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Ann Thorac Surg 1996;62:1076-1082
© 1996 The Society of Thoracic Surgeons
Cardiac Surgery Department, Institute of Cardiology, and Cardioanesthesia Department, Università Cattolica del Sacro Cuore, Rome, Italy
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. From January 1993 to October 1995 we operated on 109 patients for myocardial revascularization employing the radial artery with two different surgical techniques: in 95 patients (group 1) it was "pretreated" by opening its fascia after a gentle hydrostatic dilation and then anastomosed to the aorta; in 14 patients (group 2) it was branched to another conduit. We had two operative deaths (1.82%).
Results. At a mean interval of 532.42 days 105 patients are still alive, 2 (1.86%) having died of abdominal tumors. Fifty-six patients (52.33%) underwent angiography at a mean interval of 334.42 days: the patency of the radial artery was 88.88% in group 1 and 62.50% in group 2. Indications and contraindications are discussed.
Conclusions. The radial artery is an easily manageable conduit whose early patency is very promising, although a longer follow-up is mandatory.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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The radial artery (RA) is a muscular artery lying under the antebrachial fascia between the brachioradialis muscle and the flexor carpi radialis. Its use as a graft for coronary revascularization was first proposed by Carpentier and associates [1] in 1973 but soon abandoned because of its strong tendency to spasm. Apparently this pitfall has recently been overcome by Acar and colleagues [2], who reported in 1992 improved early results due to the adjunct of calcium-channel blockers in the postoperative period. Since then a few groups have reported their experience with this conduit [3–5], the follow-up always taking place within 1 year and often exclusively noninvasive. In January 1993 we started a prospective study assessing the use of the RA in coronary artery bypass grafting (CABG). We operated on 109 patients during a period of 33 months. The aim of the study was to evaluate angiographically the short-term patency of the RA and to describe its wall properties [6]. Angiography was performed in more than 50% of the patients at a mean follow-up of 1 year, and the vasoconstrictor profile of the RA was defined.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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.
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Radial Artery Harvesting and Preparation
The RA was taken down contemporaneously to any other surgical procedure, such as opening and cannulation of the patient or harvesting of any other conduit but the right IMA (RIMA). The nondominant arm was positioned horizontal and perpendicular to the patient's body. The incision was then made longitudinally from the wrist, somewhat proximally just lateral to the tendon of the flexor carpi radialis, toward the elbow, following the medial border of the brachioradialis muscle. The RA was then followed in its course, opening the thin fascia bridging between the brachioradialis muscle on one side and the flexor carpi radialis and pronator teres on the opposite. It is advisable to end the cutaneous incision a few centimeters before the cubital fossa to avoid any postoperative limitation of the elbow. An incision into the pedicle's fascia was made distally and gradually extended to the elbow to expose and free the RA. Major collateral branches were clipped (Pilling Division, Fort Delaware, WA) and divided. After the patient had been fully heparinized the proximal and distal vascular stumps were divided and the forearm was closed. The mean length and caliber of the RA were 21 cm and 1.6 mm, respectively. From this point the technique was different according whether a pretreated conduit (group 1) or a composite [9] one (group 2) was to be used. In the second case, the proximal anastomosis to the main conduit (IMA) was performed before the extracorporeal circulation was started. If a pretreated conduit was chosen the proximal end was cannulated, heparinized blood [10] was added to the saline solution, and papaverine was then gently injected at a pressure of less than 80 mm Hg [11]. Additional bleeding points were located and clipped at this time. With the RA maintained dilated, the subsequent opening of the pedicle's fascia and outer adventitial lining was performed easily. The RA was used in either direction, the only criterion being to obtain the best RA–coronary caliber match. All pretreated grafts were anastomosed to the aorta except one, which was branched to an SVG because of too generous proximal trimming. The composite grafts were not previously injected and were always anastomosed to the left IMA (LIMA).
