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Ann Thorac Surg 1998;66:714-720
© 1998 The Society of Thoracic Surgeons
a Departments of Cardiac Surgery, Royal Melbourne and Epwoth Hospitals, University of Melbourne, Victoria, Australia
Address reprint requests to Dr Tatoulis, Suite 28, Private Medical Centre, Royal Melbourne Hospital, Victoria, Australia 3050
e-mail: (kathie.vezzoso{at}whcn.org.au)
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
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Abstract |
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Methods. As part of their coronary reconstruction, 261 patients had 522 bilateral RA grafts from March 1995 to June 1997. Mean age was 61.1 years. There were 70 (27%) patients with non–insulin-dependent diabetes and 13 (5%) with insulin-dependent diabetes. Unstable angina was seen in 54 (21%) patients. Left ventricular ejection fraction less than 50% was noted in 74 (28.4%) patients. Coronary revascularization was completed with additional single internal thoracic artery in 229 patients (88%), bilateral internal thoracic artery in 25 patients (9.6%), and vein grafts in 13 patients (5%). Intraluminal 1% papaverine in blood was used. There were 3.6 ± 0.7 distal anastomoses per patient, with a total of 939, 921 (98%) with arterial conduits and 18 with vein grafts. Five hundred ninety-four (63%) of the anastomoses were with RAs. Of the 522 RA grafts 72 (13.8%) were used sequentially. The RA was most frequently placed to the circumflex marginals (261 patients, 100%) and posterior descending (169 patients, 65%). Proximal RA anastomosis was directly to the aorta in 472 patients, the internal thoracic artery in 42, or another RA in 8. All anastomoses were constructed during a single cross-clamp period (mean, 74.2 ± 26.6 minutes).
Results. Operative mortality was 2 patients (0.8%). Complications included stroke in 2 patients (0.8%), deep internal infection in 2 (0.8%), reoperation for hemorrhage in 1 (0.4%), and myocardial infarction in 2 (0.8%). Mean peak creatine kinase-MB was 13.2 ± 11.6 IU/L. There were no forearm infections or hand ischemia, but there were 4 (1.6%) hematomas, 1 requiring drainage. Angiography was done on 16 patients with RA grafts, a mean of 4.2 months postoperatively. Twenty of 22 distal anastomoses were patent (91%), and there was 1 occlusion and 1 string sign.
Conclusions. Bilateral RA to coronary grafting extends the scope of arterial myocardial revascularization, and is safe. Late angiographic results are required.
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Introduction |
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Reports of long-term patency in radial artery (RA) grafts in coronary surgery (those RA grafts patent in the long-term were smooth and free of atheroma) have reignited interest in the use of the RA as a graft to the coronary circulation on the premise that if technical factors and spasm could be overcome, then an arterial graft would perform better in the long term than a venous graft [4].
The ease of procurement of excellent lengths of RA [5] and its potential ease of use make it an attractive alternative conduit to either vein grafts or non-ITA arterial grafts (inferior epigastric and gastroepiploic arteries). Furthermore, by use of both RAs we would hope to achieve a very high proportion of total arterial revascularization of the coronary circulation.
We report our early experience with bilateral RA to coronary grafting to document the perioperative results and early patency and to establish a baseline for subsequent comparison with other second- and third-order grafts such as non-ITA arterial and vein grafts.
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Material and methods |
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Patients reported in the study had coronary revascularization procedures only—either primary or re-do. Those having valve or other cardiac procedures in conjunction with myocardial revascularization were not included to achieve a homogeneous study population and simplify the interpretation of the results.
Coronary revascularization was completed with additional single ITA grafts in 229 patients (88%), bilateral ITA grafts in 25 patients (9.6%), and vein grafts in 13 patients (5%).
