A retrospective audit of long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting

Effect of preoperative ultrasound mapping of the saphenous vein on leg wound complications after coronary artery bypass surgery: a systematic review

Background

The long saphenous vein is one of the most used conduits for coronary artery bypass graft surgery. The aim of this study was to assess the existing evidence regarding the effects of preoperative ultrasound mapping of the long saphenous vein with special attention to leg wound complications in patients undergoing elective coronary artery bypass graft surgery.

Main text

A systematic literature search was conducted in PubMed, Cochrane, and Embase databases. Extraction of relevant data was performed including study characteristics, patient characteristics, and all reported outcomes. The Cochrane Risk of Bias tool was used to evaluate the risk of bias of the included studies. The primary outcome measure was leg wound infections.

Of 4514 papers screened in this systematic review, 36 papers underwent full-text assessment with final inclusion of 5 studies; 3 observational studies, and 2 randomized trials. The two randomized controlled trials showed no effects of preoperative ultrasound. Data from the three non-randomized studies was pooled in a meta-analysis, which suggested a significant reduction in the risk of harvest wound complications by ultrasound mapping prior to surgery (RR 0.32; 95%CI = [0.19–0.55]).

Conclusions

The main findings of this systematic review showed, that (1) the evidence in this field is limited and of low quality, i.e., low power or methodology and (2) despite limitations of the included studies, preoperative ultrasound mapping of the saphenous vein seems to be beneficial in terms of reducing the risk of postoperative leg wound complications.

Effects of Leg Length, Sex, Laterality, and the Intermediate Femoral Cutaneous Nerve on Infrapatellar Innervation

Background:

An iatrogenic injury to the infrapatellar branch of the saphenous nerve (IPBSN) is a common precipitant of postoperative knee pain and hypoesthesia.

Purpose:

To locate potential safe zones for incision by observing the patterns and pathway of the IPBSN while examining the relationship of its location to sex, laterality, and leg length.

Study Design:

Descriptive laboratory study.

Methods:

A total of 107 extended knees from 55 formalin-embalmed cadaveric specimens were dissected. The nerve was measured from palpable landmarks: the patella at the medial (point A) and lateral (point B) borders of the patellar ligament, the medial border of the patellar ligament at the patellar apex (point C) and tibial plateau (point D), the medial epicondyle (point E), and the anterior border of the medial collateral ligament at the tibial plateau (point F). The safe zone was defined as 2 SDs from the mean.

Results:

Findings indicated significant correlations between leg length and height (r_P = 0.832; P < .001) as well as between leg length and vertical measurements (≥45°) from points A and B to the IPBSN (r_P range, 0.193-0.285; P range, .004-.049). Male specimens had a more inferior maximum distance from point A to the intersection of the IPBSN and the medial border of the patellar ligament compared with female specimens (6.17 vs 5.28 cm, respectively; P = .049). Right knees had a more posterior IPBSN from point F compared with left knees (–0.98 vs–0.02 cm, respectively; P = .048). The majority of knees (62.6%; n = 67) had a nerve emerging that penetrated the sartorius muscle. Additionally, 32.7% (n = 35) had redundant innervation, and 25.2% (n = 27) had contribution from the intermediate femoral cutaneous nerve (IFCN).

Conclusion:

We identified no safe zone. Significant innervation redundancy with a substantial contribution to the infrapatellar area from the IFCN was noted and contributed to the expansion of the danger zone.

Clinical Relevance:

The location of incision and placement of arthroscopic ports might not be as crucial in postoperative pain management as an appreciation of the variance in infrapatellar innervation. The IFCN is a common contributor. Its damage could explain pain refractory to SN blocks and therefore influence anesthetic and analgesic decisions.

Vein Grafts in Free Flap Reconstruction: Review of Indications and Institutional Pearls

SUMMARY

Vein grafts enable soft-tissue reconstruction in cases of insufficient pedicle length, a lack of nearby recipient vessels, and a wide zone of injury caused by trauma or radiation therapy. The purpose of this article is to provide a comprehensive review of vein grafts in free flap reconstruction focusing on the timing of arteriovenous loops, complications, and surgical technique. Vein graft indications, types of vein grafts, and location-specific considerations are also reviewed. Three reconstructive microsurgeons at high-volume centers were asked to offer institutional pearls on the order of anastomosis, selection of donor veins, and timing of arteriovenous loops. In terms of gap length, vessel gaps less than 10 cm may be reconstructed with an interposition or transposition vein graft. For longer gaps, surgeons should consider the use of arteriovenous loops, transposition arteriovenous loops, or flow-through flaps. Both one and two-stage arteriovenous loops are used, depending on patient comorbidities, potential exposure of critical structures, and surgeon preference. Although one-stage arteriovenous loops expedite the reconstructive process, two-stage arteriovenous loops require shorter operations and help identify patients at risk of flap failure. Although whether the use of vein grafts increases flap failure rates is controversial, complications are highest in lower extremity reconstruction, cases of a prolonged interval between stages in two-stage arteriovenous loops, and unplanned vein grafts.

Short-Term Evaluation of a Novel No-Touch Technique for Harvesting Saphenous Veins With Long-Shafted Ultrasonic Scalpel

OBJECTIVE

Saphenous vein grafts (SVGs) are widely used as bypass conduits in coronary artery bypass grafting. Compared with the conventional technique, the "no-touch" technique, wherein the saphenous veins are harvested with the surrounding tissue, may improve SVG patency; however, there are concerns regarding wound complications. To address this issue, we describe our novel no-touch technique with separate skin incisions using a long-shafted ultrasonic scalpel and report the clinical outcomes.

