Vascular wounds

Recommendations

Identify and Treat the Cause
1 Perform a preoperative evaluation to identify patients with an increased risk of developing wound healing problems after saphenous vein harvest. Level of Evidence
Not Assessed
2 Consider patient risk of complications when planning the saphenous vein harvest. Level of Evidence
Not Assessed


Address Patient-Centered Concerns
3 Provide individualized education. Level of Evidence
5


Provide Local Wound Care
4 Manage leg wound-healing problems using standard wound care practices. Level of Evidence
Not Assessed
5 Optimize the wound healing environment. Level of Evidence
Not Assessed
6 Consider the use of Apligraf and negative-pressure wound therapy to speed healing in patients with surgical wound breakdown. Level of Evidence
Not Assessed


Provide Organizational Support
7 Establish and empower an interprofessional team to facilitate post-operative care. Level of Evidence
5


Background

The most frequently used conduit for coronary artery bypass grafting (CABG) procedures is the greater saphenous vein. Problems with healing of the leg incision may be associated with underlying systemic conditions, such as unrecognized peripheral vascular disease (PVD) due to congestive heart failure, diabetes or smoking; the type of surgical procedure used for vein harvesting; surgical technique; female gender; smoking; obesity; preoperative anemia; and other factors, such as preoperative hospitalization, the use of elastic bandages in the operating room, the length of time the incision remained open in the operating room, and intravenous nicardipine administration postoperatively. Complications can cause significant morbidity, increase patient risk and delay recovery and return to normal activity.

Wound-healing problems include increased wound tension, hematoma formation, wound dehiscence, infection, and flap necrosis. Local infection can progress to a potentially fatal septicemia if not identified promptly. Complications often become evident at approximately 7–10 days after surgery.

• Ischemia: Unrecognized PVD, which may be associated with smoking, can result in persistent ischemia and impaired wound healing in the leg. These patients generally require revascularization before healing can occur.

• Type of procedure: A long continuous incision, the traditional method for harvesting this vein, is associated with problems with wound healing in up to 24% of patients, poor cosmetic results and delayed mobilization. Minimally invasive procedures using direct vision can reduce the postoperative occurrence of wound-healing problems in the leg, while providing a substantially better cosmetic outcome.

• Surgical technique: Identifying the path of the saphenous vein is critical. Extensive dissection and creation of large flaps significantly increases the risk of wound healing complications, whereas minimally traumatic surgical technique with meticulous hemostasis and elimination of dead space can reduce the development of postoperative problems.

In some cases, preoperative identification of risk factors for wound complications can prevent the occurrence of complications. In other cases, the surgical procedure can be modified to reduce the risk of complications.

Wound-healing problems are managed using standard wound care techniques. Readmission for intravenous antibiotic therapy, surgical or nonsurgical debridement, and additional surgery may be required. Negative-pressure wound therapy can reduce granulation time of these wounds. The use of Apligraf, a bioengineered skin substitute, may significantly reduce wound healing time among patients who develop complications.

References

Essential Publications
1 Coronary artery bypass grafting Quality Indicator
 Type: RCT
Stenvik M, Tjomsland O, Lien S, Gunnes S, Kirkeby-Garstad I, Astudillo R. Effect of subcutaneous suture line and surgical technique on wound infection after saphenectomy in coronary artery bypass grafting: a prospective randomised study. Scand Cardiovasc J 2006;40(4):234-237.
The impact of an additional subcutaneous suture line on the incidence of postoperative infection at the vena saphena magna harvesting site after coronary artery bypass grafting surgery is examined in this study. The difference between intracutaneous closure and additional subcutaneous closure was not statistically significant.
2 Coronary artery bypass surgery - Diabetics Quality Indicator
 Type: RCT
Li JY, Sun S, Wu SJ. Continuous insulin infusion improves postoperative glucose control in patients with diabetes mellitus undergoing coronary artery bypass surgery. Tex Heart Inst J 2006;33(4):445-451.
The purpose of this study was to compare the effect of continuous insulin infusion against glucometer-guided insulin injection on glucose control after coronary artery bypass surgery. The difference in incidence of sternal wound infection was not significant, but significantly more infusion patients achieved satisfactory blood glucose levels than injection patients. The researchers were unable to do any blinding in the study due to the different and obvious insulin administration techniques. This caused dropouts in the injection group because of physician concerns that may have had a negative impact on the study because it appeared that the continuous infusion group was able to control their blood glucose levels better.
3 Minimally invasive vein harvesting Quality Indicator
 Type: Systematic review
Athanasiou T, Aziz O, Skapinakis P, Perunovic B, Hart J, Crossman MC, Gorgoulis V, Glenville B, Casula R. Leg wound infection after coronary artery bypass grafting: A meta-analysis comparing minimally invasive versus conventional vein harvesting. Annals of Thoracic Surgery 2003;76(6):2141-6.
In this review, the minimally invasive vein harvesting technique was compared with the conventional technique to determine whether one is more effective at preventing leg wound infection during coronary artery bypass surgery. The researchers found that the minimally invasive vein harvesting significantly reduced the infection rate. Further research is necessary to fully understand all aspects of this technique.
4 Minimally invasive vein harvesting Quality Indicator
 Type: Systematic review
Athanasiou T, Aziz O, Sharif A, Philippidis P, Jones C, Purkayastha S, Casula R, Glenville B. Are wound healing disturbances and length of hospital stay reduced with minimally invasive vein harvest? A meta-analysis. European Journal of Cardio-Thoracic Surgery 2004;26(5):1015-26.
In this study, the effect of minimally invasive vein harvesting on non-infective wound healing disturbances was examined. Non-infective wound healing disturbances include wound drainage, hematoma, dehiscence, necrosis, need for surgical debridement, and seroma formation. It was found that the minimally invasive vein harvesting technique was effective at reducing the risk of non-infective wound healing disturbances.
5 Prophylactic antibiotics – Coronary artery bypass surgery Quality Indicator
 Type: RCT
Dhadwal K, Al-Ruzzeh S, Athanasiou T, Choudhury M, Tekkis P, Vuddamalay P, Lysler H, Amrani M, George S. Comparison of clinical and economic outcomes of two antibiotic prophylaxis regimens for sternal wound infection in high-risk patients following coronary artery bypass grafting surgery: A prospective randomised double-blind controlled trial. Heart 2007;93(9):1126-1133.
The purpose of this study was to compare clinical and economic outcomes of a longer and broader-spectrum prophylactic antibiotic regimen against cefuroxime in high-risk patients following coronary artery bypass grafting surgery. The longer and broader-spectrum regimen significantly reduced the incidence of sternal wound infection as well as being significantly more cost-effective.
6 Post-surgical leg wound complications Quality Indicator
 Type: Retrospective Analysis
Paletta CE, Huang DB, Fiore AC, Swartz MT, Rilloraza FL, Gardner JE. Major leg wound complications after saphenous vein harvest for coronary revascularization. Ann Thorac Surg. 2000; 70(2):492-7.
The purpose of this study was to analyze leg wound complications following coronary revascularization procedures. The results show that there are a number of risk factors for leg complications, and that it is possible to identify patients with a high likelihood of experiencing problems. Female patients with peripheral vascular disease and postoperative intraaortic balloon pumps were found to be at greatest risk for developing complications. In order to minimize complications, it would be beneficial to perform vascular evaluations prior to saphenous vein harvest. Greater attention to proper surgical technique and careful harvest site selection would also be beneficial.


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