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Ann Thorac Surg 2004;77:2071-2074
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Digital blood flow after radial artery harvest for coronary artery bypass grafting

Hyun-Sung Lee, MDa, Byung-Chul Chang, MDa*, Youn Jeong Heo, RNa

a Department of Thoracic and Cardiovascular Surgery, Yonsei Cardiovascular Center and Research Institute, Yonsei University College of Medicine, Seoul, South Korea

Accepted for publication November 20, 2003.

* Address reprint requests to Dr Chang, Yonsei Cardiovascular Center, Yonsei University College of Medicine, 134 Shinchon-dong, Seodaemun-gu, Seoul 120-752, South Korea
e-mail: bcchang{at}yumc.yonsei.ac.kr


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Despite widespread use of radial artery as a bypass conduit in coronary artery bypass surgery, flow readjustment that takes place in the hands and fingers after the removal of the radial artery is poorly understood.

METHODS: Using pulse volume recording plethysmography, a semiquantitative measurement of digital blood flow was carried out in 24 patients 7 days after harvesting of radial artery for coronary artery bypass grafting. Measurements taken from the fingers of the operated arms were evaluated and compared with those taken from the opposite or the control arms.

RESULTS: Postoperatively, there was an overall decrease in blood flow to all the fingers of the operated arms. At the same time, there was evidence of redistribution of digital blood flow favoring the first two fingers over the last two, the same distribution pattern as seen in the fingers of the control arms. The pulse amplitude studies, likewise, showed a significant drop in all fingers of the operated arms, with the decrease most pronounced in the fourth and fifth fingers. None of the patients showed signs of digital ischemia postoperatively.

CONCLUSIONS: The study showed that there was an overall decrease in digital blood flow after radial artery harvesting. The resulting blood supply by way of the remaining ulnar artery still provided more flow to the first two fingers over the last two fingers, indicating the existence of an autoregulatory mechanism operating to satisfy the physiologic needs of the fingers.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Because of its excellent patency rates when used as a bypass conduit, radial artery is being used widely in coronary artery bypass grafting [1, 2]. Although removal of radial artery in properly selected patients is considered safe [3–5, 9], the amount of information regarding the status of digital flow after radial artery " harvesting" is limited. There continues to be concern over the occurrence of postoperative circulatory insufficiency of hands and fingers in these patients [6–8].

To address this concern, attempts have been made to assess the adequacy of collateral flow by radial artery compression at wrist and the use of Doppler ultrasonography [10] or pulse volume recording (PVR) plethysmography [3, 4, 9–11]. This widely used method, however, is inadequate to assess the status of postoperative digital blood flow because it measures only the immediate and transient changes in blood flow. Starnes and associates [9] also reported a substantial number of false positives and false negatives with this test.

Pulse volume recording plethysmography has become an important instrument in the noninvasive studies of vascular disorders because of its accuracy in measuring the blood flow. Zweifler and associates [12] have clearly shown that PVR is a reliable indicator of digital blood flow. Archie and Larson [13] found a 100% correlation between PVR and arteriography, and Berger and Kleinert [14] found a 97% correlation between arteriography and various noninvasive methods, including PVR.

To evaluate the circulatory changes taking place after removal of the radial artery, we studied the digital blood flow by PVR plethysmography in 24 patients who had undergone coronary artery bypass grafting with radial artery as the bypass graft.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Twenty-four patients, 18 male and 6 female, with a mean age of 59.8 ± 7.6 years, were studied 7 days after the operation. In 10 volunteers, blood flow in both arms was measured and compared with establish the validity of using the opposite or the nonoperated arms as controls.

Radial artery harvesting
Preoperative evaluation of adequacy of ulnar artery and collateral flow were carried out in three stages. First, patients with a positive modified Allen's test and serum creatinine greater than 2.0 mg per day were excluded from the list [15]. Second, hand circulation was checked again using photo-plethysmography with oxymeter (Nellcor N-200; NELLCO Inc, Hayward, CA) in the operation theater [16, 17]. The oxymeter's digital probe was applied to the thumb, ensuring that the photoelectric sensor was correctly positioned over the nail bed. The radial and ulnar arteries were compressed manually at the wrist, and maintained for a period of approximately 30 seconds resulting in a flat line of the SpO2 of the thumbnail bed. The compression of ulnar artery was released and SpO2 was checked again. If the reappearance of the SpO2 curve was delayed more than 5 seconds, Allen's test was considered positive. Radial arteries were harvested from the nondominant left arms in all patients.

