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Ann Thorac Surg 2001;71:559-560
© 2001 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Royal Melbourne Hospital, University of Melbourne, Victoria, 3050, Australia
e-mail: james.tatoulis{at}mh.org.au
Anyanwu and colleagues report their initial experience with the radial artery (RA) in CABG, and show that complexity, operative time, mortality, and morbidity were not increased. The most catastrophic potential problem is hand ischemia. Several methods have been developed to ensure adequate ulnar collateral supply. These include the modified Allen’s test, plethysmography, and ultrasound, to determine RA size, flow, and quality. The authors do not mention which technique they use, but had no ischemic hand complications.
In over 4,300 CABG operations, where the RA was used at the University of Melbourne hospitals, we encountered only 2 cases of fingertip ischemia, both in patients with scleroderma [1]. Hand ischemia can be avoided by appropriate evaluation of the arterial supply to the hand.
The authors did not notice intraoperative spasm in the RA(s) nor postoperative hypoperfusion syndrome. They avoided hypothermia and ice slush in the pericardium. Papaverine and nitroglycerine in heparinized blood were used to treat and store the RA—both powerful vasodilators. Vasodilator use for RA spasm prophylaxis is essential.
The authors did not use calcium channel antagonists long-term. However 8% of patients had spasm demonstrated in the RA grafts angiographically (3 weeks postop), which was reversed by intragraft nitroglycerine. These observations support prophylactic use of calcium channel blockers for an number of months postoperatively.
RA use did not add to the complexity nor length of surgery. Aortic occlusion, bypass, and operation times were similar to conventional coronary bypass. With appropriate planning, the left RA can be harvested simultaneously with sternotomy and LITA harvest. Additionally, the RA is a facile and robust conduit to handle.
The authors confirmed the versatility of the RA and obtained excellent lengths. However, this versatility was only partly explored as they performed few "Y" LITA/radial grafts, only one sequential anastomosis, and no radial-to-radial "Y" grafts. The RA lends itself to sequential anastomoses both in the circumflex and right coronary systems, and as a pedicled graft with the proximal anastomosis on the LITA.
The early patency was excellent and confirms no disadvantage to the use of the RA in comparison to vein grafts. The authors suggest other significant potential benefits—avoiding leg incisions, hematomas, and infections (especially in obese, diabetic patients, or those with peripheral vascular disease), and availability of extra conduits where saphenous veins are not available.
As more than 50% of aortocoronary vein grafts will occlude within 10 years, it is appropriate to explore the use of the RA as the potential conduit of choice, after the internal thoracic arteries. This article further documents the safety and potential benefits of this strategy.
References
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