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Ann Thorac Surg 2001;71:555-559
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Does routine use of the radial artery increase complexity or morbidity of coronary bypass surgery?

Ani C. Anyanwu, FRCSa, Imran Saeed, MRCSa, Mahmoud Bustami, MRCPa, Charles Ilsley, FRCPa, Magdi H. Yacoub, FRCSa, Mohamed Amrani, MDa

a Department of Cardiac Surgery, Harefield Hospital, Middlesex, United Kingdom

Accepted for publication June 23, 2000.

Address reprint requests to Dr Amrani, Harefield Hospital, Uxbridge, Middlesex UB9 6JH, United Kingdom
e-mail: m.amrani{at}rbh.nthames.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Despite increasing data supporting its use, the uptake of radial artery coronary bypass grafting by most surgeons remains low. This may partly be from perceptions that it increases risk or complexity of coronary surgery.

Methods. Data on 151 patients who had radial grafts are compared with 179 concurrent nonrandomized controls that underwent conventional surgery using saphenous vein. Additionally, telephone interviews were conducted on 127 radial recipients to assess subjective outcome.

Results. Cardiopulmonary bypass and cross-clamp times were similar in both groups (72 versus 74 minutes and 20 versus 22 minutes). Morbidity was comparable (mortality 1% versus 2%; cerebral vascular accident 1% versus 2%; sternal infection 1% versus 2%; resternotomy 4% versus 6%). Of 127 patients contacted, 41 (32%) reported that they had experienced parasthesia, and 65 (51%) reported numbness related to radial harvest; of these, 75% reported their symptoms as resolved or resolving. Early angiography performed in 36 patients revealed a radial patency rate of 92%.

Conclusions. Concerns about increased morbidity and mortality should not hinder adoption of radial artery grafting.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Following the revival of the radial artery for coronary artery bypass surgery (CABG) in the early 1990s, the conduit has increasingly been used for myocardial revascularization. However, there is still some reluctance to acceptance of the radial artery as a routine conduit; this may be because of unknown long-term results and also a perception that use of this artery increases the complexity and risk of coronary artery bypass surgery. Following recently reported excellent clinical and angiographic results at 5 years [1, 2], and observations that in vitro and in vivo endothelial function is not markedly dissimilar to that of the left internal thoracic artery (LITA) [3, 4], we have adopted the radial artery as our conduit of choice after the internal thoracic arteries. We have examined early outcomes after radial artery coronary bypass grafting at our institution with a view to ascertaining whether routine use of the radial artery does increase the risk or complexity of CABG procedures.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patients and surgical techniques
We have reviewed consecutive patients who underwent CABG between December 1997 and April 1999. The radial artery was used as the conduit of choice after the internal thoracic arteries (ITA) in patients under the age of 70 years. In patients under 60 years, both internal thoracic arteries were preferentially used as the first conduits of choice. Bilateral ITA grafts were used selectively in patients between 60 and 70 years. Patients older than 70 generally received a LITA graft with saphenous vein used for additional grafts. We use low strength electrocautery to harvest the radial artery avoiding the use of hemostatic clips (unless branches bleed in spite of coagulation). We believe this method to be safe, and by avoiding numerous application of clips, it minimizes handling of the radial artery. The left radial artery was used preferentially regardless of the hand dominance, as this allows simultaneous harvesting of the LITA. All radial arteries were flushed, but not distended, with a mixture of 20 ml blood, 5 mg papaverine, 2,000 units heparin, and 10 mg nitroglycerin. The artery was stored in this mixture at room temperature until time of grafting. Our initial practice was to administer nifedipine sublingually during surgery and then diltiazem for 6 months postoperatively. We later abandoned this regime after our first 60 patients because of concerns about posthypotension and the absence of convincing evidence to support its use.

