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Ann Thorac Surg 2002;74:1144-1147
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Use of radial artery graft reduces the morbidity of coronary artery bypass graft surgery in patients aged 65 years and older

^a The National Heart and Lung Institute, Imperial College of Science, Technology, and Medicine, Harefield Hospital, Middlesex, United Kingdom

Accepted for publication May 29, 2002.

* Address reprint requests to Mr Amrani, Department of Cardiac Surgery, Harefield Hospital, Hill End Rd, Middlesex UB9 6JH, United Kingdom
e-mail: mr.amrani{at}rbh.nthames.nhs.uk

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The use of the radial artery graft in patients aged 65 years and older could prevent the occurrence of leg wound infection, which is known to increase the morbidity of coronary artery bypass grafting surgery.

Methods. We reviewed, retrospectively, 261 patients aged 65 years and older (age range 65 to 93 years), who underwent coronary artery bypass grafting surgery between February 1998 and August 2001. All the patients received at least one radial artery graft in addition to either a left internal thoracic artery, right internal thoracic artery, or saphenous vein graft as required. Saphenous vein grafts were used in 141 (54.1%) patients (group 1), and these were compared to 120 (45.9%) patients (group 2) who received only arterial conduits. Angiography was performed on 26 consecutive patients. The aim of the study was to review the clinical and angiographic outcomes in this population.

Results. The mean number of distal anastomoses performed was 2.98. Mean global operating time was 204 minutes. This time dropped to 201 minutes in group 1 versus 231 minutes in group 2; p = 0.009. Sixteen (11.3%) patients receiving saphenous vein grafts had leg wound infection whereas only 1 (0.3%) patient of the global population had a forearm infection. The mean global hospital stay was 9.81 days; this duration increased to 13 days when leg wound infection occurred versus 9.1 days when infection did not occur; p = 0.008. Twenty-six (10%) patients underwent an early angiographic study. Twenty-four (92.3%) radial artery grafts were patent.

Conclusions. The routine use of radial artery grafts in patients aged 65 years and older is feasible, safe, and does not increase mortality, morbidity, or the complexity of coronary artery bypass grafting surgery.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
The frequency of elderly patients referred to coronary artery bypass grafting surgery (CABG) is increasing. The morbidity and mortality of patients above the age of 65 years is known to be high [1]. Many factors, including leg wound infection, are known to increase this morbidity and could increase health costs.

Over the last two decades, arterial conduits have been used increasingly to perform CABG [2]. Their main advantage is high long-term patency compared to saphenous vein graft (SVG) [3]. The benefit of arterial grafts is now well documented [4–7]. Several studies have reported long-term patency rates of radial artery (RA) conduits [8, 9]. Improved harvesting techniques and the use of antispasmodic drugs have led to its better performance and made it an attractive option for myocardial revascularization. Another major advantage is related to a better wound healing of forearm wounds in comparison with leg wounds, promoting earlier postoperative mobilization [10]. As a result, we have expanded the use of RA to patients, aged 65 years and older, candidate to CABG surgery.

We report our experience in 261 patients, aged 65 years and older, who underwent CABG with at least one RA. We have examined early clinical and angiographical outcomes with a view to ascertain whether routine use of the radial artery does increase the morbidity, the risk, or the complexity of CABG procedures.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients and data collection
We reviewed 261 consecutive patients, aged 65 years and older, who underwent isolated CABG surgery using radial artery as a graft, at Harefield Hospital, all performed by a single surgeon (M.A.), between February 1998 and August 2001. In our institution, patient data are entered on a prospective database. Retrospective chart review was also done to obtain additional operative and postoperative data.

Wound infection was diagnosed whenever there was persistent mucopurulent discharge associated with erythematous margins. It was always diagnosed by a specialist infection nurse, who sent specimens for culture and sensitivity, and treated the patients empirically by antibiotics. On obtaining the culture results, antibiotics were either changed accordingly, if pathogens were not responsive, or stopped, if the results were negative. The nurse recorded only patients with positive results as having had wound infections on the hospital prospective database.

Radial harvest
The radial artery was used as the conduit of choice after the internal thoracic arteries. The left RA was used preferentially regardless of the hand dominance, as this allows simultaneous harvesting of the left internal thoracic artery (LITA). All the patients received at least one RA graft in addition to LITA, right internal thoracic artery, or SVG. We use low-strength electrocautery to harvest the radial artery avoiding the use of hemostatic clips. In our experience, this technique appeared to be safe and minimized handling of the RA. All RA were flushed smoothly, but not distended, with a solution containing 50 ml of phenoxybenzamine in 20 ml of warm heparinized (2,000 units) blood. This mixture was used for all the study patients. Phenoxybenzamine is a long-acting irreversible alpha-blocker, which could potentially prevent radial artery spasm for a relatively long period of time [11].

The artery was stored in this solution at room temperature until time of grafting. Most operations were performed using cardiopulmonary bypass. Continuous 7/0 polypropylene was used for distal anastomoses, and 6/0 or 7/0 polypropylene for proximal anastomoses, depending on whether the radial artery was attached to the aorta, internal thoracic arteries, or SVG, respectively.

SVG harvest
The long SVG harvest was always attempted at the lower leg. If the patient suffered from varicose veins or any overlying skin condition that contraindicated this, the SVG of the other leg was attempted. If this proved to be unfavorable as well, the SVG was harvested from the groin at the upper leg. Long SVG rather than short SVG was preferentially harvested.

Angiography
Twenty-six patients consented to and underwent angiography, at the earliest on the 4th postoperative day, the aim was to look at the quality of anastomoses and patency of grafts. All of the angiograms were performed and commented on by one cardiologist (M.B.). An ethical approval was obtained for the study.