Surgical Technique
The operations were performed at the Catholic University of Rome by different surgeons over a period of 34 months, with only minor operative changes depending on the surgeon. With regard to the myocardial protection technique, there was an important change in our policy in November 1993, when warm blood cardioplegia, anterograde/retrograde, at normothermia (37°C) took over from cold crystalloid cardioplegia in hypothermia (28°C). The first series of operations on 33 patients (30.27%) were performed with cold crystalloid cardioplegia, whereas the second series of 73 patients (66.97%) used warm blood cardioplegia. In 2 patients (1.83%) with relatively high serum creatinine levels and a favorable coronary anatomy the intervention was performed without extracorporeal circulation. In 1 patient (0.91%) aortic clamping was avoided because of a "porcelain" aorta and the intervention was carried out with a fibrillating heart. One patient (0.91%) required an associated surgical procedure at the time of operation because of an accessory atrioventricular pathway in a Wolff-Parkinson-White syndrome. A total of 335 distal anastomoses (DAs) were performed, with 3.07 ± 0.8 anastomoses per patient (range, 1 to 5). The mean aortic clamping time was 58.27 ± 19.7 minutes (range, 24 to 112 minutes). In 13 patients (11.9%) we used the composite technique (group 2), in 95 patients (group 1) (87.1%) the pretreatment technique was preferred, and in 1 patient (0.9%) a "mixed technique" had to be adopted because of too generous trimming of the RA's proximal stump. A total of 110 RA conduits were used in 109 patients: 1 RA was divided into two different grafts in 1 patient. Bilateral RAs were never used. The right RA was used only in 2 left-handed patients (1.83%). A total of 110 proximal RA anastomoses were performed: to the aorta in 93 grafts placed in 92 patients (84.54%), to the LIMA (1 free and 12 in situ) in 13 patients (11.81%), to the innominate artery in 3 patients (2.72%), and to an SVG in 1 patient (0.90%). With the RA a total of 121 DAs were performed (1.1 per patient). In 11 patients (10.09%) the RA was used as a sequential graft. In 18 patients (16.51%) it was anastomosed to an infarcted area. Complete revascularization was achieved in 90 patients (82.56%), whereas complete arterial revascularization was possible in only 48 patients (44.03%). The territorial distribution of the DAs is reported in Table 2.
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Follow-up
Most of the patients have been followed up at regular intervals (1 month, 3 months, and then every 6 months) in our institution. In addition to a clinical examination, a routine electrocardiogram, and a chest roentgenogram, the following examinations were performed only when indicated: 24-hour dynamic electrocardiogram, exercise electrocardiogram, thallium myocardial scintigraphy, and stress echocardiogram. A minority of the patients were seen only by the referring doctor, who provided us with a written report. The first 62 patients discharged from the hospital were chronologically asked to undergo a graft angiography 1 year after the operation. Written, informed consent was obtained from each patient before any investigation.
Vasoconstrictor Test
We compared the in vivo response of the RA, used as a graft, and of the pedicled LIMA to serotonin. This vasoactive substance was selectively infused into the LIMA and into the RA at increasing concentrations (10-6 and 10-5 mol/L) at a rate of 3 mL/min for 3 minutes. Finally, 2 mg of isosorbide dinitrate was injected into the RA. The angiograms obtained at baseline and after the consecutive infusions of serotonin and isosorbide dinitrate were analyzed using quantitative computerized angiography (Medis, Neuen, the Netherlands). The system had been validated and found to have a lower detection limit of 0.6 mm; thus vessels with an inferior value were considered to be 0.6 mm in diameter.
Magnetic Resonance Imaging
Examinations were performed with a GE Vectra 0.5 T machine. Axial scans were obtained from the aortic arch to a midventricular plane. Electrocardiogram-gated spin-echo was the technique of choice (matrix, 256 x 192; slice thickness, 5 mm). With the spin-echo sequence, the graft was considered patent if the normal intraluminal signal void was present in two or more anatomic levels; if the signal void was either seen only at one level or absent, the graft was considered to be occluded [12, 13].
