|Year : 2013 | Volume
| Issue : 4 | Page : 306-309
Long saphenous vein harvesting site infection after coronary artery bypass grafting
Khairy Gaballah, Mohamed Abo Elnor
Department of Cardiac Surgery, Shebein El Kom Teaching Hospital, Menofia, Egypt
|Date of Submission||15-Aug-2013|
|Date of Acceptance||05-Nov-2014|
|Date of Web Publication||1-Feb-2014|
Shebein El Kom Teachin, Menofia
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.
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 < 0.05).
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.
Keywords: Coronary artery bypass, infection, long saphenous vein
|How to cite this article:|
Gaballah K, Elnor MA. Long saphenous vein harvesting site infection after coronary artery bypass grafting. Tanta Med J 2013;41:306-9
|How to cite this URL:|
Gaballah K, Elnor MA. Long saphenous vein harvesting site infection after coronary artery bypass grafting. Tanta Med J [serial online] 2013 [cited 2018 Jun 22];41:306-9. Available from: http://www.tdj.eg.net/text.asp?2013/41/4/306/126180
| Introduction|| |
Coronary arteriosclerosis is most prevalent among men, individuals with diabetes, hyperlipidemia, and hypertension, and smokers. It affects more than 13 million Americans today and has resulted in more than 573 000 CG operations, performed in the USA, in 1995  . Despite the increased use of arterial grafts, the long saphenous vein (LSV) still remains the most frequently used conduit in coronary artery bypass graft (CABG) since its introduction in 1968  .
The reported incidence rate of leg wound complications after LSV harvest ranges from 1 to 24% , , with one series as high as 32.6%  . Commonly reported leg wound complications include dermatitis cellulites, greater saphenous neuropathy, chronic nonhealthy wounds, and lymphocele , . These complications rarely require surgical intervention and represent minor concerns in most of the CABG procedures.
However, major leg wound complications at the LSV harvest site can cause significant patient morbidity resulting in greater length of stay, increased hospital cost, and additional surgical procedures.
The purpose of this study was to review the results of treating 12 patients with major wound complication after CABG procedures to identify the associated potential 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 leg wounds were assessed daily during the postoperative period using the ASEPSIS scoring system. In our outpatient clinic, patients were rated for the first 5 postoperative days and wounds were assessed for the presence of serous exudates, erythema, purulent exudates, and the separation of deep tissues for a period of 4 weeks after hospital discharge.
A score ranging from 0 to 10 was assigned to each of these wounds according to its condition. Additional points were scored for surgical debridement, prolonged hospital stay of more than 14 days, isolation of bacteria, and antibiotic treatment.
The final ASEPSIS score was calculated by adding the daily wound characteristic scores to the additional points [Table 1].
The condition of the wound was divided into five categories according to the ASEPSIS score as satisfactory wound healing (0-10), altered wound healing (11-20), mild infection (21-30), moderate infection (31-40), and severe infection (>40).
In this study, ASEPSIS score of 21 or above was classified as wound infection.
Ten preoperative risk factors associated with leg wound complications among these patients were analyzed and compared with the entire cohort of patients undergoing CABG during the same time period. Risk factors examined in this study included age, BMI, sex, diabetes mellitus, peripheral vascular disease (PVD), duration of cardiopulmonary bypass surgery, use of intra-aortic balloon pump (IABP), use of internal thoracic artery (ITA) as a conduit, number of LSV grafts, and the duration of ICU stay in hours. Univariate comparison of qualitative variables was made to identify the significant independent predictors of major leg wound complications (P < 0.05).
| Results|| |
During this study period, 100 patients had elective CABG surgery, and there were 68 male (68%) and 32 female (32%) patients. The LSV were used as vascular conduit in all patients. Traditional open method for harvesting LSV was used exclusively during this study. The demographic data of patients are shown in [Table 2].
LSV harvesting site infections (ASEPSIS score >20) were identified in 12 (12%) patients, 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) [Table 3], with a mean age of 58.3 years (range 45-70 years) [Table 4].
|Table 3: Number and severity of the infected patients according to the time of infections|
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|Table 4: Univariate comparisons of qualitative variables as risk factor for infection|
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Four patients (33.3%) acquired infections within the first postoperative week, whereas eight patients (66.6%) were infected more than 1 week later, as detected in the outpatient clinic [Table 3].
Of the 10 variables evaluated by univariate analysis, female sex, BMI, PVD, diabetes, use of internal thoracic artery graft, and pre-existing hyperlipidemia were identified as significant independent predictors of major leg wound complications [Table 4].
| Discussion|| |
In 2007, a prospective study by Kayacioglu et al.  reported that significantly increased risk for wound complications were also observed in female patients, diabetic patients, and obese patients. Fowler et al.  reported that a major infection of the saphenous harvest site occurred in 32.6% of a population of 11 636 patients, after CABG.
Our incidence of leg wound complications (is) 12% in 100 CABG procedures with LSV harvesting.
Although obesity had been previously shown to be a risk factor for the development of leg wound complications, we found significant BMI deference among the patients with major leg wound complications. We concluded that leg wound complications were more likely to occur in women, probably because they have smaller peripheral arteries, were postmenopausal while undergoing CABG procedures, or had decreased estrogen level that impair leg wound healing  .