METHODS

We enrolled 66 male patients who underwent isolated coronary artery bypass grafting between April 2016 and April 2021. There were 30 and 36 patients treated using our no-touch technique and the conventional technique, respectively. The participants underwent coronary angiography before discharge and were followed clinically. SVG samples were taken for pathological examination.

RESULTS

SVGs harvested using our no-touch technique displayed preservation of the vessel wall structure and surrounding tissues. Our no-touch technique demonstrated no inferiority in patency compared with the conventional technique, and there was no SVG occlusion in the no-touch group. The frequency of leg wound complications was higher in the no-touch group than the conventional group, but no surgical site infections and severe complications occurred in the no-touch group.

CONCLUSIONS

SVGs harvested using our novel no-touch technique had similar pathological characteristics to those harvested using the original no-touch technique reported previously. Our no-touch technique maintained SVG patency and caused no severe wound complications. However, a large-scale, longitudinal study is required to accurately assess the clinical outcomes of our no-touch technique.

Tissue engineered bovine saphenous vein extracellular matrix scaffolds produced via antigen removal achieve high in vivo patency rates

Diseases of small diameter blood vessels encompass the largest portion of cardiovascular diseases, with over 4.2 million people undergoing autologous vascular grafting every year. However, approximately one third of patients are ineligible for autologous vascular grafting due to lack of suitable donor vasculature. Acellular extracellular matrix (ECM) scaffolds derived from xenogeneic vascular tissue have potential to serve as ideal biomaterials for production of off-the-shelf vascular grafts capable of eliminating the need for autologous vessel harvest. A modified antigen removal (AR) tissue process, employing aminosulfabetaine-16 (ASB-16) was used to create off-the-shelf small diameter (< 3 mm) vascular graft from bovine saphenous vein ECM scaffolds with significantly reduced antigenic content, while retaining native vascular ECM protein structure and function. Elimination of native tissue antigen content conferred graft-specific adaptive immune avoidance, while retention of native ECM protein macromolecular structure resulted in pro-regenerative cellular infiltration, ECM turnover and innate immune self-recognition in a rabbit subpannicular model. Finally, retention of the delicate vascular basement membrane protein integrity conferred endothelial cell repopulation and 100% patency rate in a rabbit jugular interposition model, comparable only to Autograft implants. Alternatively, the lack of these important basement membrane proteins in otherwise identical scaffolds yielded a patency rate of only 20%. We conclude that acellular antigen removed bovine saphenous vein ECM scaffolds have potential to serve as ideal off-the-shelf small diameter vascular scaffolds with high in vivo patency rates due to their low antigen content, retained native tissue basement membrane integrity and preserved native ECM structure, composition and functional properties. STATEMENT OF SIGNIFICANCE: The use of autologous vessels for the treatment of small diameter vascular diseases is common practice. However, the use of autologous tissue poses significant complications due to tissue harvest and limited availability. Developing an alternative vessel for use for the treatment of small diameter vessel diseases can potentially increase the success rate of autologous vascular grafting by eliminating complications related to the use of autologous vessel and increased availability. This manuscript demonstrates the potential of non-antigenic extracellular matrix (ECM) scaffolds derived from xenogeneic vascular tissue as off-the-shelf vascular grafts for the treatment of small diameter vascular diseases.

Perioperative routines and surgical techniques for saphenous vein harvesting in CABG surgery: a national cross-sectional study in Sweden

Background

The saphenous vein is the most commonly used conduit for coronary artery bypass grafting (CABG). Wound healing complications related to saphenous vein harvesting are common, with reported surgical site infection rates ranging from 2 to 20%. Patients’ risk factors, perioperative hygiene routines, and surgical technique play important roles in wound complications. Here we describe the perioperative routines and surgical methods of Swedish operating theatre (OT) nurses and cardiac surgeons.

Methods

A national cross-sectional survey with descriptive design was conducted to evaluate perioperative hygiene routines and surgical methods associated with saphenous vein harvesting in CABG. A web-based questionnaire was sent to OT nurses and cardiac surgeons at all eight hospitals performing CABG surgery in Sweden.

Results

Responses were received from all hospitals. The total response rate was 62/119 (52%) among OT nurses and 56/111 (50%) among surgeons.

Chlorhexidine 5 mg/mL in 70% ethanol was used at all eight hospitals. The OT nurses almost always (96.8%) performed the preoperative skin disinfection, usually for three to 5 minutes. Chlorhexidine was also commonly used before dressing the wound.

Conventional technique was used by 78.6% of the surgeons, “no-touch” by 30.4%, and both techniques by 9%. None of the surgeons used endoscopic vein harvesting. Type of suture and technique used for closing the wound differed markedly between the centres.

Conclusions

In this article we present insights into the hygiene routines and surgical methods currently used by OT nurses and cardiac surgeons in Sweden. The results indicate both similarities and differences between the centres. Local traditions might be the most important factors in determining which procedures are employed in the OT. There is a lack of evidence-based hygiene routines and surgical methods.

Polidocanol echosclerotherapy treatment for lymphocele: case report and review

Formation of lymphocele secondary to transection of lymphatic channels during surgical procedures or traumas is relatively common and is reported in the postoperative period of approximately 30% of lymph node resection procedures. The condition may be asymptomatic or can present with complications such as pain, secondary infection, and compression of blood vessels, which can cause stasis, thrombosis, and edema. There is no consensus on treatment. This article describes three cases in which treatment was provided using polidocanol echosclerotherapy. Its relevance lies in the scarcity of reports in the literature.