The patient demographics are summarized in Table 1. Indications for bilateral RA use included coronary reoperations, previously stripped varicose veins, previously used veins for vascular surgery, peripheral vascular disease, legs deemed high risk for infection (diabetes, obesity, ulcers), and where bilateral ITA grafts were inappropriate (obesity, insulin-dependent diabetes, severe emphysema). Over the same time frame, 1,237 patients had primary or re-do coronary revascularization using only one RA graft with additional other ITA and vein grafts to effect total revascularization. Generally the bilateral RA group were more likely to have diabetes, 83 (32%) versus 301 (24.3%) (p < 0.03) and more likely to be having a reoperation 32 (12%) versus 40 (3.3%) (p < 0.001). The other parameters were not statistically different.
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Modified Allen’s test
This was performed routinely. Both radial and ulnar arteries were compressed for 30 seconds just above the wrist, during which time the hand was rendered ischemic by clenching and slow relaxation, repeated three times. The ulnar artery was released and a hyperemic response in the hand extending to the thenar eminence and thumb within 10 seconds indicated satisfactory ulnar collaterals and nondominance of the RA, and that it could be safely used without potential hand ischemia.
Preparation and draping
The arms are marked for RA harvest preoperatively to prevent inadvertent cannulation of RA or forearm vein by the anesthetist.
The patient is prepared and draped as for coronary artery bypass grafting, including the legs. The arms are abducted to 70 degrees from the torso, on arm boards, and are prepared and draped at the same time. Both the RAs are harvested simultaneously if possible; if not, the right RA is harvested first, with the arm then placed beside the torso. Sternotomy and left ITA dissection can proceed while the left RA is harvested. The surgeon is located on the shoulder side of the forearm in each instance. Usually the RAs are harvested first as a separate procedure. If enough personnel are available they may be harvested simultaneously with the opening of the sternum and the harvesting of the left ITA.
Anesthetic preparation
The arterial line is previously placed in the right femoral artery. The Swan-Ganz catheter is placed by means of the right internal jugular vein.
Additional venous catheters are placed in the cephalic vein of the upper arm or in the external jugular vein avoiding the forearm operative field. An oximeter is placed on the ear lobe.
Harvesting of the radial artery
A technique similar to that described by Reyes and colleagues [7] was used, with emphasis on minimal touch and minimal diathermy.
Toward the wrist the branches occur with increasing frequency. If the desired length of RA can be estimated, one can reduce the degree of distal harvesting, leaving these branches intact and preserving the anastomotic connections around the wrist.
Distally the RA is doubly clipped and divided, and 5 mL of 1% papaverine in heparinized blood is placed intraluminally using a bulb-ended vascular 1-mm cannula. The distal end of the RA is then clipped allowing it to pulsate against its occluded end, while the more proximal branches are secured. The RA stump at the wrist always has excellent pulsation.
The proximal end of the dissection is defined by a plexus of veins around the RA, near its origin. A small recurrent RA branch often is located here and passes laterally. We do not specifically try to identify the brachial artery bifurcation. The veins are divided between small metal clips, then the RA is divided after application of two medium metal clips with at least a 3-mm cuff of artery beyond. The artery is examined, and the distal and proximal ends are prepared and then stored in a solution of heparinized arterial blood with 1% papaverine. If sequential anastomoses are to be performed, the former superficial surface of the RA is most likely used, as there are usually no branches and little perivascular fat on this side.
Hemostasis is checked, the subcutaneous tissues are closed with a continuous absorbable suture, the skin is closed with continuous absorbable monofilament subcuticular suture, dressings are placed, and a crepe bandage with firm pressure is applied. The arm is then placed by the side of the torso using a small sterile drape, and then a large new side drape is used to cover the arm.
Operative procedure
After RA harvesting (occasionally simultaneously) sternotomy is performed and the left ITA (and if appropriate the right ITA) is harvested and prepared [2].
Cardiopulmonary bypass is conducted at 33° to 34°C. Myocardial protection is by initial antegrade and retrograde blood cardioplegia at 20° to 25°C. Septal myocardial temperature is maintained at 25°C. Further retrograde blood cardioplegic solution is given after each anastomosis. All distal and proximal anastomoses are constructed during a single period of cross-clamping. The heart is vented through the aortic root. Vein grafts were usually placed first, next the RA grafts, and finally the ITA grafts.
