hajsadeghi,
Flores, French, Mao, Shavelle, Ebrahimi & Budoff, 2011). The Andreasas (2015) study
showed that in the last 6.3 years, the majority of vein transplants revealed significant
EVH instead of OVH, with no differences in long-term clinical outcomes. The results of
the angiographic monitoring did not show differences in the clinical result for the
endoscopic open endoscopic removal of the coronary arteries. EVH is a general method
to eliminate the venous virus from PAC. These results led to an increase in endoscopic
venipuncture (EVH). EVH and OVH have been reported to reduce wound complications,
9

recover recovery, reduce exposure time and then reduce postoperative pain for EVH.
Guidelines for Cardiology Cardiology 2014 (ESC) and Cardiothoracic Surgery (EACTS)
for myocardial ischemia for channel revascularization and recommendation (El-Chami,
Kilgo, Thourani, Lattouf, Delurgio, Guyton, Leon & Puskas, 2010). This
recommendation, which is the first official recommendation of EVC / EACTS for EVH, is
based on meta-analyses and randomized trials. Almost all studies have shown a
worsening of infectious and curative wounds in the wound, and the guidelines have also
confirmed this. The recommendation is based on the ESC / EACTS 2014 EVH
guidelines, which states that "endoscopic vein harvesting should be considered as a
reduction in the number of injuries caused by complications". In both groups, tissue
translocations showed no significant difference in their pathological findings in this study
(p = 0.241). The following methods are undertaken for arriving at literature searches
related to the study (Kottenberg, Thielmann, Bergmann, Heine, Jakob, Heusch &
Peters, 2012).
The shift from conventional activities to less invasive people often provides resistance.
OVH is not a technically difficult procedure and was considered a standard treatment.
For decades, surgeons have been able to reliably and reliably remove the largest
saphenous vein, either through a single long leg section or through several small
incision. Unfortunately, these conventional techniques are associated with wound
complication rates of up to 44%. The endoscopic vein harvesting technique is a method
that reduces wound complications, increasing the length of the cut is reduced, the
trauma of the tissue is reduced, and perhaps the skin fold slope is scaled down(Magee,
Alexander, Hafley, Ferguson, Gibson, Harrington, Peterson, Califf, Kouchoukos, Herbert
& Mack, 2008). Although the difference in wound complications between EVH and OVH
was not statistically significant in the current study, perhaps a secondary sample size,
there was a tendency for fewer infections in the EVH group. In the cardiology literature,
the complication rate of the wound in HIV patients has been continuously reduced
compared with OVH. A recent study of wound healing between EVH and OVH is
cardiac surgery in a patient using aseptic procedures (serious flow, erythema, pus, and
deep tissue separation, isolation of bacteria and duration of recording) performed the
balloon, 0.2, 16, this The evaluation system is validated by the judges as a method for
10

classifying wounds in the clinical trial and to describe the wounds in a reproducible
manner for an in-depth follow-up (Johansson, Souza, Bodin, Filbey, Loesch, Geijer &
Bojö, 2010).
A prospective, randomized, controlled study of 110 OVH patients was significantly
impaired in wound healing in a patient's found experience compared to those who
reported a prospective, randomized study of 100 patients treated with wound
complications heart of the literature or 8% with EVH and 34% OVH EVH.2 (P = 0.001)
improvement of wound complications. EVH literature not observed in the current study,
the conception of the study and groups of patients (Saunders, Nambi, De Lemos,
Chambless, Virani, Boerwinkle, Hoogeveen, Liu, Astor, Mosley & Folsom, 2011). Most
cardiovascular studies were prospective randomized controlled trials. In addition to
inguinal harvesting, a patient suffering from the vascular disease has the increased
inherent risk of ulcer complications with the vein due to the nature of their ischemic
disease, most of the patients subjected to different heart vein harvest. Despite the lack
of potentially randomized controlled trials in the vascular-surgical literature, all but one
reported a complication rate of the wound in patients with HIV. The largest series, which
was evaluated by EVH for infusion bypass surgery indicated previously from a wound
complication rate of 7.5%, well below the most frequently reported wound complications
for OVH. Patients also benefited from OVH (Hillis, Smith, Anderson, Bittl, Bridges,
Byrne, Cigarroa, DiSesa, Hiratzka, Hutter & Jessen, 2011). EVH legs were associated
with a reduction in postoperative pain, and less ambulation time.1 2 In addition, one
patient suffered reduced bone edema EVH reported reduced and movement of the
knees and ankles, and fewer visits to the general practitioner of relatively OVH-based
patients. 1, 2 As has often been overlooked, the cosmos and patient satisfaction in
patients with EVH have improved compared to OVH patients (Vertrees, Fox, Quan,
Cox, Adams & Gillespie, 2009).
The disadvantages of EVH are the increase in working hours in relation to the learning
curve, costs and possible trauma. Several studies report a learning curve for EVH that
0.2 in the first phase to increased operating times and wound complications, However,
implementation has reached five skills quickly and the genetic rally has been reached
11

after only 20 procedures. Our medical assistants, who already had EVH experience in
cardiac surgery, felt comfortable after about 20 years. The greatest difficulty in the
transition from cardiac surgery to the derivation of lower limb function is the need for a
longer intact lifespan(Taggart, Altman, Gray, Lees, Nugara, Yu, Campbell, Flather &
ART Investigators, 2010). The preparation is more difficult in the lower leg because
there is less space for the partner. An exclusive look at the time of harvest, but there is
little difference between EVH and OVH legs, and the smaller is the total length of the cut
treated EVH.
.
Methods
Search Strategy, Justification for Review
The health library of Cardiff School was used to lead a request for perusing material and
to search for help and direction from the custodian to find resources. The search
strategy also made use of appropriate pieces of literature available electronically from
12

Scopus, Cochrane library, PubMed, Medline and Embase by means of Ovid from
Cardiff University facilities. Google Scholar was used for the purpose of undertaking
reviews of articles only.
All cases of the beforehand said electronic databases were limited to in the region of
1971 and the present day, as the EVH was first used as a bypass conductor for
coronary channel surgery from that date.
Search was conducted in Medline and Embase by means of Ovid with selected key
search terms as "open venous harvesting", which resulted in 42 articles. The second
search was "Coronary Artery Bypass Grating" which had 49 articles. Then the search
was conducted using "EVH" which had 22 articles. Another search term was
"autologous venous patency in CABG" which had 46 articles. In Scopus, similar terms
were used and had resulted in a total of 18 articles for "autologous venous patency in
CABG". Its search showed the result of 22 for was "Coronary Artery Bypass Grating",
therefore 199 articles were found.
In order to select articles for the purpose of review, various factors were taken into
consideration. Similar terms were not used across all databases such that maximum
information and articles can be retrieved from them. Most importantly, the topic
analyzed here have been seen to have terms which similarly addresses the topic
meaning in similar ways such as Coronary Artery Bypass Grafting was found to be
similar to EVH and open vein harvesting. Most importantly only articles written in the
English language were considered, then their focus on human subjects as most
research articles were conducted on animals Published studies that had peer review
were considered crucial for this literature that had randomized clinical trials (RCT). RCT
is considered to be the gold standard for an investigation into treatment based
interventions (Yamamoto, Sakamoto, Nara, Ban, Esaki, Shimada & Kosuge, 2009).
From a review of reading abstracts and full text 10 articles were chosen
 Williams, et. al. (2012)
 Andreasen, Nekrasas, and Dethlefsen (2008)
13

 DiFedeet. et. al. (2014)
 El-Chami et al. (2010)
 McAllister et. al. (2009)
 Ouzounianet. al. (2010)
 Amouzeshi, et al.(2016)
 Santo et. al. (2014)
 Khalafi, Bradford, and Wilson (2008)
 Koniget. et. al., (2009)
The articles serves as secondary data source for the study and there will be no primary
search undertaken for the purpose of this study. Mostly qualitative data will be collected
for the purpose of this study and quantitative data will be ignored. The qualitative data
collected for the purpose of the study will be analysed using deductive reasoning.
Deductive reasoning is a technique where a theory or body of knowledge will be
identified and then possibilities to arrive at a logical conclusion is made. It makes use of
inference procedure to arrive at a conclusion related to the study. The articles once
considered as literature will be analysed in a qualitative manner. An interpretive and
deductive reasoning applied to the same will allow drawing conclusion to whether EVH
is a better procedure as compared to OVH.
Results with Prisma chart
In order to arrive at the discussion of this review, a brief understanding related to
various articles needs to be developed. Each article has been identified and information
collected from them reveals intricate details related to the understanding of the
Coronary Artery Bypass Graft surgery. The consolidation criteria that were pondered for
picking and enduring articles in this study were according to the accompanying: English
14

