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.