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Ann Thorac Surg 2002;73:143-148
© 2002 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Royal Melbourne and Epworth Hospitals, The University of Melbourne, Melbourne, Victoria, Australia
* Address reprint requests to Dr Tatoulis, Suite 28, Private Medical Centre, Royal Melbourne Hospital, Parkville, Victoria 3050, Australia
e-mail: james.tatoulis{at}mh.org.au
Presented at the Thirty-seventh Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 29–31, 2001.
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Abstract |
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Methods. We studied 6,646 consecutive patients who had a single RA (4,872), or bilateral RA (1,774), as coronary grafts, from June 1995 to June 2000. Angiograms were performed mostly in symptomatic patients, or as part of a research project in asymptomatic patients.
Results. The patients’ mean age was 65.1 years; 23% had diabetes, 14% had unstable angina, and 42% had prior myocardial infarction. An average of 3.3 grafts per patient were performed, 87% from arterial conduit. Conduits used were RA (8,420), left internal thoracic artery (6,296), and right internal thoracic artery (1,076). Operative mortality occurred in 58 (0.9%) patients, stroke in 92 (1.4%), deep sternal infection in 97 (1.4%), reoperation for hemorrhage in 56 (0.9%), and myocardial infarction in 52 (0.8%). Peak mean postoperative creatine kinase MB (CKMB) was 16.5 IU/L. Two patients developed fingertip ischemia. Postoperative angiographic RA patency was 90.2% (333 of 369 distal anastomoses).
Conclusions. Good early clinical and angiographic results can be achieved by using the RA in coronary surgery.
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Introduction |
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After the revival of radial artery (RA) use by Acar and associates [4], we used the RA [5], and subsequently made more efficient use of the conduit with sequential grafting [6] and composite grafting [7]. Others have reported similar operative strategies [8–10].
The purpose of this study was to review our initial experience, more than 5 years, in isolated coronary artery bypass grafting (CABG) surgery where the RA was used.
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Material and methods |
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Contraindications to RA use were abnormal Allen’s test, prior trauma or surgery to the relevant upper limb, known subclavian or brachial artery stenosis, Raynaud’s phenomenon, scleroderma, and RA calcification.
Graft procurement
The left RA (nondominant) was the preferred conduit. After sternotomy, the left internal thoracic artery (LITA) and left RA harvest proceeded simultaneously. If both RAs were used, these were harvested first, the forearms closed and placed by the patient’s side, and covered with a further large sterile drape before sternotomy. In long operations (combined, reoperations), a small suction drain was sometimes placed.
Radial artery harvesting
The distal one-third of the RA was usually exposed first to exclude calcification. The RA was harvested using a combination of low-power cautery [5] or sharp dissection without much cautery [11], dependent on surgeon preference. Small vascular clips were used to secure branches. Care was taken to avoid injury to the superficial radial and the lateral cutaneous nerve of the forearm.
Antispasm prophylaxis
Papaverine 1 mg/mL in heparinized arterial blood was introduced intraluminally via the distal end of the RA (5 mL) with a blunt-ended vascular needle, and the distal end of the RA was secured with a vascular clip. The RA was allowed to pulsate for 5 minutes before the proximal end was secured, and the RA was placed in an identical solution until its use. The ITAs similarly had intraluminal papaverine and a papaverine-soaked gauze placed around until use. Intravenous nitroglycerine (30 to 100 µg/min) or Milrinone (0.1 µg/kg/min) (Sanofi-Synthelabo, Sydney, Australia) were commonly used perioperatively for 24 hours according to surgeon’s preference. Oral calcium channel blockers (amlodipine or felodipine) were commenced postoperatively, and continued for a variable period (usually 6 months) after discharge.
Patient monitoring
Where bilateral RAs were harvested, a femoral arterial monitoring line was used. Swan-Ganz catheters, and transesophageal echocardiography were used routinely in all patients.
Surgical strategy
Grafting varied according to surgeon’s preference. Initially, total arterial revascularization was most frequently used in younger patients (< 65 years), but later, all patients were considered suitable. Sequential grafting became increasingly popular due to the additional length and flexibility afforded by the RA. Similarly, composite "Y" grafting became more popular.