vernacular, focusing on individuals, dispersed examinations, which must be randomized
clinical primers (RCT), the individuals inside the randomized control starter needed
ailment in no less than two coronary conductors, the individuals must have their first
elective coronary supply course evade join together, the inside mammary passageway
was in situ for the left front sliding coronary course, the winding vein conversely with
saphenous vein or right inward mammary channel was the intervention, the release
division of the part's heart inside the fundamental was more than 25% finally the base
fundamental term was multi-year. Scholars communicated that the essential inspiration
driving the joining criteria is to recognize as far as possible and to describe analyze
restrictions.
Randomized Control starters (RCTs) were picked in light of the way that this
arrangement, when associated precisely, is the best quality level for the examination of
treatment medications. If the examiner's request contains an examination, this
demonstrates the sort of study. An examination that plans to consider one intercession
against another is a "controlled starter". If such a trail randomizes individuals into social
affairs and all get-togethers are managed comparably outside of the treatment, with the
likelihood of enlistment of each get-together being proportional, by then such
examinations are regarded to be strong. The randomized controlled primer drove in
such a path is along these lines considered as the splendid standard for the
consequences of the examinations. Moreover, RCT can diminish decision tendency. In
the article, they state the viability of the radial artery joint is less clear as transplantation
has concentrated more on saphenous vein graft for CABG in almost every article.
Therefore a multi-focus forthcoming randomized control trial to think about patency and
survival between outspread conduit grafts in patients experiencing coronary course
sidestep and saphenous vein graft at one-year post-agent. Mageet. et. al. (2008) has
recorded that writers of diary articles must give brief speculations about their trials so as
to give a helpful manual for the readers. They begin their article with a sensible writing
survey. The article begins with an acceptable criticism which alludes to the question of
the examination. The fundamental point of the criticism is to give an outline of the
circumstance or the as of now known issues and to recognize holes in information. The
point of the examination and its reason are plainly recognized. Writing survey is an audit
15

of any distributed investigations identifying with a similar subject, reasoning that the
point and method of reasoning were to compose an article that would make the theme
and undertakings of the examination all the more clear. They underlined that exploration
including patients must be affirmed by an examination morals advisory group keeping in
mind the end goal to guarantee that the level of training is inside moral gauges, and in
this manner that the privileges of the members of the trial and in addition the scientists
are secured.
The extended written work review technique has been chosen for this examination since
it is a strategy for recognizing and investigating the present confirmation. Besides, time
impediments on the maker and compelled sponsoring moreover infer that this approach
is the most shrewd. Books and guidelines will moreover be used to get information
about the written work. Regardless, as point by point underneath, if data on a
comparative social occasion of individuals has been conveyed previously, simply the
most recent generation will be considered in this review.
16
Records identified through
database searching
(n = 42 )
Additional records identified
through other sources
(n =32 )
Records after duplicates removed
(n = 11 )
Records screened
(n = 10 )
Records excluded
(n = 15 )
Full-text articles assessed
for eligibility
(n =52 )

Discussion
Williams, et. al. (2012) analyzed randomized trial to compare bilateral as against single
internal mammary coronary artery bypass grafting in 1-year results of the Arterial
Revascularization Trial (ART). The article analyses usage of bilateral internal thoracic
(mammary) arteries for coronary artery bypass grafting (CABG) which have been seen
to have a long-term beneficial outcome as against single internal-thoracic-artery
including vein grafts. The article analyzed patients in a random manner, which
underwent CABG with single or bilateral internal-thoracic-artery grafting. The data was
collected across seven countries and 28 surgical centers. Outcomes of the study
included death at 10 years from any cause, and then there were outcomes related to
death from myocardial infarction or stroke. The study provided that there was not much-
associated difference amongst patient outcomes in CABG, who received single internal-
thoracic-artery grafts and bilateral internal-thoracic-artery grafts. When mortality rates
17
Full-text articles excluded,
(do not meet inclusion)
(n = 22 )
Studies included in the
literature review
(n = 10 )

were compared along with rates of cardiovascular happenings in 5 years of follow up,
then bilateral internal-thoracic-artery grafting depicted more sternal wound
complications compared to other procedure. CABG is one of the most common
operations across the world, yet it remains one of the best therapies for multivessel
ischaemic heart disease. In most cases of surgery patients required three bypass grafts
with the usage of the saphenous vein as the conduit. procedural evaluation proved that
outcome associated with single internal mammary artery (SIMA) was superior
compared to left anterior descending (LAD) coronary artery when 10-year freedom and
survival outcomes were conducted.
Andreasen, Nekrasas, and Dethlefsen (2008)analyzed endoscopic vs open saphenous
vein harvest for coronary artery bypass grafting: a prospective randomized trial. The
article analyzed endoscopic saphenous vein harvesting (EVH) for the purpose of
coronary artery bypass grafting (CABG). The procedure was established to reduce
wound in the leg as well as morbidity, hence enhancing patient satisfaction rates.
Selection of EVH from a short vein from the thigh and open venous harvesting (OVH)
from calf represented a clinical dilemma. Both procedures have their own benefits and
challenges. The scope of this study evaluates morbidity associated with each of the
procedure along with the ease of performance. Analysis of results from the study
showed similar results however when patient-oriented outcome depicted that EVH of
short vein segment from thigh had less morbidity wound as compared to OVH.
DiFede et. al. (2014) examined autologous Mesenchymal Stem Cells Produce
Concordant Improvements in Regional Function, Tissue Perfusion, and Fibrotic Burden
when Administered to Patients Undergoing Coronary Artery Bypass Grafting. The scope
of this study is to analyze the efficacy of intramyocardial cell therapy for the purpose of
improving LV functions amongst patients with ischemic cardiomyopathy in CABG. The
18

objective of this hypothesis is to analyze intramyocardial injections of autologous MSCs
from pro-recovery phenotypic effects.
El-Chami et al. (2010) analyzed new-onset atrial fibrillation predicts long-term mortality
after coronary artery bypass graft. The purpose of this paper was to understand the
relation between new-onset atrial fibrillation post CABG procedures with that of long-
term mortality amongst patients who have no atrial fibrillation. The results from the study
concluded long-term mortality in patients with atrial fibrillation.
McAllister et. al. (2009) analyzed the effectiveness of hemodialysis access with an
autologous tissue-engineered vascular graft: a multicenter cohort study. This study
discusses vascular surgery wherein tissue-engineered vascular graft of small diameter
vascular reconstruction is soughed. This study is different from other studies included in
the literary analysis as it includes tissue-engineered vascular graft and not from the
body itself. This study is conducted on ten patients with the end-stage renal disease,
who received hemodialysis by means of an access graft. The study was included in
order to analyze the effectiveness of autologous tissue-engineered vascular graft, such
as to understand its further levels of application.
Ouzounianet. al. (2010) analyzed the impact of endoscopic versus open saphenous
vein harvest techniques on outcomes after coronary artery bypass grafting. This study is
similar to other studies of literature that have been included. The study analyses
endoscopic saphenous vein harvest (EVH) effects on decreasing leg wound and on
improving cosmoses posts CABG procedure.
19

Khalafi, Bradford, and Wilson (2008) understand the topical application of autologous
blood products during surgical closure following a coronary artery bypass graft. The
scope of this article also concerns itself with surgical site infection which is further
associated with morbidity, increased cost, mortality from cardiothoracic surgery. An
analysis on 1446 patients who have received CABG was undertaken for this study. The
study concluded that patients receiving CABG procedure with application of platelet-rich
and poor plasma had reduced chest wound infections, chest drainage, and leg wound
drainage. This study needs to have a further investigation for understanding its
application in a more detailed format.
Santo et. al. (2014) analyses technical factors in lower-extremity vein bypass surgery by
diagnosing ways to improve outcomes. This article analyses a significant aspect of vein
graft failure which remains a problem which affects 50% of patients within 5 years of
surgery. The article identifies varies factors which determine the success of the
operations which includes clinical judgment, experience, creativity and technical
precision amongst others. Shorter grafts have been shown to have better rates of
patency as compared to other endovascular means. Surgeon while making a choice of
a conduit needs to check for supply unimpeded runoff to foot, conservation of conduit
length while allowing for soft tissue coverage. This article reviews technical factors
associated with graft patency while analyzing the importance of surgical judgments with
operative planning while deciding on the current practice of infrainguinal bypass
surgery.
Koniget. et. al., (2009) compared mechanical properties of completely autologous
human tissue-engineered blood vessels compared to the human saphenous vein and
mammary artery. The study establishes the clinical feasibility of small diameter tissue-
engineered blood vessel (TEBV). The study is conducted using 25 patients, who are
enrolled in an arterio-venous (A-V) shunt safety trial while comparing them with risk-
20

