Leg Wound Complications Research Articles

Smoking and wound complications after coronary artery bypass grafting

BackgroundThe harmful effects of smoking on the postsurgical wound healing disturbances have been widely investigated across various surgical procedures. These effects after coronary artery bypass graft (CABG) surgery have been less explored. We aimed to investigate the association of smoking and the wound healing problems in post-CABG patients. Materials and methodsWe compared the incidence of wound complications in 405 smokers and 405 nonsmokers who underwent an elective CABG surgery. The incidence of leg and sternal wound complications was evaluated during the first 7 d as well as at a 6-wk postoperative visit. ResultsOne hundred fifty-six leg wound complications were noted in 132 patients (16.3%). The overall rate of leg wound healing disturbances was significantly higher in smokers than those in nonsmokers (odds ratio, 1.47; 95% confidence interval, 1.109–4.019; P = 0.010). The incidence rates of leg wound edge necrosis and dehiscence were significantly higher in smokers compared with those in nonsmokers (3.7% versus 0.7%, P = 0.004 and 6.6% versus 0.7%, P < 0.0001, respectively). We found no significant differences between the incidence of postoperative leg wound infection, hematoma, wound edema, and seroma in active smokers and those who never smoked. Thirty-seven postsurgical sternal wound complications (4.6%) were developed in 33 patients (4.1%). The overall rate of sternal wound healing disturbances was similar between smokers and nonsmokers. There was a trend between the sternal wound dehiscence and smoking (P = 0.03); however, the other sternal wound complications were not associated with smoking. ConclusionsSmoking may contribute to the disturbances of wound healing, especially wound dehiscence, in post-CABG patients.

Endoscopic Saphenous Vein Harvesting versus Open Vein Harvesting Techniques

To investigate whether endoscopic saphenous vein harvesting (EVH )reduces leg wound morbidity and improves rehabilitation of lower extremity as compared to open vein harvesting (OVH) in patients with coronary artery disease. The clinical data of 333 patients who underwent isolated coronary artery bypass graft surgery (CABG) between January 2007 and December 2011 were retrospectively analyzed.These patients were divided into EVH group (n=210) and OVH group (n=123). Parameters including age,sex,with/without diabetes mellitus,leg wound complications rate,postoperative hospital stay,hospitalization expense,and vein graft patency were analyzed. The age,sex,with/without diabetes mellitus were not significantly different between two groups (P>0.05). However,the incidences of leg wound complications, poor wound healing, wound infections, wound pain,wound numbness, and edema of lower extremity were significantly lower in the EVH group than the OVH group (P<0.05). The ecchymoma and deep vein thrombosis incidences were not significantly different between these two groups (P>0.05). The postoperative hospital stay showed no significant difference (P>0.05), while the hospitalization expense was significantly higher in the EVH group than in the OVH group (P<0.05). There was no statistical difference of vein graft patency (P>0.05). The EVH system is a safe and effective alternative to OVH because it can markedly reduce postoperative leg wound morbidity and the EVH vein graft has good patency.

Decreased patency rates following endoscopic vein harvest in coronary artery bypass surgery

Objectives. Endoscopic vein harvest has gained widespread use in coronary artery bypass surgery. However, potential negative mid- and long-term effects following endoscopic vein harvest have been described. We aimed to compare long-term clinical outcomes following endoscopic and open vein graft harvesting. Design. This study was a clinical follow-up with additional computed tomographic coronary angiography among 126 first-time bypass patients originally included in a randomized study comparing early leg wound complications and cosmetic results. Deceased patients were retrospectively followed up. Results. Follow-up was complete, but information on clinical endpoints was not available in all patients. A total of 111 patients were alive at follow-up. Median observation time was 6.3 (range: 0.2–9.1) years including three in-hospital deaths. Vein graft failure was significantly higher in the endoscopic vein harvest (EVH) group (13 of 31; 42%) compared with the open vein harvest (OVH) group (2 of 32, 6%) (P = 0.001). However, this difference was not reflected by differences in recurrence of angina (P = 0.44), myocardial infarction (P = 0.11), and all-cause mortality (P = 0.15). Conclusions. Using a median follow-up time of 6.3 years significantly more vein graft failures were identified following EVH compared with OVH without any differences in long-term clinical outcomes.Trial registration: ClinicalTrials.gov identifier: NCT01480726.