When total arterial revascularization was being performed, the internal thoracic arteries were preferentially placed on the left coronary system. Where vein grafts were also being used, we preferentially placed arterial conduits on the left coronary system. Most operations were performed using cardiopulmonary bypass with cooling to 34°C and distal anastomoses constructed under intermittent periods of brief ischemic arrest with induced ventricular fibrillation. Cold blood cardioplegia with topical cooling was also used in some cases—the choice of myocardial management being dependent on surgeon preference. Continuous 7/0 polypropylene was used for distal anastomoses, and 6/0 or 7/0 polypropylene for proximal anastomoses, depending on whether the radial artery was attached to the aorta or ITA, respectively.

Data collection
All patients undergoing surgery in our unit have data entered into a prospective database. Some additional operative and postoperative data not held on this database were obtained by retrospective chart review. As data were sometimes missing, all the totals in the analysis are not similar.

Patient-based outcomes
All patients who had survived to discharge from hospital were contacted by telephone by a single observer. Questions were asked to ascertain whether they experienced any sensory symptoms, wound complications, or functional impairment related to the radial artery harvesting. Freedom from angina was ascertained using the Canadian Cardiovascular Society class and dyspnea status with the New York Heart Association classification. Quality of life index was ascertained using the EuroQol method [5]. The median time to follow-up was 8 months (range 1 to 16 months).

Angiography
The first 60 patients were approached to participate in a separate in vivo study of radial artery function. Thirty-six patients consented and underwent angiography as part of that study—data from these angiograms have been used to evaluate graft patency. Ethical approval was obtained for the angiographic study.

Statistical analysis
Where proportions have been compared, the chi-square test was used, whereas the Wilcoxon test was used for comparing group means. A p value of 0.10 or less was regarded as representing a statistically significant difference.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
Patients
During the study period, we performed 355 CABG procedures. Radial artery grafts were used in 151 procedures (43%), with or without concurrent vein grafting, whereas in 179 (50%), vein grafts were used without the use of the radial artery. The vein graft recipients who did not receive radial artery grafts are used as a comparative group to represent conventional CABG with saphenous vein grafts. The remaining 25 (7%) procedures consisted of revascularization using one or both of the internal thoracic arteries only (without use of radial artery or saphenous vein) and are not included in this analysis.

Patient characteristics of 151 patients who received radial arteries and equivalent data for the 179 patients who had conventional CABG using saphenous vein (without radial artery) are shown in Table 1.


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  		Table 1. Patient Characteristics of Radial Artery Groupa

 
Operative strategy
All radial arteries were used as one of two or more bypass grafts (no radial arteries were used for single vessel bypass procedures). In 56 of 151 (36%) procedures, the radial artery was used as part of total arterial revascularization using one or both internal thoracic arteries for additional grafts. The remaining 95 (64%) included use of saphenous vein in addition to the radial artery, usually in combination with the left internal thoracic artery. Most radial arteries were placed on a branch of the left coronary artery: 91 (60%) on a marginal branch of the circumflex artery, 18 (12%) on a diagonal branch of the left anterior descending artery (LAD), and 6 (4%) on the LAD. Other radials were placed on the main right coronary artery (RCA) (14, 10%) and the posterior descending artery (PDA) (21, 14%). The most frequent patterns of grafting were a LITA graft to the LAD, radial to the circumflex and vein graft to the RCA or PDA; and (for total arterial revascularization) a LITA graft to the LAD or circumflex, right internal thoracic artery (RITA) graft to the circumflex or LAD and radial artery to the RCA or PDA. The proximal radial anastomosis was constructed directly to the aorta in 79% of procedures, as a Y graft off a vein graft hood in 17%, a Y graft off the LITA in 3%, and a Y graft off another radial graft in 1%. One sequential radial graft was performed in this series (radial graft to two obtuse marginals).

The use of the radial artery did not prolong bypass times or cross-clamp times (Table 2). The mean skin-to-skin operation time was 230 minutes (SD 52 minutes).


