A prospective randomised study of four different methods of leg wound skin closure after removal of the long saphenous vein was carried out in 113 patients undergoing coronary artery bypass grafting. These methods were: (1) continuous nylon vertical mattress suture (27 patients); (2) continuous subcuticular absorbable (Dexon) suture (29 patients); (3) metal skin staples (Autosuture) (27 patients); and (4) adhesive sutureless skin closure ("Op-site") (30 patients).All wounds were examined by two independent observers at five, 10, and 45 days after operation. At five days, inflammation, extent of oedema, discharge, and infection were assessed. At 10 days attention was paid to the state of wound healing and at 45 days to the final cosmetic appearance. The use of continuous subcuticular suture resulted in significantly less discharge than did the use of metal staples, nylon vertical mattress suture, or Op-site. The incidence of established wound infection was 4*5% overall, with no infection in the wounds closed with Dexon. Assessment of the healing process showed subcuticular Dexon to be more effective than metal staples or vertical mattress nylon suture. The final cosmetic result showed continuous subcuticular suture to be superior to nylon vertical mattress suture and skin staples but as effective as Op-site sutureless skin closure.Coronary artery bypass grafting is now one of the most commonly performed operations in the world. The most widely used conduit for bypassing the obstructed coronary artery is still a reversed segment of the patient' s own long saphenous vein, and no synthetic substitute has yet been found that gives results as good as, let alone better than, autologous vein.' Nevertheless, removal of the entire long saphenous vein is necessary for multiple grafts and requires a long incision in the leg from ankle to groin.2 Despite complications from this wound possibly being troublesome and protracted, this part of the operation is often delegated to a junior member of the surgical team. Surprisingly little attention has been paid to the leg wound in coronary artery bypass grafting operations and in particular to the best method of skin closure. We report here the results of a prospective, randomised study of four different methods of leg wound skin closure.

Segments of saphenous vein from patients undergoing coronary artery by-pass graft surgery were frozen in liquid nitrogen immediately on dissection (control), after stripping of the adventitia and side branch ligation (manipulation), after distention with blood (distention), or at completion of the last proximal anastomosis (prepared vein). Vein was stored during the operation in patient's heparinised arterial blood at room temperature. Frozen vein was extracted with perchloric acid. ATP, ADP, and AMP, adenosine, inosine and hypoxanthine concentrations were measured by high pressure liquid chromatography. Prepared vein had ca 50% lower ATP concentrations and ATP/ADP ratio than control vein, higher concentrations of inosine and hypoxanthine and lower concentrations of AMP and adenosine. ATP concentration and ATP/ADP ratio did not correlate with the time elapsed between dissection and freezing of the prepared vein. The characteristic changes seen in prepared vein were not seen when control vein was simply stored in arterial blood at 23 degrees C, in normal saline at 23 degrees C or 4 degrees C, in Krebs-Ringer bicarbonate buffer at 37 degrees C or at St Thomas's Hospital cardioplegic solution at 4 degrees C. Distention with unlimited pressure did not distension at less than 300 mmHg gave rise to the same changes in ATP concentration and ATP/ADP ratio as in the prepared vein. These results show that vein suffered metabolic changes during preparation for bypass grafting and suggest that uncontrolled distention may contribute to these changes. Such biochemical measurements provide a quantitative estimate of tissue damage and allow objective comparison of different preparative techniques.

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We report a case of sudden onset of angina 11 years after implantation of a No. 8 Model 2300 Starr-Edwards cloth-covered aortic valve prosthesis for aortic stenosis and insufficiency. At operation the cloth covering one strut of the metal cage was tenuously attached to the ring of the prosthesis, with its free end completely occluding the right coronary artery ostium. The valve was replaced and the obstructing foreign body removed, re-establishing the patency of the right coronary artery.