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Ann Thorac Surg 2001;71:1969-1973
© 2001 The Society of Thoracic Surgeons

Original article: cardiovascular

Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery

Massimo Lemma, MDa, Guido Gelpi, MDa, Andrea Mangini, MDa, Paolo Vanelli, MDa, Cristina Carro, MDa, Annamaria Condemi, MDa, Carlo Antona, MDa

a Department of Cardiovascular Surgery, Luigi Sacco Hospital, Milan, Italy

Accepted for publication February 20, 2001.

Address reprint requests to Dr Lemma, Division of Cardiovascular Surgery, Luigi Sacco Hospital, Via GB Grassi 74, 20157, Milan, Italy
e-mail: cardsurg_sacco_h{at}hotmail.com


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft.

Methods. Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein.

Results. There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p < 0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p < 0.001) and a longer hospital stay (p < 0.001). Mean follow-up was 8.1 ± 3.9 months. The probability of survival was similar (p = not significant).

Conclusions. The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
The internal thoracic artery (ITA) is currently the conduit of choice for myocardial revascularization because of superior graft patency, reduced cardiac events, and enhanced short-term and long-term results [1]. Additional advantages in terms of long-term survival, quality of life, freedom from angina, and reintervention have been also shown using both ITAs instead of the use of one ITA in combination with saphenous vein (SV) grafts [2]. Bilateral ITA harvesting is, however, significantly underused because of the increased operative times, the potentially increased morbidity rates, and the technical complexity of the operation. Moreover, some investigators have reported contradictory results about additional survival benefits [3, 4]. These observations have led to the investigation of other types of arterial grafts as an alternative to the right ITA. Recently, a few groups have reported good short-term and mid-term results using the "discovered again" radial artery (RA) [5].

The aim of this study was to retrospectively analyze the perioperative and short-term outcomes of patients receiving a RA versus those receiving a right ITA as a second arterial graft.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient population and criteria selection
This study retrospectively analyzed two groups of patients who were operated on consecutively between February 1999 and May 2000, receiving either a right ITA (n = 94) or a RA (n = 156). All patients received a left ITA pedicle almost always on the left anterior descending coronary artery and as many supplemental SV grafts as necessary. During this period of time patients qualified for multiple arterial grafting when (1) their target vessel was greater than 1.5 mm in diameter and of good quality, (2) the coronary stenosis measured more than 50%, and (3) the left ventricular ejection fraction was more than 30%. General contraindications for arterial grafting were (1) an age more than 70 years and (2) an emergency operation. Specific contraindications for using the right ITA were the presence of (1) diabetes mellitus (patients on oral hypoglycemics or insulin); (2) chronic obstructive pulmonary disease; and (3) obesity (body mass index > 30 kg/m2). We did not use bilateral ITAs in these patient populations because of possible sternal complications [6]. We preferred to use the right ITA as an in situ graft on the coronary arteries supplying the left ventricle through the transverse sinus rather than on the right coronary system.

Patients not suitable for right ITA grafts but meeting the general criteria for multiple arterial grafting were considered for RA conduits. The RA was preferentially used on the circumflex system, less frequently on the right coronary artery, and never on the left anterior descending coronary artery. Specific contraindications for the use of RA were the presence of a (1) positive Allen test; (2) severe renal failure (need for hemodialysis); (3) a history of previous vascular trauma to the upper limbs; and (4) the presence of Raynaud’s or Dupuytren’s disease. The RA was always harvested from the nondominant arm, never bilaterally. The Allen test was routinely performed before the operation following the rules suggested by Ejrup and colleagues [7] (patient’s hand slightly flexed and relaxed to avoid false-positive tests). We modified the standard Allen test by recording an oximetric plethysmography curve from the thumb during RA occlusion. Doppler examination of the upper extremity was only performed in the presence of a doubtful result.

Operative technique
The RA was harvested simultaneously with the left ITA and SV. Oxymetric plethysmography was continuously recorded from the thumb. Electrocautery was exclusively used to cut the subcuticular tissue to prevent any thermal injury to the RA that was carefully dissected with its accompanying veins and the connective tissue to preserve its blood supply as much as possible. After systemic heparinization a small atraumatic vascular clamp (Fogarty Soft-jaw 6-mm spring clip, model 614-06; Baxter Healthcare Corp, Irvine, CA) was temporarily applied to occlude the RA. The confirmation of adequate collateral flow from the ulnar artery was obtained assessing oxygen saturation and pulse volume recorded by the pulse oxymetric probe placed on the thumb. The RA was then ligated, taken out, and flushed carefully with diltiazem (50 mg of diltiazem per 50 mL of lactated Ringer’s solution) avoiding any hydrostatic dilatation. It was then stored in a papaverine hydrochloride solution (100 mg of papaverine diluted in 100 mL of lactated Ringer’s solution).

