Preoperative thoracoabdominal multidetector computed tomography (CT) angiography was performed in patients undergoing CABG to assess their vascular status from the neck to femoral vessels due to their high atherosclerotic steno-occlusive risk^[7]. If the patient had any exertional leg symptoms or had significant steno-occlusive disease of a lower extremity, an ankle brachial index (ABI) test was performed^[8]. An ABI ratio of ≤ 0.7 in any lower limb suggested moderate to severe peripheral arterial disease and harvesting the ipsilateral SV was avoided to prevent skin wound complications. Lower extremity vein CT angiography was performed at the same time as thoracoabdominal CT without additional contrast material. Lower extremity vein CT angiography allowed thorough evaluation of lower extremity veins, such as of their course, size, and quality.

After anesthetic induction, Doppler ultrasonography mapping was performed to reassess the course, size, quality (such as ectatic change, sclerosis, or thrombosis), and tributaries of the SV^[9].

The SV from a lower leg was commonly chosen as opposed to the upper leg SV to decrease the possibility of size mismatch with native coronary arteries or internal thoracic arteries. SV with diameters between 2.5 mm and 4.5 mm and fewer tributaries were preferred for use.

The no-touch SV harvesting technique has been previously described^[10,11]. Two or three interrupted open skin incisions were made along the SV course marked by surgical pens to avoid unnecessary and large dissections of the leg. One- to 2-cm intervening bridges of skin were left intact to allow better closure of the wound and to minimize ischemic changes along the skin edges. The no-touch SV harvest included surrounding pedicle tissue, whereby the SV pedicle was harvested along with an approximately 3- to 5-mm wide margin of adjacent adipose tissues on both sides of the SV and thin layers of adherent connective tissues posteriorly, in addition to minimized manipulation of the SV and avoidance of manual intraluminal dilatation. Side branches were divided after clipping. Titanium clips were applied at least 1 mm from branch origins to prevent inadvertent endothelial injury.

The no-touch SV harvest was performed using either an electrocautery, Harmonic Scalpel™ (Ethicon Endo-Surgery, Inc., Cincinnati, Ohio, United States of America), or LigaSure™ (Medtronic, Inc., Minneapolis, Minnesota, United States of America) device. During the no-touch SV harvesting using an electrocautery, the cautery setting was kept on low throughout the dissection to avoid thermal injury to the SV pedicle. No-touch SV harvest using either the Harmonic Scalpel™ or the LigaSure™ devices had advantages of better hemostasis and minimal thermal injury over the no-touch SV harvest using an electrocautery. The Harmonic Scalpel™ device uses ultrasonic vibration technology, and the LigaSure™ device is an electrothermal bipolar-activated device. Both devices provide effective hemostasis and minimal lateral thermal spread^[12].

After protamine administration to normalize the prolonged activated clotting time at the end of CABG, a Jackson-Pratt drain was inserted into the SV harvesting site and the leg wounds were closed in layers: interrupted 3-0 absorbable sutures to the subcutaneous tissue, interrupted 4-0 subcuticular absorbable sutures, and additional staples or zip surgical closure method for the skin. Zip skin closure (ZipLine Medical, Inc., Campbell, California, United States of America) is a noninvasive skin closure system, and it has several advantages for wound healing such as providing better cosmetic results, facilitating wound healing, and reducing infection risk^[13,14]. An elasticated bandage was applied to the leg wound after surgery and was replaced by a compression stocking from the 2^nd postoperative day. The compression stocking was kept in place for 1 to 2 months postoperatively for prevention of leg swelling. The Jackson-Pratt drain was removed when the amount of drained fluid decreased to < 10 mL daily. Leg wound complications in the SV harvesting site were defined as infection or wound disruption that needed additional repair or secondary intention healing. Leg wound complications developed in eight of 518 patients (1.5%) who received no-touch SV graft and underwent wound closure using the aforementioned strategies from 2017 to 2021 (unpublished data). All eight patients recovered after secondary intention healing.

Correspondence Address: Min-Seok Kim, https://orcid.org/0000-0003-3425-882X, Cardiovascular Center, Myongji Hospital, 55, Hwasu-ro 14 beon-gil, Deogyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea, Zip Code: 10475, E-mail: minseok.kim.md.phd@gmail.com