Long-term results of percutaneous coronary intervention in no-touch vein grafts are significantly better than in conventional vein grafts.

INTRODUCTION: Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique. METHODS: This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis. RESULTS: The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4 years with a standard deviation of 3.7 years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups. CONCLUSIONS: Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

Physiologically based pharmacokinetic modelling of semaglutide in children and adolescents with healthy and obese body weights.

AIMS: To develop paediatric physiologically based pharmacokinetic modelling (PBPK) models of semaglutide to estimate the pharmacokinetic profile for subcutaneous injections in children and adolescents with healthy and obese body weights. METHODS: Pharmacokinetic modelling and simulations of semaglutide subcutaneous injections were performed using the Transdermal Compartmental Absorption & Transit model implemented in GastroPlus v.9.5 modules. A PBPK model of semaglutide was developed and verified in the adult population, by comparing the simulated plasma exposure with the observed data, and further scaled to the paediatric populations with normal and obese body weight. RESULTS: The semaglutide PBPK model was successfully developed in adults and scaled to the paediatric population. Our paediatric PBPK simulations indicated a significant increase in maximum plasma concentrations for the 10-14 years' paediatric population with healthy body weights, which was higher than the observed values in adults at the reference dose. Since gastrointestinal adverse events are related to increased semaglutide concentrations, peak concentrations outside the target range may represent a safety risk for this paediatric age group. Besides, paediatric PBPK models indicated that body weight was inversely related to semaglutide maximum plasma concentration, corroborating the consensus on the influence of body weight on semaglutide PK in adults. CONCLUSION: Paediatric PBPK was successfully achieved using a top-down approach and drug-related parameters. The development of unprecedented PBPK models will support paediatric clinical therapy for applying aid-safe dosing regimens for the paediatric population in diabetes treatment.

Percutaneous coronary intervention in saphenous vein grafts after coronary artery bypass grafting: a systematic review and meta-analysis.

To investigate the results of percutaneous coronary intervention (PCI) in saphenous vein grafts after coronary artery bypass grafting (CABG). Design. MEDLINE, Embase, and the Cochrane library were searched for relevant articles published between 1 January 2000 and 29 February 2020. The PICO (population, intervention, comparison, outcome) model was applied in constructing the clinical question. Two independent researchers performed the literature search. Thirty-six articles were identified and subjected to a quality assessment. The primary outcomes of the meta-analysis were long-term in-stent restenosis and long-term major adverse cardiac events (MACE). Results. In-stent restenosis was 9.4% (95% CI: 4.2-14.7%) and MACE was 35.3% (95% CI: 27-43.7%) at mean time 2.7 ± 1.0 years. The secondary outcomes were the unsuccessful PCI rate (7.7%; 95% CI: 2.9-12.5%), 30-day MACE (4.3%; 95% CI: 2.5-6.1%), and 1-year MACE (15.5%; 95% CI: 11.7-19.3%). The use of drug-eluting stents resulted in better outcomes at least in term of in-stent restenosis, while the benefit of using embolic protection devices was questionable. Conclusions. PCI of a stenosed or occluded saphenous vein graft is a challenge for interventional cardiologists, and is still associated with relatively high rates of restenosis, MACE, and procedural failure. All efforts to enhance the results are warranted, including improved quality of the venous grafts used during CABG.

Five-year patency for the no-touch saphenous vein and the left internal thoracic artery in on- and off-pump coronary artery bypass grafting.

