Dermatology Online Journal

Saphenous vein harvesting site dermatoses in eastern India
Sudip Kumar Ghosh MD DNB DDermat, Debabrata Bandyopadhyay MD
Dermatology Online Journal 15 (7): 13

Department Of Dermatology, Venereology, and Leprosy, R.G. Kar Medical College, Kolkata, India. dr_skghosh@yahoo.co.in

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Abstract

Coronary artery bypass grafting (CABG) has become a common surgical procedure. During this procedure, the greater saphenous vein is most often used as the conduit and the side effects of the leg vein harvesting include a variety of cutaneous changes. We report the cutaneous effects at the saphenous vein harvesting sites in 21 patients who underwent CABG.

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Coronary artery bypass grafting (CABG) is one of the most common cardiac surgical procedures during which portions of arteries or veins from the patient's own body are grafted to bypass the narrowed coronary artery segments. Commonly used conduits in CABG are the internal mammary arteries, radial arteries, and the greater saphenous vein (SV) [1]. Despite the recent trend of using arterial conduits for coronary revascularization, the majority of CABG operations use a venous conduit, harvested from the patient's legs [2]. The immediate complications of SV-harvesting are discomfort, pain, and wound infection. In the long term, owing to altered integrity of the skin, variable morbidities including a number of dermatoses can occur on SV graft harvesting sites [3, 4]. Although a few case series describing cutaneous changes following CABG have been reported, data regarding the incidence and prevalence of different dermatoses in this patient group are lacking.

We report the cutaneous changes on and around the SV graft donor sites in 21 patients from eastern India who underwent CABG. This was a prospective clinical observational study. Consecutive patients evaluated in the dermatology department of a tertiary care hospital and presenting with dermatoses localized to the SV harvesting site were included in the present study. Patients who had preexisting dermatoses or concurrent skin involvement at other body sites, peripheral neuropathy, and diabetes mellitus were excluded from the present study. The total duration of the study was three years (from April 2006 to March 2009). A detailed history was taken; all the patients were thoroughly examined clinically and routine laboratory investigations were performed. In addition, sweat test with starch iodine, patch tests using the Indian Standard Battery and additional allergens (using cosmetics or topical medicaments), and histopathological examination were done whenever needed. A total of 21 patients (mean age 56.5 years, range 42 to 72 years), with a female to male ratio of 1:6, were evaluated.

The mean interval between the time of CABG and presentation to our center was 21.5 months (range 6 to 78 months). Pruritus was the predominant (12, 54.1%) presenting symptom, followed by dryness (7, 33.3%), pigmentary alterations (3, 14.3%), neuralgic pain (2, 9.5%), and burning sensation (1, 4.8%). Eczematous reaction pattern was the commonest (8, 38%) finding, (Fig. 1) followed by xerosis (7, 33.3%), (Fig. 2) prurigo (4, 19%), harvesting site depigmentation (2, 9.5%), pigmented purpuric dermatoses (PPD) (1, 4.8%), and hypertrophic scar (1, 4.8%). No positive patch test reactions were found in any of the eight patients tested. Impaired sweating of the local area was noted in eight patients. We treated the patients with topical steroids, emollients, and/or H1 antihistamines with significant improvement.

Figure 1	Figure 2
Figure 1. Multiple excoriated and eczematous lesions and xerosis Figure 2: Xerotic change around saphenous vein harvesting site

Harvesting of the SV may result in damage of the blood vessels, lymphatics, and nerves. This often leads to decreased blood flow to the skin and the vasa nervosum supplying the peripheral nerves [4]. After denervation, motor, sensory, and autonomic functions may be disrupted resulting in xerosis, anesthesia, and loss of barrier function predisposing to dermatitis and infection [4]. Dermatitis may occur as a result of trophic changes secondary to saphenous neuralgia [3]. In consonance with previous reports, we did not find any positive relationship between the duration after CABG and different specific dermatoses [4]. Non-healing ulcers, cellulitis, vein graft dermatitis [5], sclerodermiform dermatitis [6], and painful peripheral sensory neuropathy [3] following CABG have been described previously. A study reported that saphenous neuralgia after harvesting the SV for CABG was a rare occurrence [7]. Only two of our patients had neuralgic pain. A relatively higher incidence of neuralgic pain has also been described [4]. Early onset and early disappearance of hyperesthesia and pain is considered to be a normal consequence of surgical procedure. We did not find any relationship between different dermatoses and the types of surgical procedures used during SV harvesting.

Saphenous vein grafting may impair venous return at the donor site. However, we did not find any cutaneous changes of venous stasis in our series apart from a case of PPD. In addition, none of the patients had edema of the legs. Although the patients often disregard these cutaneous changes as minor problems, in view of the fact that CABG is being increasingly performed worldwide, clinicians should be familiar with these cutaneous side effects.

References

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7. Budillon AM, Zoffoli G, Nicolini F, Agostinelli A, Congiu S, Beghi C, Gherli T. Neurologic symptoms after great saphenous vein harvesting for coronary artery bypass grafting. J Cardiovasc Surg (Torino). 2003 Dec; 44(6):707-11. [PubMed]

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