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Ann Thorac Surg 2004;78:535-538
© 2004 The Society of Thoracic Surgeons

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Original article: cardiovascular

Long-term neurologic hand complications after radial artery harvesting using conventional cold and harmonic scalpel techniques

^a Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA

Accepted for publication January 22, 2004.

^* Address reprint requests to Dr Moon, Division of Cardiothoracic Surgery, Queeny Tower, Suite 3108, One Barnes-Jewish Hospital Plaza, St. Louis, MO, USA 63110-1013
e-mail: moonm{at}msnotes.wustl.edu

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.

	Abstract

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 
BACKGROUND: The purpose of this study was to determine the incidence of neurologic hand complications after radial artery harvesting and to compare the harmonic scalpel versus conventional cold scalpel technique.

METHODS: From 1995 to 2000, 786 radial arteries were harvested from 782 patients for coronary artery bypass grafting. From 1995 to 1997, the conventional cold scalpel technique was used (422 patients), and from 1998 to 2000, the harmonic scalpel was used (360 patients). Mean follow-up was 4.2 ± 2.1 years and was 90% complete. Symptoms included thumb weakness or numbness, tingling, or pain in the hand.

RESULTS: The incidence of neurologic hand complications was similar with both techniques (11.2% ± 3.5% cold, 11.0% ± 3.6% harmonic, p > 0.95), and in 19% (13 of 67 with symptoms) there was complete resolution within 1 year. Symptoms persisted long-term in 9.0% ± 3.2% cold scalpel and 9.0% ± 3.3% harmonic scalpel patients (p > 0.81), but were considered a "constant and significant source of discomfort" in only 0.6% ± 0.9% cold scalpel and 1.4% ± 1.3% harmonic scalpel patients (p > 0.41).

CONCLUSIONS: The incidence of adverse neurologic outcomes causing significant long-term discomfort in the hand was low using either the cold scalpel or harmonic scalpel technique. However, a significant number of patients had neurologic hand symptoms in both groups, and this should be included when discussing operative risks with the patient.

	Introduction

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The most common complications in the early postoperative period after radial artery harvesting are neurologic abnormalities in the hand caused by either traction or thermal injury to adjacent sensory or motor nerves [1–7]. The lateral antebrachial cutaneous nerve lies at the level of the fascia enveloping the brachioradialis muscle at its volar border and supplies the skin of the radial aspect and adjacent dorsal surface of the forearm. The superficial radial nerve, also a sensory nerve, supplies the dorsal skin of the thumb, usually to the proximal interphalangeal joint, but occasionally more distally. The superficial radial nerve travels beneath the brachioradialis muscle and parallel to the radial artery in its proximal and middle third. The median nerve, which supplies muscular and cutaneous branches to the hand, is relatively distant and deep to the radial artery in the mid forearm, but it can potentially be injured as it approaches the radial artery at the wrist. Early neurologic hand complications have been reported in up to 49% of patients after radial artery harvesting for coronary artery bypass grafting [5], but the incidence of symptoms persisting long-term remains unclear.

Recent reports have suggested that use of the harmonic scalpel during radial artery harvesting may be less traumatic compared with conventional techniques, thereby decreasing spasm of this delicate conduit [8–10]. However, the impact of the harmonic scalpel on neurologic injury in the immediate postoperative period remains unknown, as does the long-term incidence of neurologic complications with either technique. The purpose of this study was to determine the incidence of neurologic hand complications after radial artery harvesting and to compare the harmonic scalpel versus conventional cold scalpel technique.

	Material and methods

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From January 1995 to December 2000, 782 patients underwent harvesting of 786 radial arteries at Washington University Medical Center (Barnes-Jewish Hospital). There were 554 (71%) men and 228 (29%) women, with a mean age (± 1 standard deviation) of 61 ± 10 years (range, 27 to 87 years).

