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In the earlier days of coronary bypass surgery, patients would not only have to endure the intense pain originating from the chest incision and chest cracking necessary for the surgeons to get to the heart, they also complained bitterly about the pain caused by the open surgical removal of a saphenous vein in their leg used for grafting purposes. These could leave the heart surgery patients with long incisions- at times running from the groin to the toe. Open grafting scars would add to the recovery time, cause unnecessary increased pain, and increase risk of infection. As the techniques improved over the years, the heart surgeons began to find more humane and less invasive and painful ways to harvest grafting veins. Endoscopic harvesting was developed to reduce the pain, the size of the scar, and infection risk. In the endoscopic approach, small cuts are made and a small scope and tools are used to locate and pull the veins through the small incisions. Less invasive is always better- so they thought.

The New England Journal of Medicine recently published a study that called into question the safety and advisability of such less invasive endoscopic graft approaches. The study compared outcomes for patients who had endoscopic graft harvesting with those that had open harvesting (where the vein was actually seen "under direct vision." The following surprising results were found:

Results The baseline characteristics were similar between patients who underwent endoscopic harvesting and those who underwent open harvesting. Patients who underwent endoscopic harvesting had higher rates of vein-graft failure at 12 to 18 months than patients who underwent open harvesting (46.7% vs. 38.0%, P<0.001). At 3 years, endoscopic harvesting was also associated with higher rates of death, myocardial infarction, or repeat revascularization (20.2% vs. 17.4%; adjusted hazard ratio, 1.22; 95% confidence interval [CI], 1.01 to 1.47; P=0.04), death or myocardial infarction (9.3% vs. 7.6%; adjusted hazard ratio, 1.38; 95% CI, 1.07 to 1.77; P=0.01), and death (7.4% vs. 5.8%; adjusted hazard ratio, 1.52; 95% CI, 1.13 to 2.04; P=0.005).

This study should cause surgeons to reconsider, or at least question, the advisability of always using endoscopic grafting approaches for coronary-artery bypass surgery in every case. Certainly, the risks and benfits should be discussed in detail with patients prior to any surgery, rather than leaving that issue to default. The study points out the need for further trials to evaluate the "safety and effectiveness" the endoscopic grafting techniques.

Once again, we are reminded of the need to question our health care providers in order to maintain, as much as possible, our control over our own bodies and our health. Unfortunately, it also demonstrates the true lack of understanding medicine has of the mechanisms of disease.

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