Early Outcomes of Endoscopic Vein Harvesting during the Initial Learning Period.

BackgroundThe endoscopic vein harvesting (EVH) method has been used in coronary artery bypass surgery in many countries. We started using the EVH method recently, and investigated the results during the early learning period.MethodsBetween March 2012 and June 2014, 75 patients (31 patients in the EVH method group, and 44 patients in the open method group) who underwent isolated first-time coronary artery bypass grafting using vein grafts were retrospectively analyzed with respect to the early outcomes including graft patency and risk factors for leg wound complications. For assessing the patency of vein graft, we performed coronary computed tomography angiography during the immediate postoperative period and 6 months later.ResultsMean harvesting time of endoscopic method was about 15 minutes. Patency rate during the immediate operative period and the 6-month patency rate were similar between the two groups (postoperative period: EVH 100% vs. open method 94.4%, p=0.493; at 6 months: EVH 93.3% vs. open method 90.9%, p=0.791). Leg wound complications occurred more frequently in the open method group (EVH 3.2% vs. open method 13.6%, p=0.127). According to the analysis, age was an independent risk factor for leg wound complications.ConclusionEVH is a feasible method even for beginners and can be performed satisfactorily during their learning period.

NEGATIVE PRESSURE DRESSING TO DECREASE THE INCIDENCE OF LEG WOUND COMPLICATIONS AFTER CABG: NURSING PERSPECTIVES FOR PATIENT CARE

Leg wound complications after harvesting the greater saphenous vein can occur in up to 28% of patients undergoing coronary artery bypass grafting (CABG) (1,2). Edema and pain often lead to impaired mobility, while infection can result in not only sepsis, but also psychological trauma related to loss of independence and anxiety related to isolation precautions (2,3). This prospective, single-blinded, single centre randomized controlled pilot study examines the incidence of leg wound complications following elective CABG through comparison of a negative pressure dressing (n=23) versus traditional dry gauze (n=23).

215 * COST-BENEFIT OF ENDOSCOPIC VEIN HARVESTING IN HIGH-RISK PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING

Objectives: Our aim was to assess the cost-benefit of endoscopic vein harvesting (EVH) in high-risk patients undergoing CABG. Methods: Patients at high risk of leg wound complication (female, age >75 years), diabetic, peripheral vascular disease (PVD), BMI >28 kg/m2, smoker) were selected for pilot use of EVH and were propensity-matched to patients undergoing open vein harvest (OVH). Patients had at least two of these risk factors (n = 50 patients/group). Data was prospectively collected. All wounds were assessed during in-hospital stay, regularly in the wound clinic and up until wounds had healed. Costs of treating wounds included additional in-hospital stay, costs of the various dressings, costs of attending wound clinic and any additional treatment (e.g. wound debridement, vacuum-assisted closure therapy etc.). For the EVH group, there was the additional cost for the kit (£650/patient). Results: There were no significant differences between the two groups in preoperative characteristics (age, gender, diabetes, PVD, smokers, procedure, logistic EuroSCORE, etc.). Prior to hospital discharge, 9% vs 16% (P = 0.08) of patients (EVH vs OVH) had minor leg-wound suppurations. Leg-wound pain score was lower for the EVH group (P < 0.01). There was an additional 1-day ward postoperative stay for the OVH group (P = 0.02). At follow-up, 2% vs 48% patients had leg-wound issues requiring attendance to the wound clinic, respectively (P < 0.01) costing a total of £2,758 (EVH) as compared to £78,036 (OVH) (P < 0.01). This amounted to a cost saving of £42,778 (including EVH kit costs) favouring EVH. Conclusion: EVH provided better patient outcomes (less leg-wound problems, reduced leg-wound pain and shorter ward-stay postoperatively). This was associated with significant cost savings for treating leg wound complications in high-risk patients undergoing EVH.

