Ann Thorac Surg 2002;74:1262-1263
© 2002 The Society of Thoracic Surgeons
How to do it
A novel method for performing sequential grafts with the radial artery
Silvana Marasco, FRACS*a,
Donald Esmore, FRACS, FRCS (Edin)a
a CJOB Cardiothoracic Unit, Alfred Hospital, Melbourne, Australia
Accepted for publication May 1, 2002.
* Address reprint requests to Dr Marasco, Fellow in Thoracic and Cardiovascular Surgery, University of Virginia Medical Centre, PO Box 800136, Charlottesville, VA 22908 USA
e-mail: silvanamarasco{at}hotmail.com
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Abstract
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We describe a novel technique for the construction of radial artery sequential grafts. By using a 2.7-mm aortic hole punch in the radial artery we are able to form a circular arteriotomy. This allows greater flexibility with orientation of the sequential anastomosis and potentially a wider-open anastomosis. It also avoids the problem of picking up the back wall of this often thick-walled muscular artery given the better visibility afforded by the technique.
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Introduction
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Use of the radial artery has become increasingly popular since its successful reintroduction was reported by Acar and colleagues [1] in 1992. Medium-term results are now emerging that show a conduit with medium-term patency as good as the internal thoracic artery [2]. Furthermore, follow-up studies are suggesting that total arterial revascularization is associated with improved outcomes and may confer a survival advantage [3]. For this reason sequential grafts are a popular method of conserving conduit and achieving total arterial revascularization. The radial artery is ideally suited to sequential grafting and is much easier to use than the vein, which is prone to kinking as it bends, particularly at the sites of tied-off tributaries. However, there are a couple of drawbacks when using the radial artery in a sequential configuration. First, the muscular wall of the artery tends to curl in on itself at the site of a linear arteriotomy. This makes the suturing cumbersome and increases the risk of picking up the back wall of the radial artery. Second, the best lie of the sequential graft will often not be parallel with the coronary artery, but it may need to be rotated. A full 90° rotation, or true cruciate anastomosis, leads to a degree of deformation of the radial artery. Concerns regarding the hemodynamic significance of this deformation have been raised [4].
We describe a novel technique of sequential anastomosis using the radial artery designed to avoid the problems previously outlined.
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Technique
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The radial artery is harvested as per our described technique [5]. We generally cannulate the proximal end of the radial artery with a metal olive tipped cannula. This allows gentle distension of the radial artery for a more accurate assessment of length between anastomoses. It also allows assessment of the anastomosis once completed to confirm that it is hemostatic. The distal end-to-side anastomosis is performed first. The radial artery is then gently distended and the exact site of the sequential anastomosis and the lie of the radial artery are determined. A fine point blade is used to form a linear arteriotomy while the artery is distended to avoid incising the back wall. A 2.7-mm aortic hole punch is then used to create a uniform circular hole in the wall of the radial artery (Fig 1).
This circular arteriotomy incorporates roughly 30% of the circumference of the artery. The coronary arteriotomy is linear as per standard practice. A double armed 7.0 Prolene suture (Ethicon, Somerville, NJ) is used to form the sequential anastomosis. Each needle is passed from the adventitial surface through to the intimal surface of the arterial wall at one end of the radial artery circular arteriotomy (Fig 2).
Suturing then proceeds passing from intima to adventitia on the coronary. Both needles are used passing down each side of the anastomosis and then tied on the outside of the coronary artery.
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Fig 2. Each needle of a double-armed 7.0 prolene suture is passed from the adventitial surface through to the intimal surface of the arterial wall at one end of the radial artery circular arteriotomy.
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This technique allows rotation at the side-to-side anastomosis of almost any degree without deforming the radial artery. The use of the hole punch also stops the edges of the arteriotomy from rolling in on themselves, making the risk of picking up the back wall with the needle negligible. Inspection of the anastomosis shows that the technique does not lead to any flattening or distortion of the hood, which may be seen with the more conventional linear arteriotomy sequential anastomosis.
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Comment
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Use of arterial conduits and total arterial revascularization is now standard practice in many centers. Arterial conduits have proved easy to use and afford great versatility when planning revascularization with multiple grafts. Sequential anastomoses, T grafts and Y grafts are some of the techniques used to conserve available conduit when performing total arterial revascularization. Enthusiasm for these techniques is supported by early to midterm data showing excellent patency [2] of the radial artery and reduced in-hospital mortality [3] in patients with multiple arterial grafts.
Some concern, however, has been raised regarding cruciate (diamond shaped) sequential anastomoses as reported in an angiographic study by Dion and colleagues [4]. In that study, patency as assessed at angiography was significantly worse in cruciate sequential anastomoses than in parallel sequential anastomoses (91.5% versus 97.2% [p = 0.004]). The deformation that occurs in the conduit when a sequential anastomosis is rotated 90 degrees is often readily visible at the time of construction. The study by Dion and colleagues [4] suggests that this deformation is also hemodynamically significant. The technique we have described avoids distorting the vessel and provides excellent run off as confirmed by on-table injection of the constructed grafts. Furthermore, the technique is safe, expedient, simple, and reproducible.
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References
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- Acar C., Jebara V.A., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-659.[Abstract]
- Royse A.G., Royse C.F., Tatoulis J., et al. Postoperative radial artery angiography for coronary artery bypass surgery. Eur J Cardiothorac Surg 2000;17:294-304.[Abstract/Free Full Text]
- Royse A.G., Royse C.F., Tatoulis J. Total arterial coronary revascularization and factors influencing in-hospital mortality. Eur J Cardiothorac Surg 1999;16:499-505.[Abstract/Free Full Text]
- Dion R., Glineur D., Derouck D., et al. Long-term clinical, and angiographic follow-up of sequential internal thoracic artery grafting. Eur J Cardiothorac Surg 2000;17:407-414.[Abstract/Free Full Text]
- 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.[Medline]
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Abstract
Introduction
