Coronary artery bypass grafting (CABG) is often used to treat patients with heart disease. However depending on the number of coronary vessels to be bypassed, veins may be harvested from both legs leaving difficult-to-manage wounds. This article examines how one trust’s programme for managing the lower limb following CABG helped to prevent surgical site infection (SSI) and improve the patient experience.

INTRODUCTION
This short report examines one hospital trust's plan for reducing surgical site infection (SSI) in its specialist cardio-thoracic and transplantation services for both paediatric and adult patients. The trust, which is based on two separate sites, offers complex heart and lung management, including coronary artery bypass grafts (CABG) for patients who are referred from general practitioners and other hospitals throughout the UK.

Heart disease is a lifelong condition and many of the author's patients are smokers or have diabetes mellitus, peripheral vascular disease (PVD), obesity, venous hypertension or renal failure, which predispose them to leg wound complications. Patients with coronary artery disease have a high chance of having pre-existing peripheral vascular disease, especially those with diabetes.

BACKGROUND
Vein harvest sites in CABG patients are prone to oedema and local complications due to the systemic inflammatory response following cardiopulmonary bypass, impaired venous drainage, and extensive lymphatic and soft tissue damage.

This can lead to significant fluid accumulation in the interstitial space, poor tissue oxygenation and thus poor wound healing. Improvement in the venous and lymphatic drainage in the lower limbs, with graduated compression therapy, can reduce oedema and improve microcirculation in the cutaneous tissue[1].
 
By reducing oedema there is improved tissue approximation in the wounds and wound tension is decreased. In addition, with the increased lymphatic drainage there should be less tissue fluid around the wounds thus reducing the culture medium for bacterial growth and infection[2].
 
The national incidence of leg wound complications after CABG ranges from 1-44%[3]. The vessel of preference for the bypass procedure is the internal mammary artery because of its superior patency, however in recent times the greater saphenous vein and the radial artery have been frequently used as conduits for revascularisation.
 
Recent studies have shown that using the internal mammary artery can lengthen the time the patient spends on bypass, extend operation time and leads to postoperative ischaemia to the sternotomy site. This can result in delayed wound healing and a potential site for wound infection[4,5].

When the saphenous vein is harvested an incision is made along the medial aspect of the leg, which may extend from the ankle to the knee or even the mid-thigh region. Depending on the number of coronary vessels to be bypassed, veins may be harvested from both legs[6].
 
With the trend in healthcare moving towards decreased length of inpatient stay, clinicians must be actively involved in educating patients about the leg vein harvest site during their hospital stay and how to manage it following discharge. Through education patients are more likely to follow instructions on various measures including:

• Wearing intermittent pneumatic compression therapy
• Graduated compression stockings
• Exercise
• Mobilisation
• Elevation and skin care.

Encouraging patients to be compliant with these measures through education means that optimal healing is more likely to occur and complications requiring readmission will be minimised.