BACKGROUND: Randomized trials show high long-term patency for no-touch saphenous vein grafts in coronary artery bypass grafting. The patency rate in off-pump coronary bypass surgery for these grafts has not been investigated. Our center participated in the CORONARY randomized trial, NCT00463294. This is a study aimed to assess the patency of no-touch saphenous veins in on- versus off-pump coronary bypass surgery at five-year follow-up. METHODS: Fifty-six patients were included. Forty of 49 patients, alive at 5 years, participated in this follow-up. There were 21 and 19 patients in the on- and off-pump groups respectively. No-touch saphenous veins were used to bypass all targets and in some cases the left anterior descending artery. Graft patency according to distal anastomosis was evaluated with computed tomography angiography. RESULTS: The five-year patency rate was 123/139 (88.5%). The patency for the no-touch vein grafts was 57/64 (89.1%) in the on-pump versus 37/45 (82.2%) in the off-pump group. All left internal thoracic arteries except for one, 29/30 (96.6%), were patent. All vein grafts used to bypass the left anterior descending and the diagonal arteries were patent 32/32. The lowest patency rate for the saphenous veins was to the right coronary territory, particularly in off-pump surgery (80.0% vs. 62.5% for the on- respective off-pump groups). CONCLUSIONS: Comparable 5-year patency for the no-touch saphenous veins and the left internal thoracic arteries to the left anterior descending territory in both on- and off-pump coronary artery bypass grafting. Graft patency in off-pump CABG is lower to the right coronary artery.

No-touch saphenous vein grafts in coronary artery surgery (SWEDEGRAFT): Rationale and design of a multicenter, prospective, registry-based randomized clinical trial.

The SWEDEGRAFT study (ClinicalTrials.gov Identifier: NCT03501303) tests the hypothesis that saphenous vein grafts (SVGs) harvested with the "no-touch" technique improves patency of coronary artery bypass grafts compared with the conventional open skeletonized technique. This article describes the rationale and design of the randomized trial and baseline characteristics of the population enrolled during the first 9 months of enrollment. The SWEDEGRAFT study is a prospective, binational multicenter, open-label, registry-based trial in patients undergoing first isolated nonemergent coronary artery bypass grafting (CABG), randomized 1:1 to no-touch or conventional open skeletonized vein harvesting technique, with a planned enrollment of 900 patients. The primary end point is the proportion of patients with graft failure defined as SVGs occluded or stenosed >50% on coronary computed tomography angiography at 2 years after CABG, earlier clinically driven coronary angiography demonstrating an occluded or stenosed >50% vein graft, or death within 2 years. High-quality health registries and coronary computed tomography angiography are used to assess the primary end point. The secondary end points include wound healing in the vein graft sites and the composite outcome of major adverse cardiac events during the first 2 years based on registry data. Demographics of the first 200 patients enrolled in the trial and other CABG patients operated in Sweden during the same time period are comparable when the exclusion criteria are taken into consideration. RCT# NCT03501303.

Sulphate-based electrochemical processes as an alternative for the remediation of a beauty salon effluent‡.

Beauty salons (BS) are places that deal with a wide range of cosmetics with potentially hazardous chemicals, and their effluent should be properly treated before going to the sewage system, once it represents characteristics of industrial wastewater. This work provides an extensive characterization of a BS effluent and its respective electrochemical treatment by comparing NaCl, Na2SO4, and Na2S2O8 as supporting electrolytes with a boron-doped diamond (BDD) as anode, applying 10 or 30 mA cm-2 of current density (j). The inclusion of UVC irradiation was also performed but the improvements achieved in removing the organic matter were null or lower. The analysis of chemical oxygen demand (COD) removal, energy consumption, and total current efficiency (TCE) was required to prove the efficacy of the processes and the comparative study of the performance of different technologies. Precipitate analysis was also done due to the high turbidity of the raw effluent and the appearance of a precipitate before and during the electrolysis, mainly with Na2S2O8. The precipitate confirmed the presence of silicates and small amounts of heavy metals. The results clearly showed that 6 h of treatment with Na2SO4 achieved 58% of COD removal with an energy consumption of about 0.52 kWh m-3, being the best electrolyte option for treating BS effluent by applying 10 mA cm-2. Under these experimental conditions, the final wastewater can be directly discharged into the sewage system with a lower amount of visible precipitate, and with 73% less turbidity. The treatment here proposed can be used as an alternative to decision-makers and governments once it can be a step further in the implementation of better and advanced politics of water sanitation.

A sustainable solar-driven electrochemical process for reforming lignocellulosic biomass effluent into high value-added products: green hydrogen, carboxylic and vanillic acids.