Endoscopic vein harvesting in coronary artery bypass surgery

The greater saphenous vein is the most available and frequently used conduit for coronary artery bypass grafting. Conventional (open) vein harvesting procedure requires the longitudinal skin and subcutaneous fat incision along the full conduit length. Endoscopic vein harvesting has been developed in the middle-1990s as less invasive alternative for open vein harvesting. Using this novel technique allows to harvest the whole greater saphenous vein through 3 cm long skin incision. The article reviews the history, the role and current status of endoscopic vein harvesting in coronary artery bypass surgery. Literature data of the impact of that minimally invasive approach on infective and non-infective leg wound complications, as well as postoperative pain, patient satisfaction and live quality are presented. The cost-effectiveness data of the method, resulting in reduction of treatment costs of leg wound complications both at the hospital and after patient’s discharge are mentioned. The influence of endoscopic vein harvesting on morphologic and functional conduit quality is discussed. Special attention is devoted to mid- and long-term outcomes after coronary artery bypass surgery with endoscopic vein harvesting. The majority of research including angiographic control gives evidence of comparable parameters of bypass patency after the conventional vein harvesting and endoscopic vein harvesting procedures. Recent multicenter trials showed no statistically significant differences between the conventional vein harvesting and endoscopic vein harvesting procedures in such indirect graft patency indicators as mortality, myocardial infarction rate, need for repeated revascularization and recurrence of angina pectoris. Recent findings advocate safety and clinical effectiveness of endoscopic vein harvesting.

Choice of Vein‐Harvest Technique for Coronary Artery Bypass Grafting: Rationale and Design of the REGROUP Trial

The Randomized Endo-vein Graft Prospective (REGROUP) trial (ClinicalTrials.gov NCT01850082) is a randomized, intent-to-treat, 2-arm, parallel-design, multicenter study funded by the Cooperative Studies Program (CSP No. 588) of the US Department of Veterans Affairs. Cardiac surgeons at 16 Veterans Affairs (VA) medical centers with technical expertise in performing both endoscopic vein harvesting (EVH) and open vein harvesting (OVH) were recruited as the REGROUP surgeon participants. Subjects requiring elective or urgent coronary artery bypass grafting using cardiopulmonary bypass with use of ≥1 saphenous vein graft will be screened for enrollment using pre-established inclusion/exclusion criteria. Enrolled subjects (planned N = 1150) will be randomized to 1 of the 2 arms (EVH or OVH) after an experienced vein harvester has been assigned. The primary outcomes measure is the rate of major adverse cardiac events (MACE), including death, myocardial infarction, or revascularization. Subject assessments will be performed at multiple times, including at baseline, intraoperatively, postoperatively, and at discharge (or 30 days after surgery, if still hospitalized). Assessment of leg-wound complications will be completed at 6 weeks after surgery. Telephone follow-ups will occur at 3-month intervals after surgery until the participating sites are decommissioned after the trial's completion (approximately 4.5 years after the full study startup). To assess long-term outcomes, centralized follow-up of MACE for 2 additional years will be centrally performed using VA and non-VA clinical and administrative databases. The primary MACE outcome will be compared between the 2 arms, EVH and OVH, at the end of the trial duration.

Perceived learning needs of Syrian patients postcoronary artery bypass graft surgery

To describe the perceived learning needs of Syrian patients who underwent coronary artery bypass graft surgery before hospital discharge and to examine the differences in the mean scores of the categories (subscales) of the modified Cardiac Patients Learning Needs Inventory according to the demographic characteristics of the participants. Knowledge about the learning needs of patients who underwent coronary artery bypass graft surgery can help nurses in coronary care units to provide them with the information that they need. This might improve their quality of life through decreasing complications, length of stay in the hospital and hospital readmissions. A descriptive design was used for this study. A convenience sample of 135 patients participated in this study and completed the demographic form and the modified Cardiac Patients Learning Needs Inventory. Information about chest and leg wound care, complications, medication and physical activity was the most important learning needs. There were significant differences between patients' perceptions of learning needs and their age, chronic illnesses and their working status. Syrian patients who underwent coronary artery bypass graft surgery were able to identify their learning needs that should be the focus of nursing practice. Meeting the needs of patients who underwent coronary artery bypass graft surgery should be emphasised in nursing practice. Meeting these needs might enhance their self-care behaviours.

