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Ann Thorac Surg 2004;78:539-542
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm

Alistair G. Royse, MBBS, MDa,c*, Colin F. Royse, MBBS, MDb,c, Atul Maleskar, MBChBa, Anurag Garg, MBChBa

a Department of Cardiac Surgery, The Royal Melbourne Hospital, Melbourne, Australia
b department of Anaesthesia and Pain Management, University of Melbourne, Melbourne, Australia
c department of Pharmacology, University of Melbourne, Melbourne, Australia

Accepted for publication February 17, 2004.

* Address reprint requests to Dr Royse, PO Box 2135, The Royal Melbourne Hospital, Victoria, Australia, 3050
e-mail: alistair.royse{at}mh.org.au


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 
BACKGROUND: Use of the radial artery as a conduit for coronary artery surgery has increased dramatically. It has been assumed that blood flow to the forearm will not be compromised by its removal.

METHODS: Sixteen patients who had the left radial artery harvested for coronary surgery at least 3 months earlier were studied. The right radial artery was not harvested. The radial, ulnar, and brachial artery diameters and flows were measured using pulsed wave Doppler with a 15-MHz linear array transducer. Measurements were performed at rest, with the right radial artery compressed, and after ischemia with forearm exercise.

RESULTS: At rest, the (mean ± SE) diameter of the left ulnar artery was consistently greater than the right (2.4 ± 0.09 versus 2.1 ± 0.09 mm, p = 0.001) as was flow (74 ± 9.9 versus 48 ± 8.5 mL/min, p = 0.005). There was no difference between diameters or flows in the brachial arteries. After compression of the radial artery, flow increased in the right ulnar artery from 39 ± 8.0 to 72 ± 17.6 mL/min (p = 0.019) without an increase in ulnar artery size and was not different from the left ulnar artery flow at rest (p = 0.440). After ischemic forearm exercise, flow increased in the two brachial arteries almost equally (left, 348 ± 50; right, 371 ± 63 mL/min).

CONCLUSIONS: Blood flow to the forearm and hand is not compromised by harvest of the radial artery.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Acknowledgments
 References
 
Use of the radial artery in coronary artery bypass surgery was first attempted by Carpentier and associates [1] in the early 1970s and then abandoned some years later after poor early angiographic patency [2]. The use of radial artery was first revived by Acar and coworkers [3] in 1992. Apart from patency of this conduit, the principal concern was what would be the prospective incidence of hand ischemia; this was found to be rare [4, 5]. Subsequently, angiographic patency of radial artery has been found to be good [6–9]. Late angiographic patency is not yet available. It is presumed that the durability of arterial conduit will greatly exceed that of saphenous vein.

At present, most studies have examined the Allen test or a variation on this test as an index of the immediate safety for harvesting the radial artery. There have been relatively few functional studies involving strength or dexterity of the hand and forearm or studies examining blood flow after harvesting of the radial artery [4, 5, 10–12].

We report the maximum blood flow to the forearm and hand in this study comparing one arm where the radial artery was harvested and the opposite arm where no radial artery was harvested as the control.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Acknowledgments
 References
 
Institutional Human Ethics Committee approval and informed written patient consent were obtained from 16 patients who had previously undergone coronary surgery at least 3 months earlier. In all cases, the left radial artery (nondominant hand) had been harvested as a conduit. The right radial artery had been cannulated at the time of surgery for blood pressure monitoring.

Radial artery harvest technique
The radial artery harvest included the satellite veins and occurred within the neurovascular fascia [4]. All patients received arterial grafts constructed from the left internal mammary artery and left radial artery as a Y graft and used to graft all coronary territories [13]. Operations were performed with cardiopulmonary bypass, using a membrane oxygenator and 40 µm arterial filter. Perfusion temperature was 35°C with rewarming to 36.5°C before removal of the aortic clamp. Myocardial protection was by intermittent tepid anterograde and retrograde blood cardioplegia.