Small Diameter Xenogeneic Extracellular Matrix Scaffolds for Vascular Applications

Currently, despite the success of percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) remains among the most commonly performed cardiac surgical procedures in the United States. Unfortunately, the use of autologous grafts in CABG presents a major clinical challenge as complications due to autologous vessel harvest and limited vessel availability pose a significant setback in the success rate of CABG surgeries. Acellular extracellular matrix (ECM) scaffolds derived from xenogeneic vascular tissues have the potential to overcome these challenges, as they offer unlimited availability and sufficient length to serve as "off-the-shelf" CABGs. Unfortunately, regardless of numerous efforts to produce a fully functional small diameter xenogeneic ECM scaffold, the combination of factors required to overcome all failure mechanisms in a single graft remains elusive. This article covers the major failure mechanisms of current xenogeneic small diameter vessel ECM scaffolds, and reviews the recent advances in the field to overcome these failure mechanisms and ultimately develop a small diameter ECM xenogeneic scaffold for CABG. Impact Statement Currently, the use of autologous vessel in coronary artery bypass graft (CABG) is common practice. However, the use of autologous tissue poses significant complications due to tissue harvest and limited availability. Developing an alternative vessel for use in CABG can potentially increase the success rate of CABG surgery by eliminating complications related to the use of autologous vessel. However, this development has been hindered by an array of failure mechanisms that currently have not been overcome. This article describes the currently identified failure mechanisms of small diameter vascular xenogeneic extracellular matrix scaffolds and reviews current research targeted to overcoming these failure mechanisms toward ensuring long-term graft patency.

Cutaneous Branch of the Obturator Nerve Extending to the Medial Ankle and Foot: A Report of Two Cadaveric Cases

The area of skin supplied by the cutaneous branch of the obturator nerve (CBO) is highly variable. Although most introductory anatomy texts describe the CBO as innervating only a portion of the medial thigh, there are numerous reports in the literature of CBOs passing the knee to innervate the proximal, middle, or even distal leg. There are no previous reports of CBOs extending to the ankle and foot. Herein we describe 2 cases of CBOs extending at least to the medial foot. Both cases were discovered incidentally, during routine cadaver dissections by osteopathic and podiatric medical students in the anatomy laboratory of Western University of Health Sciences in California. In both instances, the anomalously long CBOs shared several characteristics: (1) they arose as direct branches of the anterior division of the obturator nerve, not from the subsartorial plexus; (2) they coursed immediately posterior to the great saphenous vein from the distal thigh to the distal leg, only deviating away from the saphenous vein just above the medial malleolus; and (3) they terminated in radiating fibers to the posterior half of the medial ankle and foot. In both cases, the saphenous branch of the femoral nerve was present but restricted to the area anterior to the great saphenous vein. It is likely that the variant CBOs carried fibers of the L4 spinal nerve and thus provided cutaneous innervation to the medial foot and ankle, a function most commonly reserved for the saphenous branch of the femoral nerve distal to the knee. Saphenous neuropathy is a common postoperative complication of saphenous cutdowns for coronary artery bypass grafts, so the potential involvement of a long CBO can add additional complexity to regional anesthetic blocks for foot and ankle surgery and procedures such as vein harvesting for coronary artery bypass grafts.

Examination of psychological risk factors for chronic pain following cardiac surgery: protocol for a prospective observational study

INTRODUCTION

Approximately 400 000 Americans and 36 000 Canadians undergo cardiac surgery annually, and up to 56% will develop chronic postsurgical pain (CPSP). The primary aim of this study is to explore the association of pain-related beliefs and gender-based pain expectations on the development of CPSP. Secondary goals are to: (A) explore risk factors for poor functional status and patient-level cost of illness from a societal perspective up to 12 months following cardiac surgery; and (B) determine the impact of CPSP on quality-adjusted life years (QALYs) borne by cardiac surgery, in addition to the incremental cost for one additional QALY gained, among those who develop CPSP compared with those who do not.

METHODS AND ANALYSES

In this prospective cohort study, 1250 adults undergoing cardiac surgery, including coronary artery bypass grafting and open-heart procedures, will be recruited over a 3-year period. Putative risk factors for CPSP will be captured prior to surgery, at postoperative day 3 (in hospital) and day 30 (at home). Outcome data will be collected via telephone interview at 6-month and 12-month follow-up. We will employ generalised estimating equations to model the primary (CPSP) and secondary outcomes (function and cost) while adjusting for prespecified model covariates. QALYs will be estimated by converting data from the Short Form-12 (version 2) to a utility score.

ETHICS AND DISSEMINATION

This protocol has been approved by the responsible bodies at each of the hospital sites, and study enrolment began May 2015. We will disseminate our results through CardiacPain.Net, a web-based knowledge dissemination platform, presentation at international conferences and publications in scientific journals.

TRIAL REGISTRATION NUMBER

NCT01842568.

Safety and efficacy of prophylactic negative pressure wound therapy following open saphenous vein harvest in cardiac surgery: a feasibility study

Objectives

Surgical site complications following great saphenous vein (GSV) harvest presents a significant risk of morbidity. Negative pressure wound therapy (NPWT) has shown promise in the treatment and prophylaxis of open wounds and surgical incisions but has not been studied following GSV harvest. We performed a feasibility study examining the use of NPWT following GSV harvest for coronary bypass surgery.