A Retrospective Review of Leg Wound Complications After Coronary Artery Bypass Surgery

Little research or attention has been paid to finding out whether wound closure with sutures or staples attains the best outcomes after saphenous vein harvest for coronary artery bypass grafting. We undertook a quality improvement project to compare the prevalence of leg wound complications (eg, infection, seroma, hematoma, dehiscence) between two types of skin closure (ie, staples, subcuticular sutures) after conventional open surgery with bridging between incisions and vein harvesting during coronary revascularization to determine the need for practice changes. We found no significant differences between patients with wound complications and those without. However, in this project, the risk for infections was greater for patients with diabetes whose wounds were closed by using subcuticular sutures. These findings have led to practice changes for reducing leg wound complications within our institution: clinicians now assess patients for increased risk of leg wound complications preoperatively and opt to close wounds with staples for patients who have diabetes.

Endoscopic vein harvesting is influenced by patient-related risk factors and may be of specific benefit in female patients

The standard of care regarding endoscopic vein harvesting (EVH) is still inhomogeneous across Europe. The current study aimed at elucidating patient-related factors favouring its application and procedure-related outcome in a tertiary care centre. All patients who underwent coronary artery bypass grafting with or without concomitant valve procedures between 2008 and 2011 were included. Emergency surgery and all arterial revascularization patients were excluded. A total of 262 endoscopically harvested patients and 623 open vein harvested patients were included. Mortality, perfusion time and cross-clamp time were not significantly different. Peripheral artery disease predisposed open vein harvesting (odds ratio [OR] 1.9; P = 0.001); diabetes and a higher number of diseased coronary vessels favoured EVH (OR 0.6; P = 0.003 and 0.002). Further, the number of bypass grafts was significantly increased in the endoscopic group, but these patients required less periprocedural blood transfusions (1.4 ± 1.8 vs 1.8 ± 3.0; P = 0.035). Minor wound healing complications were more common in the open group (10.3 vs 3.8%; P = 0.001). Severe complications in the leg requiring surgical revision occured in 2.4% of open vein harvested patients compared with 1.1% for endoscopic patients (P = ns). After a multivariate regression analysis, only female gender remained as a significant risk factor for impaired wound healing (OR 2.4; P = 0.001), whereas EVH reduced the risk of wound-healing complications (OR 0.4; P = 0.008). EVH dramatically reduced postoperative would healing complications. Women were more likely to develop mild and severe leg wound complications. Therefore, women may benefit even more from EVH. In general, the favourable outcomes of EVH should result in a more widespread use of this technology in men and women.

Editorial Comment: Endoscopic vein harvest: standard of care?

Editorial Comment: Endoscopic vein harvest: standard of care?

The influence of endoscopic vein harvesting on outcomes after coronary bypass grafting: a meta-analysis of 267 525 patients

