Differential effects of single versus double aortic clamping on myocardial protection during coronary bypass.
ABSTRACT The effects of double (n = 60, group 1) versus single (n = 60, group 2) aortic clamping on myocardial function and protection were investigated during coronary artery bypass grafting using a heart-lung pump. In group 1, after opening the cross clamp, proximal anastomosis was completed using side clamps and, in group 2, distal and proximal anastomosis was completed with a single clamp. Cross clamping time in the single-clamp patients (group 2; 77.1 min) was significantly higher than in the double-clamp patients (group 1; 62.9 min). Troponin T was significantly higher in group 2 than in group 1 h and 24 h after surgery. Post-operative left ventricular ejection fraction decreased in both groups, but this was not statistically significant. Post-operative wall motion score index and myocardial performance index increased significantly in both groups compared with the pre-operative level. Overall, the double-clamp technique provided better myocardial protection than the single-clamp technique and neither technique seemed to have a negative impact on the early post-operative global functioning of the left ventricle, however the effect of these techniques on the global functioning of the left ventricle in the late postoperative period needs to be evaluated.
The Open Cardiovascular Medicine Journal, 2010, 4, 293-296 293
1874-1924/10 2010 Bentham Open
Unilayer Closure of Saphenous Vein Incision Lines is Better than
Osman Tiryakioglu1,*, Tugrul Goncu1, Gunduz Yumun1, Onder Bozkurt1, Ahmet Demir1,
Selma Kenar Tiryakioglu2, Ahmet Ozyazicioglu1 and Senol Yavuz1
1Bursa Yuksek ?htisas Education and Research Hospital, Department of Cardiovascular Surgery, Bursa, Turkey
2Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Education and Research Hospital, Department of
Cardiology, ?stanbul, Turkey
Abstract: Objective: To examine early results in patients with incision lines closed only along the skin and subcutaneous
tissue after removal of the great saphenous vein during coronary artery bypass surgery.
Materials and Methods: We enrolled 82 patients who underwent elective operations in our clinic between December
2008 and April 2009. The patients had similar demographic characteristics, and the method of incision closure was chosen
randomly. Three patients were excluded due to in-hospital mortality. The saphenous incision lines were closed using
continuous skin sutures in 41 patients (Group 1) or using continuous subcutaneous sutures followed by continuous
skin sutures in 38 patients (Group 2). Patients were followed every day that they were in the hospital, in the first week
after being discharged, and at the end of the second month after discharge. The incision lines were evaluated for
hematomas, infection, edema, pain and numbness.
Results: During the follow-up performed in-hospital and in the first week after discharge, infection, edema and numbness
were observed significantly more often in Group 2 than in Group 1. Hematoma was observed more often in Group 1,
and pain was observed more often in Group 2, but neither of these findings reached statistical significance. During the
follow-up at the end of the second month after discharge, infection, edema, and numbness were observed significantly
more frequently in Group 2.
Conclusion: In patients undergoing saphenous removal using standard procedures, it is sufficient to close the incision line
using only skin sutures.
Keywords: Saphenous vein graft, subcutaneous closure, coronary bypass surgery.
bypass surgery by Favaloro et al. in 1967, it has become a
routine procedure. Conventional open saphenous vein har-
vesting techniques during coronary artery bypass surgery are
the primary cause of postoperative leg wounds. Although
many types of minimally invasive saphenectomy equipment
are commercially available, the use of this equipment sub-
stantially increases operation costs, and access may be lim-
ited in the clinical setting.
After the first use of saphenous vein grafts in coronary
using a conventional incision from the anterior aspect to the
proximal aspect of the medial malleolus. For cases in which
the SVG is prepared using a conventional incision, compli-
cations may occur during the postoperative period, including
cellulitis, saphenous vein neuralgia and late leg edema. [1, 2].
In general, saphenous vein grafts (SVGs) are prepared
*Address correspondence to this author at the Bursa Yuksek ?htisas
Hastanesi Prof. Tezok cad. No:1 16320 Yildirim, Bursa, Turkey;
Tel: +902243605050; Fax: +902243605055;
The leg complication rate in cases with SVGs prepared using
a conventional incision ranges between 2 and 4% .
of the closure technique on the possible complications
for cases in which SVGs were prepared using conventional
Our aim in this study was to investigate the influence
MATERIALS AND METHODOLOGY
clinic between December 2008 and April 2009 were in-
cluded in the study. The patients had similar demographic
characteristics, and the closure method was chosen randomly
A total of 82 patients undergoing elective surgery in our
aorta-caval cannulation with a pump oxygenator. None of
the patients had additional cardiac pathology or peripheral
arterial or venous disease. There were no differences among
the patients in terms of operation time or number of by-
passes. The left internal mammary artery (LIMA) was re-
moved in all patients and anastomosed to the left anterior
All patients underwent a median sternotomy and typical
294 The Open Cardiovascular Medicine Journal, 2010, Volume 4 Tiryakioglu et al.
descending artery. Other bypasses were performed using the
tality. The saphenous incision line was closed using only
continuous skin sutures in 41 patients (Group 1), whereas it
was closed using continuous subcutaneous sutures followed
by continuous skin sutures in 38 patients (Group 2).