There is a growing concern with waste minimization and the promotion of the circular economy. Within this framework, using membrane-equipped electrochemical systems, the electrochemical oxidation (EO) of organic compounds and simultaneous hydrogen (H2) production can considerably improve the sustainability and economic viability of this process. Here, we propose an innovative-integrate electrochemical treatment strategy to maximize the economic benefits and sustainability of selectively producing organic acids and energy-saving H2 production from biomass platform compounds. The results clearly demonstrated that, on the one hand, more than 80 mg L-1 of oxalic acid was obtained in the anodic reservoir (using a boron-doped diamond electrode) with an alkaline medium (0.5 mol L-1 NaOH) by applying 100 mA cm-2 as well as vanillic acid production of 0.6795 mg L-1 under the same conditions. On the other hand, simultaneously green H2 production greater than 2.6 L was produced, in the cathodic compartment with a Ni-Fe-based mesh as cathode, with a 90% faradaic efficiency during the process. Thus, the electrochemical conversion of lignocellulosic biomass effluent into high-value-added products and an energy vector was sustainably accomplished, suggesting that it is a promising energy-saving and cost-effective integrated approach for biomass valorization using solar energy.

Alternative Methods for Pulmonary-Administered Drugs Metabolism: A Breath of Change.

Prediction of pulmonary metabolites following inhalation of a locally acting pulmonary drug is essential to the successful development of novel inhaled medicines. The lungs present metabolic enzymes, therefore they influence drug disposal and toxicity. The present review provides an overview of alternative methods to evaluate the pulmonary metabolism for the safety and efficacy of pulmonary delivery systems. In vitro approaches for investigating pulmonary drug metabolism were described, including subcellular fractions, cell culture models and lung slices as the main available in vitro methods. In addition, in silico studies are promising alternatives that use specific software to predict pulmonary drug metabolism, determine whether a molecule will react with a metabolic enzyme, the site of metabolism (SoM) and the result of this interaction. They can be used in an integrated approach to delineate the major cytochrome P450 (CYP) isoforms to rationalize the use of in vivo methods. A case study about a combination of experimental and computational approaches was done using fluticasone propionate as an example. The results of three tested software, RSWebPredictor, SMARTCyp and XenoSite, demonstrated greater probability of the fluticasone propionate being metabolized by CYPs 3A4 at the S1 atom of 5-S-fluoromethyl carbothioate group. As the in vitro studies were not able to directly detect pulmonary metabolites, those alternatives in silico methods may reduce animal testing efforts, following the principle of 3Rs (Replacement, Reduction and Refinement), and contribute to the evaluation of pharmacological efficacy and safety profiles of new drugs in development.

A Case of Using No-Touch Saphenous Vein Graft in Redo CABG after Multiple Failed Percutaneous Coronary Interventions.

The modality of repeat revascularization due to late graft failure is a debated topic. The latest available European guidelines recommend redo coronary artery bypass graft (CABG) for cases of extensively diseased and/or occluded grafts and those with diffuse native vessel disease. We present the case of a patient being relieved of recurrent unstable angina pectoris with redo CABG using no-touch saphenous vein grafts after repeated and unsuccessful attempts with percutaneous coronary intervention (PCI). This could be an alternative to PCI in patients with a complex medical history. Teamwork between cardiologists and surgeons is pivotal in deciding the best treatment modality.

Quality of Life After Percutaneous Coronary Intervention in No-Touch Saphenous Vein Grafts is Significantly Better Than in Conventional Vein Grafts.

OBJECTIVE: To compare health-related quality of life (HRQoL) of patients primarily treated with a no-touch saphenous vein graft with that of patients who received a conventional graft. METHODS: The study included all individuals treated with a percutaneous coronary intervention (PCI) on a saphenous vein graft (SVG) between January 2006 and June 2020. The RAND-36 health survey was used to assess HRQoL. The Mann-Whitney U test was used to test differences in HRQoL between the two groups. Effect size was estimated via Cohen's d. The average treatment effect between the groups was tested by propensity score matching (PSM). RESULTS: Of the 346 patients treated with a PCI in a stenosed or occluded SVG, 165 responded to RAND-36 (no-touch: n=48; conventional: n=117). Patients with a no-touch graft reported better mean values on seven of the eight health survey domains. Statistically significant differences were observed for four of the domains, all in favour of the no-touch group. The effect size estimates indicated a small difference for five domains, with the highest values (>0.40) seen for the general health and energy/fatigue domains. PSM confirmed a statistically significant difference for the physical functioning and general health domains. CONCLUSION: At a mean follow-up of 5.4 years, patients who received a PCI in no-touch vein grafts showed significantly better HRQoL than those who received a PCI in conventional vein grafts.

