Reply to Kopjar et al.

We thank Kopjar et al. [1] for their comments regarding our recent work published in Eur J Cardiothorac Surg [2]. We reported attenuated vascular smooth muscle cell activation via microRNA-145 as a possible pathogenetic mechanism for the clinical observation of improved vein graft patency using the no-touch (NT) approach. Kopjar et al. [1] focused on a critical aspect of a ‘NT’ vein harvest that has been a major barrier to wide-spread adoption, which being the morbidity of the leg incision. We have read their comments and offer our responses. In this report, our patient numbers were too small to make any definitive conclusions regarding clinical leg wound morbidity. To address this important issue, we direct Kopjar et al. to our ongoing prospective, multicentre randomized controlled clinical trial comparing conventional (CON) saphenous vein graft (SVG) harvest versus the no-touch technique (SUPERIOR SVG Study; http://clinicaltrials.gov/show/NCT01047449). The primary outcome of the SUPERIOR SVG Study is 1-year graft occlusion; the secondary outcomes include adverse SVG harvesting events at 1 year post-coronary artery bypass graft, which include infection, haematoma, swelling, neuropathy and quality-of-life measures. In this report, we found worse short-term leg assessment scores in NT versus CON at 3 months as well as more incidences of infection (4 vs 0 patients). However, as the authors have pointed out that, at 1 year, such scores were not different between groups. Our data does suggest that, in our patient population, although NT vein harvest was associated with acute morbidity, there may not be associated long-term functional consequences. As for the method of leg closure, all leg incisions were sutured closed with two layers of subcutaneous 2-0 Vicryl (Ethicon, Somerville, NJ, USA) sutures and a single 3-0 monocryl subcuticular layer. Anti-microbial sutures may minimize leg wound harvest-site infections, but were not used in these patients. In this report, all patients were included in the leg assessment study, including the one patient with preoperative peripheral vascular disease, which was not considered severe and without observable chronic skin changes. We do advocate that lower leg harvesting be avoided and thigh saphenous vein segments used for patients with more significant peripheral arterial insufficiency. We also agree that it remains to be seen whether gender will come to be an independent risk factor for infection. The Materials and Methods section points to Supplementary data, which includes the leg wound healing and functional outcomes questionnaire. This can now be accessed on the Eur J Cardiothorac Surg website. Finally, although the representative micrographs of SVG H&E staining (Figure 1) do not show statistical differences in intima, media and adventitial thickness between the two groups, there was an observed trend in the thickness of intima, media and adventitia between the NT and CON specimens (mean ± SD: 132.72 ± 42.02 vs 112.46 ± 44.18; 217.76 ± 48.73 vs 202.32 ± 45.53, and 146.19 ± 43.39 vs 132.38 ± 28.34, respectively). Finally, there was a single crossover; a CON SVG was harvested from the leg assigned to NT that developed a leg wound infection and analysed according to intention to treat. We did not perform the as-treated analysis nor would this change the outcome of the analysis. In addition, we thank Kopjar, et al. [1] for their interest in our paper and for raising these important points. Unfortunately, this report was not designed nor able to address many of the issues raised. As Kopjar et al. point out, the SUPERIOR SVG study will address these concerns.

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