Methods

Sixty-four patients were recruited in this single-centre, single-blind, randomized controlled trial. The primary endpoint assessed feasibility by examining rates of device complication and malfunction. Secondary endpoints included rates of surgical site infection, lower leg complications, discharge date, and quality of life at discharge and 6 weeks. NPWT was delivered using the Prevena NPWT device.

Results

There were no complications associated with NPWT which required intervention aside from discontinuation. NPWT was tolerated in 91% (30/33) of patients for the duration of treatment with an average of 4.8 days (±1.45 days). Device malfunction which required discontinuation was 6% (2/33) and involved a malfunctioning pressure sensor and did not affect patient care or present safety concerns. One patient had allergic contact dermatitis to the adhesive and had the device removed. NPWT patients had an earlier date of discharge (6 vs 10 days, P = 0.008), increased ability for self-care ( P = 0.0234) and quality of life ( P = 0.039) at initial assessment, and increased mobility at initial and follow-up assessment ( P = 0.0117 and 0.0123).

Conclusions

The use of NPWT following GSV harvest is safe, well tolerated and improves postoperative recovery with prolonged impact on mobility at 6 weeks.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT01698372 ; registration number: NCT01698372.

Technology-Enabled Remote Monitoring and Self-Management - Vision for Patient Empowerment Following Cardiac and Vascular Surgery: User Testing and Randomized Controlled Trial Protocol

Background

Tens of thousands of cardiac and vascular surgeries (CaVS) are performed on seniors in Canada and the United Kingdom each year to improve survival, relieve disease symptoms, and improve health-related quality of life (HRQL). However, chronic postsurgical pain (CPSP), undetected or delayed detection of hemodynamic compromise, complications, and related poor functional status are major problems for substantial numbers of patients during the recovery process. To tackle this problem, we aim to refine and test the effectiveness of an eHealth-enabled service delivery intervention, TecHnology-Enabled remote monitoring and Self-MAnagemenT—VIsion for patient EmpoWerment following Cardiac and VasculaR surgery (THE SMArTVIEW, CoVeRed), which combines remote monitoring, education, and self-management training to optimize recovery outcomes and experience of seniors undergoing CaVS in Canada and the United Kingdom.

Objective

Our objectives are to (1) refine SMArTVIEW via high-fidelity user testing and (2) examine the effectiveness of SMArTVIEW via a randomized controlled trial (RCT).

Methods

CaVS patients and clinicians will engage in two cycles of focus groups and usability testing at each site; feedback will be elicited about expectations and experience of SMArTVIEW, in context. The data will be used to refine the SMArTVIEW eHealth delivery program. Upon transfer to the surgical ward (ie, post-intensive care unit [ICU]), 256 CaVS patients will be reassessed postoperatively and randomly allocated via an interactive Web randomization system to the intervention group or usual care. The SMArTVIEW intervention will run from surgical ward day 2 until 8 weeks following surgery. Outcome assessments will occur on postoperative day 30; at week 8; and at 3, 6, 9, and 12 months. The primary outcome is worst postop pain intensity upon movement in the previous 24 hours (Brief Pain Inventory-Short Form), averaged across the previous 14 days. Secondary outcomes include a composite of postoperative complications related to hemodynamic compromise—death, myocardial infarction, and nonfatal stroke— all-cause mortality and surgical site infections, functional status (Medical Outcomes Study Short Form-12), depressive symptoms (Geriatric Depression Scale), health service utilization-related costs (health service utilization data from the Institute for Clinical Evaluative Sciences data repository), and patient-level cost of recovery (Ambulatory Home Care Record). A linear mixed model will be used to assess the effects of the intervention on the primary outcome, with an a priori contrast of weekly average worst pain intensity upon movement to evaluate the primary endpoint of pain at 8 weeks postoperation. We will also examine the incremental cost of the intervention compared to usual care using a regression model to estimate the difference in expected health care costs between groups.

Results

Study start-up is underway and usability testing is scheduled to begin in the fall of 2016.

Conclusions

Given our experience, dedicated industry partners, and related RCT infrastructure, we are confident we can make a lasting contribution to improving the care of seniors who undergo CaVS.

Above-Knee Vein Harvest for Coronary Revascularization Increases ASEPSIS Score

The long saphenous vein may be harvested from the thigh or the lower leg, depending on the operating surgeon's preference. This prospective study compared the incidence of altered wound healing between these two sites in 175 patients undergoing routine coronary artery bypass grafting over a 3-month period. The patients were divided into 3 groups. In group A, the vein harvest site was restricted to above the upper border of the patella. Group B included harvest sites that started at the ankle but extended above the level of the upper border of the patella. In group C, the vein harvest site was restricted to below the upper border of the patella. The wounds were assessed daily using the ASEPSIS scoring system. In group A, significantly more patients (24%) had an ASEPSIS score > 10, compared to group B (3%) and group C (2%). The mean ASEPSIS score was significantly lower in group C than groups A or B, 1.5 ± 2.4 vs. 6.5 ± 3.2 or 3.7 ± 1.7, respectively. The ASEPSIS score is reduced when vein harvest is restricted to below the level of the knee.

Prevention of edema after coronary artery bypass graft surgery by compression stockings

Background:

Lower limb edema may occur after removal of the saphenous veins in coronary artery bypass graft (CABG) surgery. Compression therapy is often used to prevent postoperative edema.