Saphenous veins in coronary artery bypass grafting need external support.

The saphenous vein is the most commonly used conduit for coronary artery bypass grafting. Arterial grafts are harvested with the outer pedicle intact whereas saphenous veins are harvested with the pedicle removed in the conventional graft harvesting technique. This conventional procedure causes considerable vascular damage. One strategy to improve vein graft patency has been to provide external support. Ongoing studies show that fitting a metal external support improves conventionally harvested saphenous vein graft patency. On the other hand, the no-touch technique of harvesting the saphenous vein provides an improved graft with long-term patency comparable to that of the internal mammary artery. This improvement is suggested to be due to preservation of vessel structures. Interestingly, many of the mechanisms proposed to be associated with the beneficial actions of an artificial external support on saphenous vein graft patency are similar to those underlying the beneficial effect of no-touch saphenous vein grafts where the intact outer layer acts as a natural support. Additional actions of external supports have been advocated, including promotion of angiogenesis, increased production of vascular-protective factors, and protection of endothelial cells. Using no-touch harvesting, normal vascular architecture is maintained, tissue and cell damage is minimized, and factors beneficial for graft patency are preserved. In this review, the significance of external support of saphenous vein grafts in coronary artery bypass grafting is discussed.

Pedicled versus skeletonized internal thoracic artery grafts: a randomized trial.

OBJECTIVE: Concerns have been raised regarding whether skeletonization of the internal thoracic artery could damage the graft and thereby reduces its patency. The objective of this study was to compare patency rates at mid- and long-term follow-up between pedicled and skeletonized left internal thoracic artery grafts. METHODS: This randomized controlled trial included 109 patients undergoing coronary artery bypass surgery. The patients were assigned to receive either one pedicled or one skeletonized left internal thoracic artery graft to the left anterior descending artery. Follow-up was performed at 3 years with conventional angiography, and at 8 years with computed tomography angiography. Differences between patency rates were analyzed with Fisher's exact test and a generalized linear model. RESULTS: The patency rates for pedicled and skeletonized left internal thoracic artery grafts were 46/48 (95.8%) versus 47/52 (90.4%), p = 0.44 at 3 years, and 40/43 (93.0%) versus 37/41 (90.2%), p = 0.71 at 8 years, respectively. The difference in patency rates for pedicled and skeletonized grafts was 5.4% (95% confidence interval: -4.2-14.5) at 3 years and 2.8% (95% confidence interval: -9.9-14.1) at 8 years. All failed grafts, except for one with a localized stenosis, were anastomosed to native coronary arteries with a stenosis less than 70%. Three patients suffered sternal wound infections (two in the pedicled group, one in the skeletonized group). CONCLUSIONS: The skeletonization technique can be used without jeopardizing the patency of the left internal thoracic artery. The most important factor in graft failure was target artery stenosis below 70%.

The no-touch saphenous vein is an excellent alternative conduit to the radial artery 8 years after coronary artery bypass grafting: A randomized trial.

BACKGROUND: In 2004, a prospective randomized trial demonstrated that after 3 years, saphenous veins (SVs) harvested with a no touch (NT) technique had a greater patency than radial grafts for coronary bypass surgery. Here we report the 8-year follow-up data of this trial. METHODS: The trial included 108 patients undergoing coronary artery bypass grafting (CABG). Each patient was assigned to receive 1 NT SV and 1 radial artery (RA) graft to either the left or right coronary territory to complement the left internal thoracic artery (LITA). Sequential grafting was common, so overall graft patency as well as the patency of each anastomosis were assessed. RESULTS: Angiography was performed in 84 patients (78%) at mean of 97 months postoperatively. Graft patency were high and similar for both NT and RA: 86% for NT versus 79% for RA (P = .22). The patency of coronary anastomoses was significantly higher with the NT SV grafts (91% vs 81%; P = .046). The NT grafts also had excellent patency in coronary arteries with <90% stenosis (93% patency) and in coronary arteries of small diameter (87% patency) or with mild calcification (88% patency). Patency for the LITA was 92%. CONCLUSIONS: NT SV grafts have excellent patency similar to that of RA grafts after 8 years. In addition, NT SV grafts can be used in situations that are not ideal for RA grafts.