Measurement of blood flow in arm and forearm
The radial and ulnar arteries were imaged at the flexor skin crease, and the brachial artery was imaged immediately proximal to the elbow. Patients were seated for all measurements. Pulsed wave Doppler ultrasonography was used, and vessels were imaged in both short-axis and long-axis views with a 15-MHz linear array transducer and a Sonos 4500 echocardiography machine (Philips, Andover, MA), as shown in Figure 1. Flow was measured within the vessels using pulsed wave Doppler according to the formula:

The cross-sectional area was calculated from the vessel diameter, measured from "intima to intima." The velocity time integral was measured by tracing around the edge of the pulsed wave Doppler spectral display (Fig 1). The probe was positioned and the Doppler trace optimized. One screen of tracing was stored in digital format for offline analysis and contained three or four pulse traces (Fig 1). Two independent observers performed the measurements from this offline digital data by averaging the measurements from three consecutive heartbeats. The final measurement analyzed, was the average of the measurements from these two observers. Early in the project some measurements were not correctly stored to disk and were not available for offline analysis.



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  		Fig 1. Color doppler of the radial artery with pulsed wave spectral trace of flow. Velocity time integral is calculated by tracing the area under the spectral trace.

 
Measurements were performed at two time intervals, to determine resting conditions and maximal blood flow. During resting conditions, the ulnar and brachial arteries of both forearms and the radial artery of the right forearm were measured with the patient seated. Additionally, flow in the right ulnar artery was measured immediately after pressing on the radial artery to occlude it. To determine maximal blood flow, a blood pressure cuff was placed around the patient's arm and inflated above systolic arterial pressure. The patient was instructed to exercise the hand until the forearm became fatigued; after at least 3 minutes, measurements were made. Ludbrook [14] had previously found that flow after either ischemia or exercise alone did not achieve maximal flow. Flow after the ischemic forearm exercise represents the maximal blood flow requirements to the forearm [14]. Blood flow was measured in the brachial artery immediately after deflation of the blood pressure cuff. Measurements were performed on both arms, with the right arm earlier.

Doppler as a method of measuring flow has been previously validated with plethysmography in the forearm [15], with steady state diffusion of the umbilical cord in sheep [16], with invasive arterial and electromechanical assessment in human subclavian artery and aorta [17], and with thermodilution in humans [18].

Statistical methods
Comparisons between left and right arms were performed using the paired Student's t test. Statistical significance was defined as p less than 0.05. The families of endpoints were as follows: vessel diameters and flow measurements at rest; ulnar artery measurements with radial artery compression; and brachial artery diameters and flow after ischemic forearm exercise. Values are recorded as mean ± SE. The software used was SPPS V11 (SPPS, Chicago, IL).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Acknowledgments
 References
 
Sixteen patients were included in the study. The mean ± SE (range) age was 64 ± 1.9 years (45 to 72); weight was 79.4 ± 3.2 kg (53 to 100 kg); body surface area was 1.9 ± 0.04 m2 (1.59 to 2.14 m2), and there were 14 men and 2 women.

Comparisons between vessel diameters and flow are shown in Table 1. The left ulnar artery was consistently dilated and had greater flow than the right ulnar artery. There was no significant difference in diameter or flow between the left and right brachial arteries.


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  		Table 1. Vessel Diameters and Flows at Rest

 
Compression of the right (nonharvested) radial artery did not cause a consistent increase in the diameter of the left ulnar artery (2.1 ± 0.03 mm to 2.2 ± 0.04 mm), but did cause a consistent increase in flow (39 ± 8 mL/min to 72 ± 18 mL/min; Table 2). The flow in the right ulnar artery with the radial artery compressed was not consistently different from flow in the left ulnar artery at rest (p = 0.440).


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  		Table 2. Right (Nonharvested) Forearm Measurements at Rest

 
There was no consistent difference of maximum size of the brachial artery or maximum flow after ischemic exercise between the forearms (Table 3).