Objectives:

The objective of this study was to evaluate the efficacy of medical compression stockings (TED) on the prevention of donor limbs edema and wound complications after CABG surgery.

Patients and Methods:

In this prospective cohort study, we enrolled 100 patients who underwent elective CABG surgery at Rajaie Cardiovascular Medical and Research Center. The patients were divided into two groups; group A who applied TED stockings regularly (exposure group) and group B who did not apply TED stockings at all or apply it irregularly (no exposure group). The degree of donor limb edema and the differences of the peripheries of calf and thigh before and after the surgery (in 1, 2 and 4 weeks) were recorded and analyzed statistically.

Results:

The patients' weight (P = 0.02) and the degree of their daily activity (P = 0.002) were the significant factors for the incidence of the donor limbs edema. The incidence and degree of lower limb edema were significantly lower in exposure group 4 weeks after the surgery (P < 0.001). The differences of the periphery of the calf before (at admission time) and after the surgery (in 1, 2 and 4 weeks) between two groups were also statistically significant (P = 0.41, P = 0.39, P = 0.40, respectively). Lower limb wound complications was higher in patients who have peripheral edema in the 4th week of post-CABG (P = 0.09).

Conclusions:

Regular use of TED stockings may have positive effects on the prevention of donor limb edema (especially higher degrees of edema) and wound complications after CABG surgery.

Pedicled no-touch saphenous vein graft harvest limits vascular smooth muscle cell activation: the PATENT saphenous vein graft study

OBJECTIVE

Neointimal hyperplasia secondary to vascular smooth muscle cell (VSMC) activation limits the long-term patency of saphenous vein grafts (SVGs). We compared markers of vascular injury and VSMC activation in SVGs harvested using the pedicled 'no-touch' (NT) vs the conventional (CON) technique.

METHODS

Patients undergoing coronary artery bypass surgery were enrolled in the PATENT SVG trial (clinicaltrials.gov NCT01488084). Patients were randomly allocated to have SVGs harvested with the NT technique from one leg and the CON method from the other. SVG segments underwent morphometry, histological and electron microscopy assessments and transcript measurements of VSMC activation and differentiation markers. Leg wound functional recovery and harvest site complications were assessed using a quality-of-life questionnaire.

RESULTS

A total of 17 patients (65.3 ± 7.3 years) were enrolled. SVGs harvested using the NT vs CON technique exhibited preserved intimal, medial and adventitial architecture. CON harvest was associated with greater medial Kruppel-like factor 4 transcript levels (0.26 ± 0.05 vs 0.11 ± 0.02, P < 0.05). CON samples had significantly lower medial serum response factor (0.53 ± 0.11 vs 1.44 ± 0.50, P < 0.05) and myocardin (0.59 ± 0.08 vs 1.33 ± 0.33, P < 0.05) transcript levels. MicroRNA-145, an inhibitor of VSMC activation and differentiation, was higher in the NT vs CON samples (1.84 ± 1.03 vs 0.50 ± 0.19, P < 0.05). Leg assessment scores were worse in the NT legs at 3 months, but similar to CON scores at 12 months.

CONCLUSIONS

SVGs harvested using the 'NT' technique exhibit an early molecular and morphological pattern consistent with decreased VSMC activation compared with CON harvesting. Functional leg recovery was similar in both groups at 12 months. Larger studies are required to corroborate these findings.

Neuropathic aspects of persistent postsurgical pain: a French multicenter survey with a 6-month prospective follow-up

To investigate the role of peripheral neuropathy in the development of neuropathic postsurgical persistent pain (N-PSPP) after surgery, this French multicentric prospective cohort study recruited 3,112 patients prior to elective cesarean, inguinal herniorrhaphy (open mesh/laparoscopic), breast cancer surgery, cholecystectomy, saphenectomy, sternotomy, thoracotomy, or knee arthroscopy. Besides perioperative data collection, postoperative postal questionnaires built to assess the existence, intensity, and neuropathic features (with the Douleur Neuropathique 4 Questions [DN4]) of pain at the site of surgery were sent at the third and sixth months after surgery. In the 2,397 patients who completed follow-up, the cumulative risk of N-PSPP within the 6 months ranged from 3.2% (laparoscopic herniorrhaphy) to 37.1% (breast cancer surgery). Pain intensity was greater if DN4 was positive and decreased with time since surgery; it depended on the type of surgery. In pain-reporting patients, the response to the DN4 changed from time to time in about 1:4 of the cases. Older age and a low anxiety score were independent protective factors of N-PSPP, whereas a recent negative event, a low preoperative quality of life, and previous history of peripheral neuropathy were risk factors. The type of anesthesia had no influence on the occurrence of N-PSPP.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00812734.

PERSPECTIVE

This prospective observational study provides the incidence rate of N-PSPP occurring within the 6 months after 9 types of elective surgical procedures. It highlights the possible consequences of nerve aggression during some common surgeries. Finally, some preoperative predispositions to the development of N-PSPP have been identified.

Triclosan-coated sutures reduce surgical site infection after open vein harvesting in coronary artery bypass grafting patients: a randomized controlled trial

OBJECTIVES

The incidence of surgical site infection (SSI) after open vein harvesting in coronary artery bypass grafting (CABG) patients ranges in different studies between 2 and 20%. Triclosan is an antibacterial substance that reduces the growth of bacteria by inhibiting fatty acid synthesis. We hypothesized that wound closure with triclosan-coated sutures would reduce SSI after open vein harvesting.

