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Ann Thorac Surg 1999;67:535-536
© 1999 The Society of Thoracic Surgeons
a Nuffield Department of Surgery, John Radcliffe Hospital, Headington, Oxford, England, United Kingdom
b Department of Radiology, John Radcliffe Hospital, Headington, Oxford, England, United Kingdom
Accepted for publication July 13, 1998.
Address reprint requests to Mr Fox, Nuffield Department of Surgery, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, England
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Abstract |
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Introduction |
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A 67-year-old man was admitted with progressively worsening angina. Coronary angiography confirmed triple-vessel disease amenable to coronary artery bypass grafting. Both internal mammary arteries and the right radial artery were used. The Allen test [1] was performed and confirmed that the radial and ulnar arteries were contributing to the palmar arch. Hand-held Doppler assessment revealed biphasic signals at wrist level within each vessel, and intraoperative assessment of pulsatile backbleeding from the distal radial artery was considered satisfactory before the harvest was completed.
Coronary artery bypass grafting was performed uneventfully, and the patient was transferred to the intensive care unit for 24 hours and then the ward. Thirty-six hours after the procedure, he noticed the development of forearm pain on exercise but relieved by rest, and a vascular opinion was requested. The hand was found to be viable without sensorimotor deficit. Neither radial nor ulnar pulses were palpable, and a decision was made to defer further investigation until the patient fully recovered from the operation.
Overnight, however, the patient’s hand became critically ischemic with the development of sensory and motor involvement. At this time, capillary refill was greater than 15 seconds, and no signals were obtained from the radial or the ulnar artery on Doppler ultrasound examination. Urgent selective subclavian angiograms demonstrated congenital absence of the ulnar artery (Fig 1). A small interrosseous artery filled the remnant of the radial artery and the palmar arch. Surgical injury to the ulnar artery was excluded by the absence of retrograde filling. Immediately after angiography, palmar revascularization was performed. The ipsilateral cephalic vein was harvested, reversed, and used as a brachioradial conduit from the level of the elbow to the distal radial artery remnant.
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Comment |
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Cardiac surgeons know that the forearm and hand are vascularized mainly by the ulnar artery and its collaterals [2]. Nevertheless, an assessment of the palmar supply is an essential prerequisite for an uncomplicated radial artery harvest.
The Allen test [1], Doppler examination, and backbleeding at the time of operation were used in this patient and were considered satisfactory. In retrospect, this conclusion was clearly incorrect. Despite the absence of an ulnar artery, the interosseous supply had been able to maintain a viable, but symptomatic, limb. However, the patient’s perfusion pressure decreased with the development of atrial fibrillation and resulted in the onset of limb-threatening ischemia and the requirement of revascularization. In retrospect, duplex ultrasonography could have demonstrated the presence, patency, and size of each vessel, but its reliability for this indication is not proven.
Numerous techniques are available for noninvasive assessment of peripheral perfusion. However, because hand ischemia is rare, no standardized protocol has been developed, and this condition remains poorly documented in the literature.
Dietl and Benoit [3] used the Allen test, and only if blanching persisted for longer than 6 seconds did they proceed to Doppler studies. During the operation, they verified a pulse distal to a radial artery clamp. One patient was denied operation because of ulnar occlusion, and in 8 patients, despite a positive Allen test, harvest was carried out because the Doppler flow examination results were considered normal. Reyes and colleagues [4] observed pulsation within the ligated distal radial artery stump and confirmed these findings with pulse oximetry. Acer [4] commented on his series of 324 patients without acute or chronic symptoms suggesting hypoperfusion of the hand even in those patients whose professions necessitated excessive use. Fisk and coworkers [5] assessed palmar supply, but no details of methodology were reported, and no arm morbidity was encountered.
The case of our patient demonstrates that no single method is dependable to assess adequate blood flow to the hand through collaterals. Current tests can fail in special circumstances, and thus, a combination of tests must be used to prevent adverse sequelae of radial artery harvest.
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