matched human artery and vein. The study reports minimum standards for the purpose
of clinical use of tissue engineered vessels.
Folsom et al (2008) analyses coronary artery calcification compared with carotid intima-
media thickness in the prediction of cardiovascular disease incidence. Coronary artery
calcium (CAC) and carotid intima-media thickness (IMT) have been identified in this
article to be noninvasive measures of atherosclerosis. These can be analyzed as
possible risk factors for the purpose of predicting the probability of cardiovascular
diseases (CVD) incidence. The study was conducted on a wide range of patient and it
concluded that bioimaging tests of subclinical atherosclerosis are debatable. It was
found that CAC scores to be a better predictor of CVD incidence compared to carotid
IMT.
Raja & Sarang (2013) states despite the proven benefits of EVH, many operation and
heart rate centers continue to use SV segments with open technologies. EVH, including
higher costs, potential venous quality issues, increased technical issues, and longer
collection times. EVH to OVH and to review the overall experience of our
institution.Reduction of postoperative infection. After the collection of SVG, common
bone complication lesions include wound infections and non-infectious wound healing
disorders such as dehiscence, lymphedema, ecchymosis, seroma, and hematoma.
Many studies have shown that female gender, obesity, diabetes, and peripheral
vascular disease are risk factors for lesion complications of synthesis legs 2,3,14 Allen
and colleagues. 2,14 EVH factor profile changes in risk have been found to affect
complications for six and peripheral arterial disease Patients with EVH not (Voros,
Rinehart, Qian, Joshi, Vazquez, Fischer, Belur, Hulten & Villines, 2011). In adipose and
diabetic patients, there is still the risk of complications following ectomy with EVH.
Santo, Dargon, Azarbal, item, Mitchell, Moneta & Landry (2014) provides that the use of
EVH in the presence of OVH has significantly reduced the extent of ulcer bone infection.
21

In our estimation, OVH is the only independent predictor of postoperative bone
infection; Overweight, diabetes and other risks that do not affect the infection rate. EVH
should be the usual way to collect vein and vascular surgery.Relocation from OVH to
EVH. The endoscopic venous collection has been accepted for many years in the
specialty of cardiovascular surgery. EVH has been used at the Texas Heart Institute
(THI) since 9015; SVG until 2003. During the transition phases, various challenges were
corrected and resolved, including increased costs and fees, changes and acceptance of
EVH technical support, and sufficient time to acquire skills.Switching from traditional
OVH to EVH can be frustrating for everyone involved. First and foremost, the change
can significantly increase the time of surgery, as well as the amount and value of
surgical material used in each procedure (Shroyer, Grover, Hattler, Collins, McDonald,
Kozora, Lucke, Baltz, Novitzky & Veterans Affairs Randomized On/Off Bypass
(ROOBY) Study Group, 2009). The transition is particularly difficult in our department
because the assistant who worked earlier works very well and traditional fast harvest
times cannot be achieved by the organization before they are fully capable of reaching
EVH. However, as EVH staff are more helpful and the results are positive, the settings
are more complicated than initially time-consuming techniques that are positive, and we
started to do frequent EVH.
Saphenectomy can be longer in EVH than in OVH. The 3 APs involved in this study
estimate that their average harvest time is 10 to 40 minutes, depending on the duration
of their yield (Ostrom, Gopal, Ahmadi, Nasir, Yang, Kakadiaris, Flores, Mao & Budoff,
2008). Autumn times were greatly reduced while PA was able to recover. Roden's
harvest period depends on the experiences of the individual AP and the characteristics
of both the patient and the root. Similarly, EVH, the corresponding cut is smaller and
shutter speeds are shorter. EVH can have different aspects of the coronary bypass
method, including the quality of the harvested channel. If EVH should relinquish
transplantations of lesser quality than those harvested at OVH, the EVH program is not
worth doing. During the first study, SVG harvest requires different repairs using EVH.
However, the PAs have become more comfortable and, in accordance with EVH
practices, the quality of the roots has improved considerably; That is why more
surgeons are willing to be admitted (Smith, Sidney Emelia, Robert, Lynne, Creager,
22

Franklin, Raymond, 2011). At the moment most THI surgeons EVH and OVH are doing
some of the agreements, and EVH is a big advantage for patients. Permeability rating of
6 months and 5 years. 12.16 EVH and OVH produce permeability rates of 6 months and
5 years.
Amouzeshi, Teshnisi, Zirak, Shamloo, Hoseinikhah, Alizadeh & Moeinipour (2016)
states assistance from doctors as resources for EVH. Because THI is a training
institution and has had education within the institute between 6 months and 2 years.
The hardness trained with EVH is difficult. For this reason, PA, whose posts were
permanently added, was added to the THI surgical staff in September 2003. It added
stability to the EVH efforts. Initially, PA acquires skills in the new approach. But the skills
are up-to-date, the rapid implementation of the procedures and the effective use of the
opening hours have been resumed.In 3 APs that performed EVH during the study, there
was no previous EVH experience. A PA had for many years been a cardiovascular
surgeon in a foreign country and collected arteries radially with an endoscope. The
other has had general surgery for many years, but no EVH. 3. PA is a graduate who has
no heart surgery or EVH experience (Yamamoto, Sakamoto, Nara, Ban, Esaki,
Shimada & Kosuge, 2009). Different learning and support strategies, including practical
treatments with lifeless models and bones for calves, sessions of lengthy sessions and
direct performance tests. It has proved useful in some cases. In our experience, EVS
EVA was after a fall of 15 to 35 years.
Williams, Peterson, Brennan, Sedrakyan, Tavris, Alexander, Lopes, Dokholyan, Zhao,
O’brien & Michler (2012) states that the FDA has issued a proposal for investigating the
safety issues that concern endoscopic vein harvest for the CABG surgery in the year
2009. After obtaining permission from the Duke clinical research institute as well as the
society of thoracic surgeons, an attempt has been made to undertake a study regarding
endoscopic vein-graft harvesting in the CABG. During this study, it has been found that
EVH is suitable for vein graft harvesting. While looking at the researches, it will be seen
that about 70% of the total CABG cases have used the technique in STS ACSD in the
year 2008. With the adjustment of baseline clinical components, it has been discerned
that VH and OVH are not related to revascularization MI or long-term mortality amongst
23

isolated CABG patients (Owens, 2010). There has been a reduction in the rate of
complications pertaining to wound with the rampant use of EVH method.
Multiple randomized controlled trials have gained success in exhibiting the short-term
benefits that can be obtained from EVH in relation to patient’s satisfaction and
morbidities. Rate concerning wound complications that has been demonstrated in the
randomized comparisons is quite low which is in stark contrast to the present study.
One of the possible reasons for such an outcome can be linked to inspections that are
generally protocol driven and also due to liberal definition of the morbidities (Ouzounian,
Hassan, Buth, MacPherson, Ali, Hirsch & Ali, 2010). According to Allen et al, 112 CABG
patients have been treated with the use of both open harvesting as well as EVH and the
outcome for recurrent angina or death are almost similar. (75% with EVS vs 74% with
OVH; P=0.85). On the basis of the data provided bythe researcher, the ISMICS
(International Society for Minimally Invasive Cardiothoracic Surgery) showed a
preference for EVH method as it has shown a positive result in relation to postoperative
pain and wound complication and resources for wound management.
Lopes et al have put forward certain arguments in the cardiovascular community in
support of EVH technique for treating vein-graft harvest, in the year 2009(Morice, Marie-
Claude, Serruys, Kappetein, Feldman, Ståhle, Colombo, Mack, 2010).A comparison
between 1247 OVH and 1753 EVH methods have been conducted by Lopes et al by
basing his study on the patients who have undergone vein grafting which falls part of
PREVENT IV(Project of the Ex-vivo Vein Graft Engineering via Transfection IV). The
veins that have been harvested in PREVENT IV trial where subjected to the pressurized
delivery of placebo and ex-vivo manipulation. During this investigation, it has been
found that the failure rates of vein graft exceed that of CABG trials(Andreasen,
Nekrasas & Dethlefsen, 2008). However, another analysis conducted by Lopes et al
with the help of propensity adjustment found that risk like repeated revascularization
and death (HR 1.5; 95%CI 1.1, 2.0;p<0. ()5) is associated with EVH technique. The
NICE have given suggestion regarding usage of EVH for the CABG. It has given a
memorandum that EVH can only be adopted by making adequate arrangements for
research, clinical governance and consent35. The prime motive behind such a
24

suggestion is due to the fact that the NICE group tried to spread awareness regarding
the benefits and risks associated with EVH (Hangody, Vásárhelyi, Hangody, Sükösd,
Tibay, Bartha & Bodó, 2008).
In stark contrast to the studies conducted by Lopes et al, a study group which belongs
from Northern New England failed to detect any safety issues related to EVH. This
group has taken about 8542 patients starting from the year 2001 till 2009 that have
isolated CABG and 53% of them have been treated by EVH. It was discerned that within
the term of four years there has been a reduction of about 20% of mortality
risks(adjusted rate of HR 0.74; 95% CI 0.60, 0.92 for the patients who have survived for
90 days). In fact, EVH was not linked to the increased rates of repeat revascularization
(adjusted HR 1.10, 95% CI 0.96, 1.74)(Boudriot, Thiele, Walther, Liebetrau,
Boeckstegers, Pohl, Reichart, Mudra, Beier, Gansera & Neumann, 2011).
An analysis that has been undertaken by ROOBY (randomized On/off Bypass) trial has
compared composite outcomes obtained from EVH and OVH methods. This study has
taken 471 patients as a sample from 2003 to 2007. Almost 18 medical centers in the US
have utilized EVH technique in 32% of the cases. The studies found neither any
interaction between grafting treatment for off-pump coronary and composite outcomes
of both open as well as endoscopic groups. There are further investigations conducted
on the existing findings of northern New England group in relation to decrease in the
level of wound complications. But there have been major differences encountered in the
outcomes as founded by the group (Marzilli, Merz, Boden, Bonow, Capozza, Chilian,
DeMaria, Guarini, Huqi, Morrone & Patel, 2012). The outcome that this study has been
found benefits associated with survival by using EVH and at the same time it had also
not identified potential risk associated with EVH as founded by Lopes et al in his
investigations. A lot of important facts regarding the use of EVH can be pointed out from
both previous studies as well as the present study. As per this study, it has been found
that patients who belong to the age group of 65 years have a comparatively fewer rate
of electrocautery injuries. In comparison to reports given by lope et al as well as
Northern New England group, this study is 10 fold larger in size (Chow, Wells, Chen,
25