Statistical analysis
Numerical variables are presented as mean ± standard deviation. For ordinal variables, we calculated percentages of each value. For binary variables, we studied the sample sizes for each group, along with the numbers of patients possessing the characteristic. The p-value (based on a Fisher’s exact test or Mann-Whitney U test), small values of p (<0.05) indicate significant difference. McNemar’s and ² tests were used to compare the proportions of infections in groups 1 and 2.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
During the study period, 261 patients, aged 65 years and older, had isolated CABG surgery; the average age was 69.5 years (range 65 to 93). There were 18.4% women. Patient preoperative characteristics are shown in Table 1. RA grafts were used in all of the patients. Total arterial revascularization was achieved in group 1, 120 patients (45.9%), whereas partial arterial revascularization (using SVG in addition to arterial conduits) was accomplished in group 2, 141 patients (54.1%).

Postoperative course
Mean operating time (skin to skin) was 204 minutes; when veins were used, this time increased to 231 minutes, and it dropped to 201 minutes when no veins were used (p = 0.009).

Table 2 shows the postoperative complications. There was no death among the study patients. Five (1.8%) patients had neurological accidents. Three (1.1%) had myocardial infarction, 78 (29.8%) had atrial fibrillation and 14 (5.3%) of them needed insertion of intraaortic balloon pump due to severe low cardiac output. Ventilation time was 14.2 ± 31.1 hours, intensive care unit stay was 40.3 ± 61.4 hours, and they required 1.4 ± 2 units of blood. Infection occurred in 11.3% of the leg wounds but in only 0.3% of the forearm wounds (p = 0.006), which implies that the proportion of infections was significantly higher in group 2.

Angiography
Twenty-six (10%) patients underwent angiography before discharge, at the earliest on the 4th postoperative day. Out of the studied RA grafts, 20 RA grafts were off-aorta, one RA graft was Y graft off-LITA, and five grafts were Y grafts off-SVG. Twenty-four RA grafts (24/26; 92.3%) were patent as confirmed by two orthogonal views; 22 patients had an acceptable radial graft calibre; two other radial grafts showed string-sign that did not respond to nitroglycerine, one was off-aorta to the second obtuse marginal artery and the other was off-aorta to the posterior descending artery. Two radial grafts were occluded and they were both off-aorta to the first obtuse marginal artery. On reviewing the preoperative angiograms, the two occluded RA grafts were found to be anastomosed to coronary arteries with greatest stenosis less than 70%.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
This retrospective study showed that the use of RA grafts in patients aged 65 years and older reduced operating time, leg wounds infection, and hospital stay. In elderly patients, the aim of surgery is not only to prolong life; it also aims to return the patient to normal life as soon as possible, by reducing morbidity of surgery and the hospital stay.

The most common postoperative infection developing after CABG is leg wound infection. Although the incidence of the vein harvest site infection in this study appears to be high, it compares favorably to other studies where this complication has been reported to be as high as 13% following CABG surgery [13, 14]. Harvest site infections are probably under-reported; they contribute to prolonged length of stay, readmission, and, consequently, the increased costs they add to the health system. Extreme ages and duration of surgery are among the risk factors that have been associated with surgical site infections [13, 14]. It has also been suggested that the higher incidence of sternal infections after CABG surgery than with other open-heart procedures could be related to contamination from leg wound infection [15].

Recently, we have reported that despite the use of short leg incisions, leg wound infection occurred in a high percentage of patients having had SVG in addition to RA graft [12]. This suggests that leg wound complications are a significant source of morbidity after CABG surgery, causing delayed hospital discharge. In addition, we found that the incidence of forearm infection remains significantly lower than the leg wound infection. The harvest site infection could contribute to increased health expenditures due to the cost of readmission, antibiotic treatment, or specialist nurse home-visits.

The LITA graft to the left anterior descending artery remains the first choice because of its excellent long-term patency rates, survival, and reduction in late cardiac events [4]. In patients aged 65 years and older, our second choice has become the RA graft. It is a versatile conduit, it has handling characteristics superior to those of other arterial grafts, and it can be used on any target vessel [8]. Although the long-term benefit of arterial grafting may not be realized in the elderly, our results suggest that it is still advantageous in this group of patients. In addition, the forearm wound heals very well in comparison with leg wounds, leading to earlier postoperative mobilization [10]. Although the common belief that the use of arterial grafts is more technically demanding and associated with increased morbidity, over the last 4 years, we have adopted a policy of routine use of RA grafts in all patients, including the elderly.

In our series, the use of RA did not prolong operation time nor increase mortality or morbidity when compared to a younger population reported previously in our institution [12]. It is well established that leg wounds attract more infection [13, 14]. In our patients, the occurrence of SVG harvesting site infection was significantly higher when compared to RA harvesting site infection leading to prolonged hospital stays. Indeed, postoperative hospitalization still compared favorably with a previously reported series of patients [16].

Our data suggest that routine use of the RA graft in patients, aged 65 years and older, is not associated with increased morbidity and does not increase the operative risk or the complexity of CABG surgery. The technique of harvesting the RA is easy to learn [12]. It appears to minimize the leg dissection and therefore leg wound infection, especially in elderly patients prone to infection or impaired healing of the leg wound. The procedure is safe and does not appear to compromise graft outcome, as the angiographic early patency rate (92.3%) compares favorably with other series [12, 17].

Those findings strongly suggest that avoidance of SVG could reduce morbidity of CABG particularly in elderly patients. This retrospective study shows that routine use of RA graft in patients, aged 65 years and older, is feasible, safe, and does not increase mortality, morbidity, or the complexity of CABG surgery. Total arterial revascularization could be considered in elderly patients without increasing morbidity.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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