When sequential grafting was performed the most proximal side-to-side anastomosis was constructed first and made parallel if possible, though angled or diamond-shaped anastomoses were constructed if that was appropriate for the lie of the RA graft. The RA at the site of the sequential anastomosis is usually 2.5 to 3 mm in diameter and if a diamond-shaped anastomosis was being constructed, care was taken to have a short arteriotomy in the RA so as not to distort the native coronary. Tacking sutures of 6-0 polypropylene were placed between the RA pedicle and epicardium, above and below each anastomosis to maintain orientation. All distal anastomoses were constructed with continuous 7-0 polypropylene sutures on a small (6 mm) needle. The proximal anastomoses were generally created to the ascending thoracic aorta with a continuous 7-0 polypropylene suture using a large needle (9 mm). When the aorta was thick or tough (as in redos), 6-0 polypropylene suture with a 12-mm needle was used. The ascending thoracic aorta was the commonest site for proximal RA anastomosis, 472 times; the proximal RA anastomosis was constructed to the left ITA in 42, and a Y graft, end-to-side anastomosis constructed between two portions of RA on eight occasions.
When the RA was anastomosed to the left ITA as the source of the inflow, this was usually performed before cardiopulmonary bypass. The indication for this maneuver was the need to reach inferiorly placed circumflex marginal branches, particularly in a large heart, or when the ascending thoracic aorta was atheromatous. The proximal RA to ITA anastomosis was made on the pleural side of the ITA just below the level of the second intercostal branches.
Intravenous nitroglycerin infusions were commenced immediately after the release of the cross-clamp. The thymus and pericardium were routinely closed, and drains were placed into each pleural cavity that had been opened and behind the sternum. The pleural cavities were reconstituted by picking up the pleural edges with the sternal wire sutures.
Patterns of grafting
Nine hundred thirty-nine distal anastomoses were constructed (Table 2). In general the left ITA was used to graft the left anterior descending coronary artery. The free right ITA and RA grafts were used to the coronary arteries of next importance according to the area of myocardium supplied. Finally any vein grafts were used (13 patients).
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The 522 RAs were used to construct 594 (63.2%) of all anastomoses. Seventy-two (13.8%) of the 522 RA grafts were used sequentially. The ITAs were used to construct 327 (34.9%) of all anastomoses. Hence 921 (98%) of all anastomoses were constructed with arterial grafts. The distribution of RAs to the different coronary arteries is illustrated in Figure 1. The most common vessel grafted with the RA was the circumflex marginal artery.
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Postoperative management
Postbypass systolic pressure was kept at more than 110 mm Hg, mean arterial pressure more than 80 mm Hg, and cardiac index greater than 2.5 L · min-1 · m-2. Systemic vascular resistance was maintained between 800 and 1,000 units. Nitroglycerin infusion (0.5 to 1 µg · kg-1 · min-1) or milrinone infusion (0.2 µg · kg-1 · min-1) were run routinely for 24 hours postoperatively to prevent coronary artery and coronary arterial graft spasm (Intravenous diltiazem is not available in Australia). Amlodipine (5 to 10 mg orally), a once-daily calcium-channel blocker, was commenced on the first postoperative day and maintained for 6 months. Aspirin (100 mg orally) was given daily indefinitely.
Follow-up and analysis
Clinical follow-up was by office visit or by attendance at a specially designated "radial artery clinic," where the patient’s forearm wound, digital oximetry, plethysmography, and sensory and motor function of the hand were assessed. Postoperative coronary graft angiography was performed in response to possible symptoms or cardiac events. Graft data were collected directly from the cardiologist and angiography laboratory, and each angiogram of the RA was independently reviewed by the cardiologist, radiologist, and surgeon. All data were placed on a computer database program and analyzed using the Statistical Package for Social Sciences (SPSS-PC+). Values were expressed as mean ± standard deviation. The 
2 test was used to determine the significance for discrete variables. Values of p less than 0.05 were considered significant.
