No-touch Vein Research Articles

Superior long-term patency of no-touch vein graft compared to conventional vein grafts in over 1500 consecutive patients

ObjectivesTo evaluate the long-term angiographic patency of saphenous vein grafts (SVG) harvested using the no-touch technique compared to the conventional technique.MethodsThis was a single-center, retrospective, cohort study. The inclusion criteria were individuals who underwent a CABG (coronary artery bypass grafting) between January 1995 and July 2020, and who successively needed a clinically-driven angiography. The primary endpoint was long-term patency. The secondary endpoints were differences in patency based on sub-group analysis (single vs. sequential graft, divided by target vessel).ResultsThe study included 1520 individuals (618 no-touch, 825 conventional and 77 arterial grafts). The mean clinical follow-up time was 8.4 years ± 5.5 years. The patency per patient was 70.7% in the no-touch grafts vs. 46.7% in the conventional grafts (p < 0.001, OR = 2.8). The graft patency was 75.9% in the no-touch grafts vs. 62.8% in the conventional grafts (p < 0.001, OR = 1.8).ConclusionsThe no-touch vein grafts were associated with statistically significantly higher patency at long-term compared to the conventional grafts.Clinical trial registrationNCT04656366, 7 December 2020.

Early Experiences of Serbian Surgeons Using No-Touch Technique for Vein Conduits in CABG Patients: A Follow-Up Study with Multi-Slice CT Angiography.

Background and Objectives: The saphenous vein graft (SVG) remains the most frequently used conduit worldwide, despite its common disadvantage of early graft failure. To solve the problem and reduce the SVG damage, Souza implemented a new technique where a vein is harvested with surrounding fascia and fat tissue (the so-called no-touch technique). Materials and Methods. A prospective study conducted from February 2019 to June 2024 included 23 patients who underwent myocardial revascularization using a no-touch vein, with follow-up control examinations using computed tomographic angiography to detect graft stenosis or occlusion. Results. Of the entire patient group, 17 (73.9%) were male, with a mean age of 67.39 ± 7.71 years. The mean follow-up period was 25 months. There were no major adverse cardiovascular or cerebrovascular events (MACCEs) during hospitalization, although one patient died in the hospital. Another patient died due to malignancy, but no MACCEs occurred during the follow-up period. According to multi-slice CT coronary angiography, the results were impeccable, with an astonishing 100% patency observed in all 20 IMA grafts and 58 no-touch SVGs examined. Conclusions. The excellent patency rate during the early follow-up period confirmed that the no-touch technique is a good option for surgical revascularization.

Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)

Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined. This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups. This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery. ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.

Learning Curve for No-Touch Vein Harvesting Technique in Off-Pump Coronary Artery Bypass Grafting

Introduction: The present study sought to analyze the learning curve of no-touch vein harvesting technique in off-pump coronary artery bypass grafting (CABG). Methods: Logarithmic curve fitting was used to analyze learning curves based on operative time for 160 patients that underwent no-touch CABG. The clinical data of 89 of these patients whose number of grafts was 3 were further retrospectively analyzed based on Cumulative Sum (CUSUM) analysis. Patients were divided into two groups, referring to the surgeon’s learning period and maturation period in chronological order. Perioperative outcomes were compared between two groups. Results: In this study, the learning curve for no-touch vein harvesting technique in off-pump CABG was quantitatively assessed in 51 cases through CUSUM analysis, and the results from logarithmic curve fitting corroborated these findings, indicating a significant milestone in proficiency gain for practitioners. Compared with patients in surgeon’s learning period, the median of the operative, Aorta-saphenous vein graft (SVG) anastomosis, and SVG checking time in the maturation period was significantly shorter (230 min vs. 250 min, p = 0.002; 11.5 min vs. 13.0 min, p = 0.025; 9.0 min vs. 11.0 min, p = 0.002). There was less first 48-h chest tube drainage, shorter postoperative hospital stay and rarer delayed incision healing in the leg in the late period compared with that in the early period (312.6 ± 140.7 mL vs. 401.0 ± 233.5 mL, p = 0.029; 11.0 d vs. 12.0 d, p = 0.026; 15.7% vs. 2.6%, p = 0.043). Conclusion: A cardiac surgeon mastered in CABG using the full-incision SVG harvesting method experienced a learning curve to gain early proficiency in no-touch CABG. In the initial learning period, Aorta-SVG anastomosis, bleeding check of SVG, and wound complications need to be paid more attention.

