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Ann Thorac Surg 2001;72:126-128
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Arm complications after radial artery procurement for coronary bypass operation

Accepted for publication March 28, 2001.

Address reprint requests to Dr Greene, Health First Heart Institute, 1355 S. Hickory St, Suite 204, Melbourne, FL 32901
e-mail: mgreene{at}health-first.org

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Radial arteries are being used frequently for coronary artery bypass conduits, and surgeons are appropriately concerned about the risks of ischemia, infection, and neurologic dysfunction of the "donor" arm. We present our record of donor site complications, with emphasis on the safety of radial usage in patients older than 65 years of age.

Methods. A total of 343 radial arteries were removed from 217 patients, aged 37 to 83 years. Forty-nine (23%) of the patients were women; 126 of the radial arteries were from patients aged 65 years or older. Four patients died. In the remaining 213 patients, 338 donor arms were examined for at least 6 weeks postoperatively for evidence of infection, ischemia, hematoma, seroma, or paresthesia.

Results. No donor arms developed symptoms of ischemia or motor dysfunction. Two of 338 (0.6%) arms developed hematomas requiring operative drainage. Relatively minor complications of stitch abscesses, skin dehiscence, superficial infection, and small hematomas or seromas affected another 14 arms (4.1%). Cutaneous paresthesias in the radial distribution of the lateral antebrachial cutaneous nerve or superficial branch of the radial nerve were noted postoperatively in 36 arms (10.7%). The risk of any arm complication occurring was 13% in the 65 and older group and 17% in those less than 65 years old (p = NS).

Conclusions. The risk of a major arm complication from radial artery harvesting for coronary bypass is low, even in patients of advanced age.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
In 1992, Acar and colleagues published their article, Revival of the radial artery for coronary artery bypass grafting [1]. Since then, many articles have described the technical aspects of radial artery testing [2, 3] and radial procurement [4], as well as angiographic patency rates [5–7]. The excellent long-term patency rates associated with internal thoracic artery bypass grafts have led many surgical groups to advocate total arterial coronary revascularization, including the use of radial artery grafts [8–10].

Cardiovascular surgeons are frequently challenged with patients who have limited availability of conduit material. Traditional vein or artery conduits may be unavailable because of previous coronary bypass operations, saphenous vein stripping, arteriovenous dialysis fistulas, peripheral vascular or abdominal operations, or chest wall and mediastinal radiation. Whether a surgeon advocates its routine use or not, radial artery grafting is a valuable technique to understand and to be able to perform, at least in selected cases. In this report we describe our initial experience with radial artery grafting, expanding the current body of knowledge regarding the attendant risks of radial artery usage.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
Between June 1998 and September 2000, 217 patients underwent coronary artery bypass procedures using one (n = 91) or both (n = 126) radial arteries as a bypass conduit. There were 168 men (77%) and 49 women (23%). The patients weighed up to 167 kg. The median age was 60 years (range 37 to 83 years). The 343 radial artery segments were used to construct 420 distal anastomoses. An additional 242 distal anastomoses were constructed using internal mammary, gastroepiploic, or inferior epigastric arteries, as well as 126 distal anastomoses from saphenous vein grafts. The mean number of distal anastomoses per patient was 3.6; total arterial grafting was accomplished in 129 patients (59%).

Our selection criteria for radial grafting were not strict. Neither patient sex nor size was a factor in the decision to recommend arterial grafting. Many patients were selected for radial artery grafting if they were judged physiologically younger than 65 years old. Other patients had evidence of significant lower extremity edema, venous stasis, prior vein stripping, or lower extremity arterial insufficiency. Seventeen patients (8%) were included because of previous total vein removal from one or two prior coronary bypass operations. Concomitant procedures were performed on a number of patients and are listed in Table 1.

Preoperative testing
A pulse oximeter sensor (Nellcor Puritan Bennett DS-100A, Pleasanton, CA) was placed on the thumb of the planned donor extremity. Radial arteries were not used if base line room air oxygen saturation was less than 90%. A Lifepak-12 oximeter (Physio-Control, Redmond, WA) was used, which updates the saturation measurement with each detected pulse. This oximeter also has a dynamic signal strength bar graph. If the oxygen saturation exceeded 90%, both ulnar and radial arteries were compressed at the wrist until the oximetric signal was lost. If release of the distal ulnar flow resulted in a return of the pulse oximeter signal to the base line value within 10 seconds, collateral flow was deemed adequate for radial usage.

Intraoperative techniques
Patients were started on intravenous diltiazem at 0.2 µg/kg per minute after induction of anesthesia. Sterile pulse oximetry was used to monitor transcutaneous thumb oxygen saturation during procurement of the radial graft. The general techniques of open radial harvesting as described by Reyes and colleagues [11] were used. The assistant surgeon harvested the radial artery in cases of unilateral harvest, and both surgeons removed a radial vessel for bilateral cases; the radial harvesting was done before sternotomy in bilateral cases. Most of the dissection was performed using a "harmonic" scalpel with small metallic clips used on the larger branches of the radial. Generally incisions were carried distally no further than 2 cm proximal to the wrist crease. After exposure and mobilization of the radial arteries, an atraumatic occluder was placed across the radial artery to confirm that ulnar collateral flow would preserve the thumb oxygen saturation. Occasionally the pulse oximeter waveform amplitude would disappear or significantly flatten; in these patients volume loading and intravenous nitroglycerin at 1 to 4 µg/kg per minute were used to improve collateral flow. If those measures failed, then the mobilized radial artery was left in place and the arm was rejected as a radial donor. This situation occurred twice in this series of patients. Finally, at the time of radial artery removal the antecubital end of the radial segment was transected first to confirm "retrograde" collateral flow from the ulnar supply.

