VEST external stent for coronary artery bypass grafts

Level of innovation

All 4 specialist commentator noted that VEST was novel and innovative compared with current practice. None was aware of any CE-marked alternatives available on the market.

One specialist commentator noted the disparity between the size of the potential benefitting population (that is, 17,000 CABG procedures are done each year in the UK) and the low uptake and small number of reported cases in the literature (n=60).

Potential patient impact

The specialist commentators agreed that VEST could improve patient outcomes if it were proven to be effective, specifically by reducing repeat revascularisations and reducing myocardial infarction, ischaemic heart damage and angina. One commentator agreed that VEST could improve patients' post-operative experience by reducing 'demand management', with fewer admissions for recurring angina and fewer catheter lab interventions and repeat CABGs needed. Another thought that VEST may allow for longer symptomatic and prognostic benefit after CABG. One highlighted evidence to show that people with vein graft occlusion have lower quality and quantity of life.

Two specialist commentators thought that the external wall support provided by VEST may avoid graft kinking and abnormal dilatation and reduce intimal hyperplasia, thereby increasing potentially improving graft patency. One commentator highlighted that the benefit of revascularisation depends on graft patency, and despite secondary prophylaxis, vein graft patency may be limited: older studies show that up to 50% of grafts become compromised by 10 years (although more widespread use of higher-dose statins may make these data less relevant to current practice). Another agreed that VEST may increase the lifespan of vein grafts used as conduits in CABG surgery.

Two specialist commentators stated that VEST may be of particular benefit to people with diabetes, because they are greater risk of coronary artery disease and vein graft disease so are more likely to have an earlier than expected vein graft occlusion. People with severe disease or those presenting at a young age for CABG (less than 40 years) are also likely to benefit from VEST, because these people are most affected by graft longevity.

One specialist commentator said they would like to offer VEST to all their patients with an expected lifespan of more than 5 years.

Potential system impact

One specialist commentator raised concerns that VEST may have no use to the NHS unless a prospective randomised trial on its use could demonstrate its clinical benefits. They noted there is a substantial cost associated with each VEST device.

Another specialist commentator did not think that VEST would reduce length of stay or affect the length of CABG itself, but that it would increase costs if it were used routinely for all CABG patients having venous conduits as part of their operation. This commentator stated that VEST may lead to overall cost savings by reducing demand for drug therapy, as well as catheter-based and surgical procedures for recurring angina.

Two specialist commentators observed that if better graft patency with VEST can be proven, adopting the device could lead to cost savings for the NHS both in economic terms and in increased patient life years. One of these specialist commentators highlighted that VEST has the potential to become standard care for all CABG procedures using saphenous vein grafts, which would increase upfront procedure costs.

All 4 felt that special training would be needed but most thought it would be minimal, because VEST is easily adapted to current surgical techniques. None of the specialist commentators thought any changes in facilities or infrastructure would be needed to use VEST.

General comments

All 4 specialist commentators highlighted the need for evidence from larger, well-powered studies to show improved vein graft patency and cost savings for the NHS. One stated that this could be done by following-up a significant cohort of patients for at least 5 years and comparing costs with non-VEST matched controls. Another stated this should be done in young patients over a 10-year period. One specialist commentator felt that the current evidence, comprising small single-centre studies and short follow-ups, is not strong enough to recommend a change to current practice.

None of the specialist commentators was aware of any safety alerts, but 1 quoted a published report showing that a VEST-supported saphenous vein graft with an additional coating of bioglue resulted in worse outcomes than a standard saphenous vein graft.