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Ann Thorac Surg 2002;74:S1368-S1370
© 2002 The Society of Thoracic Surgeons

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Supplement: Cardiothoracic Techniques and Technologies

Pretreatment with -adrenergic blockers for prevention of radial artery spasm

^a Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel

* Address reprint requests to Dr Mohr, Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel.
e-mail: raphmohr{at}tasmc.health.gov.il

Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
BACKGROUND: Radial artery (RA) conduits are prone to early vasospasm. Current intraoperative treatment with papaverine fails to inhibit postoperative RA constriction. Pretreatment with topical -antagonist solutions can inhibit RA vasoconstriction and cause dilatation for a longer period than achieved with papaverine.

METHODS: In 10 patients undergoing myocardial revascularization, the radial artery was harvested as a skeletonized vessel. A composite graft with reverse free RA on an in situ left internal thoracic artery was prepared before construction of distal coronary anastomoses. The RA pedicle was then put in a small syringe filled with Regitine (phentolamine methansulphonic, 0.07 mg/mL) ("Jacuzzi") and warmed by immersing the container in a warm saline bath for 8 to 15 minutes. The RA free flow was measured before and after topical treatment with Regitine.

RESULTS: The mean number of grafts per patient was 2.9 (range 2 to 4). The mean number of radial anastomoses was 1.8 per patient. Left internal thoracic artery free flow was 110 ± 29 mL/min. Regitine increased radial free flow from 49 ± 35 to 77 ± 30 mL/min (p < 0.01). Five patients underwent postoperative coronary angiography. All radial anastomoses were patent.

CONCLUSIONS: Topical treatment of RA with Regitine increases RA free flow and is an effective intraoperative means of decreasing RA spasticity.

	Introduction

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The radial artery, like all other arteries, develops spasm during harvesting. However, since its media is significantly thicker than the media of other conduits, the spasm is more intense and more difficult to reverse [1].

The spastic characteristics of the radial artery warrant the use of vasodilators during harvesting and during both the perioperative and postoperative periods [2]. In the standard protocol suggested by Acar and colleagues [2], papaverine is used topically during harvesting and diltiazem is used perioperatively and postoperatively as a systemic vasodilator. Other agents used for radial artery vasodilatation include Ca²⁺ channel blockers (verapamil, nifedipine) and organic nitrates (isosorbid dinitrate) [3].

Various vasoconstrictors have been suggested to be spasmogens of the radial artery [4]. Among these spasmogens, -adrenoreceptor stimulants are important vasoconstrictors [1], and in vitro studies have shown that -blockers (phenoxybenzamine) can prevent and abolish the -adrenoreceptor mediated radial spasm [5].

In this study, we evaluated the effect of intraoperative topical application of the -blocking agent Regitine (phentholamine methansulphonic) on spasticity of radial arteries connected end-to-side to in situ left internal thoracic arteries (ITAs).

	Material and methods

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Ten patients electively underwent complete arterial myocardial revascularization with the left internal thoracic artery (ITA) and radial artery (RA). The Allen test with pulse oxymetry was used to assess adequacy of blood supply to the nondominant hand from the ulnar artery [2]. All ITAs and RAs were harvested as skeletonized vessels [6], and small hemoclips (Ligaclip, Ethicon, Cincinnati, OH) were used to control side branches. In all patients studied, the left (nondominant) RA was harvested at the same time as the left ITA. The distal ends of both arteries were double-clipped and divided after administration of heparin (300 U/kg). The distal RA was divided 2 cm above the wrist joint to preserve collateral circulation. Closing the distal end of the arteries enabled hydraulic distention of the skeletonized artery by pulsation of the arterial pressure wave against the walls of the blocked artery. The in situ blocked skeletonized ITA was put in a small syringe filled with 1:30 papaverine:saline solution. The papaverine was warmed to 36°C by immersing the container in warm saline. This "Jacuzzi" bath of warm papaverine is suitable for relaxing any spasm produced during ITA dissection without the risk of endothelial damage associated with intraluminal mechanical dilatation or papaverine injection [7]. Similarly, the in situ blocked skeletonized RA is put into a Jacuzzi bath filled with warmed Regitine (phentholamine methansulphonic, 0.07 mg/mL) (Promedico, Petah Tikra, Israel) (Fig 1).

View larger version (90K): [in this window] [in a new window]   Fig 1. Radial artery (RA) after harvesting. Blocked distal end is immersed in a "Jacuzzi" bath filled with Regitine (phentolamine methansulphonic, 0.07 mg/mL).

View larger version (22K): [in this window] [in a new window]   Fig 2. Composite T graft with reversed free radial artery (RA) on in situ left internal thoracic artery (LITA). (A) Before exposure of proximal RA (Prox RA) to Regitine (phentolamine methansulphonic, 0.07 mg/mL). (B) Reversed RA immersed in a "Jacuzzi" bath with Regitine solution. (C) Dilated RA after topical treatment of its proximal end with Regitine solution.

Seven patients underwent surgery without extracorporeal circulation (CPB), whereas 3 underwent surgery with CPB and intermittent warm blood cardioplegic arrest. The left ITA was used for grafting the anterior descending artery and the RA for grafting circumflex marginals and PDA. Sequential anastomoses were performed with both grafts as necessary. All patients were offered the option of control postoperative angiography. However, in only 5 of them (50%) was informed consent obtained and angiography performed.