Surgical technique
Circulation to the hand was assured preoperatively with a negative Allen's test (capillary refilling within 10 seconds). The left radial artery was harvested in 86% of patients, using the nondominant hand in 90%. All radial harvesting was performed by 1 of 5 surgical assistants, all of whom used the same surgical techniques. In all patients, a standard curvilinear incision over the radial artery was used to facilitate harvesting from its origin in the proximal forearm to the wrist crease as previously described [9]. Low-current diathermy was used for the subcutaneous tissue and deep fascia in the proximal third of the forearm where the radial artery is well away from the fascia. The deep fascia in the distal forearm was incised with scissors to avoid thermal injury as the artery became more superficial. A self-retaining retractor was used to separate the brachioradialis and flexor carpi muscles, and a silicone elastomer vessel loop was placed around the radial artery pedicle to include the radial artery venous comitantes and fatty areolar tissue.

From 1995 to 1997, the conventional cold scalpel technique was used in 422 patients. In the cold scalpel group, the radial artery was mobilized using a combination of sharp and blunt dissection, and the branches of the radial artery were divided between small clips using scissors. From 1998 to 2000, the harmonic scalpel technique was used in 360 patients. Patients in the harmonic scalpel group underwent ultrasonic dissection of the radial artery pedicle (Harmonic Scalpel; Ethicon, Cincinnati, OH) using the sharp-pointed hook blade (HS2) at moderate intensity with the variable mode. Branches that bled during or after transection were controlled with small clips. After harvest, the radial arteries from both groups were bathed in 30 mL of heparinized blood containing 60 mg of papaverine for at least 5 minutes.

Operative mortality (30 days or before hospital discharge) occurred in 17 patients, yielding an overall mortality rate of 2.2% ± 1.0% (± 95% confidence limits). At the time of late follow-up, an additional 85 patients were no longer alive, leaving 680 patients available for late neurologic assessment. Surviving patients were contacted by mail or telephone during a 9-month closing interval ending October 2002. Of these, 602 patients completed the assessment (312 cold scalpel, 290 harmonic scalpel), making follow-up 90% complete. Mean follow-up for the entire group was 4.2 ± 2.1 years, longer in the cold scalpel group (5.6 ± 1.6 years) than in the harmonic scalpel group (2.5 ± 1.2 years; p < 0.01).

Patient characteristics
Selected preoperative and intraoperative clinical patient characteristics for the cold scalpel and harmonic scalpel groups are listed in Table 1. The harmonic scalpel group was slightly older (p < 0.05) with more peripheral vascular disease (p < 0.04) and diabetes mellitus (p = 0.08), but the cold scalpel group had more smokers (p < 0.004).

Statistical analysis
Continuous data are reported as mean ± 1 standard deviation and were compared between groups using Student's t test. Clinically important ratios are reported with 95% confidence limits. Univariate analysis (² test) and multivariate stepwise logistic regression analysis were used to determine the preoperative and intraoperative risk factors that were significant, independent predictors of late neurologic hand complications (SPSS 11.0 for Windows; SPSS Inc, Chicago, IL). Twenty variables were analyzed: age, year of operation, sex, race, hypertension, diabetes mellitus, cerebrovascular disease, peripheral vascular disease, chronic renal insufficiency, chronic pulmonary disease, angina class, New York Heart Association class, history of myocardial infarction, previous coronary artery bypass grafting, cigarette smoking, cardiopulmonary bypass time, cross-clamp time, right versus left radial harvest, dominant hand harvest, and cold versus harmonic scalpel technique.

	Results

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The incidence of neurologic hand complications at any time during the postoperative period was 11.1% ± 2.5% overall (67 of 602 patients) and was similar with both techniques (11.2% ± 3.5% cold scalpel, 11.0% ± 3.6% harmonic scalpel, p > 0.95). In 19% of those with symptoms (13 of 67 patients), there was complete resolution within 1 year (mean time to resolution, 9.3 months). Symptoms persisted at late follow-up in 9.0% ± 2.3% (54 patients at 4.2 ± 2.1 years). The incidence of late neurologic hand complications was similar in the cold scalpel (9.0% ± 3.2%) and harmonic scalpel (9.0% ± 3.3%) groups (p > 0.81; Table 2). Late complications for the entire population included thumb weakness in 2.8% ± 1.3%, dorsal hand symptoms in 6.6% ± 2.0%, and palmar hand symptoms in 5.3% ± 1.8%. Palmar symptoms were isolated to the base of the thumb in all patients, suggesting superficial radial nerve injury rather than median nerve injury, which would have affected the midpalm. The distribution of neurologic hand complications to the dorsal or palmar surface of the hand was similar in the cold scalpel and harmonic scalpel groups (Table 2). In patients with long-term complications, the symptoms were considered a "constant and significant source of discomfort" in 0.6% ± 0.9% (2 patients) in the cold scalpel group and 1.4% ± 1.3% (4 patients) in the harmonic scalpel group (p > 0.41).