Statistical Analysis
All results were expressed as means ± standard deviation, and differences were considered significant when the p value was less than 0.05. Risk factors, patency, and other categoric data were examined with contingency tables and 
2 or Fisher's exact test as appropriate. Independent predictors of graft patency were estimated by multiple logistic regression. For the comparison between two populations, the statistical analyses were made by the unpaired Student's t test for continuous variables and by 2 for dichotomous variables.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Follow-up
There were two late deaths (1.86%) 420 and 527 days after the operation caused by hepatic and intestinal tumors respectively, in otherwise "cardiac symptom-free" patients. At a mean interval of 532.42 ± 275.25 days (range, 47 to 1,024 days), 105 patients (98.13%) are still attending the follow-up program. The actuarial survival rate at 3 years is 85% for the whole population. Recurrent angina is present in 7 patients (6.66%). Among these, 2 patients (1.90%) required rehospitalization. The first patient underwent angiography 352 days after the operation: the composite graft was occluded. Subsequently he underwent two percutaneous transluminary coronary angioplasties on the distal left anterior descending artery with an apparently good result and relief of symptoms. Three months after this procedure the patient has been reoperated on for recurrent angina; today he is asymptomatic. The second patient underwent angiography at 240 days because of recurrent refractory angina: the GEA to the right posterior descending coronary artery showed an irreversible spasm, the LIMA to the LAD was occluded, and the RA to the first diagonal artery was patent. The patient was then reoperated on through a left lateral thoracotomy under hypothermia with a fibrillating heart. The total rate of reoperation is 1.9%. Residual ischemia, as documented by a reduced coronary reserve, was present in 4 patients: 3 patients complained of angina and 1 patient (0.95%) had silent ischemia. In 60 patients a dynamic Doppler test of the upper limb was repeated 1 year after operation and it was possible to detect adequate restoration of the preoperative blood flow to the hand in all of them. One patient (1.6%) had a paler hand in the absence of any symptoms. Three patients (2.85%) had subtle complaints of parahypesthesia of the forearm or of the first three fingers, whereas 2 patients (1.9%) complained of tension at the elbow-bend when overextending the forearm, probably resulting from the skin incision being too long.
Patency
To validate the surgical technique 18 patients (15.7%), chosen randomly from those operated on during the first year, were evaluated angiographically early after the operation (<6 months) at a mean interval of 24.3 days. There were 10 pretreated grafts and 7 composite grafts. Every other conduit was evaluated during the same procedure: 14 LIMA, 3 RIMA, 1 GEA, and 14 SVG were all patent. The overall RA conduit patency was 100%, but only 58.82% were judged to be angiographically satisfactory. Particularly in 2/7 group 2 patients (28.57%) the RA appeared to be diffusely narrowed, due to either a proximal or a DA stenosis, and in 1/11 group 1 patients (9.09%) the tract interposed between the latero-lateral and termino-lateral anastomoses of a sequential graft appeared to be narrowed by a DA stenosis. We proposed to repeat coronary angiography at 1 year to all 18 patients, but 2 group 1 patients and 1 group 2 patient refused. Of these patients, 1 in each group was then submitted to magnetic resonance imaging evaluation, which confirmed the previous normal aspect of the grafts. Finally, 14 patients (9 from group 1 and 5 from group 2) underwent a second study at a mean interval of 348.05 days from the first: the LIMAs, RIMAs, SVGs, and the GEA showed no change apart from 1 RIMA, which was occluded. The two composite grafts which already presented important lesions, were occluded. In contrast, the severely diseased pretreated grafts remained stable. Finally, 5 patients with marked irregularities or a small caliber showed an improvement in caliber and a considerably smoother inner lining.
One-Year Control
Fifty-six patients (52.33%) were consecutively restudied angiographically at a mean interval of 334.42 ± 83.25 days (range, 219 to 806 days). Among those patients who were asked to participate in the invasive follow-up, 3 patients (2.83%) were excluded: the first suffered from chronic renal failure; the second had sustained a monolateral amaurosis at the time of the preoperative study, and the third had experienced a significant deterioration of the preexisting lower limb arteriopathy. At the time of the study 1 patient (0.93%) had an important dye reaction that prevented the study being completed. Four patients (3.73%) refused to participate: 1 patient was then submitted to magnetic resonance imaging evaluation, as was the case for 2 patients among the 3 who already had an angiography before discharge. The results obtained with each surgical technique will be analyzed separately: group 1 and 2 populations were matched for demographic data, preoperative risk factors, and the mean follow-up interval. We applied a graft morphologic description (Table 3) to obtain, beyond the patency, a more detailed analysis of the graft, considering the concomitant IMA to be the reference.
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GROUP 2.