As a final check during the operation, adequacy of ulnar blood flow was determined by ligating and dividing the radial artery proximally and then, after releasing the proximal end, observing the blood flow from the divided end. The presence of a pulsatile flow was arbitrarily used as evidence of an adequate collateral flow. Finally, the distal part of the radial artery was tied and divided. The harvested vessel was preserved in heparinized autologous blood mixed with 5.0 mL of 1.0% papaverine.

Radial artery was exposed using a modified protocol with an ultrasonic scalpel (Ultracision, Smithfield, RI) [18]. The harvested radial artery was used either as a free graft or as part of a composite Y-graft with left internal mammary artery. Coronary artery bypass grafting was under mild hypothermic (33°C) cardiopulmonary bypass, and all patients received diltiazem hydrochloride (Herben SR; Hanil Pharmaceutical Co., Seoul, Korea) and nicorandil (Sigmart; Choongwae Pharmaceutical Co. LTD, Seoul, Korea) postoperatively.

Pulse volume recording
Pulse volume recording plethysmography (MVL Modulab; Life Sciences, HealthWatch Company; Vista, CA) of the arm and the fingers was performed 7 days after the removal of the radial artery. The patients were completely relaxed, and the ambient temperature in the laboratory was maintained between 23°C and 25°C to prevent excessive vasoconstriction induced by cold air. With the patients in supine position without sedation, the PVRs were obtained from the upper arms (12 cm x 23 cm cuffs), proximal forearms (12 cm x 23 cm cuffs), and the wrist (6 cm x 12 cm cuffs). A pressure of 65 mm Hg was applied with 100 ± 15 mL of air. Digital pressure cuffs were then attached to all fingers and the thumb (7 cm x 2 cm cuffs for most fingers and 9 cm x 3 cm for larger fingers). Air, 5 mL ± 3 mL, was injected into the cuffs to attain 40 mm Hg pressure.

Statistical analysis
Analysis of the data were performed with SPSS for Windows, version 11.0 (SPSS, Chicago, IL). Results are presented as mean and standard deviation. The Wilcoxon signed-rank test (paired test) was used to compare differences in digit pulse amplitudes between operated and unoperated arms. Pearson's {chi}2 test or Fisher's exact test was applied to compare differences in pulse morphology. A value of p less than 0.05 was taken as significant.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
In 10 volunteers, the pulse morphology and amplitude studies failed to show significant difference in the brachial, forearm, wrist, and all the fingers between the dominant and nondominant arms, making it possible for us to use the dominant (nonoperated) arms as controls (Table 1).


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  		Table 1. Comparison of Pulse Amplitudes at Various Locations Between Dominant and Nondominant Arms in 10 Volunteersa

 
The pulse morphology was divided into three general categories: normal, no reflected wave, and blunted wave forms, each representing normal, intermediate, and minimum blood flow (Fig 1). The distribution of each category in the fingers of the operated and control arms is shown in Figure 2. There was an overall diminution of digital flow of the operated arms in comparison with that of the control arms, indicated by the increased number of blunted flow forms. It was noticeable also that, in the absence of the radial artery, there was still more blood going to the thumb and index fingers than to the fourth and the fifth fingers.



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  		Fig 1. Types of wave forms recorded by pulse volume recording plethysmography. Normal: characterized by rapid systolic up-slope, a sharp systolic peak, and a diastolic down-slope with a dicrotic wave. Absence of reflected wave: a rapid ascending limb, an anacrotic notch, and a dicrotic notch high on the down-slope. Blunted: a delayed up-slope, a rounded peak, and a convex down-slope that bows away from the baseline.

 


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  		Fig 2. Distribution of the three wave forms among the fingers of the operated on and control arms. Digital pulse wave forms were classified into normal, absent reflected wave, and blunted types. (C = control arms; Op = operated arms; RWA = absence of reflected wave; 1 = first finger; 2 = second finger, 3 = third finger; 4 = fourth finger; 5 = fifth finger.)

 
The pulse amplitude findings are shown in Figure 3. In the operated arms, there was again general decline in the amplitude in all the fingers of the operated arms. Again, as in the fingers of the control arms, the wave amplitude was the greatest in the thumb, gradually tapering to the minimum height in the fifth finger. Table 2 shows that there was a statistically significant decrease in pulse amplitude in all the fingers, except for the middle finger.



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  		Fig 3. Comparison of digital pulse amplitudes between operated and nonoperated arms. (C = control arms; Op = operated arms; 1 = first finger; 2 = second finger, 3 = third finger; 4 = fourth finger; 5 = fifth finger.)