Yam, Galiwango, Abraham, Sheth, Dennie, Beanlands & Ruddy, 2010). Small and large
communities along with diverse groups have been included in this study.
The forest plot is used for describing ratio point for the long-term mortality rates
gathered by comparing open as well as endoscopic harvesting. Unlike the clinical
analysis of Northern New England group as well as Lopes et al, this study has failed to
find out the differences in conduit caliber that exist between OVH as well as EVH
groups. It is regarded as a significant variable in undertaking a comparison between
OVH and EVH methods. The trials have to strike a comparison between specimens of
tissue which exist in between conventional even harvesting and endoscopic vein
harvesting. However, no histologic differences have been encountered.For continuing
with the process of vein grafts through endoscopy, the tissue specimen is taken from
the knee area (Hannan, Wu, Walford, Culliford, Gold, Smith, Higgins, Carlson & Jones,
2008). On the other hand, ankle area is taken into consideration for conducting open
grafts techniques. A vein began to grow from the cephalad course till lower extremity
while harvesting. Mostly, studies have found that poor level of patency is associated
with large vein caliber. The significance lies in the level for saphenous veins. The
influence felt on SVGs with the use of carbon dioxide is not stated in any of the studies.
It can be assessed that each and every endoscopic vein harvest are not similar. Both
the present as well as earlier studies have not succeeded in assessing techniques like
the experience of the endoscopic harvester, use of carbon dioxide and also adopting
electro-cautery.
A number of limitations have been identified in the present study(Bennett-Guerrero,
Zhao, O'brien, Ferguson, Peterson, Gammie & Song, 2010). Firstly, in the year 2008
clinical identifications regarding EVH were not direct and 3-year median follow up has
also not consulted. So, it becomes quite difficult for a surgeon to transform endoscopic
to open harvesting method while operating a patient. This situation crops up whenever
challenges are faced for harvesting veins. The scenario will be seen as endoscopic by
the method adopted in this study and it can also be said that the harvested vessel is
successfully allocated in the given analysis. In order to identify non-differential
misclassification along with the EVH, billing has been put into practice. The analysis
26

indicates towards the fact that with the coding of EVH, it performs well while its
performance slows down when it is devoid of any code (McAllister, Maruszewski,
Garrido, Wystrychowski, Dusserre, Marini, Zagalski, Fiorillo, Avila, Manglano &
Antonelli, 2009). The group misclassification could obscure the distinctions which
existed amongst treatment groups thereby bringing biased outcomes towards null. As a
result of it, it cannot be said that no difference lies in revascularization, mortality, and
MI. In this study, there have been efforts made for undertaking sensitivity analysis by
making use of those sites that have at least more than 80 % sensitivity.It is due to the
null effect that an increased billing precision in EVH billing turns out its null effect lesser
while demonstrating misclassification (Mehta, Ferguson, Lopes, Hafley, Mack,
Kouchoukos, Gibson, Harrington, Califf, Peterson & Alexander, 2011). Success has
been achieved for finding out the differences between various treatments groups with
the help of sensitivity analysis. The findings in relation to wound complication and
association of the EVH have shown significant support to the analytic assay. Information
related to the device to be used for EVH has also not been found in this analysis.
It can be concluded that this study has been unable to reach for any evidence related to
the association between MI, mortality with that if endoscopic vein-graft harvest. It has
been found that the endoscopic method is related to the incidence of reduced wound
complications (Min, Dunning, Lin, Achenbach, Al-Mallah, Budoff, Cademartiri, Callister,
Chang, Cheng, & Chinnaiyan, 2011). The problems that are faced regarding the issue
of morbidity of the wound through open or traditional techniques have opened avenues
for a variety of lesser and minimally invasive methods. These methods include
endoscopic methods, non-specialist techniques, and even use equipment for the
harvesting of the saphenous vein. The developments that are made in CABG surgery
have allowed the patients to recover fast. Mobility can be regarded as one of the
significant aspects of getting back to normal life. After the surgery patients might face
problems pertaining to infection, pain and wound discharge. Although the intensity
wound-related problems are quite low, however, inflammation, pain or other such
complications is basically underestimated(Ostrom, Gopal, Ahmadi, Nasir, Yang,
Kakadiaris, Flores, Mao & Budoff, 2008).
27

The signs that indicate towards inflammation of the wound has been reduced
successfully (P=0.01, Table 3). During the course of this study, four patients have
successfully completed open harvesting. Amongst these patients, two of them were
given antibiotics in case of the face problems due to open harvest.There is an urgent
requirement for repairing vein among this group of four people. It is quite impossible to
clip branches as a result of a poor vision or sometimes problems are fed while suing
LigaclipTM applicator. In order to conduct this study successfully, a modified technique of
bridging has been applied. It is comparatively cheaper as well as uses lesser space in
comparison to other techniques (Seung, Park, Kim, Lee, Lee, Hong, Park, Yun, Gwon,
Jeong & Jang, 2008). The usage of a non-randomized technique for the endoscopic
harvest so as to lower down wound complications has been recommended by Hovarth
et al. The complication which concerned endoscopic harvest is identified as
hematomas. In order to harvest 48cm vein, total five incisions have been used in this
study. With the help of SaphLITE TM, there had been four incisions made for harvesting
veins that are of the same length within the stipulated time. As per Tevaearai alternative
type of bridging was used for invasive harvest. The harvested vein here has exceeded
incision length three times, however, in the present study veins are four times longer
than that of incision length. Hence, the technique that has been adopted in the present
study seems to strike a comparison with other techniques (Konig, McAllister, Dusserre,
Garrido, Iyican, Marini, Fiorillo, Avila, Wystrychowski, Zagalski & Maruszewski, 2009).
A comparison was undertaken by Puskas et al regarding open as well as traditional
harvest. The incidence of ecchymosis is comparatively higher amongst the invasive
group. It is discerned after conducting this study that advantages of invasive harvesting
are quite limited. In the case of long harvest times like 62 min can well hamper the
operation of this method. As per the reports were given by Allen et al. the harvest rate is
much faster in the endoscopic group (0.9+0.4versus .2+0.5 cm/min, P<<0.02). It has
been found that patients had no such different opinion regarding pain on the second or
even after six weeks.
ASEPSIS method has been put into practice for ranking wounds for infection. It is
comprised of different variables(Folsom, Kronmal, Detrano, O’Leary, Bild, Bluemke,
28

Budoff, Liu, Shea, Szklo & Tracy, 2008). In this research work, serous discharge is
largely associated with leg wounds. None of the patients who belong to the invasive
groups were admitted to hospitals because of leg problems. It is quite difficult to
measure pain that occurs due to wound, however, VAS techniques have been adopted
for measuring the level of pain faced by each patient. As supplement patients are often
instructed to record pain levels through sterna incisions and also record the quantity of
supplemental analgesia that is utilized by each of the patients. Those patients who fall
under the invasive group had not felt any sort of pain during their stay at a hospital. It
can be discerned that with the use of modified bridging method the post-operative pain
is reduced to a great extent. Although arterial grafts are adopted for the CABG to obtain
patency for a longer period of time, saphenous vein turns out to be one of the most
popularly used conduits for bypass surgery (DiFede, Gerstenblith, Pham, Symes,
Zambrano, FishmanPattany, McNiece, Conte, Schulman & Wu, 2014). A large number
of complications like edema, dehiscence, infection, hematomas, and drainage are
associated with the conventional method of the open longitudinal incision. These
complications further lead to higher cost pertaining to post-operation, long stay in the
hospital and the discomfort faced by the patients. Reports have shown that almost
24.3% of the patients who have undergone open vein harvesting had suffered
complication in leg wounds. With the recent trends encountered in cardiothoracic
surgery for the less invasive methods, developments have been encountered in the
minimally invasive techniques for registering reduction of morbidity. At the time of
minimally invasive technique that is conducted through the bridged incision, endothelial
dysfunction with the traction injury is often reported. In order to prevent vein trauma, this
study has tried to compare the stenosis rate with that of angiographic patency ( Chlupac,
Filova & Bacakova, 2009). One can get a clear understanding of the fact that
complications pertaining to wound have significantly reduced with the use of EVH.
Complications that might have been encountered in EVH are quite lower than that of
OVH. However, while conducting this study there were no reports gathered regarding
the risk of diabetes. One of the possible reason can be thigh veins are only harvested
and diabetes affected area that are below knees. While conducting this study, almost
20% occlusion rate along with 11.5% in the stenotic region has been found (Conte,
29