Long-term results of percutaneous coronary intervention in no-touch vein grafts are significantly better than in conventional vein grafts.

Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique. This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis. The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4years with a standard deviation of 3.7years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups. Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

To touch or not to touch: unveiling the key to vein graft patency.

The Graft Patency Between No-Touch Vein Harvesting Technique and Conventional Approach in Coronary Artery Bypass Graft Surgery (PATENCY) trial, a large multicenter study, compared the no-touch (NT) technique with conventional vein harvesting in coronary artery bypass graft (CABG) surgery. The study included 2655 patients and assessed graft patency at 3months and 1year using computed tomography (CT) angiography. The NT group showed a significantly lower occlusion rate at 3months (2.8% vs. 4.8%) as well as at 1year (3.7% vs. 6.5%). Recurrence of angina was also lower in the NT group at 1year. The study provides robust evidence supporting the NT technique's efficacy in improving vein graft patency.

Quantitative flow ratio and graft outcomes of coronary artery bypass grafting surgery: A retrospective study

ObjectiveQuantitative flow ratio (QFR) is a novel noninvasive tool for the functional assessment of coronary stenosis. Whether or not QFR could predict graft outcomes after coronary artery bypass grafting procedure is unknown. This study aimed to investigate the association of QFR value with graft outcomes after coronary artery bypass grafting surgery. MethodsThe QFR values were retrospectively obtained from patients receiving coronary artery bypass grafting surgery from 2017 to 2019 in the Graft Patency Between No-Touch Vein Harvesting Technique and Conventional Approach in Coronary Artery Bypass Graft Surgery (PATENCY) trial. QFR calculation was conducted in eligible coronary arteries, defined as those with ≥50% stenosis and a diameter ≥1.5 mm. A threshold of QFR ≤0.80 was considered functionally significant stenosis. The primary outcome was graft occlusion at 12 months evaluated by computed tomography angiography. ResultsTwo thousand twenty-four patients with 7432 grafts (2307 arterial grafts and 5125 vein grafts) were included. For the arterial grafts, the risk of 12-month occlusion was significantly increased in the QFR >0.80 group than in the QFR ≤0.80 group (7.1% vs 2.6%; P = .001; unadjusted model: odds ratio, 3.08; 95% CI, 1.65-5.75; fully adjusted model: odds ratio, 2.67; 95% CI, 1.44-4.97). No significant association was observed in the vein grafts (4.6% vs 4.3%; P = .67; unadjusted model: odds ratio, 1.10; 95% CI, 0.82-1.47; fully adjusted model: odds ratio, 1.12; 95% CI, 0.83-1.51). Results were stable across sensitivity analyses with a QFR threshold of 0.78 and 0.75. ConclusionsTarget vessel QFR >0.80 was associated with a significantly higher risk of arterial graft occlusion at 12 months after coronary artery bypass grafting surgery. No significant association was found between target lesion QFR and vein graft occlusion.

Techniques and Outcomes of the No-Touch Vein Conduit as a Y-Composite Graft.

Although the saphenous vein is a widely used conduit for coronary artery bypass grafting, revascularization using the saphenous vein as an aortocoronary bypass graft has shown disadvantages of lower long-term graft patency rates and subsequently worse clinical outcomes, compared with revascularization using the internal thoracic artery. Of the various efforts to overcome the limitations of vein conduit that are resulting from structural and functional differences from arterial conduit, recent technical improvement in no-touch vein composite graft construction and outcomes of revascularization using no-touch vein composite grafts based on the left internal thoracic artery will be discussed in this topic.