In recent times, practice in cardiac surgery has shifted towards using endoscopic techniques to harvest the saphenous vein from the leg for use as a bypass graft. A paper published in the New England Journal of Medicine (NEJM) in 2009 raised concerns over increased graft occlusion rates in veins harvested endoscopically. This NEJM paper has been criticized, but has nonetheless been influential in guiding practice. We have undertaken this meta-analysis to provide evidence on the clinical outcomes of endoscopic vein harvesting (EVH), so that clinicians can make an informed judgement about whether this technique, popular as it is with patients, should still be offered. We systematically reviewed the global literature and performed a meta-analysis of clinical outcomes after endoscopic and open vein harvesting. In all outcomes, endoscopic harvesting appears to be equal, if not superior, to open harvesting. The suspicion of higher rates of vein graft occlusion was not borne out by randomized studies. When considering evidence from only randomized studies, there is no statistical difference in vein graft stenosis or occlusion between open and endoscopically harvested veins. In conclusion, EVH reduces pain and leg wound complications. At a median follow-up of 2.6 years, we found no significant difference in mortality, myocardial infarction, repeat revascularization, angina recurrence, vein graft stenosis or occlusion. Therefore, the authors support the ongoing use of endoscopic harvesting techniques.

The Early and Late Effects of Calcium Dobesilate on Leg Wound Complications After Saphenous Vein Harvesting for Coronary Revascularization

Giris: Bu calismanin amaci profilaktik olarak kullanilan kalsiyum dobesilatin koroner baypas grefti olarak safen ven kullanimi sonrasi safenektomi komplikasyonlarini azaltmada etkili olup olmadigini gostermektir. Gerec ve Yontem: Klinigimizde akut koroner baypas grefti operasyonu yapilmis ardisik toplam 209 elektif koroner baypas olan hasta prospektif olarak taranarak iki gruba ayrildi. Birinci grup, operasyonu gerceklestiren ekipler tarafindan rutin uygulama ile uc ay boyunca 2 x 500 mg/gun kalsiyum dobesilat verilen 98 hastadan, ikinci grupta ise herhangi bir sekilde operasyon sonrasi kalsiyum dobesilat verilmeyen 111 hastadan olustu. Bacakta gelisen dort potansiyel komplikasyon analiz edilerek birinci hafta, birinci ay ve ucuncu ay sonuclari karsilastirildi. Bulgular: Bu calismada, koroner baypas ameliyati icin safenektomi yapilan hastalarimizda kalsiyum dobesilat kullaniminin; birinci haftada yuzeyel ve debridman gerektiren yara yeri infeksiyonlarinda, ilk hafta ve birinci ayda selulit gelisimini onlemede, birinci ay ve ucuncu ayda odemi azaltmada etkili oldugu gorulmustur. Sonuc: Koroner baypas operasyonu icin greft olarak safen ven kullanilan hastalarda safenektomi komplikasyonlari azalmak icin uc ay sureyle kalsiyum dobesilat 2 x 500 mg/gun dozunda kullanimi onerili

Long saphenous vein harvesting site infection after coronary artery bypass grafting

Introduction Coronary artery bypass grafting is a very common surgery with highly successful outcomes; however, wound complications from harvesting the long saphenous vein (LSV) can be a major source of postoperative morbidity. The aim of this study was to identify the incidence of LSV harvesting site infection in coronary artery bypass grafting and to detect the possible risk factors. Patients and methods Between September 2009 and December 2010, 100 patients who were diagnosed with coronary artery disease were included in our study and were admitted at Shebien El-Kom Teaching Hospital. All patients who developed major leg wound complication were assessed daily during the postoperative period using the ASEPSIS scoring system and 10 risk factors were analyzed and compared with the entire cohort of patients undergoing similar bypass procedure during the same time period. Results LSV harvesting site infections (ASEPSIS score >20) were identified in 12 patients (12%), including nine patients with mild infection (ASEPSIS score 21-30), two with moderate infection (ASEPSIS score 31-40), and one with severe infection (ASEPSIS score >40). Of the 10 variables evaluated using multivariate analysis, age, sex, obesity, smoking, diabetes, peripheral vascular disease, level of LSV harvesting, usage of intra-aortic balloon pump, Cardio-Pulmonary Bypass (CPB) time, and use of internal thoracic artery graft were identified as significant independent predictors of major leg wound complications (P Conclusion Identification of independent risk factors for infection is important to develop strategies that prevent infection and to allow for recognition of patients at high risk who may need more careful monitoring so as to prevent development of infection.