METHODS

An investigator-initiated prospective randomized double-blind single-centre study was performed with 374 patients, randomized to subcutaneous and intracutaneous leg-wound closure with either triclosan-coated sutures (Vicryl Plus and Monocryl Plus, Ethicon, Somerville, NJ, USA) (n = 184) or identical sutures without triclosan (n = 190) from the same manufacturer. All patients were followed up after 30 days (clinical visit) and 60 days (telephone interview). Primary endpoint was SSI within 60 days after surgery according to the definition of Center for Disease Control. Predefined secondary endpoints included culture-proven and antibiotic-treated SSI.

RESULTS

The primary endpoint occurred in 23 patients (12.5%) with triclosan-coated sutures and in 38 patients (20.0%) in the group without triclosan (P = 0.0497, risk ratio 0.63, (95% confidence interval 0.39-1.00). Corresponding figures for culture-proven infections were 7.6 vs 12.1%, (P = 0.15), and for antibiotic-treated infections, 10.9 vs 18.4%, (P = 0.039). Staphylococcus aureus and coagulase-negative staphylococci were the most common pathogens in both groups. Insulin-treated diabetes and vein-harvesting time were associated with SSI after vein harvesting.

CONCLUSIONS

Leg-wound closure with triclosan-coated sutures in CABG patients reduces SSIs after open vein harvesting. (ClinicalTrials.gov number NCT01212315).

Categorizing the distribution of the saphenous nerve in relation to the great saphenous vein

Saphenous donor site neuralgia is a cause of morbidity post-coronary artery bypass surgery. Saphenous nerve damage during harvesting of the great saphenous vein is thought to be responsible. We dissected 37 cadaveric lower limbs from the knee fold to the dorsal venous arches, to study the spatial relations of the saphenous nerve and great saphenous vein to identify its distribution within the leg. Distribution of the saphenous nerve was categorized into Type A, where the nerve traveled inferiorly and split into an anterior and posterior branch during its course between the knee fold and medial malleolus, Type B, where the nerve traveled anterior to the vein with a small caliber branch traveling posteriorly at the proximal end, Type C where two main branches originated at the knee fold, one anterior to and one posterior to the vein. Overall the vein and nerve crossed in 27 out of the 37 cases (73%), occurring between 5 and 29 cm from the malleolus (60% occurred between 16 and 26 cm). In 32 (86%) of cases, the distal part of the nerve and vein were tightly adhered to each other within a common sheath. The length of adherence ranged from 3 to 26 cm with an average of 14 cm. The saphenous nerve is highly vulnerable during harvesting of the great saphenous vein due to its close relationship and crossing branches. Knowledge of the distribution categories of the nerve can help guide the surgeon to avoid damaging nerve branches during harvesting.

Lymphoscintigraphic findings: delayed oedema after great saphenous vein harvesting

Objective

The aim of this study was to identify lymphoscintigraphic changes associated with lower-extremity oedema after the harvesting of the saphenous vein using a series of short Q2 incisions for coronary bypass.

Method

Forty-four patients (32 males and 12 females) with a mean age of 62.7 ± 7.8 (47–75 years old) were evaluated in a retrospective, quantitative, cross-sectional study from June 2007 to January 2008, three to 188 months (mean: 46 months) after the surgical procedure. Assessment was by water displacement volumetry and lymphoscintigraphy of the lower limbs. Results expressed as means with standard deviations were compared employing the Student's t-test and the chi-square or Fisher's exact tests were used to compare data expressed as frequencies. An alpha error of 5% was considered acceptable ( P ≤ 0.05).

Results

The presence of dermal backflow, as identified by lymphoscintigraphy with an accumulation of radiotracer in the thoracic duct and popliteal lymph nodes was significantly greater on the operated side.

Conclusion

There was a significant association between dermal backflow and delayed oedema.

Antibacterial prophylaxis in dermatologic surgery: an evidence-based review

Clean, non-contaminated skin surgery is associated with low rates of surgical site infection (SSI), bacterial endocarditis, and joint prosthesis infection. Hence, antibacterial prophylaxis, which may be associated with adverse effects, the emergence of multidrug-resistant pathogens, and anaphylaxis, is generally not recommended in dermatologic surgery. Some body sites and surgical reconstructive procedures are associated with higher infection rates, and guidelines for SSI antibacterial prophylaxis have been proposed for these cases. Large prospective, controlled trials are needed to ascertain the role of oral SSI prophylaxis for these surgical sites and procedures especially in patients with diabetes mellitus who are intrinsically at greater risk of SSI. Topical antibacterial ointment and sterile paraffin appear to make no difference to healing or the incidence of SSIs in clean wounds. Although further research is needed, preliminary studies have shown that intraincisional antibacterials, which may be associated with fewer adverse effects and a lower risk of multidrug-resistant bacteria, could potentially be helpful for SSI prophylaxis. Trials using honey- and silver-impregnated dressings have found no advantage in the healing of chronic wounds. However, several case studies, which need corroboration in larger studies, suggest that these dressings may be helpful in preventing and treating SSIs. Bacterial endocarditis and joint prosthesis infection prophylaxis are not routinely recommended in cutaneous surgery. The updated 2007 American Heart Association guidelines now advocate bacterial endocarditis prophylaxis for high-risk cardiac patients having surgery involving the oral mucosa or infected skin. The latest American Dental Association/American Academy of Orthopaedic Surgery guidelines recommend considering antibacterial prophylaxis for oral procedures where bleeding is anticipated and for surgery involving acute orofacial skin infections if the patient has had a total joint replacement within 2 years or is in a high-risk group and has had a joint replacement at any time.