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  		Table 2. Operative Variables

 
Postoperative course
The frequency of postoperative complications was not increased in the patients who had radial artery grafts (Table 3). There was one perioperative death in the radial group (cerebrovascular accident). The median extubation time was 6 hours after surgery (interquartile range 2 to 10 hours). The median blood loss from the chest drains was 760 ml in the first 24 hours (interquartile range 560 to 1040 ml). Although radial (forearm) drains were routinely placed, in 75% of cases, the drainage within the first 12 hours was less than 25 ml. Two patients had excessive blood loss from the radial drains requiring reexploration of the forearm—in both instances, bleeding was from a muscular branch of the artery. One patient required late reexploration for evacuation of a hematoma, while 2 patients required needle aspiration of a seroma. There was no ischemic hand complications.


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  		Table 3. Postoperative Data

 
Telephone interviews
Of the 150 surviving patients, we were able to contact 130. One patient refused to answer questions, 1 was unable to answer questions because of ill health, and another patient had died of lung carcinoma. Data from the remaining 127 patients are included in this analysis. Table 4 shows the incidence of hand- and forearm-related symptoms as reported by the patients. Most of the symptoms were self-limiting. All 7 patients who reported wound infections responded to antimicrobial therapy prescribed by their general practitioner. Two patients experienced wound dehiscence requiring application of steri-strips; in the other 4 patients with dehiscence, this was minor and was managed conservatively. Although 41 patients reported paresthesia, 31 reported that their symptoms were resolved or resolving. The site of paresthesia was in the hand in 58% and in the scar or forearm in 42%. The site of numbness was in the hand in 50% and in the scar or forearm in 50%. Three-quarters of patients reporting numbness said the numbness had resolved or was resolving. Four patients reported mild limitation in hand activity following radial artery harvest. Of the 127 patients who responded to the telephone survey, 81 (63%) also had saphenous vein harvested. Leg wound infections were reported by 12 (15%) of these patients, and paresthesia or numbness in 28 (35%).


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  		Table 4. Incidence of Hand or Forearm Symptoms After Radial Artery Harvestinga

 
Most patients were in New York Heart Association class I (104 respondents) or II (18 respondents). Five patients (4%) were in class III. One patient reported recurrent anginal symptoms. The median health utility (on a scale of 0 to 1; 0 representing death and 1 representing the best possible health state) as determined by the EuroQol method was 0.85 (interquartile range 0.80 to 1.0).

Angiography
Thirty-six patients underwent angiography at 3 weeks after surgery. Three radial grafts were occluded as confirmed by angiography in two orthogonal views. One graft was a Y radial graft from the LITA to a diagonal LAD branch, whereas the other two were aortocoronary grafts to marginal branches of the circumflex artery. The other 33 anastomoses were all satisfactory. Fifteen arteries appeared to be of small caliber. In 3 patients, spasm of the radial artery was observed, which responded to intragraft infusion of nitroglycerin. All patients who had angiography had internal mammary grafts—none were found to be occluded.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Our data suggest that the routine use of the radial artery is not associated with increased morbidity and does not make the CABG procedure more complex. We have also observed good patient-based outcomes. The procedure is safe and does not appear to compromise graft outcome. Our early patency rate of 92% compares favorably with others series [6–8]. Superior long-term patency rate, survival, and reduction in late cardiac events are well documented in patients receiving a LITA graft to the left anterior descending artery [9], making it the first conduit of choice. There is also increasing evidence to suggest that use of both internal thoracic arteries has superior outcome compared with a single LITA graft [10, 11]; for this reason, several workers, including our group, now use the RITA as the second conduit of choice for younger patients. Because of encouraging midterm clinical and angiographic results [1, 2], the radial artery is increasingly emerging as the next conduit of choice after the internal thoracic arteries [12]. Routine use of arterial grafts other than the LITA, however, remains uncommon. In 1998, only 8% of triple vessel coronary artery bypass grafts done in the United Kingdom involved the use of more than one arterial graft [13]. In the United States, 20% of CABG procedures done in 1997 did not include the use of an internal thoracic artery (The Society of Thoracic Surgeons (STS) database, http://www.ctsnet. org/graphics/sts/db/us98). Although the low uptake of arterial grafting may be partly explained by absence of long-term data, we believe it also reflects a perception that the use of arterial grafts is more technically demanding and is associated with increased morbidity.