Could routine saphenous vein ultrasound mapping reduce leg wound complications in patients undergoing coronary artery bypass grafting?

A best evidence topic was written in cardiothoracic surgery based on a structured protocol. The question addressed was whether ultrasound mapping of the long saphenous vein (LSV) might reduce leg wound complications by reducing unnecessary leg incisions due to poor quality veins. Altogether, 32 abstracts were identified from the search, from which 5 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Surgical site infections can be extremely distressing for patients, and it is estimated that treating a surgical wound can cost up to £1554 each. Ultrasound mapping of the LSV has been reported to be an accurate way of assessing vein quality preoperatively, reducing unnecessary surgical dissection, theatre time and cost to both the patient and the health service. We identified four studies that showed that ultrasound scanning preoperatively could accurately predict the anatomy and quality of the LSV (correlation coefficient 0.87). One paper showed that ultrasound scanning reduced length of incision (P = 0.005), harvest time (P = 0.04) and hospital stay and reduced morbidity (although not statistically significant). However, one study found that it could not accurately predict vein wall changes. Evidence from the papers supports the use of preoperative ultrasound assessment of the saphenous vein. Benefits to the patient include a smaller scar, reduced harvest time and minimizing unnecessary incisions.

157 Surgical Management of Infant Transposition of the Great Arteries With Ventricular Septal Defect and Pulmonary Stenosis: Nikaidoh Versus Rastelli

stream regulator of KLF4 mediated VSMC differentiation, in SVGs harvested using the CON (vs. NT) technique. Selfreported functional recovery of the NT leg at 3 months was reduced compared to the CON leg (p 0.0005) and harvest site wound complications greater (p 0.13). There were 4 harvest site infections in the NT leg vs. 0 in the CON leg (p 0.05); all infected patients had diabetes. CONCLUSIONS: SVGs harvested using the NT technique exhibit a molecular and morphological pattern consistent with decreased VSMC activation. Self-reported functional recovery was decreased in the NT leg at 3 months. Prospective clinical trials (SUPERIOR-SVG) will evaluate whether these early biological signals translate into improved patency in SVG harvested using the NT technique. CIHR

Radial artery patency

The benefit of a graft or stent is dependent on persistent patency. After a false start in the 1970s, the radial artery (RA) enjoyed rapid and widespread adaptation following its reintroduction in 1992 [1]. The Parisian experience, where it began on both occasions and spans 20 years from the second start, is herein reported [2, in this issue]. The authors report angiographic follow-up in 351/819 patients having 548 conventional and 205 computed tomography (CT) angiograms. Patency has disappointed by not equaling that of the left internal thoracic artery (ITA) to the left anterior descending (LAD) (95.5% but is a respectable 82.8% at 7 years and similar to that from Rome and Melbourne) [3, 4]. It is well known that target vessel influences patency and usually the RA is grafted to a vessel other than the LAD which is associated with best patency. When the diagonal was the target, RA patency was 93.1% (95/102) [2]. Our unpublished data of the RA as a T-graft to the LAD, diagonal or ramus artery revealed patency of 94% (15/16) at a mean of 10.2 years. Free ITA patency, 80% (49/55), was not different from the RA [2]. Patency for the RA was improved by sequential anastomosis to 91.2% (52/57) from 82.0% (469/572) (p = 0.08) for single anastomosis [2]. Asymptomatic patients had significantly better patency – 88.1%, (347/394) than did those with symptomatic ischemia 74.0% (174/235) (p < 0.001) as the indication for angiography [2]. Most graft failures occurred in the first year beyond which the linear attrition rate was about 0.37% per year. Importantly, there was no evidence for graft atherosclerosis [2] nor in the other two reports [3, 4] or in our unpublished observations to 15.7 years. Although RA patency is no better than for vein grafts, it is likely that this will change in the second decade of observation as graft atherosclerosis develops. How or should we utilize the RA in the future? It has several advantages over the ITA including length, concomitant harvest, less fragility, and reduced sternal infection if combined with one ITA, but the liabilities of spasm and vulnerability to competitive flow. In many instances, the RA falls in line behind the right ITA but there are instances (obese diabetic, morbid obesity, chest wall concerns, and reoperation) where the RA may be preferable. Harvesting is easier and leg-wound complications are avoided if RA is substituted for vein in obese patients where either conduit is otherwise an option including the older patient. Fractional flow reserve is routinely obtained by our cardiologists to assess lesions which are not high grade and only those lesions having a gradient are considered for RA grafting [5]. I continue to selectively use the RA as a T-graft for circumflex and right coronaries but do not graft the posterior descending artery for a right coronary lesion of <90%.

