Endoscopic Vein Harvesting in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Patients diagnosed with multi-vessel coronary artery disease (2- or 3-vessel disease) confirmed on coronary angiography with SYNTAX score typically >22, where CABG is preferred over PCI

• Patients with left main coronary artery stenosis ≥50%

• Patients with CAD and comorbid Type 2 diabetes, where CABG demonstrates a proven long-term survival advantage over stenting (FREEDOM trial data)

• Patients with reduced left ventricular ejection fraction (LVEF 35–50%) requiring surgical revascularization

• Patients with a patent, adequately sized great saphenous vein confirmed on pre-operative duplex ultrasound mapping (vein diameter ≥3 mm considered optimal)

• Patients who have failed or are not candidates for prior PCI attempts

• Patients with symptomatic angina (CCS Class III–IV) refractory to maximal medical therapy

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• Coronary angiography (invasive or CT coronary angiography/CCTA) with SYNTAX score calculation

• Transthoracic Echocardiogram (TTE/ECHO) to assess LVEF, wall motion abnormalities, and valvular function

• Duplex ultrasound mapping of the great saphenous vein (bilateral) to confirm vein quality, caliber, and patency

• 12-lead ECG and 24-hour Holter monitoring if arrhythmia suspected

• Pulmonary function tests (PFTs) for patients with respiratory comorbidities

• Complete blood panel: CBC, coagulation profile (PT/INR/aPTT), renal function (eGFR, creatinine), liver function tests, HbA1c

• Carotid Doppler ultrasound in patients with history of stroke or TIA

• Chest X-ray and CT chest where indicated

• Cardiac MRI (CMR) or nuclear stress imaging (SPECT/PET-CT) for myocardial viability assessment in patients with low LVEF

• EuroSCORE II and STS Risk Score calculation for operative mortality stratification

• CONTRAINDICATIONS TO EVH SPECIFICALLY:

• Absent, thrombosed, or severely varicose great saphenous vein confirmed on duplex ultrasound (necessitating radial artery or LIMA conduit use)

• Prior saphenous vein stripping or ligation surgeries

• Active lower limb infection, lymphedema, or severe peripheral arterial disease compromising tissue perfusion

• Morbid obesity with BMI >40 (relative contraindication — surgeon and center-dependent)

• CONTRAINDICATIONS TO CABG GENERALLY:

• Severely reduced LVEF <20% without evidence of viable myocardium on PET-CT viability study

• Non-bypassable distal coronary targets on angiography

• Prohibitive operative risk (EuroSCORE II >20%) in the absence of compelling clinical indication

STANDARD OPEN VEIN HARVESTING (Conventional — Reference Technique): The traditional method requires a continuous longitudinal incision from the ankle or mid-calf to the upper thigh, spanning 30–60 cm. The saphenous vein is directly visualized, side branches ligated with sutures or clips, and the vessel excised. While offering direct tactile feedback, this technique carries wound infection rates of 2–5%, significant postoperative leg pain, risk of delayed healing especially in diabetic patients, and prolonged functional recovery of the donor leg.

MINIMALLY INVASIVE ENDOSCOPIC VEIN HARVESTING (EVH — Current Preferred Standard): EVH is performed through 1–3 small (1–2 cm) incisions at strategic anatomical points along the saphenous vein tract. A dedicated endoscopic harvesting device — most commonly the LeMaitre VasoView system, the Terumo Clearglide system, or the Ethicon Vasoview Hemopro — is advanced through a subcutaneous tunnel. The system integrates a high-definition endoscopic camera, CO2 insufflation (pressurized to 10–12 mmHg to create working space), and bipolar or ultrasonic electrocautery for hemostatic side-branch division.

- CO2 Insufflation-Based (Closed Tunnel) EVH: The dominant technique. A sealed tunnel is created subcutaneously, inflated with CO2 gas, and side branches are divided under endoscopic visualization with electrocautery. Offers excellent visualization, reduced tissue trauma, and the lowest wound complication profile.

- Mechanical Retractor-Based (Open Tunnel) EVH: Uses a mechanical retractor rather than CO2 inflation to create the working space. Some surgeons prefer this in patients where CO2 absorption is a concern. Slightly higher wound complication rate than closed CO2 EVH in meta-analyses.

- No-Touch EVH Technique: An evolving refinement where the saphenous vein is harvested with a pedicle of surrounding adipose tissue intact, preserving the vasa vasorum and adventitial vascularity. No-Touch harvesting has demonstrated superior 16-year graft patency rates compared to conventional EVH in the PREVENT IV substudies and Scandinavian trials, approaching the gold standard of Left Internal Mammary Artery (LIMA) grafts. Not universally available; offered at select high-volume centers.

CONDUIT ALTERNATIVES USED ALONGSIDE OR INSTEAD OF SAPHENOUS VEIN: - Left Internal Mammary Artery (LIMA) to LAD: Used in virtually all CABG cases as the primary conduit to the left anterior descending artery; EVH provides the supplementary venous conduits. - Radial Artery Harvesting: Endoscopic radial artery harvesting (ERAH) using similar endoscopic principles is performed when saphenous vein is unsuitable; requires preoperative Allen's test and modified Barbeau test to confirm ulnar collateral adequacy. - Right Internal Mammary Artery (RIMA): Used in bilateral IMA (BIMA) grafting strategies for younger patients; associated with increased sternal wound risk in diabetics.