	Comment

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Few reports have examined the incidence of long-term neurologic hand complications (greater than 12 months), but in the early postoperative period, the incidence ranges from 9% to 49% [1–7]. Meharwal and Trehan [3] reported a 28% incidence of hand numbness or paresthesias in 3,977 patients immediately after radial harvesting, but the sensory symptoms persisted in only 10% at 3 months. Denton and associates [4] similarly reported a 30% incidence of hand complaints in 615 patients immediately postoperatively, but the symptoms persisted after an average of 15 months in only 12%, with most patients reporting resolution by 9 months. Using multivariate analysis, they identified smoking as the most important predictor of sensory loss at late follow-up. In the current report, we were unable to isolate any independent predictors of late neurologic hand complications; most specifically, the incidence was 8% in smokers compared with 10% in nonsmokers (p > 0.31).

Hata and associates [6] from Melbourne prospectively studied 155 low-risk patients (no peripheral vascular disease, obesity, or diabetes) at 3 and 12 months. Hand pain fell from 16% to 8% during the first year, whereas numbness decreased from 21% to 13%. In the current series, hand symptoms similarly resolved in 19% of patients at 1 year. These authors also noted at 3 months that 4% of patients thought that their daily activities were negatively affected by the neurologic problems in their hand; this declined to 1.3% at 12 months, consistent with the incidence of major long-term functional impairment in 0.6% with the cold scalpel and 1.4% with the harmonic scalpel technique in the current report. In another prospective analysis of 271 patients, Budillon and colleagues [7] reported sensory complaints in 9% at the time of hospital discharge, which decreased to only 4% at 8 weeks. However, smoking and diabetes, both of which were identified as risk factors for neurologic complaints, were not very common in their series, present in only 15% and 18%, respectively, compared with 60% and 33% in the current report.

Previous investigators have speculated that the harmonic scalpel may decrease neurologic hand complications, but in the current report, the incidence of neurologic complications was similar with the cold scalpel and harmonic scalpel harvesting techniques. In the harmonic scalpel group, 9% ± 2% of patients experienced numbness, pain, or subjective weakness 2.5 ± 1.2 years postoperatively compared with 9% ± 3% in the cold scalpel group at 5.6 ± 1.6 years. We believe, however, that the harmonic scalpel may offer some benefit in regards to flow dynamics immediately after harvesting, and therefore continue to use it when available. In an earlier report from our group it was noted that flow through the radial artery was higher after harmonic versus conventional cold scalpel harvesting both in situ (53 mL/min versus 17 mL/min; p < 0.001) and after proximal anastomosis to the internal thoracic artery as a T graft (51 mL/min versus 39 mL/min; p < 0.01) [9]. Experimentally, however, Cikirikcioglu and colleagues [11] assessed vasoreactivity and endothelial integrity of radial arteries harvested using the harmonic scalpel compared with low-energy electrocautery and found that the vasoreactive response to contraction (phenylephrine, 5-hydroxytryptamine) and relaxation (acetylcholine, nitroglycerin) was equal with both techniques.

Endoscopic harvesting techniques were originally proposed to improve cosmesis and hasten healing [12, 13], but although early reports suggest that these techniques do not impact neurologic complications in the hand, they may decrease the incidence of sensory loss in the distribution of the lateral antebrachial cutaneous nerve. Similar to the current series, Connolly and associates [13] reported a 9% incidence of objective dorsal thenar numbness in 300 patients undergoing endoscopic radial artery harvesting, presumably because of superficial radial nerve trauma. However, they noted that paresthesias and numbness did not occur in the forearm, presumably because of avoidance of the lateral antebrachial cutaneous nerve, which traverses over the brachioradialis muscle fascial sheath proximally. With endoscopic techniques, the need for traction and diathermy in the proximal forearm is minimized. In the current report, forearm numbness was not specifically evaluated, but the absence of forearm symptoms in the series by Connolly and coworkers [13] compares favorably with others reporting forearm sensory loss in 10% of patients and scar discomfort in 33% of patients undergoing radial harvesting with open techniques [1].