2009). There were no differences in terms of patency in the OVH and EVH veins. This
study has been able to examine 59 vein grafts out of 336 grafts. This sample size is too
small to find out the difference between wound complications. In fact, occlusion data
which is obtained at the need of the third month will prove to be effective in comparison
to the one that is meant to be obtained from six months period. However, it can be
concluded that 35.5% graft showed traces of more than 25% of stenosis.
The total occlusion rate that has been gathered after 1-year vein graft lies between 5 to
30 percent(Dashwood & Tsui, 2013). According to the National Defense Medical
Centre, the occlusion rate has been specified as 12% and 19% respectively within a
year. Out of these grafts, almost 6 percent has stenosis thereby minimizing the graft's
caliber to lesser than 50 percent. The occlusion rate of 20% has been achieved in this
study at the sixth month. The figures as obtained can lead to some disappointments as
it might indicate that bypassing of smaller vessels with the more distal disease with the
introduction of multivessel stenting. A fact which is useful to support the argument is
interventions that were conducted through catheter have suddenly risen to 22%. On the
other hand, isolated CABG slowed down to 15%. For finding out the variation at the
patient's level as well as the graft level, multivariable ordinal hierarchic regression is
selected.
The poor distal runoff in the infarcted regions leads to congestive heart failure (Mohr,
Morice, Kappetein, Feldman, Ståhle, Colombo, Mack, Holmes Jr, Morel, Van Dyck
&Houle, 2013). In the year 1977 to 1999 ejection fraction lowered down the graft
patency in the hospitals of Australia, Melbourne, and Victoria. The increased severity of
the targeted disease seems to be a predictor of the occlusion rates. Patency is basically
had an inverse relation with the vein conduit. However, there are no valid reasons for
such a relation. One of the disadvantages of such a technique can be harvesting of
thigh veins is based on some preferences. Controversy surrounds the fact that whether
the targeted territory significant factors for patency. Shah, as well as the coworkers24,
has found that even graft which is bypassed to diagonal artery can have patency of
longer period of time (Farooq, Serruys, Bourantas, Vranckx, Diletti, Garcia Garcia,
Holmes, Kappetein, Mack, Feldman & Morice, 2012). On the contrary, Bjork and the
30

associates 18 failed to detect any difference between 1-year graft patency with other
territories. The diagonal artery has been linked to the occlusion rates and development
of diseases during the sixth month of this study.
A large number of limitations are required to paid attention to this study. Dissection is
required for conducting the EVH method and surrounding tissues needs to be removed
from the groups. It is quite essential to preserve the fatty pedicle for demonstrating
external support. In the future, there will be an attempt made to find out whether
modifications are required for EVH method so as to incorporate no-touch components.
Furthermore, most part of the study has only put emphasized on clinical variables so,
the future studies is going to be more preoccupied with factors leading to vein graft
occlusion. A few of the patients were displaying symptoms of renal insufficiency as well,
as a chronic pulmonary disease so there have not been dealt in the study (Lamy,
Devereaux, Prabhakaran, Taggart, Hu, Paolasso, Straka, Piegas, Akar, Jain & Noiseux,
2012). One might find problems while conducting learning phase as EVH is mainly
based upon 300 cases. So, it can be said that generalizations pertaining to reports
published by other institutions is not be applicable. The sample size that has been taken
for conducting this study might not be sufficient for striking a comparison between OVH
and EVH techniques. There will be problems faced while detecting the patency rates
due to incomplete follow up of angiography. Nonetheless, it can well be said that OR
which is of 1015 unit that has a CI support of about 95% can provide some validity to
the outcomes that have been found in this study. It can be summarized that the use of
EVH method is known to minimize the complication that is encountered in wound
experienced in the legs. Success has been gained while treating patients through the
methods of open harvesting method (Liu, Wang, Li, Wu, Shan, Su, Li, Yu, Shi, Huang &
Sun, 2009). The patency rate is mainly connected to the variables related to the vein
and largely dependent upon the target and also upon the characteristics of a patient.
Mostly, people believe that it is dependent on the procedure of vein harvesting when it
is not.
31

Limitations
The study has been conducted using articles and journals, which imply all data sources
analyzed, are from sources secondary in nature Hence, the study is limited in nature
and has not been able to include primary studies into the scope. The patient population
selected for the purpose of this study differed amongst all the studies. This is a limitation
as patient population is not uniform hence findings cannot be accepted throughout for
this study. However, a common factor which connected them comprised of surgery
done on coronary artery bypass graft. Outcomes and findings associated with most of
the studies indicated the superiority of choices while using vein grafts. Moreover, due to
lack of time literature in discussion, design and sample size has been limited. Due to the
availability of limited funds, the study scopes had been limited in nature and the author
could not extend the study area or include another perspective of being.
Recommendations
Above analysis of varied literature proves that randomized clinical trial has to be
conducted for the purpose of clarity on the choice of the conduit. As suggested and
articles included from various literature and systematic reviews radial artery as a choice
of the conduit can be considered but needs further investigation. There is a need for
further research and particularly a large RCT, which can robustly be managed.
Conclusion
EVH is rapidly being used as a routine surgical procedure for multiple cardiovascular
centers worldwide. The rapid introduction of EVH is due to a large reduction in invasion
compared to traditional OVH technology. The available video confirms two or three
improvements in the degree of complications and infections caused by EVH wounds.
Significantly shortening the duration of surgery when transplanted by EVH causes fewer
tissue wounds resulting in increased patient satisfaction. Although the one-time, one-
time costs have increased, hospital stays, wound infections, and the reduction of
NIWHD compared to OVH will retain the cost-effectiveness of EVH (Marzilli, Merz,
Boden, Bonow, Capozza, Chilian, DeMaria, Guarini, Huqi, Morrone & Patel, 2012).
32

On the other hand, the link between this technique and the low permeability of the graft
has recently been called into question. Some available evidence does not suggest that
EVH is a naturally inadequate method of acquiring vascular channels. However, the
poor channel quality due to the EVH learning curve showed a prediction of early graft
failure, positive silly reconstruction, and large negative reconstruction. Given the EVH
annual CABG process, the learning curve for this procedure is an important and poorly
recognized public health problem. There is a greater need for strategies to minimize the
negative impact of the learning curve on the quality of intravenous profiles. Future
studies in the form of long-term follow-up studies should prove to be an important factor
in managing misunderstandings and misunderstandings at HLE and improving their
overall acceptance.
The results of this study showed that EVH withdrawal times are generally shorter than in
a number of other studies. The difference in the results can be based on the experience
of the technical experts and the equipment used for them. A shorter harvest results in a
shorter postoperative treatment for fetal morbidity. It appears that we have again
demonstrated an important connection between the saphenous vein that minimizes
invasive extraction and tissue repair compared to conventional open surgery. However,
further studies are still needed to examine esthetic outcomes, hospital costs, and cost-
effectiveness. More importantly, the long-term permeability of the graft must be
investigated in EVH technology. Considering the fact that a large number of CABG
procedures have been carried out in our area of EVH technology, their training needs to
be evaluated and further improved by improving the quality of venous delivery and
marginally damaging the surrounding tissue.
Reference
Ahmadi, N., Nabavi, V., Hajsadeghi, F., Flores, F., French, W.J., Mao, S.S., Shavelle,
D., Ebrahimi, R. and Budoff, M., 2011. Mortality incidence of patients with non-
obstructive coronary artery disease diagnosed by computed tomography
angiography. The American journal of cardiology, 107(1), pp.10-16. Retrieved on 3rd
May 2018, from https://www.sciencedirect.com/science/article/pii/S0002914910017170
33