Quality of Life After Percutaneous Coronary Intervention in No-Touch Saphenous Vein Grafts is Significantly Better Than in Conventional Vein Grafts.

ObjectiveTo compare health-related quality of life (HRQoL) of patients primarily treated with a no-touch saphenous vein graft with that of patients who received a conventional graft.MethodsThe study included all individuals treated with a percutaneous coronary intervention (PCI) on a saphenous vein graft (SVG) between January 2006 and June 2020. The RAND-36 health survey was used to assess HRQoL. The Mann-Whitney U test was used to test differences in HRQoL between the two groups. Effect size was estimated via Cohen’s d. The average treatment effect between the groups was tested by propensity score matching (PSM).ResultsOf the 346 patients treated with a PCI in a stenosed or occluded SVG, 165 responded to RAND-36 (no-touch: n=48; conventional: n=117). Patients with a no-touch graft reported better mean values on seven of the eight health survey domains. Statistically significant differences were observed for four of the domains, all in favour of the no-touch group. The effect size estimates indicated a small difference for five domains, with the highest values (>0.40) seen for the general health and energy/fatigue domains. PSM confirmed a statistically significant difference for the physical functioning and general health domains.ConclusionAt a mean follow-up of 5.4 years, patients who received a PCI in no-touch vein grafts showed significantly better HRQoL than those who received a PCI in conventional vein grafts.

Increased patency with comparable mortality and revascularization risk: Is the case for no-touch vein harvesting open and shut?

Journal of Cardiac SurgeryVolume 36, Issue 11 p. 4376-4377 COMMENTARY Increased patency with comparable mortality and revascularization risk: Is the case for no-touch vein harvesting open and shut? Makoto Hibino MD, MPH, PhD, Corresponding Author Makoto Hibino MD, MPH, PhD [email protected] orcid.org/0000-0002-0017-8744 Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada CorrespondenceMakoto Hibino, MD, MPH, PhD, Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada. Email: [email protected]Search for more papers by this authorNitish K. Dhingra BHSc, Nitish K. Dhingra BHSc Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, CanadaSearch for more papers by this authorSubodh Verma MD, PhD, Subodh Verma MD, PhD Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, CanadaSearch for more papers by this author Makoto Hibino MD, MPH, PhD, Corresponding Author Makoto Hibino MD, MPH, PhD [email protected] orcid.org/0000-0002-0017-8744 Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, Canada CorrespondenceMakoto Hibino, MD, MPH, PhD, Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 30 Bond St., Toronto, ON M5B 1W8, Canada. Email: [email protected]Search for more papers by this authorNitish K. Dhingra BHSc, Nitish K. Dhingra BHSc Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, CanadaSearch for more papers by this authorSubodh Verma MD, PhD, Subodh Verma MD, PhD Division of Cardiac Surgery, The Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, Toronto, CanadaSearch for more papers by this author First published: 03 September 2021 https://doi.org/10.1111/jocs.15973Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume36, Issue11November 2021Pages 4376-4377 RelatedInformation

Harvesting techniques of the saphenous vein graft for coronary artery bypass: Insights from a network meta-analysis.

