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Successful surgery without the usual scarring

Architect Stephen Davis felt out of breath first and then came the chest pains after a round of golf while on holiday in Portugal. He returned to the UK swiftly and was diagnosed with a blockage to the heart that needed triple by-pass surgery.

Stephen, who runs his own practice in Birmingham, had already been diagnosed with high blood pressure and high cholesterol, and was booked in for surgery on January 27 this year.

Remarkably, he was back at work the following week and enjoying a ski holiday within two months of the operation, which was carried out using endoscopic vessel harvesting (EVH). This uses special instruments and powerful imaging to help the surgeon remove vein from the leg or the radial artery from the arm through a small incision immediately before the by-pass surgery.

Around 20,000 coronary artery by-pass graft (CABG) operations are performed in the UK every year to improve blood flow to the heart muscle. One of the more daunting features has been the lengthy cut in the leg or arm to remove the vessel to be used in the by-pass. Around 85 per cent of by-pass operations use lengths of the great saphenous vein, which runs the length of the leg.

But rather than have the traditional cut tracking from his groin to ankle, 59-year-old Stephen had it removed via EVH in a precision keyhole procedure via a 3cm cut just below his knee.

“I had a phenomenal recovery,” he says. “Under the knife on Monday, walking around easily on the Wednesday, out on Thursday and I went into work for a few hours the following week.

“I had spoken to a few people who had by-pass surgery and they said the biggest pain was from the leg, and they were left with a pretty horrific looking scar from groin to ankle.

“But I have a barely noticeable scar just below my knee and I now play golf regularly. It was a real success and has given me a new lease of life.”

His operation was performed by Heyman Luckraz, consultant cardiothoracic surgeon at New Cross Hospital in Wolverhampton. Prabhjeet Kaur, surgical care practitioner at New Cross Hospital, is presenting their research evidence on the benefits of EVH at the annual meeting of the European Association for Cardio-Thoracic Surgery (EACTS) next month.

Dr Luckraz was concerned that around 50 per cent of his hospital patients had difficulty with infection, swelling, leakage or pain after their operation and moved to the EVH system, which drastically reduced infection rates and demonstrated a “phenomenal” cost saving to the NHS.

EVH, which also works for harvesting the radial artery in the arm, has been standard practice in US hospitals for more than 12 years and is becoming more widely available in the UK.

It helps surgeons retrieve a quality vessel, swiftly and efficiently to enhance their task of repairing the heart. For the patient, it is a passport to rapid recovery times with vastly reduced wound problems.

“A clear preference for CABG over the use of angioplasty with stents in patients with moderate to severe coronary artery disease was established by the five-year SYNTAX study of 1,800 patients in Europe and the United States,” says David Taggart, professor of cardiovascular surgery at Oxford University. It demonstrated up to an almost 10 per cent improvement of long-term survival and a significant reduction of later heart attacks with CABG.

“It is a clear winner,” he says. “The key thing we need to get into the equation is to make sure patients are aware of this information because for many years the patients were often treated by the cardiologist and did not always get the option of CABG.”

He advises that treatment decisions should be made by a heart team not a single doctor, adding: “It is vital that they are given the appropriate information so they can make a truly informed choice.”

Consultant cardiac surgeon Toufan Bahrami, of Royal Brompton & Harefield NHS Foundation Trust, is a pioneer in EVH. He was first involved in UK early trials in 2005 and has since trained many UK and European surgeons.

It worked a treat with no complications and the result has been incredible

Mr Bahrami has witnessed the growth of EVH and seen first hand its surgical and financial effectiveness. His trust is now the only one in the UK performing EVH on 100 per cent of its CABG patients, both on the NHS and privately, with eight years of follow-up data from 3,000 patients – the largest in Europe – demonstrating outstanding short and long-term outcomes. This data will be presented at EACTS. “Out of 3,000 EVH operations we have had no infections,” he says. “I am sure in the next five to ten years, every patient should have EVH.”

Currently EVH is not available at every UK hospital.


Sunil Ohri, consultant cardiac surgeon from Southampton, who performed his first EVH operation in 2002, says: “The benefits to the patients are very clear and have been well documented. The most important factor is with wound complications. This is a 2 to 3cms incision compared to one long incision on the leg. Wound breakdown is not a problem and infection is minimized, and there is less pain.

“Reduced pain levels, particularly if you are elderly, means you can mobilise faster, getting out of bed within 48 hours which down-risks potential complications from staying in a hospital bed,” says Mr Ohri. “Patients get home quicker and there is the cosmetic aspect, particularly with younger patients, of not having a big scar.