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  		Table 3. Maximal Brachial Artery Diameters and Flows

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Acknowledgments
 References
 
After at least 3 months postoperatively, we found no difference in the maximum blood flow to the forearm after harvesting of the radial artery (Table 3). This is an important finding because many patients undergoing coronary artery bypass surgery may undertake physical activity that involves strenuous muscular contraction of the forearm. Other studies have found a small and nonclinically significant reduction using technetium [11], digital plethysmography [10, 12, 19], Doppler [10], or transcutaneous oxygen tension [20].

If the blood supply to the forearm were compromised by harvesting the radial artery, then one may expect there to be weakness or possibly claudication of the arm during vigorous physical activity involving the arm. That has rarely been reported by patients in clinical series [4, 5, 12], suggesting preservation of the blood flow to the forearm after radial artery harvesting. This study, therefore, confirms the clinical experience.

We found that there was evidence of dilation of the ulnar artery at least 3 months after radial artery harvest (Table 1). That would appear to make logical sense in that loss of the radial artery would lead to chronic enlargement of the remaining artery to the forearm.

A theoretical concern, therefore, may arise in the short term regarding the ability of the nondilated ulnar artery being able to provide adequate blood flow of the forearm. This study demonstrated no acute dilation of the ulnar artery, when the radial artery was occluded by compression (Table 2). Yet the flow in the ulnar artery almost doubled, and was not different from the flow in the ulnar artery of the harvested hand. Hence, these data would suggest there is no acute reduction in blood flow to the forearm despite the ulnar artery not acutely dilating. The immediate increase in flow in the ulnar artery when the radial artery is compressed or removed must therefore be consequent on an increase in stroke volume within the ulnar artery with each heartbeat.

In this study, assessment of the radial and ulnar arteries was made immediately proximal to the wrist. The flows calculated therefore represent the flow to the hand, as most of the flow to the forearm muscles will have already occurred proximal to the wrist. Assessment of these two arteries at the more proximal location, however, is not easily achieved, as they lie beneath muscles and are not readily accessible to compression and are less readily accessible to ultrasound examination. Nevertheless, the blood flow of the forearm muscles was able to be assessed by measurement of the brachial artery flow because this point is proximal to the branches leading to the forearm muscles.

The study by Ludbrook [14] found that blood flow after ischemia alone or exercise alone did not elicit maximal blood flow. A combination of ischemia and exercise induced fatigue did elicit maximal blood flow. Consequently, we used this method to elicit the maximal potential blood flow in the forearm. Maximum blood flow measured in the brachial artery therefore reflects the maximal potential blood flow to both the forearm muscles as well as the hand. This study did not find any significant difference of maximal blood flow to the forearm of affected by the harvest of the radial artery compared with the normal forearm (Table 3).

Alternative measurements of flow have been advocated. Pulse oximetry of the skin of the finger would appear to be intrinsically flawed as a measure of blood flow to the forearm musculature and hand, as it reflects predominantly skin blood flow at the time of measurement. Transcutaneous oxygen pressure measurement has been discarded in vascular surgery owing to insufficient accuracy [21, 22]. Brodman and colleagues [10] found pulse oximetry and pulsatility index and thumb perfusion index changes in the forearms where radial artery was harvested did not have clinical correlates. A recent study by Chong and associates [12] using plethysmography support the findings of this study, suggesting no difference in blood flow to the forearm after radial artery harvest and after ischemic exercise.

These data support the continued use of radial artery as a conduit for coronary artery bypass surgery, and they suggest that arterial insufficiency even in the presence of vigorous physical activity involving the arm is unlikely.