 

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  		Table 2. Comparison of Digital Pulse Amplitudes Between the Operated and Nonoperated Armsa

 
Clinically, none of our patents showed signs of arm and hand ischemia. One patient complained of a transient dysesthesia along the distribution of the superficial branch of the radial nerve; however, he felt no such symptom several months later.


   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Evaluation of the blood flow of the hand and fingers is difficult because of the dual arterial supply and the complex and inconsistent anastomosing branches. Coleman and Anson [19] stated that a complete arch is present in about 80% of cases and, in the remaining 20%, the collateral flow between the ulnar and radial systems may be inadequate. Ruengsakulrach and associates [20], in a study of 50 cadaver hands, reported that superficial palmar arch of the ulnar artery supplied flow to all fingers in 66% of the hands and deep palmar arch of the radial artery was found in 90% of the hands. They found that there was at least one major branch connecting the radial and the ulnar arteries and that, in the absence of vascular disease, harvesting the radial artery should be considered safe. This anatomical study fails to address the actual blood flow through the vessels. Dumanian and associates [21] suggested that vascular networks of the hand and fingers act much more like a single vascular bed than a set of semi-independent vascular beds based on the ulnar and radial arteries. They showed that the thumb and fifth fingers reacted the same way to ulnar artery compression at the wrist and that majority of fifth fingers lose pulsatile flow with radial artery compression.

In our study, digital blood flow was measured semiquantitatively using PVR plethysmography, which is considered to be accurate in measuring the blood flow [12–14]. The amplitude of the first fingers was higher than those of the third, fourth, and fifth fingers in the control group. Also, the amplitude of the second fingers was higher than that of the fifth fingers. These data were consistent with those of flow index difference calculated by photoelectric plethysmography reported by Stead and Stirt [22]. There was a significant decrease in blood flow to all fingers after the removal of the radial artery. It is important to note too that the inflow from the remaining ulnar artery still provided more flow to the thumb and the index finger than the last two fingers, indicating a rapid and substantial readjustment in blood flow to the fingers. This preferential flow to the thumb makes sense since it has larger tissue mass requiring more blood flow, a pattern seen in the operated arms as well as in the control arms. These findings suggest that the vascular bed of the hand and fingers may be considered, functionally, as a single vascular network, allowing redistribution of blood flow to occur between the fingers to satisfy the needs of individual fingers.

Another important factor which should be considered in the evaluation of digital blood flow is the change in size of the inflow vessel, the ulnar artery, after removal of the radial artery. Brodman and colleagues [23] reported that, after radial artery removal, there was an 11% increase in diameter of the ulnar artery by color flow Doppler scanning and 20% increase blood flow velocity by pulsed Doppler scanning. Similarly, Pola and associates [3] reported increased blood flow velocity in the ulnar artery within 10 days and again at 1 year after radial artery harvesting.

As regards serious complications after radial artery harvest, Nunoo-Mensah [24] reported a patient who developed an acute ischemia in spite of perioperative studies showing adequate collateral vessels. Angiography showed an absence of ulnar artery and vessel continuity was reestablished by a vein graft. Fox and associates [25] reported a patient who developed an acute upper limb ischemia despite adequate preoperative and intraoperative assessment with Allen test, hand-held Doppler, and radial artery back-bleeding. It was successfully treated with a brachioradial bypass using reversed vein graft. Fortunately such complications are rare in properly selected patients. Clinically, all of our patients did well, despite overall decrease of digital flow in the operated arms. Compensatory increase of the ulnar blood flow combined with redistribution of the digital blood flow that is adequate to meet the physiologic demands of the hands and fingers may explain the relatively benign outcome.

In conclusion, this study shows that, 7 days after radial artery harvest, there is substantial reduction of blood flow to the fingers of the operated arm and that there is redistribution of flow to the fingers whereby more blood flow goes to the thumb and the index fingers than to the fourth and fifth fingers even in the absence of the radial artery. This finding implies the existence of abundant collateral channels between the two arteries and an autoregulating mechanism where blood flow to the fingers is determined by the physiologic needs of individual fingers.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Drs S. H. Cho and K. C. Tark for their insightful comments in preparing this article. We are also grateful to Dr P. W. Hong for reviewing this article.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

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  11. Rodriguez E., Ormont M.L., Lambert E.H., et al. The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting. Eur J Cardiothorac Surg 2001;19:135-139.[Abstract/Free Full Text]
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