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Results |
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Perioperative morbidity
Two patients (0.8%) had a stroke, defined as any clinical neurologic abnormality producing a motor, speech, or sensory deficit. Two patients (0.8%) had a deep sternal wound infection that required treatment with intravenous antibiotics and reoperation to debride and rewire the sternum. No patient required a muscle flap transfer.
Only 1 patient (0.4%) required reoperation for postoperative hemorrhage. There was no instance of postoperative bleeding from RA branches. Two patients (0.8%) experienced a perioperative myocardial infarction, indicated by new Q waves or creatine kinase-MB (CKMB) level twice the upper limit of normal (normal value in our laboratory is 0 to 25 IU/L). Plasma CKMB levels were taken routinely at 24 hours on all patients. The mean peak CKMB was 13.2 ± 11.6 IU/L (range, 4 to 75 IU/L).
Follow-up
The follow-up period was short, for a mean of 5.5 ± 4.2 months (range, 1 to 23 months). The follow-up was 99% complete, with only 2 patients lost to follow-up. There were two deaths in the follow-up period. The actuarial survival of patients at 1 year was 97.1% ± 0.8%.
Postoperative angiography
Sixteen patients with RA grafts underwent coronary and graft angiography, including the RA graft(s) at a mean of 4.2 ± 3.1 months postoperatively (range, 1 to 16 months). One RA graft was completely occluded, and one displayed a string sign. Both were grafted to large coronary arteries in which the stenosis was less than 60%.
All other RA grafts were widely patent and free of any wall disease, and free of anastomotic stenosis. Twenty of 22 (91%) distal RA to coronary artery anastomoses were patent. By comparison all 16 left ITA grafts and one free right ITA graft, studied at the same time were widely patent.
Hand and forearm complications
There were no deep forearm infections. One (insulin-dependent) diabetic patient had mild erythema along the skin wound in both forearms, which settled without antibiotics. There were no episodes of hand ischemia. Pulsatile wave outputs on plethysmography on the index finger were obtained on all patients in the intensive care unit. There were four (1.6% of patients) hematomas; three were settled with firm dressings and forearm elevation, one required drainage of 40 mL of blood and clots.
At the radial artery clinic, functional assessment was made on 192 patients, at a mean of 3 months postoperatively. Nineteen (10%) had objective sensory loss (pinprick sensation), and 1 had objective motor loss (interosseous muscle) function (0.5%). Sixty-four patients (33%) complained of forearm scar discomfort. Sixteen (8%) felt their work performance was affected by the forearm wound, and 13 patients (6.5%) were undertaking forearm rehabilitation. One patient (0.5%) with scleroderma had skin necrosis in the distal 2 mm of the left index finger.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Spasm was a significant factor in RA grafts thought to be occluded early but subsequently found to be widely patent 15 years later. Serial angiograms of RA grafts performed months or years apart have demonstrated segmental areas of narrowing completely resolving, again providing evidence for acute dynamic changes in the RA lumen [4].
From the reports of medium and long-term coronary graft patency, in every instance patency rates of arterial grafts (leaving aside the left ITA), whether they be free right ITA, inferior epigastric, gastroepiploic, or RA, are always superior to the patency of vein grafts at similar time periods [10]. Specifically reports by Calafiore and coworkers [11] and Acar and associates [4] show excellent midterm (2 to 5 years) patency rates for the RA graft.
The ease of procurement of the RA, and its potential for better long-term patency than vein grafts, has made it a very attractive alternative as a secondary coronary graft conduit (after the ITA[s]). We further extended this concept, using bilateral RA grafts in appropriate cases to increase the proportion of arterial myocardial revascularization, with the goal of improved long-term myocardial perfusion especially to the inferior and lateral cardiac walls (in addition to the ITA to the anterior wall).