   Acknowledgments
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
References
 
We thank Karen Groves for assistance with data management and Prof John Ludbrook (Biomedical Statistical Consulting Pty, Ltd) for statistical advice. We thank Philips (Andover, MA) for the loan of the Sonos 4500 and the 15-MHz transducer.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Carpentier A., Guermonprez J., Deloche A., et al. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111-121.[Medline]
  2. Carpentier A. Discussion of: Geha AS, Krone RJ, McCormick JR, Baue AE: Selection of coronary bypass: anatomic, physiological and angiographic considerations of vein and mammary artery grafts. J Thorac Cardiovasc Surg 1975;70:429-430.
  3. Acar C., Jebara V., Portoghese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-659.[Abstract]
  4. Royse A., Royse C., Shah P., et al. Radial artery harvest technique, use and functional outcome. Eur J Cardiothorac Surg 1999;15:186-193.[Abstract/Free Full Text]
  5. 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]
  6. Calafiore A.M., Di Mauro M., D'Alessandro S., et al. Revascularization of the lateral wall: long-term angiographic and clinical results of radial artery versus right internal thoracic artery grafting. J Thorac Cardiovasc Surg 2002;123:225-231.[Abstract/Free Full Text]
  7. 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]
  8. Iaco A.L., Teodori G., Di Giammarco G., et al. Radial artery for myocardial revascularization: long-term clinical and angiographic results. Ann Thorac Surg 2001;72:464-469.[Abstract/Free Full Text]
  9. Acar C., Ramsheyi A., Pagny J.Y., et al. The radial artery for coronary artery bypass grafting: clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981-989.[Abstract/Free Full Text]
  10. Brodman R.F., Hirsh L.E., Frame R. Effect of radial artery harvest on collateral forearm blood flow and digital perfusion. J Thorac Cardiovasc Surg 2002;123:512-516.[Abstract/Free Full Text]
  11. Rafael Sadaba J., Conroy J.L., Burniston M., et al. Effect of radial artery harvesting on tissue perfusion and function of the hand. Cardiovasc Surg 2001;9:378-382.[Medline]
  12. Chong W.C., Ong P.J., Hayward C.S., et al. Effects of radial artery harvesting on forearm function and blood flow. Ann Thorac Surg 2003;75:1171-1174.[Abstract/Free Full Text]
  13. Royse A. Complete arterial grafting using a left ITA and a single radial artery Y graft. In: Buxton B., Westaby S., Frazier O., eds. Ischemic heart disease: surgical management. London: Mosby International, 1998:219-221.
  14. Ludbrook J. Collateral artery resistance in the human lower limb. J Surg Res 1996;6:423-434.
  15. Fitchett D., Bouthier J.D., Simon A.C., et al. Forearm arterial compliance: the validation of a plethysmographic technique for the measurement of arterial compliance. Clin Sci (Lond) 1984;67:69-72.[Medline]
  16. Galan H.L., Jozwik M., Rigano S., et al. Umbilical vein blood flow determination in the ovine fetus: comparison of Doppler ultrasonographic and steady-state diffusion techniques. Am J Obstet Gynecol 1999;181:1149-1153.[Medline]
  17. Marcus R.H., Korcarz C., McCray G., et al. Noninvasive method for determination of arterial compliance using Doppler echocardiography and subclavian pulse tracings. Validation and clinical application of a physiological model of the circulation. Circulation 1994;89:2688-2699.[Abstract/Free Full Text]
  18. Royse C.F., Royse A.G., Blake D.W., Grigg L.E. Measurement of cardiac output by transoesophageal echocardiography: a comparison of two Doppler methods with thermodilution. Anaesth Intens Care 1999;27:586-590.[Medline]
  19. 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]
  20. Serricchio M, Gaudino M, Tondi P, et al. Hemodynamic and functional consequences of radial artery removal for coronary artery bypass grafting. Am J Cardiol 1999;84:1353–6, A8
  21. de Graaff J.C., Ubbink D.T., Legemate D.A., et al. Interobserver and intraobserver reproducibility of peripheral blood and oxygen pressure measurements in the assessment of lower extremity arterial disease. J Vasc Surg 2001;33:1033-1040.[Medline]
  22. Byrne P., Provan J.L., Ameli F.M., Jones D.P. The use of transcutaneous oxygen tension measurements in the diagnosis of peripheral vascular insufficiency. Ann Surg 1984;200:159-165.[Medline]



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