Coronary anastomoses were performed using continuous 7-0 polypropylene (Ethicon, Johnson-Johnson; Brussels, Belgium) sutures. Proximal anastomoses were performed on the beating heart with continuous 6-0 polypropylene sutures using a 4.5-mm aortic punch (Pilling Weck Surgical Fort; Washington, PA) for SV grafts and a 4.0-mm punch for arterial conduits. Free arterial grafts were usually anastomosed directly to the aorta. If required when used in sequential fashion on the obtuse marginal branches, the proximal anastomosis of the RA was performed in a T or Y fashion on the left ITA.

To minimize the risk of arterial spasm patients receiving a RA graft were administered with a continuous intravenous infusion of diltiazem throughout the operation (0.25 to 0.50 µg · kg-1 · min-1). Continuous infusion was maintained until patients were able to take medications orally. Diltiazem was prescribed after discharge for a period of 6 months postoperatively at a dosage of 180 mg/day.

Postoperative complications: definitions
Mortality was defined as death occurring within 30 days from operation. Low cardiac output syndrome was defined as the presence of a mean blood pressure less than 60 mm Hg or a cardiac index of less than 2 L · min-1 · m-2 lasting for more than 30 minutes and requiring inotropic support or intraaortic balloon pumping despite adequate preload and appropriate afterload reduction. Postoperative myocardial infarction was defined by the appearance of new Q waves on the electrocardiogram or by an increase in the creatine kinase MB isoenzyme fraction of more than 100 UI/L or more than 10% of the total creatine kinase level. The need of chest reopening for bleeding was defined as the presence of more than 500 mL of bleeding from the chest tubes during the first hour, more than 400 mL during the second hour, and more than 300 mL during the third hour, or a total bleeding of more than 1,000 mL within the fourth hour [8]. Sternal wound infection or dehiscence was defined as superficial if it involves only the skin and the subcuticular tissue, and deep if it involves the sternum and the mediastinum. The length of intensive care unit stay was defined as the number of hours from patient arrival in the intensive care unit to patient transfer to the ward. Hospital length of stay was defined as the number of days from the operation to patient discharge.

Statistical analysis
All statistical analyses were performed using the SPSS Base 7.5 software (SPSS Inc, Chicago, IL). Continuous data are presented as mean ± standard deviation and were analyzed by Student’s t test. Nominal data are presented as the absolute frequency or as a percentage and were analyzed by {chi}2 test or Fisher’s exact test where appropriate. Survival was evaluated by Kaplan-Meier analysis. A p value less than 0.05 was considered to indicate significant statistical differences.


   Results
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 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
As a consequence of selection criteria there was a significant prevalence of diabetes mellitus (19.2% versus 7.74%, p = 0.011), chronic obstructive pulmonary disease (15.3% versus 3.2%, p = 0.005), hypertension (50% versus 26.6%, p < 0.001), three-vessel disease (85.2% versus 72.3%, p = 0.002), and elderly age (60 ± 9 versus 57 ± 9 years, p = 0.011) in the RA group. There was no significant difference in the prevalence of other traditional predictors of cardiac morbidity and mortality (Table 1).


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  		Table 1. Preoperative Characteristics of the Study Population

 
Patients who received the RA as a second arterial graft had significantly shorter cardiopulmonary bypass times (102 ± 26 versus 116 ± 45 minutes, p = 0.002) and aortic cross-clamp times (64 ± 18 versus 91 ± 36 minutes, p < 0.001). In the RA group more bypass grafts per patient (3.17 ± 0.88 versus 2.88 ± 0.77, p < 0.001), more SV bypass grafts per patient (0.58 ± 0.31 versus 0.41 ± 0.57, p = 0.030), more arterial bypass grafts per patient (left ITA and RA versus left ITA and right ITA: 2.61 ± 0.73 versus 2.43 ± 0.61, p = 0.008), and more bypass grafts per patient with the second arterial graft (RA versus right ITA: 1.37 ± 0.49 versus 1.06 ± 0.28, p < 0.001) were performed. The left ITA was grafted to the left anterior descending coronary artery in 100% of patients receiving an RA and in 89.3% of patients receiving a right ITA. The RA went mainly to the obtuse marginal branches (83.6%), less frequently to the right coronary artery (10.3%) or diagonal artery (6.1%). In 31 patients (19.8%) the RA was used in sequential fashion and in 20 (12.8%) of these patients the proximal anastomosis was performed as a Y or T graft from the left ITA. The right ITA was used preferentially as an in situ graft (89.3%) and most of the time was used on the obtuse marginal branches (59.4%), less frequently on the right coronary artery (31.7%), and very seldom on the left anterior descending coronary artery (6.9%) and diagonal (1.9%) coronary arteries. In 10 patients (10.6%) the right ITA was used as a free graft and in 7 (7.4%) as a sequential graft (Table 2).