Initially we used bilateral RAs when there was a lack of adequate conduit to fully revascularize the myocardium and the ITAs alone could not achieve total myocardial revascularization (varicose veins, leg veins, stripped or previously used), or when bilateral ITA grafting was inappropriate in patients with insulin-dependent diabetes, significant obesity, advanced age, and severe emphysema [12].
We prefer to prepare and drape all the potential operative fields simultaneously. Despite the multiple operative fields, the sternal and other wound infections were low.
The arterial monitoring catheter is placed in the femoral artery, and is usually removed within 24 hours. We have not seen any femoral artery puncture complications in the 261 patients.
We have routinely used the modified Allen’s test to screen for RA dominance. An upper limit of 10 seconds for hyperemic reperfusion of the radial aspect of the hand is a conservative safe limit. Using this criterion in 98% of patients the RA may be used without fear of rendering the hand ischemic. Acar and colleagues [4] are less conservative, and they have not experienced hand problems.
The usual length of RA procured is 20 to 22 cm, which is usually adequate to reach from the aorta to the inferolateral cardiac wall. In cases in which there is marked cardiomegaly, the RA will reach from the left ITA to the inferior aspect of the heart. The skin incision for RA harvesting is kept distal to the elbow crease and proximal to the wrist flexion crease to minimize discomfort from the scar.
By clipping the distal end of the RA after intraluminal papaverine, the vessel pulsates against its occluded end with the entrapped papaverine solution providing excellent pharmacologic dilation. There is no instrumentation, nor any forcible hydrostatic dilation of the radial artery, so that injury to the endothelium is avoided.
Routine immediate closure of the forearm wound (before heparinization) together with a firm crepe bandage lessens the chance of infection and of hematoma. There was no deep infection, and the incidence of hematoma was low. This approach allows the arm to be placed by the torso, out of the way of the operating surgeon by comparison to other approaches [5, 13] in which the arm is left open and placed at the side until the protamine is given some hours later, or a drain tube used.
If a Y graft is to be constructed between the left ITA and the RA, this is best done before cardiopulmonary bypass to facilitate the anastomoses at the front of the sternal wound. The anastomosis can be immediately checked, as can both grafts for length and bleeding sites. Construction of the anastomosis just below the second intercostal branches, on the pleural side of the ITA, allows for smooth entry of the RA into the pericardium. With this technique the RA can usually reach distally to the inferior circumflex marginal branches, the left ventricular region of the right coronary artery, and even the posterior descending artery.
Performing the proximal aorta anastomoses with the cross-clamp in place greatly facilitates their construction, lessens potential trauma to the aorta, and lessens the chance of embolization of particulate matter from the ascending aorta. If the aorta is grossly atheromatous or thickened, or if the RA does not comfortably reach, then an end-to-side anastomosis is constructed either to the left ITA or another graft. The proximal end of the RA is usually 3 to 3.5 mm in diameter. The RAs are always fully dilated at the time of use.
Avoidance of spasm is essential [14, 15]. The use of intravenous milrinone or nitroglycerin infusions immediately after release of the aortic cross-clamp, for a period of at least 24 hours, further protects against RA and ITA spasm, maximally dilates the coronary vascular bed to enhance graft runoff, and optimizes the preload and, to a lesser degree, the afterload of the heart. We have not recognized RA graft spasm, either intraoperatively or in the first 48 hours postoperatively. The description of late RA graft spasm [4] has convinced us to use calcium-channel blockers in the long term. Amlodipine (5 to 10 mg orally daily) is used empirically, as a potent calcium-channel blocker, with the advantage of once-daily administration.
In the last 100 patients, in only 2 was the RA severely calcified, totally precluding its use. In another 5% there was patchy calcification, particularly distally, but the RA could be used. The calcification, when mild, usually occurs on one (superficial) surface of the RA, and the anastomosis can be constructed on the opposite surface.