Edema de membro inferior secundário a exérese de veia safena magna para utilização como enxerto na revascularização do miocárdio

CONTEXTO: A revascularização do miocárdio utilizando-se a veia safena magna ainda é procedimento cirúrgico bastante realizado na atualidade. O edema que surge no membro inferior operado causa grande desconforto e necessita ser melhor estudado. OBJETIVOS: Caracterizar o edema de membro inferior secundário a exérese da veia safena magna pela técnica de incisões escalonadas para sua utilização como enxerto venoso na revascularização do miocárdio. MÉTODOS: Foram selecionados aleatoriamente 44 indivíduos submetidos a exérese de veia safena magna para revascularização miocárdica há mais de 3 meses. Excluíram-se fatores que pudessem interferir na formação de edema dos membros inferiores. Foram avaliados por volumetria e perimetria maleolares ambos os membros inferiores. Considerou-se como presença de edema significativo a diferença de volume maior que 50 mL e maior de 2 cm em relação ao membro não-operado. Para a análise estatística foram empregados o teste do qui-quadrado, teste exato de Fisher, teste t de Student e o teste de McNemar. O nível de significância adotado foi de 5% (a = 0,05). RESULTADOS: Encontraram-se diferenças estatisticamente significativas (p < 0.05) entre os membros operados e os não-operados, sendo 56,8% com volume maior que 50 mL e 31,9% com perímetro maleolar maior que 2 cm. Não se encontrou associação entre a presença do edema e características da amostra ou da cirurgia e de intercorrências clínicas perioperatórias ou tardias. CONCLUSÕES: Pacientes submetidos a ressecções de veia safena magna para sua utilização como ponte coronariana poderão apresentar edema no membro associado.

The influence of coronary artery bypass graft harvest site on women's pain, functional status, and health services utilization throughout the first post-operative year: a longitudinal study

BACKGROUND

Coronary artery bypass graft surgery is a commonly performed procedure aimed at managing coronary symptoms and prolonging life. Researchers have typically examined morbidity and mortality outcomes of predominantly male populations. Less is known about the influence of graft harvest site on recovery outcomes such as surgery-related pain, functional status, and health services utilization, especially in women.

OBJECTIVES

We aimed to examine the relationships between coronary artery bypass graft harvest site (saphenous vein, internal mammary arteries or both) and surgery-related pain, functional status, health services use at 6 weeks, 12 weeks and 12 months post-operatively.

DESIGN

Longitudinal extension survey following participation in a clinical trial.

SETTING

Ten Canadian centres.

PARTICIPANTS

Women (222) who participated in the Women's Recovery from Sternotomy Trial, underwent coronary artery bypass graft surgery with or without heart valve surgery, and completed the 12-month follow-up interview.

METHODS

Harvest site data were collected by health record audit at the time of hospital discharge. Surgery-related pain, functional status, pain medication use and health services use data were collected by standardized interview over the telephone at 6 weeks, 12 weeks and 12 months post-operatively. Surgery-related pain and functional status were measured using the short Health Assessment Questionnaire. Health services use was measured by questionnaire and recorded as reported by the participants.

RESULTS

Surgery-related pain, functional disability and health services use decreased over the first post-operative year. Participants who had left internal mammary artery grafts were more likely to have surgery-related pain (Adjusted Odds Ratio (AOR)=2.79; 95% Confidence Interval (CI) 1.40-5.70) and use pain medication (AOR=4.32; 95% CI 1.44-12.91) than those who had saphenous vein grafts. Conversely, participants who had saphenous vein grafts reported significantly more functional disability (AOR=2.63; 95% CI 1.16-6.25) over 12 months post-surgery than those with left internal mammary artery grafts. Participants who had pain over the course of follow-up were more likely to visit their family physician or nurse practitioner (p=0.017), visit another type of provider (i.e., naturopath or chiropractor, p=0.004), or use any health care service (p<0.0001).

CONCLUSIONS

Following coronary artery bypass graft surgery, women who had left internal mammary artery grafts reported more pain and health services use while those who had saphenous vein grafts were more functionally disabled. Women who reported surgery-related pain also used more health services.

Postoperative and mid-term wound disturbance outcomes of minimally invasive saphenous vein harvest using the VEGA system

Great saphenous vein harvest is associated with a significant risk of impaired wound healing. The purpose of this study was to determine efficacy of one system designed for minimally invasive vein harvest (MIVH) and to assess postoperative and mid-term wound-healing disturbances. From February 2004 to June 2005, great saphenous harvest for coronary artery bypass grafting (CABG) was performed in a group of 120 consecutive patients employing the VEGA system (B/Braun-Aesculap, Tuttlingen, Germany). Patients were evaluated on 7th postoperative day, at the 3-month and 1-year follow-up for wound healing disturbances, residual leg edema, and saphenous neuropathy. The mean age was 67.3 years, male patients dominated (70%), and the leading procedure was CABG (83%). The mean number of harvested venous grafts was 1.9 +/- 1.2 and the mean number of skin incisions was 3.7 +/- 2.2. The mean total vein harvesting time was 40.2 +/- 16.8 minutes. Satisfactory healing was achieved in 98% patients on 7th postoperative day and at the 3-month follow-up all wounds were completely healed. Saphenous neuralgia remained a significant cause of morbidity, although its incidence decreased from 25% presented on 7th postoperative day to 8% presented at 1-year follow-up. Likewise, the incidence of leg edema decreased from 34% on the 7th postoperative day to 7% at 1-year follow-up. Minimally invasive vein harvest is a safe method associated with a significant reduction of wound disturbances. The VEGA system appears to be suitable and effective equipment for MIVH. Nevertheless, residual edema and mainly saphenous neuropathy represent a relatively frequent cause of patient morbidity at the postoperative and mid-term follow-up.