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  		Table 2. Distal Anastomoses Performed in the Study Population

 
The analysis of the perioperative outcome showed that there was no significant difference between the two groups of patients (RA versus right ITA) considering the mortality rate (1.92% versus 0%, p = not significant [ns]), the incidence of perioperative myocardial infarction (3.84% versus 2.12%, p = ns), the incidence of low cardiac output (1.92% versus 2.12%, p = ns), the length of mechanical ventilation (16.4 ± 26.8 versus 19 ± 22.2 hours, p = ns), and the length of intensive care unit stay (48.6 ± 28.7 versus 53.4 ± 34.7 hours, p = ns). There was a significantly higher incidence of bleeding (501 ± 232 versus 1,042 ± 708 mL, p < 0.001) and longer hospitalization (8.1 ± 2.6 versus 10.7 ± 5.7 days, p < 0.001) in the group of patients receiving a right ITA as a second arterial graft. There was no significant difference between the two groups of patients (RA versus right ITA) regarding the incidence of chest reopening for bleeding (0.64% versus 1.06%, p = ns) and new sternal closure (0% versus 2.12%, p = ns) for deep sternal wound complications. The incidence of superficial sternal wound infection or dehiscence was greater in the right ITA group (6.3% versus 1.3%), but without statistically significant difference.

In the early postoperative days 5 patients (3.26%) of the RA group complained of thumb dysesthesia; it completely resolved in 3 at the time of hospital discharge. Other complications associated with the harvesting procedure of the RA (wound infection, skin necrosis, ischemic pain, motor dysfunction of the forearm) were not observed. In 11 patients (7.05%) postoperative diltiazem administration had to be stopped because of undesirable side effects (bradycardia, hypotension, and allergic reaction).

Mean follow-up time was 8.1 ± 3.9 months (range, 1 to 17 months) in 152 of 153 patients (99.3%) in the RA group and in all 94 patients of the right ITA group. Figure 1 displays the survival curve for both groups of patients. No patient had major cardiac events such as acute myocardial infarction, percutaneous coronary angioplasty, or reoperation. Exercise stress testing was performed on 101 patients (66%) of the RA group and on 72 patients (76.6%) of the right ITA group, with positive results for ischemia in 2 patients from each group (1.98% versus 2.7%, p = ns). One of the 2 patients of the RA group with recurrent angina and positive exercise stress test underwent postoperative angiography with evidence of diffuse narrowing of the RA lumen. At present, this is the only postoperative angiographic control in both groups (Table 3).



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  		Fig 1. Estimate survival including hospital deaths. (RA = radial artery; RITA = right internal thoracic artery.)

 

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  		Table 3. Follow-up

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
The use of the left ITA on the left anterior descending coronary artery is considered as the major surgical objective, because of the better long-term patient survival [1], cardiac-related event-free survival [9], and conduit patency rates [10] when compared with SV grafts. The excellent results obtained with the left ITA led to the use of both ITAs [11] with the aim to reduce SV grafts use. Nevertheless, some studies [3, 4] have failed to show additional survival benefits using bilateral ITA grafting and only recently two large-scale studies have shown that long-term survival with both ITAs is better than that with a single ITA [2, 12]. These conflicting results about survival benefits, as well as a longer and more technically demanding operation, are the probable reasons for the relative lack of popularity of bilateral ITA harvesting [13].

The RA has been recently proposed as possible alternative to the right ITA for myocardial revascularization [14]. This artery was first introduced as a coronary bypass by Carpentier and associates in 1973 [15]. Two years later Carpentier [16] suggested that the RA should be abandoned because of the high incidence of narrowing or occlusion at postoperative angiography. About 20 years later the fate of the RA was changed by the unexpected good long-term patency discovered in three patients in whom the RA examined immediately after the operation was thought to be occluded. These observations led the group of Carpentier to reinvestigate the RA in 1992 [17], using a different harvesting technique and calcium antagonists to prevent spasm. Short-term results were then definitely better, with a patency rate of 93.5% after a mean follow-up of 9.2 months. Since that time the RA has gained popularity among cardiac surgeons and two recent articles have reported a 5-year RA overall patency rate of 84.4% [18] and 91.9% [19], respectively.