The most common patterns of grafting were the LITA to the left anterior descending (LAD), the right internal thoracic artery (RITA) (if used) to the proximal circumflex or posterior descending artery (PDA), and the RAs to the distal circumflex, left ventricular branch of the right coronary artery (RCA), or PDA.
Four thousand eight hundred seventy-two patients had one RA used, and 1,774 patients had both RAs harvested. The arterial conduits used are detailed in Table 2. Eighty-seven percent of all distal anastomoses were performed with arterial grafts, and the rest with saphenous vein.
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All anastomoses were completed during one period of cross-clamping, with the use of a partial occlusion aortic clamp being rare. A "hot shot" dose (1,000 mL) of aspartate-enriched warm blood cardioplegia was usually given before cross-clamp release.
If a Y graft was constructed, the proximal LITA/RA anastomosis was completed after heparinization but before bypass. The distal anastomoses were performed with continuous 7/0 polypropylene. The proximal anastomoses were performed directly onto a 3.5-mm punched opening in the ascending aorta with continuous 6/0 polypropylene. Sequential distal anastomoses were performed in a manner to ensure the best lie of the graft [7, 11]. Preference was for parallel sequential anastomoses if possible. In general, the LITA to LAD anastomosis was performed last. Pericardial cold slush was not used. The intraoperative details are shown in Table 3.
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Postoperative angiography
Postoperative angiography was performed as part of an ethics-approved study (Royal Melbourne Hospital Research and Ethics Committee), or in response to symptoms [12]. Grafts with string signs were considered not patent.
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Results |
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Perioperative morbidity
The perioperative major morbidity was low (Table 4).
Fifty-two patients (0.9%) developed perioperative myocardial infarction by electrocardiogram (new Q-wave) and enzyme criteria (creatine kinase MB /cardiac iso-enzyme [CKMB]). The mean postoperative peak level of CKMB was 16.5 ± 22 IU/L (normal laboratory values, 0 to 25 IU/L). In 80 patients (1.2%), an intraaortic balloon pump was used for vascular support in the perioperative phase. In 21 (25%), the intraaortic balloon pump had been placed prebypass for unstable hemodynamics or because of poor left ventricular function.
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Six patients died after a severe stroke, and 7 died from intraabdominal catastrophes (five mesenteric ischemia, two abdominal aortic aneurysms).
Fifty-six patients (0.9%) required return to the operating room for control of postoperative hemorrhage. In no instance was the source of bleeding from an RA branch.
Ninety-seven patients (1.4%) developed a deep sternal wound infection, defined as any sternal infection that required intravenous antibiotics, or a further operation on the sternum. The most common pathogen was Staphylococcus aureus (92 patients, 95%).
The mean time to extubation was 8.5 ± 8.6 hours (range 0 to 226 hours), and the mean hospital stay was 7.7 ± 5.4 days (range 4 to 126 days).
Hand and forearm complications
Objective upper limb morbidity was minimal. Twenty-one (0.3%) infections required intravenous or oral antibiotics, or some form of operative drainage. All except one were due to S aureus. Fourteen patients (0.2%) required evacuation of a forearm hematoma, most commonly between the 3rd and 5th postoperative days. Two patients developed fingertip (index finger) ischemia. Both had scleroderma, Raynaud’s phenomenon, severe peripheral vascular disease, and were early in our experience [13]. There was no difference in complications between patients with excellent (< 5 seconds) and those with satisfactory (5 to 10 seconds) ulnar collaterals.
Radial artery graft patency
Two hundred seventy-one patients from both institutions underwent RA coronary graft angiography, a mean of 14.4 ± 10.4 months postoperatively (range 1 to 35 months). Early patency data have been previously published [11–14]. Two hundred eighty RA conduits were studied with 369 RA to coronary anastomoses.
RA segments to 36 (10%) anastomoses were either occluded or had string signs. Three hundred sixty-three of 369 (90.2%) anastomoses were widely patent (Table 5).
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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Loop and associates [2] clearly demonstrated the clinical and angiographic superiority of the LITA grafted to the left anterior descending artery compared with SVG. Bilateral ITA grafting did not show an early advantage, mainly due to the concomitant use of SVG in both single and bilateral ITA groups. Recent studies suggest improved outcome with bilateral ITA [16, 17]. However, many surgeons may have been concerned by longer operation times or the potential for increased morbidity in the obese, diabetic, or those with chronic airways disease. Additionally, the RITA often cannot reach the distal circumflex and PDA territories.