Three patients were excluded from the study due to mor-
sion from the medial malleolus to the inguinal area, through
the saphenous trace. The length of saphenous vein harvested
was proportional to the number of bypasses to be performed.
Both the graft and the venous collaterals at the side of leg
were tied using 4/0 silk sutures. Bleeding was controlled
only with ligation along the dissection line. In all cases, the
SVG was harvested from the right lower extremity. The sub-
cutaneous tissue was closed using absorbable, 2:0 Coated
Vicryl sutures with a round needle (ETHICON, Belgium),
whereas the skin was closed using absorbable, 2:0 Coated
Vicryl sutures with a sharp needle (ETHICON, Belgium).
Following closure, the leg was wrapped with a sterile elastic
The SVG was harvested in all patients via a linear inci-
in the first week after discharge and at the end of the second
month after discharge. Measurements were recorded, and
averages were calculated. The incision lines were assessed
for hematomas, infection, edema, pain and numbness.
The patients were followed daily during hospitalization,
amination, whereas edema was evaluated using a tape meas-
urement at the same level. The patient’s medical history was
used to evaluate pain and numbness.
Hematomas and infection were evaluated by clinical ex-
tive, and postoperative data and the results of each group
with the method of median +/- t standard deviation and with
the utilization of SPSS 17.0 statistics software to get the
categorical data X2 (chi-square) and to get the multiple Vari-
ables and the Independent-Samples- T Test methods were
utilized. Values lower than 0.05 for p value were considered
For the analysis of the demographic, preoperative, opera-
age, gender, body surface area, number of bypasses per-
formed, hospitalization period, diabetes mellitus (DM), Eu-
roSCORE value or leg incision level (p>0.05) (Table 1).
There were no differences between groups in terms of
The surgically data shown in Table 2.
period and in the first postoperative week were compared,
infection, edema and numbness were found to be signifi-
cantly more common in Group 2 than in Group 1 (p<0.005).
There were no differences in leg diameter at the point where
the saphenous vein was harvested (Table 3).
When measurements taken during the hospitalization
patients in Group 1 had no significant complaints about the
leg from which the saphenous vein was harvested. Patients in
Group 2, however, had significant complaints about numb-
ness and pain (Table 4).
During follow-up in the second month after discharge,
proach, it begins at the anterior aspect of the medial malleo-
lus and is extended depending on the length of venous graft
required. This region has scarce subcutaneous supportive
tissue, however, and shows poor wound healing. Particularly
in obese patients with diabetes and peripheral vascular dis-
ease, even footwear can traumatize the area, resulting in
complications [1, 2]. In all of our patients, the saphenous
incision line began at the medial malleolus and was extended
along the saphenous incision line to the required graft length.
When an SVG is prepared using a conventional ap-
vein is harvested in approximately 1-24% of cases in which
the SVG is prepared using a conventional incision . This
rate is even higher in female patients and in patients with
DM, peripheral vascular disease or left ventricular dysfunc-
tion . There is no clear information regarding why com-
plications in the leg from which the saphenous graft is har-
vested are more frequent in female patients; however, coro-
nary artery disease is more common in the postmenopausal
period in females. It has been suggested that changes in es-
Complications occur in the leg from which the saphenous
Table 1. Demographic Characteristics and Operation Features of the Patients Studied. NS, not Statistically Significant
Group 1 (n=41) Group 2 (n=38) p
Age (years) 63.1±11 63.7±9.6 NS
Gender (M/F) 31/10 28/10 NS
Body surface area (m2) 1.77±0.2 1.84±0.1 NS
Diabetes mellitus (n) 20 16 NS
EuroSCORE 2.3±1.8 2.1±1.5 NS
Peripheral arterial disease 0 0
Peripheral venous disease 0 0
Additional cardiac pathology 0 0
Preoperative right leg measurements (cm) 35±2.5 34.9±4.8 NS
Closure of Saphenous Vein Incision The Open Cardiovascular Medicine Journal, 2010, Volume 4 295
trogen levels during this period could compromise wound
healing. In our study, there were no differences between the
two groups in terms of risk factors.
