Ann Thorac Surg 2002;73:1316-1317
© 2002 The Society of Thoracic Surgeons
Case report
Upper extremity deep vein thrombosis after radial artery harvesting
Mitsumasa Hata, PhD*a,
Alexander Rosalion, FRACSa,
Siven Seevanayagam, FRACSa,
Kazuhiro Kohch, MDa,
Brian F. Buxton, FRACSa
a Department of Cardiac Surgery, Austin and Repatriation Medical Centre, Melbourne>, Australia
Accepted for publication September 9, 2001.
* Address reprint requests to Dr Seevanayagam, Department of Cardiac Surgery, Austin and Repatriation Medical Centre, Austin Campus, Studley Rd, Heidelberg, Vic 3084 Australia
e-mail: siven.seevanayagam{at}armc.org.au
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Abstract
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A 47-year-old diabetic man with unstable angina underwent coronary bypass surgery using bilateral radial arteries and left internal thoracic artery. After surgery, the patient suffered from severe right arm pain and swelling without any bleeding. The postoperative immediate digital subtraction angiogram detected thrombotic occlusion of the right axillary vein. We report here a rare case of deep vein thombosis related to radial artery harvesting.
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Introduction
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Recently, the use of radial artery (RA) as a conduit in coronary artery bypass grafting (CABG), has become a topic of renewed interest. The procedure of RA harvesting has been reported to be successful, with a low incidence of morbidity [1]. However, several complications have been reported after RA harvesting such as hand numbness, sensory nerve injury, harvest site infection, and others [2, 3]. We experienced a rare case that was complicated by upper extremity deep vein thrombosis (UEDVT) after RA harvesting. Following is our report on the case of DVT related to RA harvesting and discuss the causes of this complication with review of the relevant literature.
A 47-year-old diabetic man was hospitalized with effort angina pectoris. The coronary angiogram showed 90% stenosis on the left anterior descending artery (LAD), the first diagonal branch (D1), the proximal portion of circumflex, and right coronary artery, respectively. The elective CABG four grafts was performed on June 9, 2000 using bilateral RAs and left internal thoracic artery (LITA). The patient’s hemodynamics were monitored with Swan-Ganz and triple lumen central venous catheters inserted through the right internal jugular vein. Both of the arms were retracted to less than 80 degrees. Surgical assistants standing at patient’s topside harvested the right RA. The left RA was harvested by an assistant standing at the bottom side of the arm. A median sternotomy and LITA harvesting were performed by the operator at the same time as the RA harvesting. After clipping all the side branches of the RA, it was removed together with its collateral veins. The wound was closed in two layers. The anastomoses were carried out as follows: LITA to LAD, right RA to between the aorta and posterior descending artery, half of left RA to between the aorta and D1, the remainder of left RA to between the side hole of right RA and obtuse marginal branch. It was easy to be weaned from cardiopulmonary bypass without any inotropic agents and the patient was transferred to the cardiac recovery room without any hemodynamic instability. The patient then suffered from severe right arm pain and swelling without any bleeding from the RA harvest site. These symptoms were further developed despite a topical warming and elevation of the right arm. Digital subtraction angiography was performed 5 hours postoperatively and detected the thrombosed occlusion of the right axillary vein (Fig 1).
Serum creatinine level increased to 0.338 mmol/L on postoperative day 1. Intravenous fluid and frusemide infusions were commenced to prevent acute renal failure. The right arm wound was partially reopened to release the tension, and anticoagulant therapy was commenced using intravenous heparin 25,000 units, 300 mg of oral aspirin a day. The patient was also placed on warfarin, and his International normalized ratio was maintained at approximately 2.0. His arm pain was well controlled by intravenous morphine injection. The symptoms improved gradually and the patient was discharged on postoperative day 12 without further complications.
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Comment
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It has been reported that UEDVT is a critical disease and should be managed as aggressively as leg DVT, because of a significant incidence of pulmonary embolism and high mortality rate [4]. The most common risk factors of UEDVT are the presence of central venous catheters, malignancy, renal failure, and a previous history of leg DVT [4]. This patient had no history of malignancy, renal failure, or leg DVT. The patient had central venous catheters inserted through the internal jugular vein just before operation, the only risk factor associated with UEDVT. However, UEDVT associated with central venous catheters may occur in the long-term presence of a catheter [5]. In this patient, furthermore, thrombosed occlusion was found in the axillary vein. Therefore, it may not be associated with the catheter.
A recent article has reported that patients who undergo CABG may be at an additional risk for leg DVT because of positioning for vein harvest and immobilization in the intensive care unit [6]. This article also reported that the mechanisms of thrombus formation include venous stasis, endothelial damage due to anesthetic agents, immobilization, and positioning during operation [6]. In our patient, the venous return of the right arm may have been compromised by the operator’s body during harvesting of the conduits. During positioning, the arms were not widely retracted to safeguard the brachial plexus, and the LITA and RAs were harvested simultaneously. At that stage, the patient has not been heparinized. As strongly suggested above, the venous stasis due to the arm positioning and compression of the upper right arm by the LITA harvesting operator were the most likely causes of UEDVT. Trick and colleagues reported that the right side RA harvest may have a higher complication rate than the left, because it is close to the surgeon’s back, which is not sterile [3]. This close proximity may make it difficult to perform the radial artery graft harvest procedure without contaminating the incision site and without compression to the arm. Since this experience, we have never again harvested bilateral RAs concomitantly with LITA.
We report a case of RA harvesting, complicated by UEDVT. We conclude that it is important that LITA harvesting is undertaken after bilateral RAs harvesting.
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References
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Reyes A.T., Frame R., Brodman R.F. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118-126.[Abstract/Free Full Text]
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Arons J.A., Collins N., Arons M.S. Permanent nerve injury in the forearm following radial artery harvest: a report of two cases. Ann Plastic Surg 1999;43:299-301.[Medline]
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Trick W.E., Scheckler W.E., Tokars J.I., et al. Risk factors for radial artery harvest site infection following coronary artery bypass graft surgery. Clin Infect Dis 2000;30:270-275.[Medline]
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Treotola S.O., Kuhn-Fulton J., Johnson M.S., Shah H., Ambrosius W.T., Kneebone P.H. Tunneled infusion catheters: increased incidence of symptomatic venous thrombosis after subclavian versus internal jugular venous access. Radiology 2000;217:89-93.[Abstract/Free Full Text]
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Reis S.E., Polak J.F., Hirsch D.R., et al. Frequency of deep venous thrombosis in asymptomatic patients with coronary artery bypass grafts. Am Heart J 1991;122:478-482.[Medline]
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L. R. Sajja, G. Mannam, N. R. Pantula, and S. Sompalli
Role of Radial Artery Graft in Coronary Artery Bypass Grafting
Ann. Thorac. Surg.,
June 1, 2005;
79(6):
2180 - 2188.
[Abstract]
[Full Text]
[PDF]
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Abstract
Introduction
