Endoscopic vein harvest is associated with worse but improving outcomes in infrainguinal bypass

The impact of great saphenous vein harvest technique on infrainguinal bypass outcomes remains a matter of debate, with no robust evidence favoring a specific technique over the other. This study aims to compare the outcomes of open vein harvest (OVH) with endoscopic vein harvest (EVH) in patients undergoing infrainguinal bypass surgery.

Patients who underwent an infrainguinal bypass from a femoral origin using a single-segment great saphenous vein between 2011 and 2023 were identified in the Vascular Quality Initiative infrainguinal bypass module. Only patients undergoing a bypass for peripheral artery disease were included, and those undergoing in-situ bypass were excluded. Patients were then classified according to their vein harvest technique into OVH and EVH groups. Three-to-one nearest-neighbor propensity score matching without replacement was performed to ensure balance of covariates between the two comparison groups. Kaplan-Meier and Cox regression analysis were used to estimate long-term event rates and evaluate the association of vein harvest technique with the primary outcomes of primary patency, primary-assisted patency, secondary patency, reintervention, amputation, and major adverse limb events, defined as the composite outcome of amputation and/or reintervention.

A total of 7929 patients who underwent OVH were matched to 2643 patients who underwent EVH. All baseline characteristics, demographics, and operative details were balanced after propensity score matching. EVH had a significantly lower rate of surgical site infections (1.8% vs 2.9%; P = .003), whereas other perioperative outcomes, including graft infection (P = .12), myocardial infarction (P = .16), stroke (P = .13), and return to operating room (P = .14) were similar between the two groups. At 1-year follow-up, OVH patients had a significantly higher primary patency (71% vs 65%; P < .001), primary-assisted patency (86% vs 81%; P < .001), and secondary patency (90% vs 85%; P < .001), and significantly lower rates of amputation (6% vs 9%; P < .001), reintervention (20% vs 25%; P < .001), and major adverse limb events (25% vs 30%; P < .001) compared with EVH patients. The primary patency of EVH bypasses significantly increased from 59% to 70% between 2011 and 2020 (P = .042). Although OVH had a significantly higher primary patency compared with EVH in 2011 to 2012 (72% vs 59%; P = .006), this difference diminished over time, with no significant difference observed in the most recent interval (2019-2020) studied (73% vs 70%; P = .214).

Although EVH is associated with a lower postoperative wound complication rate, OVH conferred superior long-term outcomes of patency, reintervention, and limb salvage over the study period. Nonetheless, EVH has demonstrated improvements in primary patency over the years, significantly narrowing the gap in this outcome between the two harvest methods.