Where the RA has been previously cannulated, there are fenestrations and multiple channels of chronic dissection in the distal segment. This may be discarded, and the proximal two thirds of the RA used. In one instance, the RA was chronically dissected throughout its length, precluding its use.
The perioperative mortality and morbidity were low and similar to our [2] and other investigators’ [4, 5, 11, 13, 16] experience with coronary surgery using ITA grafts, attesting to the adequacy of myocardial protection and the single cross-clamp technique, and that the acute perioperative hemodynamics and myocardial performance were not compromised by the high number of arterial (including RA) grafts.
The excellent length of the two RA grafts (20 to 22 cm each) allowed distal grafting in any of the coronary vessels beyond all proximal disease, hence selection of the most ideal site for distal anastomosis was not compromised, especially on the inferolateral wall.
A high number (3.6) of distal anastomoses were routinely constructed. This is higher than is normally reported with coronary series using predominantly vein grafts [16], but similar to series using multiple arterial grafts [16, 17].
In only 13 patients (5%) was a vein graft used additionally to achieve full myocardial revascularization, and, when used, vein grafts predominantly went to the least important vessels (diagonal or intermediate), hence 95% of patients in whom bilateral RAs were used had total arterial revascularization.
Of the 939 anastomoses in the 261 patients, the use of bilateral RAs allowed 921 (98%) anastomoses to be constructed with arterial conduits. These figures are among the highest rates for total arterial revascularization reported in routine primary or re-do coronary artery bypass graft operations [16–18].
We did not recognize any episode of postoperative hemorrhage relating to RA branches. These are well defined (they bleed if accidentally divided) and small by comparison to those in some vein grafts or even in ITA grafts.
The number of postoperative angiograms in this series thus far is small. A program for angiography on a number of patients, at 3 months, 12 months, and 3 years postoperatively is now in place. The anastomotic patency of 91% is less than previously published patency rates for left ITA and free right ITA [2]. Published anastomotic patency rates for RAs vary from 98% to 88% at between 1 week and 3 years [4, 5, 11], and are inferior to ITA grafts; however, the RA allows much greater versatility.
We propose that the role of the RA graft would not be to compete with the ITA, but as the graft of second choice (instead of other arterial and vein grafts). The importance of the location of the proximal anastomosis (inflow) for the RA grafts—aorta or ITA—has yet to be established.
That the two nonfunctioning RA grafts in a small postoperative angiographic sample went to native coronary arteries with only mild to moderate stenosis is similar to our experience with free right ITA to coronary grafts, and we would caution against the use of free arterial grafts to large coronary arteries without tight proximal stenosis.
The fact that there were no major hand or forearm complications in 522 forearms was comforting, and verifies the fact that the Allen’s test is a reliable, conservative predictor of appropriateness of harvesting of the RA. Avoidance of leg incision in 95% of patients allowed for early ambulation.
In conclusion, bilateral RA grafts as part of a coronary revascularization procedure (in conjunction with single or bilateral ITA grafting) can be performed safely, with a low operative mortality, minimal hemodynamic and physical morbidity, and importantly, no major hand or forearm morbidity. Bilateral RA grafts also vastly extend the possibilities of total arterial to coronary revascularization.
Intuitively we would anticipate that midterm and late angiographic studies will show good patencies and confirm the RA as the second graft of choice in the coronary circulation, after the ITA.