The optimal harvesting technique of saphenous vein (SVG) in coronary artery bypass grafting (CABG) is still to be elucidated. The present study aimed to compare the methods of SVG harvesting technique, which were open vein harvesting (OVH), endoscopic vein harvesting (EVH), and no-touch vein harvesting (NT), using a network meta-analysis of randomized controlled trials (RCTs), and propensity-score matched (PSM) studies. MEDLINE and EMBASE were searched through April 2021 to identify RCTs and PSM studies that investigated the outcomes in patients who underwent CABG with the SVG using one of three methods; OVH, EVH, and NT. The outcomes of interest were all-cause mortality, the rates of revascularization, and graft failure. Risk ratios (RRs) were extracted for the rates of graft failure, and hazard ratios (HRs) were extracted for all-cause mortality and the rates of revascularization. Eligible seven RCT and five PSM studies were identified which enrolled a total of 8111 patients. All-cause mortality was significantly lower in patients with EVH compared with OVH (HR [95% confidence interval (CI)] =0.77 [0.65-0.92], p = .0032). The rates of revascularization were similar among the groups. The rate of graft failures was significantly lower in patients with NT compared with OVH (HR [95% CI] =0.54 [0.32-0.90], p = .019) and with EVH (HR [95% CI] =0.39 [0.17-0.86], p = .023). NT vein harvesting is favorable for graft patency, and OVH showed higher all-cause mortality than EVH. Further well-powered RCTs are needed to confirm our findings.

The Short-Term Patency Rate of a Saphenous Vein Bridge Using the No-Touch Technique in off-Pump Coronary Artery Bypass Grafting in Vein Harvesting.

ObjectiveThis study aimed to examine the short-term effect of the no-touch technique on the patency rate of a great saphenous vein (GSV) bridge used during off-pump coronary artery bypass grafting (OPCABG).MethodsBetween June 2018 and September 2020, 140 patients undergoing OPCABG, with grafts obtained from the GSV using the “no-touch” technique or the left internal mammary artery (LIMA), were enrolled in this study. The early clinical results and short-term patency rate of the OPCABG were evaluated at a three-month follow-up by comparing the patency rate of the LIMA bridge and the GSV bridge obtained by the no-touch technique. This study also analyzed the impacts of the postoperative complications of the lower limbs and the distribution area of diseased vessels on the patency rate of a GSV bridge obtained by the no-touch technique at an early stage.ResultsNo perioperative death or adverse cardiovascular or cerebrovascular events occurred in the 140 patients undergoing OPCABG. The difference in the early patency rate between the GSV bridge obtained by the no-touch technique and the LIMA bridge was not statistically significant (95.9% vs 97.1%, p = 0.501). There was no significant difference in the patency rate between an end-to-side anastomosed venous bridge and a LIMA bridge (95.0% [248/261] vs 97.1% [136/140], p = 0.314). The overall patency rate of a no-touch vein bridge in the right coronary artery region was lower than it was in the left coronary artery region (93.8% [165/176] vs 97.9% [183/187], p = 0.049).ConclusionThe no-touch technique may improve the early patency rate of a GSV bridge, and its effect is similar to that of a LIMA bridge.

Rationale and design of a multicenter randomized trial to compare the graft patency between no-touch vein harvesting technique and conventional approach in coronary artery bypass graft surgery

Vein graft failure is a crucial challenge in coronary artery bypass graft (CABG) surgery. Previous studies have suggested a patency benefit of the No-Touch vein harvesting technique, but only with small sample sizes. This study is a prospective, multicenter randomized clinical trial with a large sample size, aiming to investigate the efficacy of the No-Touch technique compared with the conventional approach. All patients requiring isolated CABG with left internal mammary artery plus at least one saphenous vein graft will be considered for entry into the study. Two thousand cases (1000 in each arm) will be enrolled over 1 to 2 years in 7 hospitals in China. Participants will be randomized in equal proportions between two surgical strategies: the No-Touch or conventional technique. The primary endpoint is graft vessel occlusion at 3 months after CABG surgery by CT coronary angiography. Secondary outcomes are major adverse cardiac or cerebrovascular events at 3 and 12 months post-operation and graft vessel occlusion at 1 year. This study will define the role of the No-Touch vein harvesting technique in CABG surgery and provide strong evidence to answer whether this technique could reduce vein graft occlusion.