An attempt to chemically state the cross-talk between monomers of COX homodimers by double/hybrid inhibitors mofezolac-spacer-mofezolac and mofezolac-spacer-arachidonic acid.

Cardiovascular diseases (CVDs) account for over 17 million death globally each year, including arterial thrombosis. Platelets are key components in the pathogenesis of this disease and modulating their activity is an effective strategy to treat such thrombotic events. Cyclooxygenase-1 (COX-1) isoenzyme is involved in platelet activation and is the main target of non-steroidal anti-inflammatory drugs (NSAIDs) and new selective inhibitor research. Inhibitors of general formula mofezolac-spacer-mofezolac (mof-spacer-mof) and mofezolac-spacer-arachidonic acid (mof-spacer-AA) were projected to investigate the possible cross-talk between the two monomers (Eallo and Ecat) forming the COX-1 homodimer. Mofezolac was chosen as either one or two moieties of these molecules being the known most potent and selective COX-1 inhibitor and administrated to humans as Disopain™, then arachidonic acid (AA) was used to develop molecules bearing, in the same compound, in addition to the inhibitor moiety (mofezolac) also the natural COX substrate. Depending on the nature of the spacer, COX-1 and COX-2 activity was differently inhibited by mof-spacer-mof set with a preferential COX-1 inhibition. The highest COX-1 selectivity was exhibited by the compound in which the spacer was the benzidine [N,N'-(biphenyl-4,4'-di-yl)bis (2-[3,4-bis(4-methoxyphenyl)isoxazol-5-yl]acetamide) (15): COX-1 IC50 = 0.08 µM, COX-2 IC50 > 50 µM, Selectivity Index (SI) > 625]. In the case of mof-spacer-AA set, the COX inhibitory potency and also the isoform preference changed. (5Z, 8Z, 11Z, 14Z)-N-(4-{2-[3,4-Bis(4-methoxyphenyl)isoxazol-5-yl]acetamido}butyl)icosa-5,8,11,14-tetraenamide (19) and (5Z, 8Z, 11Z, 14Z)-N-(4'-{2-[3,4-bis(4-methoxyphenyl)isoxazol-5-yl]acetamido}-[1,1'-biphenyl]-4-yl)icosa-5,8,11,14-tetraenamide (21), in which the spacer is the 1,2-diaminobutane or benzidine, respectively, selectively inhibited the COX-2, whereas when the spacer is the 1,4-phenylendiamine [(5Z, 8Z, 11Z, 14Z)-N-(4-{2-[3,4-bis(4-methoxyphenyl)isoxazol-5-yl]acetamido}phenyl)icosa-5,8,11,14-tetraenamide) (20) the COX preference is COX-1 (COX-1 IC50 = 0.05 µM, COX-2 IC50 > 50 µM, with a COX-1 selectivity > 1000). Molecular modelling by using FLAP algorithm shows fundamental interactions of the novel compounds at the entry channel of COX and inside its catalytic cavity. The effect of these mof-spacer-mof and mof-spacer-AA in inhibiting in vitro free arachidonic acid-induced platelet aggregation was also determined. A positive profile of hemocompatibility in relation to their influence on the blood coagulation cascade and erythrocyte toxicity was observed. Cytotoxicity and genotoxicity safety were also found for these two novel sets of compounds.

Twenty-Five Years of No-Touch Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: Structural Observations and Impact on Graft Performance.

The saphenous vein is the most common conduit used in coronary artery bypass grafting (CABG) yet its failure rate is higher compared to arterial grafts. An improvement in saphenous vein graft performance is therefore a major priority in CABG. No-touch harvesting of the saphenous vein is one of the few interventions that has shown improved patency rates, comparable to that of the left internal thoracic artery. After more than two decades of no-touch research, this technique is now recognized as a Class IIa recommendation in the 2018 European Society of Cardiology and the European Association for Cardio-Thoracic Surgery guidelines on myocardial revascularization. In this review, we describe the structural alterations that occur in conventional versus no-touch saphenous vein grafts and how these changes affect graft patency. In addition, we discuss various strategies aimed at repairing saphenous vein grafts prepared at conventional CABG.