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A. Rukosujew, R. Reichelt, A. M. Fabricius, G. Drees, T. D. T. Tjan, M. Rothenburger, A. Hoffmeier, H. H. Scheld, and C. Schmid Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel Ann. Thorac. Surg., January 1, 2004; 77(1): 120 - 125. [Abstract] [Full Text] [PDF]
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G. Possati, M. Gaudino, F. Prati, F. Alessandrini, C. Trani, F. Glieca, M. A. Mazzari, N. Luciani, and G. Schiavoni Long-Term Results of the Radial Artery Used for Myocardial Revascularization Circulation, September 16, 2003; 108(11): 1350 - 1354. [Abstract] [Full Text] [PDF]
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B. F. Buxton, J. S. Raman, P. Ruengsakulrach, I. Gordon, A. Rosalion, R. Bellomo, M. Horrigan, and D. L. Hare Radial artery patency and clinical outcomes: Five-year interim results of a randomized trial J. Thorac. Cardiovasc. Surg., June 1, 2003; 125(6): 1363 - 1371. [Abstract] [Full Text] [PDF]
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G. E. Drossos, I. K. Toumpoulis, D. G. Katritsis, J. P. A. Ioannidis, P. Kontogiorgi, E. Svarna, and C. E. Anagnostopoulos Is vitamin C superior to diltiazem for radial artery vasodilation in patients awaiting coronary artery bypass grafting? J. Thorac. Cardiovasc. Surg., February 1, 2003; 125(2): 330 - 335. [Abstract] [Full Text] [PDF]
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M. Haase, A. Sharma, A. Fielitz, S. Uchino, J. Rocktaeschel, R. Bellomo, L. Doolan, G. Matalanis, A. Rosalion, B. F. Buxton, et al. On-pump coronary artery surgery versus off-pump exclusive arterial coronary grafting: a matched cohort comparison Ann. Thorac. Surg., January 1, 2003; 75(1): 62 - 67. [Abstract] [Full Text] [PDF]
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O. Lev-Ran, R. Mohr, G. Uretzky, D. Pevni, C. Locker, Y. Paz, and I. Shapira Graft of choice to right coronary system in left-sided bilateral internal thoracic artery grafting Ann. Thorac. Surg., January 1, 2003; 75(1): 88 - 92. [Abstract] [Full Text] [PDF]
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E. Kuralay, E. Ozal, N. Kucukarslan, and H. Tatar Bifid proximal anastomosis technique of radial artery Eur. J. Cardiothorac. Surg., January 1, 2003; 23(1): 112 - 113. [Abstract] [Full Text] [PDF]
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Y. J. Woo and T. J. Gardner Myocardial Revascularization with Cardiopulmonary Bypass Card. Surg. Adult, January 1, 2003; 2(2003): 581 - 607. [Full Text]
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 C. Beghi, F. Nicolini, A. M. Budillon, B. Borrello, L. Ballore, C. Reverberi, and T. Gherli Midterm Clinical Results in Myocardial Revascularization Using the Radial Artery Chest, December 1, 2002; 122(6): 2075 - 2079. [Abstract] [Full Text] [PDF]
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M. W. Connolly, L. D. Torrillo, M. J. Stauder, N. U. Patel, J. C. McCabe, D. F. Loulmet, and V. A. Subramanian Endoscopic radial artery harvesting: results of first 300 patients Ann. Thorac. Surg., August 1, 2002; 74(2): 502 - 506. [Abstract] [Full Text] [PDF]
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J. Tatoulis, A. G. Royse, B. F. Buxton, J. A. Fuller, P. D. Skillington, J. C. Goldblatt, R. P. Brown, and M. A. Rowland The radial artery in coronary surgery: a 5-year experience--clinical and angiographic results Ann. Thorac. Surg., January 1, 2002; 73(1): 143 - 148. [Abstract] [Full Text] [PDF]
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I. Saeed, A. C. Anyanwu, M. H. Yacoub, and M. Amrani Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life Eur. J. Cardiothorac. Surg., December 1, 2001; 20(6): 1142 - 1146. [Abstract] [Full Text] [PDF]
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S. V. Moran, R. Baeza, E. Guarda, R. Zalaquett, M. J. Irarrazaval, E. Marchant, and C. Deck Predictors of radial artery patency for coronary bypass operations Ann. Thorac. Surg., November 1, 2001; 72(5): 1552 - 1556. [Abstract] [Full Text] [PDF]