Seven patients (12.5%) had a composite RA graft: because they were all single grafts, 7 conduits and 7 anastomoses were analyzed. A normal aspect was found in 80% of the patent grafts. In none of these cases could a string sign be observed. Of the distal anastomoses, 62.5% were patent.
The conduit patency may shift from 87.75% to 88.23% and from 62.5% to 66.66% in groups 1 and 2, respectively, when taking into consideration the magnetic results.
Other Conduits
All data regarding IMAs, SVGs and GEAs are shown in Table 4. With regard to their aspect, it was considered normal in 86.95% of the IMAs, in 50% of the RIMAs, in 60% of the GEAs, and in 68.57% of the SVGs. The LIMA showed a significantly higher patency rate than the SVG (p = 0.03). The patency rate of the RA, considered as a whole, was not significantly different from that of the LIMA (p = 0.11) or of the SVG (p = 0.67). Comparable results were obtained when considering group 1 alone. On the contrary the patency rate of group 2 was comparable with that of the SVG (p = 0.36) but significantly less than the patency rate of the LIMA (p = 0.014). The patency rate of the RA was not significantly different when evaluated according to the territorial distribution of the DAs. The risk factors considered in Table 1
and the postoperative symptoms or the calcium-channel blockers therapy were not found to be statistically significant predictors of short-term patency. According to the date of operation, there is an evident increase, although not statistically significant (p = 0.06), of the patency rate in those patients operated on after the first year of experience: from 70.4% (32 patients during the first year) to 96.2% (24 patients after the first year).
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). Similar behavior was shown by both groups. In each case the constriction could be reversed by selective infusion of 2 mg isosorbide dinitrate. None of the patients complained of angina though in some deviation of ST segment was noted. It was apparent that 240 mg/day of oral diltiazem offers no protection against such an important stimulus.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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When the first series of angiographic controls showed satisfactory results, we broadened our indications: the RA was not proposed as a substitute for other conduits but in addition to those conduits. However, for ethical reasons, we regularly chose to revascularize (whenever possible) the most important coronary artery with the LIMA. Only in a minority of patients did the RA prove to be contraindicated. A small number of patients who were eligible for CABG with the RA were excluded as a positive dynamic Doppler test showed inadequate ulnar compensation or Doppler echocardiography revealed the presence of either atherosclerosis or anatomic lesions of the upper limb arteries, otherwise undetected by Allen test or routine physical examination. Indeed, in our series we did not encounter any major problem related to the RA harvesting.
From a technical point of view the RA has several advantages over other conduits: it can be dissected contemporaneously with other surgical procedures, its length allows grafting of all target vessels, its diameter matches with the diameter of most coronary arteries, and its resistant wall is easy to handle. Bilateral RAs have not been used because other arterial conduits have been available.
The longer-than-normal clamping time in our series can be explained by the policy we have adopted of performing the proximal anastomoses under aortic clamp to avoid multiple maneuvers on heavily calcified aortas and to reperfuse retrogradely with cardioplegia the "still ischemic" myocardial areas. In patients presenting with heavily calcified aortas we adopted three different techniques: fibrillating heart, proximal anastomosis to the innominate artery, and composite graft. After the first disappointing results we abandoned the composite technique; in fact, the RA is usually long enough to reach any coronary target even when anastomosed to the innominate artery. The observation that the RA reacts more than the LIMA in response to serotonin regardless of calcium-channel blocker therapy encouraged us to give more attention to the RA harvesting procedure. Those RA grafts affected by some degree of disease appear to be more reactive, although this is not statistically significant, than normal-looking grafts. This might explain the hypothesis of a protective role of the endothelial lining even 1 year after operation. It is important to underline that in those patients who presented spontaneously with a string sign at the angiographic control before discharge, a technical anastomotic defect was constantly noted. Furthermore, few grafts presenting with an abnormal aspect at the first angiography showed a normal aspect at the following. For this reason the clinical relevance of the morphologic and the histological alterations, as of the higher provoked reactivity of the RA, needs to be clarified [19]. Finally, the encouraging patency rate shown by the pretreated group (88.88%), higher than the reported patency for other free grafts [20] and considerably increased (96.2%) after the learning phase, may allow us to identify the RA as a satisfactory complementary graft to achieve complete arterial revascularization together with the LIMA and the GEA.