Saphenous vein grafts in contemporary coronary artery bypass graft surgery.

Myocardial ischaemia resulting from obstructive coronary artery disease is a major cause of morbidity and mortality in the developed world. Coronary artery bypass graft (CABG) surgery is the gold-standard treatment in many patients with complex multivessel coronary artery disease or left main disease. Despite substantial improvements in the outcome of patients undergoing CABG surgery in the past decade, graft patency remains the 'Achilles' heel' of this procedure. Whereas the use of the left internal mammary artery as a conduit is associated with the highest 10-year patency rate (>90%), saphenous vein grafts - the most commonly used conduit in CABG surgery - fail in 40-50% of treated patients by 10 years after surgery. Vein graft disease (VGD) and failure result from complex pathophysiological processes that can lead to complete occlusion of the graft, affecting long-term clinical outcomes. Optimal harvesting techniques, intraoperative preservation strategies and intraoperative patency control have important roles in the prevention of VGD. In addition, several studies published in the past decade have reported similar mid-term patency rates between vein grafts and arterial grafts when veins are used as a composite graft based on the internal mammary artery. In this Review, we present the latest evidence on the utilization of saphenous vein grafts for CABG surgery and provide an overview of the current practices for the prevention of VGD and vein graft failure.

No touch vein harvesting technique for CABG improves the long-term clinical outcome.

OBJECTIVES: To investigate the long-term clinical outcome, averaging 8.5 years, of two saphenous vein harvesting techniques for CABG; no touch (NT) versus conventional (C). DESIGN: In a randomized study, 49/52 in group NT and 44/52 in group conventional were evaluated for reangina, myocardial infarction, new revascularization, functional class, risk factors and medical treatment. The vein grafts and the native coronary arteries were correlated to the occurrence of reangina. RESULTS: There were significantly more patients free from angina and in NYHA class I (67.3 versus 43.2%; p =0.02) in group NT compared to group C. No cardiac death was found in group NT versus three in group C. There were trends towards fewer patients with cardiac death or myocardial infarction (3.8 vs. 13.4%; p =0.16), more patients free from angina (75.5 vs. 63.6%; p =0.26) and fewer patients with graft occlusion (24.3 vs. 43.2% (p =0.14) in group NT. CONCLUSIONS: The results of the NT-technique are encouraging with no cardiac deaths, significantly more asymptomatic patients and a trend towards impact on hard clinical endpoints compared to the conventional technique.

Surgical Aspects of No-Touch Saphenous Vein Graft Harvesting in CABG: Clinical and Angiographic Follow-Up at 3 Months.

With more than 800,000 coronary artery bypass grafting (CABG) operations annually worldwide and the saphenous vein being the most common conduit used, there is no question that improving saphenous vein graft patency is one of the most important tasks in CABG. This video describes the no-touch harvesting procedure of the saphenous vein on an 80-year old man with hypertension, hyperlipidemia and a previous myocardial infarction with percutaneous coronary intervention to the right coronary artery. He was complaining of exertional chest pain and was diagnosed with stable angina pectoris. The coronary angiography showed advanced three vessel disease with significant stenoses in the left anterior descending (LAD) artery, two marginal arteries (MAs) and the posterior descending artery (PDA), in addition to an occluded diagonal artery (DA). The patient received a triple sequential no-touch vein graft to the PDA and two MAs together with a double sequential no-touch vein graft to the DA and LAD. A vein graft was used to bypass the LAD due to the age of the patient and the low degree of stenosis in the LAD. The no-touch harvesting technique is described in detail in the film with complete narration. A follow-up of this patient was performed at three months both clinically and with a computed tomography angiography (CTA). No angina pectoris symptoms were reported by the patient and the wounds in the chest and lower limb were completely healed. The CTA showed patent no-touch saphenous vein grafts to all the distal anastomoses.