Albert, B., Elena, H., Nicole, W., Süleyman, E., Ralph, K., Richard, K. and Udo, L.,
2015.Neointimal hyperplasia in allogeneic and autologous venous grafts is not different
in nature. Histochemistry and cell biology, 144(1), pp.59-66. Retrieved on 21st April
2018, from https://link.springer.com/article/10.1007/s00418-015-1317-3
Amouzeshi, A., Teshnisi, M.A., Zirak, N., Shamloo, A.S., Hoseinikhah, H., Alizadeh, B.
and Moeinipour, A., 2016. Clinicopathological comparisons of open vein harvesting and
endoscopic vein harvesting in coronary artery bypass grafting patients in
Mashhad. Electronic physician, 8(1), p.1693. Retrieved on 21st April 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4768916/
Andreasen, J.J., Nekrasas, V. and Dethlefsen, C., 2008. Endoscopic vs open
saphenous vein harvest for coronary artery bypass grafting: a prospective randomized
trial. European Journal of Cardio-Thoracic Surgery, 34(2), pp.384-389. Retrieved on 23rd
May 2018, from https://academic.oup.com/ejcts/article/34/2/384/413147
Bennett-Guerrero, E., Zhao, Y., O'brien, S.M., Ferguson, T.B., Peterson, E.D., Gammie,
J.S. and Song, H.K., 2010.Variation in use of blood transfusion in coronary artery
bypass graft surgery. jama, 304(14), pp.1568-1575. Retrieved on 16th April 2018, from
https://jamanetwork.com/journals/jama/fullarticle/186710
Boudriot, E., Thiele, H., Walther, T., Liebetrau, C., Boeckstegers, P., Pohl, T., Reichart,
B., Mudra, H., Beier, F., Gansera, B. and Neumann, F.J., 2011. Randomized
comparison of percutaneous coronary intervention with sirolimus-eluting stents versus
coronary artery bypass grafting in unprotected left main stem stenosis. Journal of the
American College of Cardiology, 57(5), pp.538-545. Retrieved on 5th May 2018, from
http://www.onlinejacc.org/content/57/5/538
Chlupac, J., Filova, E. and Bacakova, L., 2009. Blood vessel replacement: 50 years of
development and tissue engineering paradigms in vascular surgery. Physiological
research, 58, p.S119. Retrieved on 1st May 2018, from
https://pdfs.semanticscholar.org/7d97/b20e00c0cb33a9a9c7f5334c7b2a5780451b.pdf
34

Chow, B.J., Wells, G.A., Chen, L., Yam, Y., Galiwango, P., Abraham, A., Sheth, T.,
Dennie, C., Beanlands, R.S. and Ruddy, T.D., 2010. Prognostic value of 64-slice
cardiac computed tomography: severity of coronary artery disease, coronary
atherosclerosis, and left ventricular ejection fraction. Journal of the American College of
Cardiology, 55(10), pp.1017-1028. Retrieved on 14th April 2018, from
http://www.onlinejacc.org/content/55/10/1017
Conte, M.S., 2009, December. Technical factors in lower-extremity vein bypass surgery:
how can we improve outcomes?.In Seminars in vascular surgery (Vol. 22, No. 4, pp.
227-233). WB Saunders. Retrieved on 15th April 2018, from
https://www.sciencedirect.com/science/article/pii/S0895796709000684
Dashwood, M.R. and Tsui, J.C., 2013. ‘No-touch’saphenous vein harvesting improves
graft performance in patients undergoing coronary artery bypass surgery: a journey
from bedside to bench. Vascular pharmacology, 58(3), pp.240-250. Retrieved on 1st
May 2018, from https://www.sciencedirect.com/science/article/pii/S1537189112001346
Desai, M., Seifalian, A.M. and Hamilton, G., 2011. Role of prosthetic conduits in
coronary artery bypass grafting. European Journal of Cardio-Thoracic Surgery, 40(2),
pp.394-398. Retrieved on 21st April 2018, from
https://academic.oup.com/ejcts/article/40/2/394/442259
Domanski, M.J., Mahaffey, K., Hasselblad, V., Brener, S.J., Smith, P.K., Hillis, G.,
Engoren, M., Alexander, J.H., Levy, J.H., Chaitman, B.R. and Broderick, S.,
2011.Association of myocardial enzyme elevation and survival following coronary artery
bypass graft surgery. Jama, 305(6), pp.585-591. Retrieved on 22nd May 2018, from
https://jamanetwork.com/journals/jama/fullarticle/645525
DiFede, D.L., Gerstenblith, G., Pham, S.M., Symes, J.F., Zambrano, J.P., Fishman, J.,
Pattany, P.M., McNiece, I., Conte, J.V., Schulman, S.P. and Wu, K.C., 2014.
Autologous Mesenchymal Stem Cells Produce Concordant Improvements in Regional
Function, Tissue Perfusion and Fibrotic Burden when Administered to Patients
Undergoing Coronary Artery Bypass Grafting-The PROMETHEUS Trial. Circulation
35

research, pp.CIRCRESAHA-113. Retrieved on 31st April 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/24565698
El-Chami, M.F., Kilgo, P., Thourani, V., Lattouf, O.M., Delurgio, D.B., Guyton, R.A.,
Leon, A.R. and Puskas, J.D., 2010. New-onset atrial fibrillation predicts long-term
mortality after coronary artery bypass graft. Journal of the American College of
Cardiology, 55(13), pp.1370-1376. Retrieved on 30th April 2018, from
http://www.onlinejacc.org/content/55/13/1370
Erbel, R., Möhlenkamp, S., Moebus, S., Schmermund, A., Lehmann, N., Stang, A.,
Dragano, N., Grönemeyer, D., Seibel, R., Kälsch, H. and Bröcker-Preuss, M., 2010.
Coronary risk stratification, discrimination, and reclassification improvement based on
quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall
study. Journal of the American College of Cardiology, 56(17), pp.1397-1406. Retrieved
on 1st May 2018, from http://www.onlinejacc.org/content/56/17/1397
Emerging Risk Factors Collaboration, 2009. Lipoprotein (a) concentration and the risk of
coronary heart disease, stroke, and nonvascular mortality. JAMA: the journal of the
American Medical Association, 302(4), p.412. Retrieved on 28th April 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3272390/
Folsom, A.R., Kronmal, R.A., Detrano, R.C., O’Leary, D.H., Bild, D.E., Bluemke, D.A.,
Budoff, M.J., Liu, K., Shea, S., Szklo, M. and Tracy, R.P., 2008. Coronary artery
calcification compared with carotid intima-media thickness in the prediction of
cardiovascular disease incidence: the Multi-Ethnic Study of Atherosclerosis
(MESA). Archives of internal medicine, 168(12), pp.1333-1339. Retrieved on 25th May
2018, from https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/414332
Farooq, V., Serruys, P.W., Bourantas, C., Vranckx, P., Diletti, R., Garcia Garcia, H.M.,
Holmes, D.R., Kappetein, A.P., Mack, M., Feldman, T. and Morice, M.C., 2012.
Incidence and multivariable correlates of long-term mortality in patients treated with
surgical or percutaneous revascularization in the synergy between percutaneous
36

coronary intervention with taxus and cardiac surgery (SYNTAX) trial. European heart
journal, 33(24), pp.3105-3113. Retrieved on 13th May 2018, from
https://academic.oup.com/eurheartj/article/33/24/3105/2398641
Johansson, B.L., Souza, D.S., Bodin, L., Filbey, D., Loesch, A., Geijer, H. and Bojö, L.,
2010. Slower progression of atherosclerosis in vein grafts harvested with ‘no
touch’technique compared with conventional implantation procedure in coronary artery
bypass grafting: an angiographic and intravascular ultrasound study. European Journal
of Cardio-Thoracic Surgery, 38(4), pp.414-419. Retrieved on 15th April 2018, from
https://academic.oup.com/ejcts/article/38/4/414/407737
Khalafi, R.S., Bradford, D.W. and Wilson, M.G., 2008. Topical application of autologous
blood products during surgical closure following a coronary artery bypass
graft. European Journal of Cardio-Thoracic Surgery, 34(2), pp.360-364. Retrieved on
17th May 2018, from https://academic.oup.com/ejcts/article/34/2/360/412577
Konig, G., McAllister, T.N., Dusserre, N., Garrido, S.A., Iyican, C., Marini, A., Fiorillo, A.,
Avila, H., Wystrychowski, W., Zagalski, K. and Maruszewski, M., 2009. Mechanical
properties of completely autologous human tissue engineered blood vessels compared
to human saphenous vein and mammary artery. Biomaterials, 30(8), pp.1542-1550.
Retrieved on 10th April 2018, from
https://www.sciencedirect.com/science/article/pii/S014296120800879X
Kottenberg, E., Thielmann, M., Bergmann, L., Heine, T., Jakob, H., Heusch, G. and
Peters, J., 2012. Protection by remote ischemic preconditioning during coronary artery
bypass graft surgery with isoflurane but not propofol–a clinical
trial. ActaanaesthesiologicaScandinavica, 56(1), pp.30-38. Retrieved on 4th May 2018,
from https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1399-6576.2011.02585.x
Hangody, L., Vásárhelyi, G., Hangody, L.R., Sükösd, Z., Tibay, G., Bartha, L. and Bodó,
G., 2008. Autologous osteochondral grafting—technique and long-term
37