Over the last 2 years, we have adopted a policy of routine total arterial revascularization in patients below 60 years of age and partial arterial revascularization (two arterial grafts) in patients between 60 and 70 years. We have performed our radial grafts using the same techniques we use for saphenous vein and ITA grafting. The use of the radial artery did not increase our cross-clamp or cardiopulmonary bypass time, or lead to unnecessary prolongation of the procedure. The techniques of harvesting the radial artery are easy to teach and learn—in our institution radial arteries are often harvested by junior surgeons with little prior cardiac operative experience, or by appropriately trained (nonmedically qualified) surgeon’s assistants. Several aspects of the cardiac operations were performed by trainee surgeons including aortic, Y graft, and distal coronary radial anastomoses. We therefore do not see arterial grafting as necessarily more technically demanding than saphenous vein grafting.

The morbidity after radial artery grafting did not exceed that of saphenous vein grafting. Complication rates for the radial group were not higher than expected. Although some complications were lower in the radial group compared with the conventional CABG group, we do not suggest that arterial grafting carries lower morbidity, as patients in the conventional CABG group were older and often sicker thus predisposing them to greater morbidity. The intubation times were short (10% of patients were extubated on the operating table), as were the lengths of stay in intensive care and hospital suggesting the use of arterial grafts does not place any additional demands on postoperative care. Five patients required forearm intervention related to bleeding from the radial artery bed—these were early in our experience and we believe were related to our learning curve with the harvesting technique. These complications have not been encountered in our recent experience.

Although the patient survey has limitations because of the cross-sectional study design, and the lack of verification by objective neurological assessment, it does suggest that a substantial proportion of patients experience peripheral neurological symptoms related to the radial artery harvest. Although the response rate was 86% for the telephone survey, we believe this is sufficiently high for the purposes of this study, and is representative of the entire group, as there is no reason to expect the forearm symptoms of nonresponders to differ from that of the responders. Nonresponders were recontacted on at least two occasions without success. None of the defects reported had any major implication on hand function. Most patients reported a good quality of life with health status similar to that expected for their age group. Leg wound hematoma, dehiscence, or infection was reported by 23% of those radial patients who had saphenous vein harvested. This was despite the majority of these patients having had a short leg incision, as only one length of saphenous vein was harvested. Leg wound complications are a significant source of morbidity after CABG and a prominent cause of delayed hospital discharge—avoiding the leg wound incision and its inherent morbidity is an understated but important advantage of arterial grafting [14]. Although we have reported forearm morbidity related to radial harvesting, the forearm wound remains a less morbid wound compared with the leg wound. Based on the results of this study, we have, however, modified our technique of harvesting the radial artery in a bid to reduce the incidence of neurological sequelae. We no longer place a subcutaneous fat suture, but close the wound with skin clips or suture without the placement of any deep sutures, as neurological symptoms may sometimes be related to catching of the cutaneous nerves by subcutaneous sutures. We, however, believe most neurological symptoms are inherent (but reversible) consequences of radial harvesting related to often inevitable tissue trauma and edema around the superficial branch of the radial nerve, regardless of the mode of harvesting.