tions arising from SVG preparation. Some of these include
stripping modifications, incision lines in the form of skin
bridges along the saphenous vein trace and endoscopic tech-
niques. The latter have become more common recently, and
removal of the saphenous vein has even been carried out
using a laryngoscope [6-11]. In a study of endoscopic vein
Various methods have been used to reduce leg complica-
harvesting with 50 cases, Carrizo et al.  found lymphe-
dema in 5 cases (10%) and ecchymosis in 6 cases (12%), and
the procedure was necessarily shifted to an open method in 2
cases (4%). Although that study showed that an endoscopic
approach could be safely used within a short period, the re-
sulting complications were not negligible. An endoscopic
approach, however, offers better cosmetic results. Based on
studies using an endoscopic approach, graft availability and
the prevention of complications have led to expectations of
good long-term outcomes, indicating that endoscopic proce-
Table 2. Operative Data. NS, Not Statistically Significant
Group 1 (n=41) Group 2 (n=38) P
Under knee 18 12 NS
Above knee 23 26 NS
Incision length (cm) 40±5.5 43± 6 NS
Incision/leg ratio 0.48 0.51 NS
Hospitalization period (days) 7.3±3 8±2 NS
Total operation time (min) 224±43 239±55 NS
Number of bypasses 3.1±1.8 3.2±2.1 NS
Table 3. Data Obtained During Hospitalization and in the First Week after Discharge. NS, Not Statistically Significant. *Measured
using the Leg-O-Meter
Group 1 (n=41) Group 2 (n=38) P
Hematoma 6 (14%) 2 (5.2%) NS
Infection 2 (4.8%) 8 (21%) 0.033
Pain 6 (14%) 8 (21%) NS
Edema 3 (7%) 10 (26%) 0.023
Numbness 2 (4.8%) 12 (31.5%) 0.002
Number of patients with complaints 6 (14%) 8 (21%) NS
Right leg diameter (cm)* 37.1±3.5 40.2±4.8 NS
Table 4. Data from Follow-up During the Second Postoperative Month. NS, Not Statistically Significant. NS, Not Statistically
Significant. *Measured using the Leg-O-Meter
Group 1 (n=41) Group 2 (n=38) P
Hematoma 0 0 -
Infection 0 2 (5.2%) 0.05
Pain 1 (2.4%) 4 (10.4%) NS
Edema 1 (2.4%) 6 (15.7%) 0.04
Numbness 0 10 (26%) 0.001
Number of legs with complaint 1 (2.4%) 6 (15.7%) 0.04
Right leg diameter (mean cm.)* 36.1±3.1 40.4±4.5 NS
296 The Open Cardiovascular Medicine Journal, 2010, Volume 4 Tiryakioglu et al.
dures for minimally invasive vein or artery harvesting are
more practicable .
edema and dysfunction did not occur following SVG prepa-
ration using a traditional incision in subjects with normal
venous circulation. When no particular findings are present,
SVGs in our clinic are harvested using a traditional incision
and direct view, and this method was used for all of the pa-
tients in this study.
In contrast, in a study conducted by Terada et al. ,
leg volume because leg circumference measurements do not
always provide accurate results. Leg volume can be meas-
ured using optoelectronic methods or high-resolution mag-
netic resonance imaging, although the validity of this ap-
proach has not yet been completely confirmed. Alternatively,
validated methods such as dynamic leg volume devices and
plethysmography can be used. These methods are expensive,
however, making their routine use difficult. Therefore, we
used a measuring tape mounted on a fixed surface (the Leg-
O-Meter) to evaluate leg edema. In a study conducted by
Berard et al., the reliability of the Leg-O-Meter was found to
be over 97%. Based on this finding, we preferred to use this
practical and reliable device [13, 14].
The correct method to determine leg edema is to measure
patients undergoing coronary bypass due to its ease of use,
ease of accessibility and dimensions. Although many meth-
ods have been reported for harvesting the saphenous vein,
the most commonly used and most reliable method is an
open incision under direct vision. Closure of the skin and
subcutaneous closure along the incision line may cause com-
plications such as nerve compression, damage to the lym-
phatics, compromised blood supply and associated infection,
pain and edema. These complications may even overshadow
the benefits obtained from coronary bypass. As shown in this
study, however, using only skin closure prevents many of the
Received: October 18, 2010
The saphenous vein is still the most common graft in
above-mentioned complications and, therefore, should be the
method of choice.
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Revised: October 29, 2010 Accepted: November 02, 2010
© Tiryakioglu et al.; Licensee Bentham Open.
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