The revival of the RA has made available an additional arterial conduit, which can be used in addition to the ITA to achieve predominantly or total arterial coronary revascularization. Significant advantages for the RA are potential availability of two in most patients, excellent length, and excellent handling characteristics for constructing anastomoses. It is also resistant to kinking; and avoidance of leg wounds allows rapid ambulation [11, 13].
As well as being available for routine use, the RA is extremely important when there is conduit shortage: stripped saphenous vein, reoperations, peripheral vascular disease, or in patients with chronic airways disease or obese diabetics where RITA use may be avoided. Conversely, the RA may have distal calcification, or distal fibrosis from prior cannulation [11]. With a combination of the ITA and RA, we were able to achieve a very high rate (87%) of total arterial revascularization.
Objective forearm and hand morbidity (hematoma and infection) was very low, at less than 1%. Discomfort, pain, paraesthesia, and wound tightness are more common complaints but settle with time [5]. If only one RA is to be used, the nondominant arm (usually left) should be preferred, as the efficiency of the surgery is enhanced and there is less potential for disturbance of function. There was no relationship between the degree of ulnar collateral flow and postoperative forearm complications or function.
RA spasm is not commonly seen during surgical procedure. Intraoperative prophylactic antispasmodic agents varied according to surgeon preference. All surgeons used intraluminal papaverine during harvest as previously used for the LITA. No topical "ice slush" was used in any of these patients. This may also protect against RA spasm. Most also administered low-dose glycerine Trinitrate, as was previously used for the LITA. Some surgeons preferred to administer intravenous Milrinone for its potent vasodilating effect. Calcium channel antagonists were normally prescribed postoperatively, and these were usually ceased within 3 to 6 months. These strategies have not been tested scientifically. The clinical role of postoperative oral calcium antagonists is not defined. However, isolated instances of discrete postoperative RA spasm have been reported [4].
RA calcification can be problematic, though rare [11]. When it occurs, it is more pronounced distally, on the superficial surface, and may be so severe that the RA is rigid and cannot be used. Difficulties include technical problems and hemostasis of the distal anastomosis, potential disruption of calcified plaques, intima, and possible thrombosis. Minimal calcification where the RA wall remains supple is acceptable. There are no data relating presence or absence of RA calcification to outcome.
Overall, RA patency was 90.2% beyond 1 year and is similar to other reports [18–20]. We have also found a lower patency when the RA was anastomosed to coronaries with lesser stenosis [12]. The patency findings are similar to those with the free RITA grafts [3]. The moderately stenosed coronary artery at the time of coronary operation poses a dilemma with respect to conduit choice.
The patency was least in RA grafts to the RCA territory. Others have also noted a lower patency in this territory [9, 12, 15]. Relevant factors may be a higher incidence of coronary wall disease, the length of the RA conduit required, steal into the circumflex territory by sequential anastomoses, and potential for competitive flow in the setting of moderate (lesser) stenoses in large dominant RCA systems.
Intuitively, it is expected that those RAs that are patent and are functioning well, beyond 1 year, should continue to do so into the long term.
As a proportion of RA angiograms were performed for possible cardiac symptoms, the patency results may possibly underestimate the "true" patency of RA grafts.
Current strategies in RA deployment include routine use to the circumflex and distal RCA/PDA territories. The favored in-flow is from the aorta, though in-flow from the LITA to create pedicled grafts is routinely used by one author (A.G.R.) and favored by all authors for off-pump CABG, or for conventional CABG where there is graft shortage or aortic wall disease and where clamps on the aorta are best avoided. Conduit choice for the moderately stenosed (< 60%) dominant RCA is problematic. The pedicled RITA may be the most appropriate graft.
Limitations of the study include the fact that it is observational, and that the RA was routinely used in our CABG group. However, in a study comparing the earlier half of this experience when SVG was still commonly used, radial artery use and total arterial revascularization were associated with significantly improved operative survival [6].
In conclusion, widespread routine use of the RA (in addition to the ITAs) is possible. The RA has proven to be an extremely versatile conduit and its use has been associated with extremely satisfactory clinical and angiographic results. Further evaluation into the long term is required.