The analysis of our experience showed that the RA could be harvested in almost every patient, because clinical contraindications (positive Allen test, need for hemodialysis, history of previous vascular trauma to the upper limbs, and the presence of Raynauds’s or Dupuytren’s disease) are quite rare. On the contrary, to prevent possible sternal wound complications, bilateral ITA harvesting was usually reserved for a selected group of young nonobese nondiabetic patients. The prevalence of diabetes, elderly age, and chronic obstructive pulmonary disease in the RA group reflects our concern of possible sternal wound complications after bilateral ITA harvesting [6].

Our patient selection strategy has resulted in an increased incidence of three-vessel coronary artery disease in the RA group. As a consequence, the number of bypass grafts per patient was significantly greater in the RA group, even if aortic cross-clamp time and cardiopulmonary bypass time were significantly shorter. These results can be explained with the fact that the RA has a thicker wall and larger diameter than the right ITA, features that make it more accessible during the operation and rendering the coronary anastomosis easier and faster to perform. Moreover, the average harvested length of the RA is longer than that of the right ITA, particularly when used as an in situ graft, allowing anastomosis to any of the coronary arteries and proximal aortic anastomosis if desired. In our experience we preferred to use the right ITA as an in situ graft to avoid the technical problems related to the anastomosis between a thin-walled vessel and the thicker aortic wall, which may produce stenosis and thrombosis of the free RITA grafts [20, 21].

Despite the higher prevalence of risk factors and triple-vessel coronary artery disease in the RA group, the incidence of perioperative mortality, myocardial infarction, and low cardiac output was similar in both groups of patients. These results further highlight the reliability of the RA for myocardial revascularization, also in patients with severe coronary artery disease.

The intensive care unit stay was slightly longer for the patients in the right ITA group as a consequence of a longer period of mechanical ventilation. Postoperative bleeding was significantly less in the RA group, probably because the right ITA is less accessible and as a consequence, bleeding sites are more difficult to locate and control. However, there was no difference regarding the incidence of chest reopening for bleeding between the two groups. Hospital stay was significantly longer in the right ITA group because of the greater number of superficial and deep sternal wound complications among these patients.

Complications related to the RA harvesting were negligible. Only 5 patients complained of thumb dysesthesia for a few days postoperatively, completely resolved at discharge in 3 of them.

Limitation of the study
This is an observational study in which selection criteria were not the same for both groups of patients. It must be noted, however, that a randomized clinical trial would have required to harvest both ITAs in patients supposed to be at risk for sternal complications such as elderly patients, patients with chronic obstructive pulmonary disease, obesity, and diabetic patients [6, 22]. On the contrary, our strategy was to choose for each patient selected for multiple arterial grafting the surgical treatment with the lowest risk benefit ratio, creating as a consequence two different groups of patients.

Two additional limitations are the shortness of the follow-up period and the lack of angiographic controls. Shortness of follow-up is because we routinely started to use the RA at the beginning of 1999, whereas the lack of angiographic controls depends on the policy of cost containment of our department, which allows us to perform postoperative angiography only for clinical reasons. The literature would suggest, however, similar RA and right ITA graft patency rates. Perfect patency rates of 87.1% and 82.8% at 5 years for RA grafts has been recently reported by Possati [19] and Acar [18] and their colleagues, in comparison with a 89.9% rate for right ITA grafts reported by Sakata and associates [23] during the same period of time. Longer angiographic follow-up is available only for the right ITA, with a patency rate of 85% at 13 years [24].

In conclusion, despite a significant prevalence of risk factors in the RA group, the incidence of perioperative cardiac morbidity and mortality was the same both for the RA and the RITA group of patients, emphasizing the safety and efficacy of the RA for myocardial revascularization. The RA proved to be more accessible during the operation, allowing more coronary artery bypasses to be performed when compared to the right ITA. Moreover, the operation is easier using the RA.

We can conclude that the RA can safely extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting for the presence of multiple risk factors (advanced age, diabetes, chronic obstructive pulmonary disease, and obesity), without additional risks related to the harvesting site and with good perioperative and short-term results. If mid- and long-term studies will confirm these results the RA could be proposed as the graft of second choice for myocardial revascularization after the left ITA.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

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