Statistical analysis
Data are expressed as mean ± standard deviation. Student’s t and paired t tests were used as required to compare arterial flow data.

	Results

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The study group included 8 men and 2 women. Mean age was 70 years (range 61 to 70 years). Six patients were older than 70 years, 3 were diabetic, and 3 had left ventricular dysfunction (EF <35%). The mean number of grafts was 2.9 (range 2 to 4) per patient. The mean number of radial anastomoses was 1.8 per patient.

The average rate of free flow of the skeletonized ITA with topical application of papaverine after construction of composite T anastomosis was 110 ± 29 mL/min. This rate of free flow was significantly higher than the free flow in the RA sidearm of the composite T graft (49 ± 35 mL/min, p < 0.001).

After being immersed in the Regitine Jacuzzi bath for 8 to 15 minutes, the proximal segment of the RA was dilated (Fig 2), and RA free flow increased in all patients (mean 77 ± 30 mL/min). This increase in RA free flow was highly significant (p < 0.001 paired t test).

There was no operative mortality in this group of 10 patients. All ITA and RA anastomoses were patent in the 5 patients who consented to postoperative coronary angiography.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The results of this study showed that topical application of the -antagonist Regitine to skeletonized RA, by immersing it in a Jacuzzi bath filled with the drug, is an effective means to counteract the vasospastic response of this artery. All segments of the RA were evenly exposed to the compound effect of the -adrenergic blocker and the hydraulic distension of the artery by pulsation of the arterial pressure wave against the walls of the blocked artery. This technique caused a significant increase in RA diameter and consequently a significant increase in its measured spontaneous free flow. This antispastic maneuver was also clinically very effective.

None of the patients studied had lapsed hypoperfusion syndrome [8] during the immediate postoperative course. All patients are well and asymptomatic 1 to 12 months postoperatively, and all RAs were found to be patent in patients who underwent control postoperative angiography.

The RA spasm and the hypoperfusion syndrome, which is more common in patients undergoing CABG with RA, is probably related to increased levels of catecholamines and other vasoconstrictor mediators released perioperatively [9]. Endogenous levels of catecholamines are increased around 3- to 4-fold in association with cardiopulmonary bypass. These levels persist for about 24 hours [10]. Furthermore, exogenous catecholamines with -agonist effect (norepinephrine, high-dose dopamine) that can cause further RA contraction are commonly used perioperatively. In vitro studies have shown that RA reactivity to vasoconstrictors is significantly greater than that of ITA or saphenous vein grafts [11]. This may be related to increased muscularity of this artery, but may also be the result of RA denervation during harvesting. Denervation caused an increased expression of -adrenoceptors in the artery, which would potentiate vasoconstriction in response to -adrenoceptor agonists [12].

Our study confirms the results of recently published in vitro studies that showed excellent antispastic effect of topical -antagonist treatment on the radial artery [5].

The study results suggest that exposure of RA to Regitine by our technique for a very short period (8 to 15 minutes) is sufficient to relieve the spasm induced by surgical handling of the skeletonized artery. The RA is dilated, and its free flow is probably sufficient for the circumflex and right coronary territories. Based on results of in vitro studies and postoperative coronary angiography, we can assume that this antispastic effect lasts longer than the intraoperative period. Further studies are required to compare this technique with other methods and to assess long-term patency of RA treated with this -blocking agent.

	References

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1. Chardigny C., Jebara V.A., Acar C., et al. Vasoreactivity of the radial artery: comparison with the internal mammary artery and gastroepiploic arteries with implications for coronary artery surgery. Circulation 1993;88:115-127.
2. Acar C., Buxton B., Norsworthy C., Eizenberg N., Liu J.J., Taggart D. Radial Artery. In: Buxton B., Frazier H., Westaby S., eds. Ischemic heart disease and surgical management. London: Mosby, 1999:155-157.
3. Cable D.G., Caccitolo J.A., Pearson P.J., et al. New approaches to prevention and treatment of radial artery graft vasospasm. Circulation 1998;98:II-15-22.
4. He G.-W., Yang C.-Q., Starr A. Overview of the nature of vasoconstriction in arterial grafts for coronary operations. Ann Thorac Surg 1995;59:676-683.[Abstract/Free Full Text]
5. Taggart D.P., Dipp M., Mussa S., Nye P.C.G. Phenoxybenzamine prevents spasm in radial artery conduits for coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;170:115-117.
6. Gurevitch J., Kramer A., Locker C., et al. Technical aspects of double-skeletonized internal mammary artery grafting. Ann Thorac Surg 2000;69:841-846.[Abstract/Free Full Text]
7. Cooper G.J., Gillot T., Parry E.A., Kennedy A., Wilkinson G.A.L. Papaverine injures the endothelium of the internal mammary artery. Cardiovasc Surg 1995;3:553-555.[Medline]
8. Manasse E., Sperti G., Suma H., et al. Use of the radial artery for myocardial revascularisation. Ann Thorac Surg 1996;62:1076-1082.[Abstract/Free Full Text]
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12. Massa G., Johansson S., Kimblad P., et al. Might free arterial grafts fail due to spasm?. Ann Thorac Surg 1991;51:94-101.[Abstract]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): C. Locker O. Lev-Ran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Locker, C. Articles by Shapira, I. Search for Related Content PubMed PubMed Citation Articles by Locker, C. Articles by Shapira, I. Related Collections Coronary disease