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Ann Thorac Surg 2002;73:1695-1696
© 2002 The Society of Thoracic Surgeons

Correspondence

Preventing radial artery spasm

Franklin L. Rosenfeldt, FRACSa, Donald S. Esmore, FRACSa

a Cardiothoracic Surgery Department, The Alfred Hospital, Commercial Rd, Prahran, Victoria 3181, Australia

e-mail: f.rosenfeldt{at}alfred.org.au

To the Editor

We compliment Bond and coauthors for their systematic organ-bath study of radial artery vasospasm comparing diltiazem hydrochloride, amlodipine besylate, and nifedipine in reversing radial artery contraction induced by endothelin and norepinephrine [1]. With the revival of the use of radial artery as a coronary artery bypass conduit, long-term postoperative diltiazem administration was introduced empirically as part of a multifaceted strategy to reduce the spasm that occurred in the very early experience with this artery. Although the new strategy has been very effective, it has never been demonstrated that postoperative systemic diltiazem makes any useful contribution to the prevention of radial artery spasm. In fact, Shapira and colleagues [2] demonstrated in human volunteers that intravenous administration of diltiazem has no vasodilative effect on the radial artery, whereas nitroglycerin is very effective.

Bond and associates [1] demonstrated in the organ bath that amlodipine and nifedepine, but not diltiazem, reduce radial artery vasoconstriction. However, caution should be exercised in immediately applying these in vitro results to clinical practice because for all calcium antagonists given systemically, there is the potential for undesirable effects on myocardial contractility and electrical conduction. As pointed out by the authors and the commentator on their article (Shapira), a clinical trial is clearly justified to compare these various agents in the prevention of radial artery spasm in vivo.

However, our experience suggests that postoperative therapy with any systemic calcium antagonist is unnecessary. We use electrocautery to harvest the radial artery, and this is likely to exacerbate any tendency to spasm. To prepare the radial artery, we [3] have used a local vasodilative solution containing nitroglycerin and verapamil hydrochloride without any postoperative calcium antagonists in more than 2,000 patients with good clinical results. This solution was developed on the basis of extensive organ-bath studies [4]. After harvesting, we flush the radial artery with the vasodilative solution and leave it soaking in the same solution for at least 20 minutes prior to implantation. The patient receives an infusion of nitroglycerin (20 to 30 µg/min) intraoperatively and for the first 24 hours. This regimen is a convenient and safe way to counteract radial artery spasm, and it avoids the short- and long-term costs and side effects of systemic calcium antagonists.

References

  1. Bond B.R., Zellner J.L., Dorman B.H., et al. Differential effects of calcium channel antagonists in the amelioration of radial artery vasospasm. Ann Thorac Surg 2000;69:1035-1041.
  2. Shapira O.M., Xu A., Vita J.A., et al. Nitroglycerin is superior to diltiazem as a coronary bypass conduit vasodilator. J Thorac Cardiovasc Surg 1999;117:906-911.
  3. Esmore D.S., Burton P.R., Smith J.A., et al. A simplified method of harvesting and dilating the radial artery achieves acceptable clinical outcomes. Aust N Z J Surg 2000;70:366-370.
  4. Rosenfeldt F.L., He G.-W., Buxton B.F., Angus J.A. Pharmacology of coronary artery bypass grafts. Ann Thorac Surg 1999;67:878-888.




This Article
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