Arms were irrigated with antibiotic solution, and then closed in layers with absorbable suture. The arm donor sites were closed immediately, without regard to whether the patient had received anticoagulation agents at the time of closure. All distal radial anastomoses were constructed with 8-0 polypropylene monofilament suture, with proximal anastomoses using 6-0 polypropylene. In most cases the proximal radial anastomoses were directly to the aorta, although occasionally to a vein hood, or from an ascending aortic graft.

Postoperative care
Donor arms were dressed with loose gauze wraps, elevated on pillows for the first 24 hours, with constant monitoring of digital oxygen saturation. As soon as the patients were taking oral medications, the intravenous calcium-channel blocker was converted to oral diltiazem, usually 60 mg every 8 hours continued for 90 days postoperatively. Arm intravenous sites and arm blood pressure cuffs were avoided if possible in the first few postoperative days. Patients were allowed to shower around the third postoperative day. Survivors were examined at weekly or biweekly intervals until complete wound healing had occurred, at least 6 weeks postoperatively. Patient inquiries were directed toward assessing subjective arm and hand complaints, and donor arm sensation was tested by light touch and pinprick.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Two hundred thirteen patients survived (98%). These 213 patients had 338 radial "donor arms" for evaluation. Arm complications are listed in Table 2. A summary of all arm complications reveals 52 arms were affected, including 17 of the 126 donor arms (13%) in patients 65 years old or older. This incidence in older patients compares with a 17% incidence (25 of 212 arms) in those patients less than 65 years old (p = NS).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Surgical groups throughout the world are increasing their use of arterial conduits, including radials, for coronary bypass [2, 3, 9, 10]. This trend can be attributed to a belief that long-term angiographic patency rates will be superior, compared with vein bypasses, and to the challenges imposed by patients who have no available venous conduits.

Cardiac surgeons do have concerns regarding conduit procurement site complications, and many articles have discussed these problems in detail as they relate to usage of the saphenous veins and internal mammary arteries. Little information is available pertaining to radial artery harvest site complications; what is available is reassuring. Tatoulis and coworkers [10] had a large experience involving 2,417 patients with radial usage, and they reported a 0.08% incidence of fingertip ischemia, noting this complication only in scleroderma patients. They also reported a 0.4% incidence of forearm hematoma and no major forearm infection. Cutaneous dysthesia have a reported incidence ranging from 2.6% to 15.2% [6, 7, 9, 12, 13].

Acute hand ischemia developing after radial harvest has been reported, occurring in a patient who was also found to have absence of the ulnar artery [14]. There are many methods to assess collateral hand blood supply preoperatively. Which method is "best" is disputable, because the incidence of significant postoperative ischemia is virtually nil in all published reports.

In conclusion, this study documents an acceptably low risk of arm donor site complications in individuals undergoing coronary artery bypass grafting with the radial artery, including those patients aged 65 to 83 years.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Acar C., Jebara V.A., Portoghese B., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-659.[Abstract]
2. Pola P., Serricchio M., Flore R., Manasse E., Favuzzi A., Possati G. Safe removal of the radial artery for myocardial revascularization: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996;112:737-744.[Abstract/Free Full Text]
3. Jarvis M.A., Jarvis C.L., Jones P.R., Spyt T.J. Reliability of Allen’s test in selection of patients for radial artery harvest. Ann Thorac Surg 2000;70:1362-1365.[Abstract/Free Full Text]
4. Brodman R., Frame R. The radial artery for myocardial revascularization. Operative Techniques in Cardiac and Thoracic Surgery 1996;1:137-146.
5. Chen A., Nakao T., Brodman R., et al. Early postoperative angiographic assessment of radial artery grafts used for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1996;111:1208-1212.[Abstract/Free Full Text]
6. Tatoulis J., Buxton B., Fuller J. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998;66:714-720.[Abstract/Free Full Text]
7. Weinschelbaum E., Macchia A., Caramutti V., et al. Myocardial revascularization with radial, and mammary arteries. Initial and midterm results. Ann Thorac Surg 2000;70:1378-1383.[Abstract/Free Full Text]
8. Sundt T., Barner H., Camillo C., Gay W. Total arterial revascularization with an internal thoracic artery and radial artery T graft. Ann Thorac Surg 1999;68:399-405.[Abstract/Free Full Text]
9. Brodman R., Frame R., Camacho M., Hu E., Chen A., Hollinger I. Routine use of unilateral and bilateral radial arteries for coronary artery bypass graft surgery. J Am Coll Cardiol 1996;28:959-963.[Abstract]
10. Tatoulis J., Buxton B., Fuller J., Royse A. Total arterial coronary revascularization: techniques and results in 3,220 patients. Ann Thorac Surg 1999;68:2093-2099.[Abstract/Free Full Text]
11. Reyes A., Frame R., Brodman R. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118-126.[Abstract/Free Full Text]
12. Acar C. Invited commentary. Ann Thorac Surg 1995;59:126.[Free Full Text]
13. Arons J., Collins N., Arons R. Permanent nerve injury in the forearm following radial artery harvest: a report of two cases. Ann Plast Surg 1999;43:299-301.[Medline]
14. Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1998;66:929-931.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael A. Greene Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Greene, M. A. Articles by Malias, M. A. Search for Related Content PubMed PubMed Citation Articles by Greene, M. A. Articles by Malias, M. A. Related Collections Coronary disease