In conclusion, in our opinion it is essential to perform a complete physical and instrumental vascular examination of the upper limb prior to patient selection, and great care should be paid during RA harvesting. The radial artery is an easily manageable conduit, and spasm can be overcome by respecting the following: "no-touch" harvesting technique, meticulous opening of the pedicle's fascia, warm hematic cardioplegia in normothermia, continuous calcium-channel blocker therapy, and coronary target caliber greater than 1.5 mm with a good "run-off." However, a better understanding of its behavior and a longer follow-up are required to further broaden our indications.
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Acknowledgments |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Manasse, Via Achille Loria 23, 00191 Roma, Italy.
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentAcknowledgmentsReferences |
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A. C. Anyanwu, I. Saeed, M. Bustami, C. Ilsley, M. H. Yacoub, and M. Amrani Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery? Ann. Thorac. Surg., February 1, 2001; 71(2): 555 - 559. [Abstract] [Full Text] [PDF]
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G. Cohen, M. G. Tamariz, J. Y. Sever, N. Liaghati, V. Guru, G. T. Christakis, G. Bhatnagar, C. Cutrara, L. Abouzahr, B. S. Goldman, et al. The radial artery versus the saphenous vein graft in contemporary CABG: a case-matched study Ann. Thorac. Surg., January 1, 2001; 71(1): 180 - 186. [Abstract] [Full Text] [PDF]
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E. E. Weinschelbaum, A. Macchia, V. M. Caramutti, H. A. Machain, H. A. Raffaelli, M. R. Favaloro, R. R. Favaloro, E. A. Dulbecco, J. A. Abud, M. D. Laurentiis, et al. Myocardial revascularization with radial and mammary arteries: initial and mid-term results Ann. Thorac. Surg., October 1, 2000; 70(4): 1378 - 1383. [Abstract] [Full Text] [PDF]
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O. M. Shapira, J. D. Alkon, D. S.F. Macron, J. F. Keaney Jr, J. A. Vita, G. S. Aldea, and R. J. Shemin Nitroglycerin is preferable to diltiazem for prevention of coronary bypass conduit spasm Ann. Thorac. Surg., September 1, 2000; 70(3): 883 - 888. [Abstract] [Full Text] [PDF]
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M. Gaudino, F. Glieca, C. Trani, A. Lupi, M. A. Mazzari, G. Schiavoni, and G. Possati Midterm endothelial function and remodeling of radial artery grafts anastomosed to the aorta J. Thorac. Cardiovasc. Surg., August 1, 2000; 120(2): 298 - 301. [Abstract] [Full Text] [PDF]
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A. Parolari, P. Rubini, F. Alamanni, A. Cannata, W. Xin, T. Gherli, G. Polvani, T. Toscano, M. Zanobini, and P. Biglioli The radial artery: which place in coronary operation? Ann. Thorac. Surg., April 1, 2000; 69(4): 1288 - 1294. [Abstract] [Full Text] [PDF]
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J. R. Sadaba, K. Mathew, C. M. Munsch, and D. J. Beech Vasorelaxant properties of nicorandil on human radial artery Eur. J. Cardiothorac. Surg., March 1, 2000; 17(3): 319 - 324. [Abstract] [Full Text] [PDF]
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T. Sato, T. Isomura, H. Suma, T. Horii, and N. Kikuchi Coronary artery bypass grafting with gastroepiploic artery composite graft Ann. Thorac. Surg., January 1, 2000; 69(1): 65 - 69. [Abstract] [Full Text] [PDF]
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P. Ruengsakulrach, R. Sinclair, M. Komeda, J. Raman, I. Gordon, and B. Buxton Comparative Histopathology of Radial Artery Versus Internal Thoracic Artery and Risk Factors for Development of Intimal Hyperplasia and Atherosclerosis Circulation, November 9, 1999; 100 (2009): II-139 - II-144. [Abstract] [Full Text] [PDF]