The effect of calcium dobesilate on venous function following saphenectomy in coronary artery bypass grafting

BACKGROUND

The aim of this study was to determine whether prophylactic use of calcium dobesilate (CD) can improve venous function after saphenous vein harvest in coronary artery bypass graft (CABG).

MATERIALS AND METHODS

A total of 100 patients who underwent elective CABG were divided into four equal groups. In Group A, the greater saphenous vein (GSV) was harvested below the knee and, in Group B, through the knee till the groin. These patients remained untreated. Group C received CD in a dosage of 1500 mg po daily after the GSV was harvested below the knee. Group D received same dosage of CD after the GSV was harvested through the knee till the groin. Venous function of ipsilateral leg was evaluated clinically and by Doppler ultrasonography in the postoperative first week and second month.

RESULTS

Clinical findings of venous insufficiency were observed with a similar rate between groups at both early and late periods. In Groups A and B, after 2 months, flow velocities decreased and reflux periods increased significantly. In groups C and D, treatment with CD for 2 months after saphenectomy resulted in a significant increase in flow velocities and a significant decrease in reflux periods. Patients in Groups B and D have significantly more impaired venous functions.

CONCLUSION

Saphenectomy results in ipsilateral leg venous dysfunction, which seems to be unrelated to leg swelling and to be more prominent in patients with high-level saphenectomy. In addition, to be careful about the restriction of the saphenectomy procedure into the most appropriate level, prophylactic use of CD can prevent this deterioration when it was added to varice socks.

Prospective study of wound infections in dermatologic surgery in the absence of prophylactic antibiotics

OBJECTIVE

The study aimed to identify wound sites/procedures where infection incidence was over 5%, such that these circumstances may warrant wound infection antibiotic prophylaxis.

METHOD

We undertook a 3-year prospective study of 5,091 lesions (predominantly nonmelanoma skin cancer) treated on 2,424 patients from July 2002 to June 2005. No patient was given prophylactic antibiotics, and no patient ceased warfarin or aspirin.

RESULTS

Overall infection incidence was 1.47%. Individual procedures had the following infection incidence: curettage 0.73% (3/412); skin flap repairs 2.94% (47/1601); simple excision and closure 0.54% (16/2974); skin grafts 8.70% (6/69); and wedge excision 8.57% (3/35). Analysis of regions of the body demonstrated that surgery below the knee (n = 448) had an infection incidence of 6.92% (31/448) (p < .0001). Subanalysis demonstrated that all regions below the knee were at high infection risk. Elsewhere, groin excisional surgery had an infection incidence of 10% (1/10) (p = .027). No other body site demonstrated an infection incidence beyond 5% of statistical significance. Procedures on the face demonstrated an infection incidence of 0.81% (18/2,209). Diabetic patients, those on warfarin and/or aspirin, and smokers showed no difference in infection incidence.

CONCLUSION

Based on a prediction of infection incidence over 5%, the following cutaneous oncologic procedures warrant consideration of oral antibiotic wound infection prophylaxis: all procedures below the knee, wedge excisions of lip and ear, all skin grafts, and lesions in the groin. Other than under these circumstances, surgery to the nose, ear, fingers, lips, skin flap surgery, and surgery on diabetics, smokers, and those on anticoagulants have previously been considered for wound infection prophylaxis but do not warrant such intervention based on our data. The authors have indicated no significant interest with commercial supporters.

Prevalence, characteristics, and predictors of chronic nonanginal postoperative pain after a cardiac operation: A cross-sectional study

OBJECTIVE

This study was designed to assess the prevalence, characteristics, effect, and predictors of chronic postoperative pain 1 to 3 years after cardiac surgery.

METHODS

Seven hundred thirty-six patients who underwent coronary artery bypass surgery, valve replacement, or both between 1999 and 2002 were mailed questionnaires (response rate, 79% [n = 579]; 564 questionnaires were analyzed), and their hospital records were reviewed.

RESULTS

Nonanginal chronic postoperative pain affected 23% of patients. Eighty percent of them had pain 1 or more days per week. The worst and usual pain intensities during the week preceding the survey reached moderate to severe levels (> or =4/10) in more than half of the patients. Thirty-one percent of the patients with chronic postoperative pain had taken analgesic pain medication during that week. During the same period, pain interfered significantly (> or =4/10) with various aspects of patients' daily life (eg, general activity level: 39.1%, sleep: 36.7%). When patients with and without chronic postoperative pain were compared, the former group had significantly higher levels of anxiety and depression, and they perceived their health-related quality of life as more compromised. Multivariate logistic regression analysis revealed that greater analgesic needs in the first few days postoperatively were associated with an increased risk of chronic postoperative pain. The only other significant factor was the time elapsed from surgical intervention to survey: the longer it was, the less likely the patients were to report chronic postoperative pain.

CONCLUSION

The prevalence, severity, and effect of chronic postoperative pain after cardiac surgery should not be underestimated. Longitudinal prospective studies are needed to further evaluate risk factors, including inadequate postoperative pain relief in the acute period.