Short-term clinical safety and efficacy of No-touch great saphenous vein harvesting technique for off-pump coronary artery bypass grafting

Objective: To evaluated early clinical outcomes of saphenous vein grafts harvested with a No-touch technique in off-pump coronary artery bypass graft (OPCABG) surgery. Methods: A total of 124 patients with three-vessel disease undergoing OPCABG by No-touch technique between June and November 2017 in Beijing An Zhen Hospital were respectively reviewed. Results: The average age of patients was (60.7±10.3) years, and 80 cases (64.5%) were male, with the average body mass index (BMI)of (25.4±2.5) kg/m(2,) the mean preoperative left ventricular ejection fraction (LVEF) of (58.0±7.0%). The operative time was (4.0±0.4) hours, and 16 cases (12.9%) were harvested for whole vein grafts. The number of vein grafts and venous anastomoses was 144 and 284, respectively. There were 16 cases of single bridge NTSVG-LAD, 4 cases of single bridge NTSVG-D, 99 cases of sequential bridge NTSVG-OM-PDA, 5 cases of sequential bridge NTSVG-OM-PLV, 4 cases of sequential bridge NTSVG-OM-RCA, 16 cases of sequential bridge NTSVG-D-OM-PDA. The mean flow volume of No-touch vein grafts was (51.9±2.4) ml/min. There was no death case in hospital. Postoperative re-exploration for hemorrhage of anastomosis happened in 1 case (0.8%), which was caused by pericardial tamponade due to insufficiency of hemostasis in internal mammary bed. There were 1 case of bad wound healing of lower extremity incision (0.8%). A total of 124 cases were followed up after operation, and the follow-up rate was 100%. There was one all-cause death (0.8%) 27 days after the operation. Conclusion: The short-term clinical observation of the application of No-touch great saphenous vein harvesting technique for OPCABG is safe and effective.

The no-touch saphenous vein graft in elderly coronary bypass patients with multiple comorbidities is a promising conduit to substitute the left internal thoracic artery

ObjectivesWe investigated the patency rates of no-touch saphenous vein grafts anastomosed to the left anterior descending artery compared with the left internal thoracic artery. Further, we compared the patency of no-touch vein grafts to the left anterior descending artery with the patency of no-touch vein grafts to other coronary arteries. MethodsOf 2635 consecutive patients undergoing coronary artery bypass grafting between 2003 and 2008, 168 (6.3%) were given at least a saphenous vein graft to the left anterior descending artery to avoid harvesting complications in high-risk patients or in response to a left internal thoracic artery injury. A total of 97 patients were consecutively included after informed consent. A clinical examination and computed tomography angiography were performed on 91 patients at a mean of 6 (4-9) years. ResultsThe mean age of patients was 75.6 ± 8.5 years. Postoperatively, 88.7% of patients (86/97) were free of angina. The 91 examined patients had 163 grafts with 286 distal anastomoses. Crude patency, according to distal anastomoses, was 94.4% (270/286). The patency of single versus sequential no-touch vein grafts to the left anterior descending artery was 98% (50/51) versus 92.5% (37/40). The total patency rate was 95.6% (87/91), similar to the reported patency rate for the left internal thoracic artery. The no-touch grafts to the left anterior descending artery versus other coronaries had a patency of 95.6% (87/91) versus 93.8% (183/195), a high similarity confirmed by an equivalence analysis. ConclusionsIn elderly coronary bypass patients with multiple comorbidities, a no-touch saphenous vein graft is a promising substitute for the left internal thoracic artery.

The no-touch saphenous vein for coronary artery bypass grafting maintains a patency, after 16 years, comparable to the left internal thoracic artery: A randomized trial