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Z. S. Meharwal and N. Trehan Functional status of the hand after radial artery harvesting: results in 3,977 cases Ann. Thorac. Surg., November 1, 2001; 72(5): 1557 - 1561. [Abstract] [Full Text] [PDF]
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M. Gaudino, F. Glieca, N. Luciani, F. Alessandrini, and G. Possati Clinical and Angiographic Effects of Chronic Calcium Channel Blocker Therapy Continued Beyond First Postoperative Year in Patients With Radial Artery Grafts: Results of a Prospective Randomized Investigation Circulation, September 18, 2001; 104 (2009): I-64 - I-67. [Abstract] [Full Text] [PDF]
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A. L. Iaco, G. Teodori, G. Di Giammarco, M. Di Mauro, L. Storto, V. Mazzei, G. Vitolla, B. Mostafa, and A. M. Calafiore Radial artery for myocardial revascularization: long-term clinical and angiographic results Ann. Thorac. Surg., August 1, 2001; 72(2): 464 - 468. [Abstract] [Full Text] [PDF]
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M. A. Greene and M. A. Malias Arm complications after radial artery procurement for coronary bypass operation Ann. Thorac. Surg., July 1, 2001; 72(1): 126 - 128. [Abstract] [Full Text] [PDF]
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T. A. Denton, L. Trento, M. Cohen, R. M. Kass, C. Blanche, S. Raissi, W. Cheng, G. P. Fontana, and A. Trento Radial artery harvesting for coronary bypass operations: Neurologic complications and their potential mechanisms J. Thorac. Cardiovasc. Surg., May 1, 2001; 121(5): 951 - 956. [Abstract] [Full Text] [PDF]
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J. Tatoulis, B. F. Buxton, and J. A. Fuller The radial artery in coronary re-operations Eur. J. Cardiothorac. Surg., March 1, 2001; 19(3): 266 - 273. [Abstract] [Full Text] [PDF]
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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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J. Chanda, I. Brichkov, and C. C. Canver Prevention of radial artery graft vasospasm after coronary bypass Ann. Thorac. Surg., December 1, 2000; 70(6): 2070 - 2074. [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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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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 H. S. Bedi Regarding "Is the Use of Suboptimal Saphenous Veins Justifiable for Limb Salvage?": The Radial Artery as an Autologous Conduit for Limb Salvage in Absence of Optimal Saphenous Vein Vascular and Endovascular Surgery, January 1, 2000; 34(1): 97 - 98. [PDF]
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J. Tatoulis, B. F. Buxton, J. A. Fuller, and A. G. Royse Total arterial coronary revascularization: techniques and results in 3,220 patients Ann. Thorac. Surg., December 1, 1999; 68(6): 2093 - 2099. [Abstract] [Full Text] [PDF]
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J. Tatoulis, G.-C. Jiang, J. D. Moffatt, and T. M. Cocks Storage of radial artery grafts in blood increases vessel reactivity to vasoconstrictors in vitro Ann. Thorac. Surg., December 1, 1999; 68(6): 2191 - 2195. [Abstract] [Full Text] [PDF]
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O. Wendler, B. Hennen, T. Markwirth, J. Konig, D. Tscholl, Q. Huang, E. Shahangi, H.-J. Schafers, and S. H. G. Borst T GRAFTS WITH THE RIGHT INTERNAL THORACIC ARTERY TO LEFT INTERNAL THORACIC ARTERY VERSUS THE LEFT INTERNAL THORACIC ARTERY AND RADIAL ARTERY: FLOW DYNAMICS IN THE INTERNAL THORACIC ARTERY MAIN STEM J. Thorac. Cardiovasc. Surg., November 1, 1999; 118(5): 841 - 848. [Abstract] [Full Text] [PDF]
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T. M. Sundt III, H. B. Barner, C. J. Camillo, and W. A. Gay Jr Total arterial revascularization with an internal thoracic artery and radial artery T graft Ann. Thorac. Surg., August 1, 1999; 68(2): 399 - 404. [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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S. Noda and H. B. Barner Arterial conduits Ann. Thorac. Surg., January 1, 1999; 67(1): 285 - 286. [Full Text] [PDF]
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