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O. M. Shapira, A. Xu, J. A. Vita, G. S. Aldea, N. Shah, R. J. Shemin, and J. F. Keaney Jr NITROGLYCERIN IS SUPERIOR TO DILTIAZEM AS A CORONARY BYPASS CONDUIT VASODILATOR J. Thorac. Cardiovasc. Surg., May 1, 1999; 117(5): 906 - 911. [Abstract] [Full Text] [PDF]
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D. G. Cable, J. A. Caccitolo, E. A. Pfeifer, R. C. Daly, J. A. Dearani, C. J. Mullany, T. O'Brien, T. A. Orszulak, and H. V. Schaff Endothelial regulation of vascular contraction in radial and internal mammary arteries Ann. Thorac. Surg., April 1, 1999; 67(4): 1083 - 1090. [Abstract] [Full Text] [PDF]
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 C.A Hamilton, R Williams, V Pathi, G Berg, K McArthur, A.R McPhaden, J.L Reid, and A.F Dominiczak Pharmacological characterisation of endothelium-dependent relaxation in human radial artery: comparison with internal thoracic artery Cardiovasc Res, April 1, 1999; 42(1): 214 - 223. [Abstract] [Full Text] [PDF]
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T. Tashiro, K. Nakamura, A. Iwakuma, R. Zaitu, H. Iwahashi, A. Murai, and M. Kimura Inverted T graft: novel technique using composite radial and internal thoracic arteries Ann. Thorac. Surg., March 1, 1999; 67(3): 629 - 631. [Abstract] [Full Text] [PDF]
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D. G. Cable, C. J. Mullany, and H. V. Schaff The Allen test Ann. Thorac. Surg., March 1, 1999; 67(3): 876 - 877. [Abstract] [Full Text] [PDF]
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F. D. Loop Coronary artery surgery: the end of the beginning Eur. J. Cardiothorac. Surg., December 1, 1998; 14(6): 554 - 571. [Abstract] [Full Text] [PDF]
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C. Acar, A. Ramsheyi, J.-Y. Pagny, V. Jebara, P. Barrier, J.-N. Fabiani, A. Deloche, J.-L. Guermonprez, and A. Carpentier THE RADIAL ARTERY FOR CORONARY ARTERY BYPASS GRAFTING: CLINICAL AND ANGIOGRAPHIC RESULTS AT FIVE YEARS J. Thorac. Cardiovasc. Surg., December 1, 1998; 116(6): 981 - 989. [Abstract] [Full Text] [PDF]
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A. H. Chester, A. J. Marchbank, J. A.A. Borland, M. H. Yacoub, and D. P. Taggart Comparison of the morphologic and vascular reactivity of the proximal and distal radial artery Ann. Thorac. Surg., December 1, 1998; 66(6): 1972 - 1976. [Abstract] [Full Text] [PDF]
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G. Possati, M. Gaudino, F. Alessandrini, N. Luciani, F. Glieca, C. Trani, C. Cellini, C. Canosa, and G. D. Sciascio MIDTERM CLINICAL AND ANGIOGRAPHIC RESULTS OF RADIAL ARTERY GRAFTS USED FOR MYOCARDIAL REVASCULARIZATION J. Thorac. Cardiovasc. Surg., December 1, 1998; 116(6): 1015 - 1021. [Abstract] [Full Text] [PDF]
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G. A. Dumanian, K. Segalman, L. A. Mispireta, J. A. Walsh, M. F. Hendrickson, and E.F. S. Wilgis Radial Artery Use in Bypass Grafting Does Not Change Digital Blood Flow or Hand Function Ann. Thorac. Surg., May 1, 1998; 65(5): 1284 - 1287. [Abstract] [Full Text] [PDF]
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B. F. Buxton, A. T. Chan, A. S. Dixit, N. Eizenberg, R. D. Marshall, and J. S. Raman Ulnar Artery as a Coronary Bypass Graft Ann. Thorac. Surg., April 1, 1998; 65(4): 1020 - 1024. [Abstract] [Full Text] [PDF]
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J. G. Motwani and E. J. Topol Aortocoronary Saphenous Vein Graft Disease : Pathogenesis, Predisposition, and Prevention Circulation, March 10, 1998; 97(9): 916 - 931. [Abstract] [Full Text] [PDF]
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T. O. Cheng Radial Artery in Coronary Operations Ann. Thorac. Surg., April 1, 1997; 63(4): 1209 - 1209. [Full Text]
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