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Acknowledgments |
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Discussion |
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TopAbstractIntroductionMaterial and methodsResultsCommentAcknowledgmentsDiscussionReferences |
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DR ROBBIN G. COHEN (Los Angeles, CA): I just have one question. It is a huge experience in radial arteries, but if you look at your angiographic follow-up, it turns out to be about 5% or less. Don’t you have a little bit of trouble extrapolating patency data when your follow-up is in such a limited number of patients?
DR SAMUEL RUSSELL VESTER (Cincinnati, OH): I was just curious if any of these were done off-pump and if there was an off-pump versus on-pump differential in the patency of your radial artery grafts?
DR DOUG ADAMS (Merrillville, IN): How does the performance of radial angiography preoperatively affect your use of the radial artery?
DR JOHN D. PUSKAS (Atlanta, GA): Let me ask one other question, and that relates again to the angiographic patency that Dr Cohen alluded to. There were 87% total arterial revascularization cases, therefore, 13% of patients had one or more saphenous vein grafts done. Can you compare for us the patency of those saphenous veins compared with the radial arteries at 1 year?
DR TATOULIS: I would like to thank the discussants for their questions. Dr Connolly, with regard to endoscopic harvest, we have not attempted that. I guess we have adopted this technique of radial artery use fairly readily and I think most of the patients have come to accept it. The wounds heal very well, and an additional bonus is the ambulation is very rapid because you do not have leg incisions, and in fact, that is a bonus that we had not expected but it certainly is. But the wounds heal well and the patients are certainly accepting.
With regard to the angiographic follow-up, I do acknowledge that 336 anastomoses followed up is small by comparison with 6,000-odd patients, however, we do have a prospective ongoing ethics-approved study to see these angiograms at 1 month, 1 year, 3 years, and 5 years. So we do have that as an ongoing study. And as you may well appreciate, it is not easy to get angiographic follow-up on patients in a routine fashion.
There was a question regarding off-pump surgery. We have done 450 off-pump cases, almost all involving the radial. The mean number of anastomoses was 2.6 in that series, and we mainly used the Y graft for that series because it allows us to totally avoid the aorta. I do not have a differential between the patency of the off-pump cases and the regular cases. My understanding was that they were very similar. So there was no statistical significance at this point in time. Otherwise, we would not be doing it.
With regard to radial arteries that had been used for angiography, our cardiologists do not use the radial artery as a site for angiography or for angioplasty, so that has not been an issue. What can sometimes be an issue is the use of the radial artery in reoperations where the radial artery has been previously cannulated for the first coronary operation or for a major vascular procedure. In that case, we certainly explore the artery distally if the Allen’s test is appropriate, and sometimes it is normal; sometimes the distal 2 or 3 cm is partly fibrosed or dissected and that can be discarded and the proximal segment used.
With regard to saphenous veins, yes, we do. All these patients obviously had all their grafts studied, and indeed there was something like 60-odd saphenous veins in this group, and the patency at 1 year was 87%. So it was very similar. I think the point being is we know that the patency of the saphenous veins declines over time, but we would hope once the technical and other issues relating to the implantation of the radial arteries are overcome, then we would hope that the patency then would plateau and stay the same.
I thank the Association for the privilege of presenting this information.
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B. F. Buxton, J. S. Raman, P. Ruengsakulrach, I. Gordon, A. Rosalion, R. Bellomo, M. Horrigan, and D. L. Hare Radial artery patency and clinical outcomes: Five-year interim results of a randomized trial J. Thorac. Cardiovasc. Surg., June 1, 2003; 125(6): 1363 - 1371. [Abstract] [Full Text] [PDF]
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 D. Pevni, R. Mohr, O. Lev-Ran, Y. Paz, A. Kramer, I. Frolkis, and I. Shapira Technical Aspects of Composite Arterial Grafting With Double Skeletonized Internal Thoracic Arteries Chest, May 1, 2003; 123(5): 1348 - 1354. [Abstract] [Full Text] [PDF]
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M. W. Connolly, L. D. Torrillo, M. J. Stauder, N. U. Patel, J. C. McCabe, D. F. Loulmet, and V. A. Subramanian Endoscopic radial artery harvesting: results of first 300 patients Ann. Thorac. Surg., August 1, 2002; 74(2): 502 - 506. [Abstract] [Full Text] [PDF]
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