ObjectivesThis study investigates whether the no-touch (NT) vein graft, at a mean time of 16 years, maintains a significantly higher patency rate than conventional (C) vein grafts and still has patency comparable to that of the left internal thoracic artery (LITA). MethodsA total of 156 patients accepted for coronary artery bypass grafting were randomly allocated to 1 of 3 groups. In the C group, the saphenous vein (SV) was stripped and distended. In the intermediate group, the SV was stripped but not distended. In the NT group, the SV was neither stripped nor distended, but rather harvested with a fat pedicle. This study is an angiographic follow-up of the C and NT groups, at a mean time of 16 years postoperatively. ResultsFifty-four patients were included (C group = 27; NT group = 27). In all, 72 and 75 vein grafts were completed in groups C and NT, respectively. Crude SV graft patency was 64% in the C group versus 83% in the NT group (P = .03), which was similar to the patency of the LITA (88%). The harvesting technique had a major impact on the patency with a hazard ratio for occlusion of 1.83 for the C group (P = .04). ConclusionsHarvesting the SV with the NT technique conferred, at a mean time of 16 years, a significantly higher patency than the conventional technique that was still comparable to that of the LITA.

The no-touch vein graft for coronary artery bypass surgery preserves the left ventricular ejection fraction at 16 years postoperatively: long-term data from a longitudinal randomised trial

ObjectivesTo assess the left ventricular heart function and the clinical outcome 16 years after coronary artery bypass surgery.DesignIn a randomised trial, the no-touch (NT) vein graft in coronary artery bypass...

No difference in 1-year wound morbidity following no-touch versus conventional vein harvesting for coronary artery bypass surgery: a new beginning

Controversy surrounding the issue of greater wound morbidity when using the ‘no-touch’ (NT) saphenous vein graft (SVG) when compared with the conventional (CON) harvesting technique has been addressed for the first time by the recent study of Verma et al .[ 1], who showed no significant difference in wound complications and functional recovery after 1 year of follow-up. Due to the relatively low use of the NT technique, introduced in 1996, data are limited to a single randomized study showing that NT harvesting of the SVG results in a superior patency over CON [2]. Various vasculoprotective mechanisms in NT SVGs have been demonstrated. Although the primary outcome measure of the paper by Verma et al. shows a decreased vascular injury in NT SVGs, we find the results of the secondary study, regarding leg wound healing and functional outcome, to be crucial for the NT technique to attain warranted popularity. We congratulate the authors on conducting this study and point out a few additional factors that we believe should be considered when interpreting the results. It is difficult to understand why no differences in intima, media and adventitial thicknesses were seen between the two groups particularly as CON veins were stripped of its adventitial layer. Also, an earlier study on NT versus CON vessel morphology has shown differences in media thickness [3]. Although there appears no clear evidence of a difference in the risk of infection when staples rather than sutures are used to close leg wounds after SVG harvesting during coronary artery bypass grafting (CABG) [4], information regarding the proportion of wounds closed using staples is missing. To maintain as high homogeneity of the sample as possible all patients should either have staples or absorbable cuticular sutures, particularly in the larger, ongoing, SUPERIOR-SVG trial (clinicaltrials.gov identifier: NCT01047449). In the light of recent data indicating that antibacterial sutures reduce the incidence of infections after CON harvesting in CABG patients by 35% [5], we consider that the data regarding the suture material used are both relevant and necessary for adequate interpretation of the results. SVG harvest-site complications are often managed in legs with arterial insufficiency. Did the patient with peripheral vascular disease have an equal severity of the disease in both legs and was he/she included in the leg assessment analysis? The importance of accounting for arterial insufficiency in the donor site is crucial when comparing postoperative leg wound morbidity rates between groups. The vast majority of patients included in the study by Verma et al .[ 1] were men (94%). Whether these results will remain similar in a mixed sex population remains to be seen. The Materials and Methods section points to Supplementary data on leg wound healing and functional outcomes, although no such data can be found. Finally, there was a single crossover; a CON SVG was harvested from the leg assigned to NT. This patient developed a leg wound infection of the leg assigned to NT and analysed according to intention to treat. What impact would per treatment analysis have on the 3-month follow-up results of leg assessment? When considering that reduced leg wound morbidity has resulted in the recent adoption of endoscopic vein harvesting as a standard of care in spite of dubious graft patency [6], resolving the issue of NT wound morbidity is more important for greater uptake of the technique. We congratulate the authors once again on conducting this study and hope they find our comments useful for the SUPERIOR-SVG ‘NT versus CON’ trial that is underway.