Endoscopic Saphenous harvesting with an Open CO2 System (ESOS) trial for coronary artery bypass grafting surgery: study protocol for a randomized controlled trial

BackgroundIn coronary artery bypass grafting surgery, arterial conduits are preferred because of more favourable long-term patency and outcome. Anyway the greater saphenous vein continues to be the most commonly used bypass conduit. Minimally invasive endoscopic saphenous vein harvesting is increasingly being investigated in order to reduce the morbidity associated with conventional open vein harvesting, includes postoperative leg wound complications, pain and patient satisfaction. However, to date the short and the long-term benefits of the endoscopic technique remain controversial. This study provides an interesting opportunity to address this gap in the literature.Methods/DesignEndoscopic Saphenous harvesting with an Open CO2 System trial includes two parallel vein harvesting arms in coronary artery bypass grafting surgery. It is an interventional, single centre, prospective, randomized, safety/efficacy, cost/effectiveness study, in adult patients with elective planned and first isolated coronary artery disease. A simple size of 100 patients for each arm will be required to achieve 80% statistical power, with a significant level of 0.05, for detecting most of the formulated hypotheses. A six-weeks leg wound complications rate was assumed to be 20% in the conventional arm and less of 4% in the endoscopic arm. Previously quoted studies suggest a first-year vein-graft failure rate of about 20% with an annual occlusion rate of 1% to 2% in the first six years, with practically no difference between the endoscopic and conventional approaches. Similarly, the results on event-free survival rates for the two arms have barely a 2-3% gap. Assuming a 10% drop-out rate and a 5% cross-over rate, the goal is to enrol 230 patients from a single Italian cardiac surgery centre.DiscussionThe goal of this prospective randomized trial is to compare and to test improvement in wound healing, quality of life, safety/efficacy, cost-effectiveness, short and long-term outcomes and vein-graft patency after endoscopic open CO2 harvesting system versus conventional vein harvesting.The expected results are of high clinical relevance and will show the safety/efficacy or non-inferiority of one treatment approach in terms of vein harvesting for coronary artery bypass grafting surgery.Trial registrationwww.clinicalTrials.gov NCT01121341.

Lymphocele following saphenous vein harvesting

Case Study 58 yrs old female with coronary artery bypass graft (CABG) 10-months ago presented with a soft ball size lump on her left leg at the incision point where her saphenous vein was stripped off. The lump had gradually increased in size over months. Patient denied any local trauma, pain, or discharge. An examination revealed a 12 x 8 x 5 cm size, soft, mobile, non-pulsatile swelling medial and just above the knee without any associated erythema or tenderness (see figure ). An ultrasound with duplex doppler showed a non-vascular homogenous anechoic cystic fluid collection. Patient refused the needle aspiration or surgery due to fear of recurrence, but the findings were consistent with a diagnosis of lymphocele. So far, patient has had no symptoms except for the inconvenience of having a big lump on her thigh. Discussion: Lymphocele post- CABG is a subcutaneous collection of lymph fluid that develops due to disruption of lymphatic vessels during s aphenous vein harvesting. Although uncommon (1), it is associated with risk factors like female gender, obesity, diabetes mellitus and open saphenous vein harvesting (2,3). Treatment of these lymphoceles should initially be conservative, but if this approach fails, surgical excision should be performed and special attention paid to identifying and ligating the feeding lymphatic vessel (4).