“In Southampton, we ran a follow-up study of 200 CABG patients tracking them after discharge. We wanted to understand what the post-discharge care demand was and found that EVH patients hardly had any additional requirements for care once they had been discharged.

“While the patients with the classic open operation on their leg needed additional antibiotics, had wound breakdowns dealt with by a district nurse over a few weeks or attended a wound clinic at their GP surgery. But the information showed we can get patients out faster with EVH and that there is less risk once they have left.”

In Wolverhampton, Dr Luckraz’s own study revealed that only two people from 50 EVH patients had minor infection problems with overall group treatment costs of £40,000 compared with 50 who received the traditional method and had an infection rate of around 25 per cent with costs reaching £78,000.

Globally more than 1.8 million patients have been successfully treated with the EVH procedure giving them the opportunity to concentrate on getting better quicker. Patients are often told the worst problem is how their leg recovers, but the pain and swelling is much less with EVH.

EVH is particularly effective with heavier and diabetic patients, who have reduced wound-healing capabilities, and a study showed that the procedure decreases infection risk by 78 per cent in high-risk and unhealthy patients. The combined results of three studies, covering 16,000 patients, showed wound complication reduction greater than 50 per cent with EVH.

A further study, published in the Annals of Thoracic Surgery, reported that no EVH patient needed treatment for wound complications compared with 6 per cent of those who underwent the traditional vein harvesting operation.

Research also shows that traditionally treated patients spend an average 1.5 days longer in hospital and cost the health service up to ten times more than EVH patients for follow-up treatments.


The National Institute for Health and Care Excellence (NICE), the government body that regulates medical procedures in the UK, issued updated guidance on EVH in June giving its approval of the technique.

Its systematic analysis of 44 clinical studies, covering 269,474 patients, ruled there was no difference in long-term results between EVH and open techniques. NICE listed reduced hospital stay, reduced risk of wound infection, early rehabilitation, reduced rate of re-admission and patient satisfaction among the benefits.

“It is very promising,” says Dr Heyman Luckraz, who is a member of the Society of Clinical Perfusion Scientists’ Council. “With this guidance, and the data we have collected and generated, we have shown this is a safe thing to use for the patient and it is cost-effective in the longer term.”



Two patients, who underwent heart surgery, tell of their experience and the benefits of EVH

Richard Lea, a 66-year-old retired joiner from Macclesfield, Cheshire, received EVH as part of his quadruple by-pass surgery at Wythenshawe Hospital, University Hospital of South Manchester NHS Trust, on August 13, under Professor Nizar Yonan.

“I had two friends who had by-pass surgery and they said the leg wound was the worst part of it,” says Mr Lea. “I had four blockages to my heart so needed a quadruple by-pass and they said they were going to get the vein with keyhole surgery.

“It worked a treat with no complications and the result has been incredible. I was out in six days and I’ve only got three nicks in my leg that you can barely see. To think it was only a couple of weeks ago is amazing. I saw my friend, who had it done 16 years ago, and he said he could still feel the scar down his leg.”

Professor Yonan says: “Wythenshawe Hospital has carried out more than 1,500 EVH cases since 2008 – as routine practice and for research purposes, having published scientific papers suggesting EVH offers better patient satisfaction through less scarring, reduced GP and district nurse visits and reduced wound complications.

“Although every patient gets benefit from EVH through their experience, the most beneficial patients are diabetic, those with peripheral vascular disease and women who love the cosmetic benefits.”

Veronica Stokes can just about detect the tiny white scar where her watch sits, which is one of two minute signs of her surgery. The 81 year old was admitted to London’s Royal Brompton Hospital after feeling cramp in her shoulders and some breathlessness.

“I also had cramp in my jaw sometimes, but they were not the classic symptoms,” she says. “The cardiologist wanted me to go to Royal Brompton and I’ve had extremely good care throughout.”

A surgical team, led by consultant surgeon Anthony de Souza, used EVH to get a radial artery from her left arm to perform a double by-pass and heart valve replacement.

Seven months on and the former dyslexia teacher, who lives near Winchester, Hampshire, is playing tennis again and marvelling at the lack of scarring on her arm.

“I’ve recovered very well and didn’t need any pain killers throughout the recovery,” she says. “I obviously have the scar on my chest from the surgery, but if you look carefully at my left arm, just where the watch strap is, you will see a little nick and another on the inner side of the elbow, where the radial artery was taken out. It was all done very skillfully and there was no long incision in my arm.”

All patients’ procedures were performed on the MAQUET Vasoview Endoscopic Vessel Harvesting system