Reply to Kopjar et al.

We thank Kopjar et al. [1] for their comments regarding our recent work published in Eur J Cardiothorac Surg [2]. We reported attenuated vascular smooth muscle cell activation via microRNA-145 as a possible pathogenetic mechanism for the clinical observation of improved vein graft patency using the no-touch (NT) approach. Kopjar et al. [1] focused on a critical aspect of a ‘NT’ vein harvest that has been a major barrier to wide-spread adoption, which being the morbidity of the leg incision. We have read their comments and offer our responses. In this report, our patient numbers were too small to make any definitive conclusions regarding clinical leg wound morbidity. To address this important issue, we direct Kopjar et al. to our ongoing prospective, multicentre randomized controlled clinical trial comparing conventional (CON) saphenous vein graft (SVG) harvest versus the no-touch technique (SUPERIOR SVG Study; http ://clinicaltrials.gov/show/NCT01047449). The primary outcome of the SUPERIOR SVG Study is 1-year graft occlusion; the secondary outcomes include adverse SVG harvesting events at 1 year postcoronary artery bypass graft, which include infection, haematoma, swelling, neuropathy and quality-of-life measures. In this report, we found worse short-term leg assessment scores in NT versus CON at 3 months as well as more incidences of infection (4 vs 0 patients). However, as the authors have pointed out that, at 1 year, such scores were not different between groups. Our data does suggest that, in our patient population, although NT vein harvest was associated with acute morbidity, there may not be associated long-term functional consequences. As for the method of leg closure, all leg incisions were sutured closed with two layers of subcutaneous 2-0 Vicryl (Ethicon, Somerville, NJ, USA) sutures and a single 3-0 monocryl subcuticular layer. Anti-microbial sutures may minimize leg wound harvest-site infections, but were not used in these patients. In this report, all patients were included in the leg assessment study, including the one patient with preoperative peripheral vascular disease, which was not considered severe and without observable chronic skin changes. We do advocate that lower leg harvesting be avoided and thigh saphenous vein segments used for patients with more significant peripheral arterial insufficiency. We also agree that it remains to be seen whether gender will come to be an independent risk factor for infection. The Materials and Methods section points to Supplementary data, which includes the leg wound healing and functional outcomes questionnaire. This can now be accessed on the Eur J Cardiothorac Surg website. Finally, although the representative micrographs of SVG HE 217.76 ± 48.73 vs 202.32 ± 45.53, and 146.19 ± 43.39 vs 132.38 ± 28.34, respectively). Finally, there was a single crossover; a CON SVG was harvested from the leg assigned to NT that developed a leg wound infection and analysed according to intention to treat. We did not perform the as-treated analysis nor would this change the outcome of the analysis. In addition, we thank Kopjar, et al. [1] for their interest in our paper and for raising these important points. Unfortunately, this report was not designed nor able to address many of the issues raised. As Kopjar et al. point out, the SUPERIOR SVG study will address these concerns.

The no-touch vein graft harvesting technique for coronary artery bypass grafting surgery reduces mortality: a long-term follow-up study

Background The saphenous vein is still the most widely used conduit in CABG surgery despite its poor long term patency. In the 1990’s a new No-touch technique for saphenous vein graft harvesting for CABG was introduced where the vein graft is harvested with a pedicle of surrounding tissue. With the No-touch technique the vein graft does not go into spasm and the vessel wall does not have to be exposed to distension-induced trauma. A previous randomized trial has shown a significantly higher patency rate for vein grafts harvested with the No-touch technique compared to vein grafts harvested with conventional technique and the patency for No-touch vein grafts was comparable to the patency of the left internal thoracic artery, 8.5 years after surgery. The aim of this study was to evaluate whether the increased patency rate for No-touch vein grafts is reflected in clinical outcome.