results. Injury, 39(1), pp.32-39. Retrieved on 20th April 2018, from
https://www.sciencedirect.com/science/article/pii/S0020138308000612
Hannan, E.L., Wu, C., Walford, G., Culliford, A.T., Gold, J.P., Smith, C.R., Higgins, R.S.,
Carlson, R.E. and Jones, R.H., 2008. Drug-eluting stents vs. coronary-artery bypass
grafting in multivessel coronary disease. New England Journal of Medicine, 358(4),
pp.331-34. Retrieved on 25th April 2018, from
https://www.nejm.org/doi/full/10.1056/NEJMoa071804
Harskamp, R.E., Lopes, R.D., Baisden, C.E., de Winter, R.J. and Alexander, J.H., 2013.
Saphenous vein graft failure after coronary artery bypass surgery: pathophysiology,
management, and future directions. Annals of surgery, 257(5), pp.824-833. Retrieved
on 10th April 2018, from
https://journals.lww.com/annalsofsurgery/Abstract/2013/05000/Saphenous_Vein_Graft_
Failure_After_Coronary_Artery.7.aspx
Hassantash, S.A., Bikdeli, B., Kalantarian, S., Sadeghian, M. and Afshar, H.,
2008.Pathophysiology of aortocoronary saphenous vein bypass graft disease. Asian
Cardiovascular and Thoracic Annals, 16(4), pp.331-336. Retrieved on 2nd May 2018,
from http://journals.sagepub.com/doi/abs/10.1177/021849230801600418
Hillis, L.D., Smith, P.K., Anderson, J.L., Bittl, J.A., Bridges, C.R., Byrne, J.G., Cigarroa,
J.E., DiSesa, V.J., Hiratzka, L.F., Hutter, A.M. and Jessen, M.E., 2011. 2011
ACCF/AHA guideline for coronary artery bypass graft surgery. Circulation, 124(23),
pp.e652-e735. Retrieved on 29th April 2018, from
http://citeseerx.ist.psu.edu/viewdoc/download?
doi=10.1.1.675.5987&rep=rep1&type=pdf
Lamy, A., Devereaux, P.J., Prabhakaran, D., Taggart, D.P., Hu, S., Paolasso, E.,
Straka, Z., Piegas, L.S., Akar, A.R., Jain, A.R. and Noiseux, N., 2012. Off-pump or on-
pump coronary-artery bypass grafting at 30 days. New England Journal of
Medicine, 366(16), pp.1489-1497. Retrieved on 21st April 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/22449296
38

Locker, C., Schaff, H.V., Dearani, J.A., Joyce, L.D., Park, S.J., Burkhart, H.M., Suri,
R.M., Greason, K.L., Stulak, J.M., Li, Z. and Daly, R.C., 2012. Multiple Arterial Grafts
Improve Late Survival of Patients Undergoing Coronary Artery Bypass Graft
SurgeryClinical Perspective: Analysis of 8622 Patients With Multivessel
Disease. Circulation, 126(9), pp.1023-1030. Retrieved on 29th April 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/22811577
Lopes, R.D., Williams, J.B., Mehta, R.H., Reyes, E.M., Hafley, G.E., Allen, K.B., Mack,
M.J., Peterson, E.D., Harrington, R.A., Gibson, C.M. and Califf, R.M.,
2012.Edifoligideand long-term outcomes after coronary artery bypass grafting: PRoject
of Ex-vivo Vein graft ENgineering via Transfection IV (PREVENT IV) 5-year
results. American heart journal, 164(3), pp.379-386. Retrieved on 1st May 2018, from
Liu, Y.H., Wang, D.X., Li, L.H., Wu, X.M., Shan, G.J., Su, Y., Li, J., Yu, Q.J., Shi, C.X.,
Huang, Y.N. and Sun, W., 2009. The effects of cardiopulmonary bypass on the number
of cerebral microemboli and the incidence of cognitive dysfunction after coronary artery
bypass graft surgery. Anesthesia & Analgesia, 109(4), pp.1013-1022. Retrieved on
22ndApril 2018, from
https://www.sciencedirect.com/science/article/pii/S0002870312003754
Magee, M.J., Alexander, J.H., Hafley, G., Ferguson, T.B., Gibson, C.M., Harrington,
R.A., Peterson, E.D., Califf, R.M., Kouchoukos, N.T., Herbert, M.A. and Mack, M.J.,
2008. Coronary artery bypass graft failure after on-pump and off-pump coronary artery
bypass: findings from PREVENT IV. The Annals of thoracic surgery, 85(2), pp.494-500.
Retrieved on 20th April 2018, from
https://www.sciencedirect.com/science/article/pii/S0003497507020401
Marzilli, M., Merz, C.N.B., Boden, W.E., Bonow, R.O., Capozza, P.G., Chilian, W.M.,
DeMaria, A.N., Guarini, G., Huqi, A., Morrone, D. and Patel, M.R., 2012. Obstructive
coronary atherosclerosis and ischemic heart disease: an elusive link!. Journal of the
American College of Cardiology, 60(11), pp.951-956. Retrieved on 30th April 2018, from
http://www.onlinejacc.org/content/60/11/951
39

McAllister, T.N., Maruszewski, M., Garrido, S.A., Wystrychowski, W., Dusserre, N.,
Marini, A., Zagalski, K., Fiorillo, A., Avila, H., Manglano, X. and Antonelli, J., 2009.
Effectiveness of haemodialysis access with an autologous tissue-engineered vascular
graft: a multicentre cohort study. The Lancet, 373(9673), pp.1440-1446. Retrieved on
23rd April 2018, from
https://www.sciencedirect.com/science/article/pii/S0140673609602488
McLean, R.C., Nazarian, S.M., Gluckman, T.J., Schulman, S.P., Thiemann, D.R.,
Shapiro, E.P., Conte, J.V., Thompson, J.B., Shafique, I., McNicholas, K.W. and Villines,
T.C., 2011. Relative importance of patient, procedural and anatomic risk factors for
early vein graft thrombosis after coronary artery bypass graft surgery. The Journal of
cardiovascular surgery, 52(6), p.877. Retrieved on 19th April 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4430084/
Mehta, R.H., Ferguson, T.B., Lopes, R.D., Hafley, G.E., Mack, M.J., Kouchoukos, N.T.,
Gibson, C.M., Harrington, R.A., Califf, R.M., Peterson, E.D. and Alexander, J.H., 2011.
Saphenous vein grafts with multiple versus single distal targets in patients undergoing
coronary artery bypass surgery: one-year graft failure and five-year outcomes from the
Project of Ex-Vivo Vein Graft Engineering via Transfection (PREVENT) IV
trial. Circulation, pp.CIRCULATIONAHA-110. Retrieved on 24th April 2018, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5144829/
Menasché, P., Alfieri, O., Janssens, S., McKenna, W., Reichenspurner, H., Trinquart,
L., Vilquin, J.T., Marolleau, J.P., Seymour, B., Larghero, J. and Lake, S., 2008. The
Myoblast Autologous Grafting in Ischemic Cardiomyopathy (MAGIC) trial: first
randomized placebo-controlled study of myoblast transplantation. Circulation, 117(9),
pp.1189-1200. Retrieved on 25th April 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/18285565
Min, J.K., Dunning, A., Lin, F.Y., Achenbach, S., Al-Mallah, M., Budoff, M.J.,
Cademartiri, F., Callister, T.Q., Chang, H.J., Cheng, V. and Chinnaiyan, K., 2011. Age-
and sex-related differences in all-cause mortality risk based on coronary computed
tomography angiography findings: results from the International Multicenter CONFIRM
40

(Coronary CT Angiography Evaluation for Clinical Outcomes: An International
Multicenter Registry) of 23,854 patients without known coronary artery disease. Journal
of the American College of Cardiology, 58(8), pp.849-860. Retreived on 26th April 2018,
from http://www.onlinejacc.org/content/58/8/849
Mohr, F.W., Morice, M.C., Kappetein, A.P., Feldman, T.E., Ståhle, E., Colombo, A.,
Mack, M.J., Holmes Jr, D.R., Morel, M.A., Van Dyck, N. and Houle, V.M., 2013.
Coronary artery bypass graft surgery versus percutaneous coronary intervention in
patients with three-vessel disease and left main coronary disease: 5-year follow-up of
the randomised, clinical SYNTAX trial. The lancet, 381(9867), pp.629-638. Retrieved on
25th April 2018, from
https://www.sciencedirect.com/science/article/pii/S0140673613601415
Serruys, P.W., Morice, M.C., Kappetein, A.P., Colombo, A., Holmes, D.R., Mack, M.J.,
Ståhle, E., Feldman, T.E., van den Brand, M., Bass, E.J. and Van Dyck, N., 2009.
Percutaneous coronary intervention versus coronary-artery bypass grafting for severe
coronary artery disease. New England Journal of Medicine, 360(10), pp.961-972.
Retrieved on 2nd May 2018, from
https://moh-it.pure.elsevier.com/en/publications/outcomes-in-patients-with-de-novo-left-
main-disease-treated-with-
Nissen, S.E., Nicholls, S.J., Wolski, K., Nesto, R., Kupfer, S., Perez, A., Jure, H., De
Larochellière, R., Staniloae, C.S., Mavromatis, K. and Saw, J., 2008. Comparison of
pioglitazone vs glimepiride on progression of coronary atherosclerosis in patients with
type 2 diabetes: the PERISCOPE randomized controlled trial. Jama, 299(13), pp.1561-
1573. Retrieved on 5th May 2018, from
https://jamanetwork.com/journals/jama/fullarticle/181728
Ostrom, M.P., Gopal, A., Ahmadi, N., Nasir, K., Yang, E., Kakadiaris, I., Flores, F., Mao,
S.S. and Budoff, M.J., 2008. Mortality incidence and the severity of coronary
atherosclerosis assessed by computed tomography angiography. Journal of the
American College of Cardiology, 52(16), pp.1335-1343. Retrieved on 6th May 2018,
from https://www.ncbi.nlm.nih.gov/pubmed/18929245
41