In summary, the current report demonstrated that neurologic hand complications are not uncommon after radial artery harvesting, persisting in 9.0% ± 2.3% of patients 4.2 ± 2.1 years postoperatively. However, there was no difference in the incidence of late neurologic hand complications when comparing patients undergoing conventional cold scalpel versus harmonic scalpel harvesting techniques. Fortunately, disabling symptoms were rare, and most patients tolerated sensory loss and subjective thumb weakness without a significant limitation in hand activities. The risk of long-term neurologic hand complications should be included when discussing operative risks with the patient and patient's family preoperatively.

	Acknowledgments

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The authors gratefully acknowledge the clinical contributions of Thoralf M. Sundt III, MD, and William A. Gay, Jr, MD, and the statistical contributions of Tracey J. Guthrie, RN.

	Discussion

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DR THORALF SUNDT (Rochester, MN): Marc, have these data tempered your enthusiasm at all for the use of the radial artery? We have used the skeletonized right internal mammary artery quite a bit in Rochester because of this kind of a problem. It really puts a dent in some people's golf game, these neurologic complications.

DR MOON: Thor, I think you are right. The neurologic complications can have a negative impact on an interlocking grip. These potential complications are something we certainly have to discuss with the patient preoperatively and see what their impressions are and how such a complication could impact their daily activities. Specifically, for patients who work with their hands, the possibly of long-term changes needs to be discussed. I find that cosmesis can also be an issue; patients end up with a scar on the arm as opposed to the leg, which can obviously be hidden with a pair of slacks. I do not currently use bilateral mammary arteries, mostly because of my concerns about infection and delayed sternal healing, but some in our group have been quite pleased with this option in selected patients.

I had a plastic surgeon a couple of months ago who wanted to know the pros and cons of radial artery harvesting; he was 50 years old. I showed him our data, and he said, "I think I'll stick with the vein."

	References

Top Abstract Introduction Material and methods Results Comment Acknowledgments Discussion References

 

1. Tatoulis J., Buxton B.F., Fuller J.A. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998;66:714-720.[Abstract/Free Full Text]
2. Greene M.A., Malias M.A. Arm complications after radial artery procurement for coronary bypass operation. Ann Thorac Surg 2001;72:126-128.[Abstract/Free Full Text]
3. Meharwal Z.S., Trehan N. Functional status of the hand after radial artery harvesting: results in 3,977 cases. Ann Thorac Surg 2001;72:1557-1561.[Abstract/Free Full Text]
4. Denton T.A., Trento L., Cohen M., et al. Radial artery harvesting for coronary bypass operations: neurologic complications and their potential mechanisms. J Thorac Cardiovasc Surg 2001;121:951-956.[Abstract/Free Full Text]
5. Saeed I., Anyanwu A.C., Yacoub M.H., Amrani M. Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life. Eur J Cardiothorac Surg 2001;20:1142-1146.[Abstract/Free Full Text]
6. Hata M., Raman J., Seevanayagam S., Hare D., Buxton B.F. Post radial artery harvest hand perception: postoperative 12-month follow-up results. Circ J 2002;66:816-818.[Medline]
7. Budillon A.M., Nicolini F., Agostinelli A., et al. Complications after radial artery harvesting for coronary artery bypass grafting: our experience. Surgery 2003;133:283-287.[Medline]
8. Posacioglu H., Atay Y., Cetindag B., Saribulbul O., Buket S., Hamulu A. Easy harvesting of radial artery with ultrasonically activated scalpel. Ann Thorac Surg 1998;65:984-985.[Abstract/Free Full Text]
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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): Marc R. Moon Hendrick B. Barner Marci S. Bailey Jennifer S. Lawton Nader Moazami Michael K. Pasque Ralph J. Damiano, Jr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Moon, M. R. Articles by Damiano, R. J. Search for Related Content PubMed PubMed Citation Articles by Moon, M. R. Articles by Damiano, R. J., Jr Related Collections Coronary disease