Our initial experience has led us to expand the use of the radial artery and we increasingly use it routinely in preference to the saphenous vein for the majority of our patients, as it has not increased the risk of our procedures and available data do not suggest that it would emerge as an inferior conduit to saphenous vein. Although the long-term benefits of arterial grafting may not be realized in elderly patients, radial artery grafting may still be advantageous in this group, as it may be desirable to minimize leg dissection, especially in those patients who are prone to infection or impaired healing of the leg wound. Although most of the procedures in this series were performed with the use of cardiopulmonary bypass, arterial grafting is not a barrier to the application of off-pump technology. Indeed, we now routinely perform our procedures without cardiopulmonary bypass. With adoption of the off-pump technique, we now preferentially place the proximal anastomosis of the radial artery on an internal thoracic artery and also increasingly perform sequential grafts in a bid to minimize aortic manipulation.

Although we favor the use arterial conduits over saphenous vein, this article does not attempt to demonstrate superiority of the radial artery conduit over the saphenous vein, as there remain unanswered questions regarding long-term function and patency. Concern is repeatedly raised about the potential for spasm with radial artery grafts. Although calcium channel blockers are widely used to prevent spasm, recent studies suggest they may be ineffective and unnecessary [15, 16]. Clinically, we have not experienced problems attributable to acute graft spasm. It has also been suggested that radial arteries are more prone to atherosclerosis, intimal hyperplasia, and medial calcification compared with the internal thoracic artery [17], although implications of this observation on graft function and patency are unclear. Our data do, however, suggest that routine radial artery grafting does not necessarily add complexity to CABG, does not lead to increased morbidity, and achieves early results comparable to that of saphenous vein grafting. Although long-term definitive data on this conduit are required, concerns about increased complexity or morbidity alone should not prevent the adoption of routine radial artery grafting.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Acar C., Ramsheyi A., Pagny J.Y., et al. The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981-989.[Abstract/Free Full Text]
  2. Possati G., Gaudino M., Alessandrini F., et al. Midterm clinical and angiographic results of radial artery grafts used for myocardial revascularization. J Thorac Cardiovasc Surg 1998;116:1015-1021.[Abstract/Free Full Text]
  3. Chester A.H., Marchbank A.J., Borland J.A., Yacoub M.H., Taggart D.P. Comparison of the morphologic and vascular reactivity of the proximal and distal radial artery. Ann Thorac Surg 1998;66:1972-1976.[Abstract/Free Full Text]
  4. Chester A.H., Amrani M., Borland J.A. Vascular biology of the radial artery. Curr Opin Cardiol 1998;13:447-452.[Medline]
  5. Brooks R. EuroQol: the current state of play. Health Policy 1996;37:53-72.[Medline]
  6. Tatoulis J., Buxton B.F., Fuller J.A. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998;66:714-719.[Abstract/Free Full Text]
  7. Da Costa F., da Costa I., Poffo R., et al. Myocardial revascularization with the radial artery: a clinical and angiographic study. Ann Thorac Surg 1996;62:475-479.[Abstract/Free Full Text]
  8. Chen A.H., Nakao T., Brodman R.F., et al. Early postoperative angiographic assessment of radial grafts used for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1208-1212.[Abstract/Free Full Text]
  9. Loop F.D., Lytle B.W., Cosgrove D.M., et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.[Abstract]
  10. Buxton B.F., Komeda M., Fuller J.A., Gordon I. Bilateral internal thoracic artery grafting may improve outcome of coronary artery surgery. Risk-adjusted survival. Circulation 1998;98(Suppl II):II1-II6.
  11. Lytle B.W., Blackstone E.H., Loop F.D., et al. Two internal thoracic artery grafts are better than one. J Thorac Cardiovasc Surg 1999;117:855-872.[Abstract/Free Full Text]
  12. Taggart D.P. The radial artery as a conduit for coronary artery bypass grafting. Heart 1999;82:409-410.[Free Full Text]
  13. Society of Cardiothoracic Surgeons of Great Britain and Ireland. National Adult Cardiac Surgical Database Report 1998. London: 1999.
  14. Buxton B., Fuller J., Gaer J., et al. The radial artery as a bypass graft. Curr Opin Cardiol 1996;11:591-598.[Medline]
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