ROBOTIC-ASSISTED EVH: Robotic platforms (da Vinci Surgical System) can facilitate totally endoscopic or robot-assisted minimally invasive CABG (TECAB/MIDCAB) procedures, including robotic vein harvesting, at select quaternary cardiac centers in India (Narayana Health, Fortis Escorts, AIIMS-affiliated centers) and the UAE (Cleveland Clinic Abu Dhabi, Mediclinic City Hospital Dubai). Robotic approaches offer tremor filtration, 3D magnified visualization, and wristed instrument articulation — beneficial in anatomically challenging cases.

ON-PUMP vs. OFF-PUMP CABG WITH EVH: EVH can be performed in conjunction with both conventional on-pump CABG (using cardiopulmonary bypass/heart-lung machine) and off-pump CABG (OPCAB/beating-heart surgery). OPCAB eliminates the inflammatory cascade associated with cardiopulmonary bypass and may be preferred in patients with significant renal impairment, calcified aorta, or prior stroke. EVH timings are coordinated with the cardiac surgical team regardless of pump strategy.

PRE-OPERATIVE PHASE (Days -7 to 0 — At Home and In Destination Country):

• Step 1 — Remote Medical Review (Before Travel): Patient submits coronary angiography reports, ECHO results, blood work, and surgical history to GAF Healthcare's medical coordination team. Partner hospital cardiologist and cardiac surgeon conduct a tele-consultation to confirm candidacy, calculate EuroSCORE II/STS risk, and finalize operative plan (number of grafts, conduit strategy).

• Step 2 — Arrival and Pre-Admission Workup (Days 1–2): Patient arrives in India or UAE. GAF Healthcare arranges airport pickup and hotel or hospital guesthouse accommodation. Hospital admission for comprehensive pre-operative workup: repeat ECHO, duplex ultrasound vein mapping, anesthesia consultation, hematology panel, chest X-ray, ECG. Anti-platelet therapy (aspirin, clopidogrel/ticagrelor) is strategically discontinued per anesthesiology protocol — typically 5–7 days prior if not already stopped.

• Step 3 — Cardiac Surgery Team Consultation (Day 2–3): Formal pre-operative consultation with the lead cardiac surgeon. Informed consent for CABG with EVH. Surgical plan finalized: number of bypass grafts (typically 2–4), conduit allocation (LIMA + saphenous vein EVH ± radial artery), on-pump vs. off-pump strategy.

INTRA-OPERATIVE PHASE (Operative Day — Approximately 4–6 Hours Total):

• Step 4 — Anesthesia and Positioning: General endotracheal anesthesia with invasive arterial line monitoring, central venous access, and transesophageal echocardiography (TEE) probe placement for real-time cardiac monitoring.

• Step 5 — Simultaneous EVH and Sternotomy Preparation: A dedicated EVH-trained surgical technician or second surgeon begins endoscopic saphenous vein harvesting from the leg simultaneously as the primary surgeon performs median sternotomy. CO2 insufflation (10–12 mmHg) creates the subcutaneous tunnel. The endoscopic camera identifies the vein; side branches are coagulated and divided with bipolar electrocautery. The harvested segment is checked for integrity, flushed with heparinized saline, and prepared as graft conduit.

• Step 6 — CABG Procedure: Cardiopulmonary bypass is established (on-pump) or stabilizer systems applied (OPCAB). The LIMA is anastomosed to the LAD. The prepared saphenous vein grafts are sequentially anastomosed to the target coronary vessels (RCA, OM, diagonal branches) using 7-0 or 8-0 prolene sutures under surgical loupe magnification or robotic visualization. Proximal anastomoses are constructed to the ascending aorta.

• Step 7 — Graft Verification and Closure: Graft flow is verified using transit-time flow measurement (TTFM) and/or intraoperative angiography/Doppler to confirm patency before chest closure. EVH leg port sites are closed with absorbable sutures.

POST-OPERATIVE RECOVERY PHASE:

• Day 0–2 (ICU): Patient is extubated typically within 4–8 hours post-surgery in the cardiac ICU. Hemodynamic monitoring, chest drain output assessment, and early ambulation protocol initiated.

• Day 2–3 (Step-Down/Ward): Transfer from ICU to cardiac step-down unit. Oral medications initiated: aspirin (lifelong), beta-blocker, ACE inhibitor/ARB, statin therapy. Physiotherapy-guided breathing exercises (incentive spirometry) and supervised walking.

• Day 3–5 (Ward): Chest drains removed (typically Day 2–3). Wound inspection. Increasing ambulation distances. Dietary consultation. Cardiac rehabilitation education session.

• Day 5–8 (Discharge): Hospital discharge with complete discharge summary, medications, wound care instructions, and follow-up echocardiogram scheduled. EVH leg sites typically heal significantly faster than open harvesting wounds — most patients note minimal leg discomfort by Day 5.

• Week 2–3 (Hotel/Serviced Apartment Recovery): Outpatient wound check at Day 10–14. Sternal wound and EVH port sites inspected. Suture/staple removal if non-absorbable materials used. Activity restrictions: no lifting >2 kg, no driving, sternal precautions maintained for 6–8 weeks.

• Week 4 (Fit-to-Fly Assessment): Formal physician review including clinical assessment, 12-lead ECG, and chest X-ray. If hemodynamically stable, sternal healing progressing satisfactorily, and no active complications, international air travel is medically cleared at a minimum of 4 weeks. Patients are advised to wear compression stockings, ambulate every 60–90 minutes in-flight, and maintain anticoagulation/antiplatelet therapy per protocol.

• Week 6–12 (Home Country Recovery): Continuation of cardiac rehabilitation program in home country. Sternal restrictions lifted at 6–8 weeks. Return to sedentary work at 6–8 weeks; physically demanding work at 3 months. Follow-up ECHO at 3 months recommended.