Advice

The technology

The technology

VEST (venous external support; Vascular Graft Solutions [VGS]) is an external stent for use in coronary artery bypass graft (CABG) surgery in which at least 1 saphenous vein is used as the bypass conduit. It is designed to improve conduit haemodynamics and reduce lumen irregularities, wall tension and intimal hyperplasia, with the ultimate aim of reducing the progression of vein graft disease and therefore the need for reintervention.

VEST is made of a cobalt chromium alloy mesh, which is designed to be kink and crush resistant. It is available in various lengths and diameters, and its implantation is done in a similar way to standard grafting techniques. Before being implanted, the correct size is chosen using the VGS selection tool (provided with the device). During CABG, VEST is threaded over the nonpressurised vein graft towards the distal anastomosis, then manipulated to cover the distal end of the graft (for sequential segments, an additional VEST device may be needed). VEST is then expanded by gently squeezing until it covers the entire vessel length. In doing so, VEST elongates and simultaneously reduces in diameter (for sequential grafts, this step is repeated for each VEST threaded onto each segment). Expansion can be done either before or after stitching the proximal anastomosis.

VEST cannot be used:

  • for vein graft segments less than 4 cm

  • for vein graft segments with an external pressurised diameter less than 3 mm

  • in people with a known allergy to cobalt chrome alloy or its components. VEST was previously marketed as VGS Fluent.

Innovations

VEST is the only external stent designed to be used with vein grafts during CABG. It is designed to reduce the incidence of future cardiac events and the need for further interventions in people who have had CABG.

Current NHS pathway

There are 2 main revascularisation procedures used to treat coronary heart disease: CABG, and percutaneous coronary intervention (PCI).

The NICE guideline on stable angina recommends that both CABG and PCI should be considered for people with stable angina whose symptoms are not satisfactorily controlled with optimal medical treatment. It recommends that CABG should be used as standard revascularisation care in people with complex coronary lesions or left main coronary diseases. The choice of revascularisation strategy will depend on many factors including angiographic suitability, patient choice, age, and the presence of diabetes and other comorbidities. If both CABG and PCI are options, the guideline states that PCI is preferable because it is more cost effective (but patient preference should be taken into account once the risks, benefits and limitations of each procedure have been explained). The NICE guideline on unstable angina and NSTEMI makes similar recommendations. The use of vein grafts during CABG is not covered by NICE guidance.

NICE is not aware of similar CE-marked technologies which fulfil a similar function to VEST.

Population, setting and intended user

VEST is intended to be implanted by cardiac surgeons in hospital operating theatres, which may be in secondary or specialist tertiary care centres. VEST will be used during CABG. It may be of particular use in younger patients or in those at higher risk of complications.

The company states that no changes are needed to current surgical techniques to incorporate VEST. Surgeons must be trained in implanting the device, but clinical experts advised that any training would be minimal.

Costs

Technology costs

A single VEST costs £700 (excluding VAT); 1 or 2 devices may be needed per procedure. No other consumables are needed, but this would be in addition to the cost of a standard CABG (see below).

It takes about 1 minute to implant VEST and no stitches or adhesives are needed to keep the device in place. The cost of VEST includes training provided by the company, consisting of in-theatre training with company representatives, local proctors and a dedicated implantation model.

Costs of standard care

The 2017/18 national tariff for a CABG ranges from £6,594 (HRG code ED28C, standard CABG with CC score 0 to 4) to £13,547 (HRG code ED26A, complex CABG with CC score of 10 and above).

Resource consequences

No published economic evidence was identified.

Using VEST would increase the costs of CABG by 10% to 20%. These costs could be offset if the device reduced the incidence of vein graft failure, and if this meant that fewer reinterventions were needed.

It is unlikely that any changes will be needed in the way services are organised and provided in order to adopt VEST.

VEST has been available since 2014 and is currently used in 5 NHS trusts.