Pre-existing PVD has strong correlations with the development of major leg wound complications at the site of LSV harvesting. Paletta et al.  reported that 1872 patients had internal mammary artery (IMA) grafts with their CABG procedures, limb ischemia did not develop in any of these patients, and there was no significant correlation found between the use of IMA and major leg wound complications. However, our results are consistent with that of Paletta et al.  , Olsen et al.  , and Ku et al.  , who found a significant relationship between the pre-existing PVD and the development of major leg wound complications at LSV harvest site  .
The reported lower extremity complication rates after IABP insertion ranged from 20 to 30% with limb ischemia being the most common problem  . In our study, intraoperative IABP was required in five patients, and none of them developed infection at the LSV harvest site.
Although statistical analysis failed to identify diabetes mellitus as a significant independent risk factor in our study, Garland et al.  and Ku et al.  reported diabetes as a risk factor for LSV harvest site infection.
We did not report any significant difference between the infected patients who had their vein harvested below the knee and those who had their vein harvested above knee up to thigh. However, these results were not in agreement with the findings of Akowuah et al.  , where they used the ASEPSIS score to evaluate the LSV harvesting wound and found that patients who had the saphenous vein harvested up to thigh had a significantly higher ASEPSIS score than those who had their vein harvested below the knee, and explained this finding as the wound being in close proximity to the groin, with greater extent of dissection and longer operating time to close the wound.
We did not compare between different methods for LSV harvesting and the rate of leg wound infection as traditional open technique was used in all patients.
| Conclusion|| |
Adherence to basic surgical principles and proper vein harvest site selection still remain the essential factor in preventing leg wound complications, especially in patients with compromised lower extremity circulation. Minimal dissection, adequate homeostasis, and careful approximation of subcutaneous tissues and skin are the key principal factors in reducing leg wound complications. The risk is high in the presence of diabetes mellitus and PVD. More studies are required with regard to the impact of the less invasive techniques, such as endoscopic vein harvest, and the incidence of harvest site infection in high-risk patients.
| Acknowledgements|| |
Conflicts of interest
There are no conflicts of interest.
| References|| |
|1.||American Heart Association Coronary heart disease and angina pectoris. 1998;Dallas: American Heart Association. |
|2.||Rao C, Aziz O, Deeba S, Chow A, Jones C, Ni Z, et al. Is minimally invasive harvesting of the great saphenous vein for coronary artery bypass surgery a cost-effective technique? J Thorac Cardiovasc Surg 2008;135:809-815. |
|3.||L′cuyer PB, Murphy D, Little JR, Fraser VJ. The epidemiology of chest and leg wound infections following cardiothoracic surgery. Clin Infect Dis 1996; 22:424-429. |
|4.||Slaughter MS, Olson MM. Lee IT Jr, Ward HB A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg 1993; 56:1063-1068. |
|5.||Fowler VG Jr, O′Brien SM, Muhlbaier LIT Corey GR, Ferguson TB, Peterson LD. Clinical predictors of major infections after cardiac surgery. Circulation 2005; 112(Suppl):I358-I365. |
|6.||Velanovich V, Mallory P, Collins PS, Lower extremity lymphocele development after saphenous vein harvesting. Mil Med 1991; 156:146-150. |
|7.||Kayacioglu I, Camur G, Gunay R, Ates M, Sensoz Y Alkan P, et al. The risk factors affecting the complications of saphenous vein graft harvesting in aortocoronary bypass surgery. Tohoku J Exp Med 2007; 211:331-337. |
|8.||Hasselquisl MB Ioldherg N Schroeler A Spelsherg TC Isolation and characterization of the estrogen receptor in human skin. J Clin Endocrinol Metab 1980; 50:76-82. |
|9.||Paletta CE, Huang DB, Fiore AC, Svvartz ML, Rilloraza FL, Gardner JE Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg 2000; 70:492-497. |
|10.||Ku CH, Ku SL, Yin JC, Lee AJ Risk factors for sternal and leg surgical site infections after cardiac surgery in Taiwan. Am J Epidemiol 2005; 161:661-671. |
|11.||Baddour LM Bisno AL. Recurrent cellulitis after saphenous venectomy for coronary bypass surgery. Ann Intern Med 1982; 97:493-496. |
|12.||Garland R, Frizelleb FA, Dobbsb RA, et al. A retrospective audit of long-term lower limb complications following leg vein harvesting for coronary artery bypass grafting. Eur J Thorac Cardiovasc Surg 2003; 23:950-955. |
|13.||Akowuah E, Shrivastava V, Ponniah A, Jamnadas B, Chilton G, Cooper G. Above-knee vein harvest for coronary revascularization increases ASEPSIS score. Asian Cardiovasc Thorac Ann 2006; 14:57-59. |
|14.||Olsen MA, Sundt TM, Lawton JS, Damiano RJ Jr, Hopkins-Broyles D, Lock-Buckley P, et al. Risk factors for leg harvest surgical site infections after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2003; 126:992-999. |
[Table 1], [Table 2], [Table 3], [Table 4]