Ouzounian, M., Hassan, A., Buth, K.J., MacPherson, C., Ali, I.M., Hirsch, G.M. and Ali,
I.S., 2010.Impact of endoscopic versus open saphenous vein harvest techniques on
outcomes after coronary artery bypass grafting. The Annals of Thoracic Surgery, 89(2),
pp.403-408. Retrieved on 7th May 2018, from
https://www.sciencedirect.com/science/article/pii/S0003497509019717
Owens, C.D., 2010. Adaptive changes in autogenous vein grafts for arterial
reconstruction: clinical implications. Journal of vascular surgery, 51(3), pp.736-746.
Retrieved on 8th May 2018, from
https://www.sciencedirect.com/science/article/pii/S0741521409015742
Raja, S.G. and Sarang, Z., 2013. Endoscopic vein harvesting: technique, outcomes,
concerns & controversies. Journal of thoracic disease, 5(Suppl 6), p.S630. Retrieved on
21st April 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831843/
Sareyyupoglu, B., Schaff, H.V., Ucar, I., Sundt, T.M., Dearani, J.A. and Park, S.J., 2009.
Surgical treatment of saphenous vein graft aneurysms after coronary artery
revascularization. The Annals of thoracic surgery, 88(6), pp.1801-1805. Retrieved on 3rd
May 2018, from https://www.sciencedirect.com/science/article/pii/S000349750901532X
Santo, V.J., Dargon, P.T., Azarbal, A.F., Liem, T.K., Mitchell, E.L., Moneta, G.L. and
Landry, G.J., 2014. Open versus endoscopic great saphenous vein harvest for lower
extremity revascularization of critical limb ischemia. Journal of vascular surgery, 59(2),
pp.427-434. Retrieved on 1st May 2018, from
https://www.sciencedirect.com/science/article/pii/S074152141301519X
Saunders, J.T., Nambi, V., De Lemos, J.A., Chambless, L.E., Virani, S.S., Boerwinkle,
E., Hoogeveen, R.C., Liu, X., Astor, B.C., Mosley, T.H. and Folsom, A.R., 2011. Cardiac
troponin T measured by a highly sensitive assay predicts coronary heart disease, heart
failure, and mortality in the Atherosclerosis Risk in Communities Study. Circulation,
pp.CIRCULATIONAHA-110. Retrieved on 9th May 2018, from
https://www.ncbi.nlm.nih.gov/pubmed/21422391
42

Serruys, P.W., Morice, M.C., Kappetein, A.P., Colombo, A., Holmes, D.R., Mack, M.J.,
Ståhle, E., Feldman, T.E., van den Brand, M., Bass, E.J. and Van Dyck, N., 2009.
Percutaneous coronary intervention versus coronary-artery bypass grafting for severe
coronary artery disease. New England Journal of Medicine, 360(10), pp.961-972.
Retrieved on 19th April 2018,
fromhttps://www.nejm.org/doi/full/10.1056/NEJMoa0804626
Seung, K.B., Park, D.W., Kim, Y.H., Lee, S.W., Lee, C.W., Hong, M.K., Park, S.W., Yun,
S.C., Gwon, H.C., Jeong, M.H. and Jang, Y., 2008. Stents versus coronary-artery
bypass grafting for left main coronary artery disease. New England Journal of
Medicine, 358(17), pp.1781-1792. Retrieved on 13th April 2018, from
https://www.nejm.org/doi/full/10.1056/nejmoa0801441
Shahian, D.M., O'brien, S.M., Filardo, G., Ferraris, V.A., Haan, C.K., Rich, J.B.,
Normand, S.L.T., DeLong, E.R., Shewan, C.M., Dokholyan, R.S. and Peterson, E.D.,
2009. The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 1—
coronary artery bypass grafting surgery. The Annals of thoracic surgery, 88(1), pp.S2-
S22. Retrieved on 16th April 2018, from https://ci.nii.ac.jp/naid/10030035605/
Shroyer, A.L., Grover, F.L., Hattler, B., Collins, J.F., McDonald, G.O., Kozora, E., Lucke,
J.C., Baltz, J.H., Novitzky, D. and Veterans Affairs Randomized On/Off Bypass
(ROOBY) Study Group, 2009. On-pump versus off-pump coronary-artery bypass
surgery. nengl J med, 361(19), pp.1827-37. Retrieved on 17th April 2018, from
https://ccforum.biomedcentral.com/track/pdf/10.1186/cc9248?site=http://
ccforum.biomedcentral.com
Smith, Sidney C., Emelia J. Benjamin, Robert O. Bonow, Lynne T. Braun, Mark A.
Creager, Barry A. Franklin, Raymond J. Gibbons et al. "AHA/ACCF secondary
prevention and risk reduction therapy for patients with coronary and other
atherosclerotic vascular disease: 2011 update: a guideline from the American Heart
Association and American College of Cardiology Foundation endorsed by the World
Heart Federation and the Preventive Cardiovascular Nurses Association." Journal of the
43

American College of Cardiology58, no. 23 (2011): 2432-2446. Retrieved on 11th April
2018, from http://www.onlinejacc.org/content/58/23/2432
Stone, G.W., Maehara, A., Lansky, A.J., de Bruyne, B., Cristea, E., Mintz, G.S.,
Mehran, R., McPherson, J., Farhat, N., Marso, S.P. and Parise, H., 2011. A prospective
natural-history study of coronary atherosclerosis. New England Journal of
Medicine, 364(3), pp.226-235. Retrieved on 9th April 2018, from
https://www.nejm.org/doi/full/10.1056/Nejmoa1002358
Taggart, D.P., Altman, D.G., Gray, A.M., Lees, B., Nugara, F., Yu, L.M., Campbell, H.,
Flather, M. and ART Investigators, 2010. Randomized trial to compare bilateral vs.
single internal mammary coronary artery bypass grafting: 1-year results of the Arterial
Revascularisation Trial (ART). European heart journal, 31(20), pp.2470-2481. Retrieved
on 7th April 2018, from
https://academic.oup.com/eurheartj/article-abstract/31/20/2470/613651
Vertrees, A., Fox, C.J., Quan, R.W., Cox, M.W., Adams, E.D. and Gillespie, D.L., 2009.
The use of prosthetic grafts in complex military vascular trauma: a limb salvage strategy
for patients with severely limited autologous conduit. Journal of Trauma and Acute Care
Surgery, 66(4), pp.980-983. Retrieved on 8th April 2018, from
https://journals.lww.com/jtrauma/Abstract/2009/04000/The_Use_of_Prosthetic_Grafts_i
n_Complex_Military.3.aspx
Voros, S., Rinehart, S., Qian, Z., Joshi, P., Vazquez, G., Fischer, C., Belur, P., Hulten,
E. and Villines, T.C., 2011. Coronary atherosclerosis imaging by coronary CT
angiography: current status, correlation with intravascular interrogation and meta-
analysis. JACC: Cardiovascular Imaging, 4(5), pp.537-548. Retrieved on 4th April 2018,
from http://imaging.onlinejacc.org/content/4/5/537.full
Williams, J.B., Peterson, E.D., Brennan, J.M., Sedrakyan, A., Tavris, D., Alexander,
J.H., Lopes, R.D., Dokholyan, R.S., Zhao, Y., O’brien, S.M. and Michler, R.E., 2012.
Association between endoscopic vs open vein-graft harvesting and mortality, wound
complications, and cardiovascular events in patients undergoing CABG
44

surgery. JAMA, 308(5), pp.475-484. Retrieved on 4th April 2018, from
https://jamanetwork.com/journals/jama/fullarticle/1273015
Yamamoto, Y., Sakamoto, Y., Nara, S., Ban, D., Esaki, M., Shimada, K. and Kosuge,
T., 2009.Reconstruction of the portal and hepatic veins using venous grafts customized
from the bilateral gonadal veins. Langenbeck's archives of surgery, 394(6), pp.1115-
1121. Retrieved on 4th May 2018, from https://link.springer.com/article/10.1007/s00423-
009-0500-1
45