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Ann Thorac Surg 2005;79:1987-1989
© 2005 The Society of Thoracic Surgeons

Original article: Cardiovascular

Midterm Angiographic Patency and Vasoreactive Profile of Proximal Versus Distal Radial Artery Grafts

Mario Gaudino, MDa,*, Giuseppe Nasso, MDa, Carlo Canosa, MDb, Franco Glieca, MDa, Andrea Salica, MDa, Francesco Alessandrini, MDb, Gianfederico Possati, MDa

a Department of Cardiac Surgery, Catholic University, Rome, Italy
b Centro ad Alta Tecnologia Nelle Scienze Biomediche, Campobasso, Italy

Accepted for publication January 3, 2005.

* Address reprint requests to Dr Gaudino, Divisione di Cardiochirurgia, Policlinico Universitario A. Gemelli, Largo A. Gemelli 8, Rome 00168, Italy (E-mail: mgaudino{at}tiscali.it).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: No data are available on the different angiographic results and the in vivo vasoreactivity of radial artery (RA) grafts obtained from different parts of the conduit, although it is known that the distal segment of the artery has a more pronounced muscular component. This study was conceived to evaluate the angiographic patency and tendency to spasm of proximal versus distal RA grafts.

METHODS: In 29 patients, at the time of surgical myocardial revascularization, the radial artery was divided into two separate conduits, so that these patients received a total of 58 radial grafts (29 from the proximal and 29 from the distal portion of the artery). All cases were submitted to midterm angiography and vasoactive challenges to verify angiographic patency and vasoreactive profile.

RESULTS: Radial artery patency rate was 28 of 29 for both groups. Nine cases of string sign were reported, all in the distal series (p = 0.001). The perfect patency rate of distal grafts was markedly lower than that of proximal grafts (19 of 29 versus 27 of 29; p = 0.02). Vasoactive challenges testified to a higher vasospastic attitude of distal grafts.

CONCLUSIONS: Radial artery grafts obtained from the distal portion of the artery have a higher vasospastic tendency, greater incidence of string sign, and lower midterm perfect patency rate than graft taken from the more proximal part of the artery. The proximal part of the RA should be preferred for use as a conduit for surgical myocardial revascularization.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
The radial artery (RA) is gaining widespread acceptance as complementary arterial conduits for surgical myocardial revascularization, and several groups have reported excellent midterm to long-term angiographic patency [1–6]. Since the introduction of this conduit into clinical practice, however, major theoretical concerns have been expressed by different authors owing to the muscular arterial wall of the artery and its enhanced vasoreactivity [1, 7].

Despite the fact that the histologic architecture of the RA varies along its course and is more muscular in its distal segment [7], no data are currently available on the angiographic results and vasoreactive profile of graft obtained from the proximal versus distal portion of the artery. This report was conceived to evaluate the angiographic patency and tendency to spasm of proximal versus distal RA grafts.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patient Population
Our experience with the RA started in January 1993 with a large single-institution study, for which local Institutional Review Board approval was obtained. The details of RA harvesting and pharmacologic handling, early midterm and long-term clinical and angiographic results, as well as the early and midterm alterations of the forearm circulation and the midterm vasodilatory profile of the RA grafts have been the subject of previous publications [8–11]. The present report is intended to describe the angiographic patency and tendency to spasm of proximal versus distal RA grafts.

During all our experience, a total of 29 patients received two RA grafts obtained by dividing in two the RA, so that one graft was taken from the proximal half of the artery (elastomuscular) and the second graft derived from the more distal half of the conduit (muscular). Definitions were based on the intraoperative subjective judgment of the operating surgeon, in the absence of objective measurement. The main preoperative and intraoperative features of these 29 cases are depicted in Table 1. Written informed consent was given by every patient.


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  		Table 1. Preoperative Characteristics of Patients
 
Follow-Up
For the purpose of the present study, all cases were submitted to clinical and scintigraphic control and to control angiography of all implanted grafts and native coronary arteries at a mean of 66 ± 9 months from surgery. At the time of follow-up, all patients were on a regimen of aspirin and statins, and none was taking calcium channel blockers or nitrates.

Graft morphology was graded according to the four-grade scale in use at our institution [9, 11]: perfectly patent graft, patent graft with irregularities, string sign, and occluded graft. All angiograms were reviewed blindly by two expert observers; in case of disagreement, a third external masked review was requested. Moreover, in order to verify the spastic attitude of the conduits, we evaluated the response of the RA to the endovascular infusion of serotonin and acetylcholine, following a described method [10].

Statistical Analysis
Results are expressed as mean value ± standard deviation. Statistical analysis comparing the two groups was performed with parametric or nonparametric tests for independent samples (Student’s t test and the Mann-Whitney U test for continuous or ordinal data, respectively), and the {chi}2 or two-tailed Fisher exact tests were used to compare nominal data of the two groups. Yates’ correction was applied when required (Statistical Package for the Social Science Program; SPSS, Chicago, Illinois). A p value less than 0.05 was considered significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The mean preoperative clinical and angiographic characteristics of the 29 patients are summarized in Table 1. The radial artery target vessels and the severity of recipient coronary artery stenosis were similar between proximal and distal grafts.

No patients died during the follow-up period.

Symptomatic angina was reported by only 1 patient. Myocardial scintigraphy demonstrated inducible ischemia in 8 cases, including the symptomatic one. All the patients with angina or scintigraphic evidence of ischemia recurrence, or both, were submitted to reangiography; in 3 cases (2 proximal, p = 0.97), RA malfunction was the cause for the ischemia recurrence.

Midterm angiographic results are summarized in Table 2. Overall RA patency and perfect patency rates were 56 of 58 (96.5 %) and 46 of 58 (79.3 %), respectively. Nine cases of string sign were reported, all in the distal series (p = 0.001). For this reason, the perfect patency rate of distal RA grafts was markedly lower than that of proximal RAs (19 of 29 versus 27 of 29; p = 0.02).


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  		Table 2. Midterm Angiographic Results
 
The results of the endovascular challenges are summarized in Table 3. Distal RA grafts showed a higher propensity to graft spasm after all pharmacologic stimuli.


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  		Table 3. Results of the Vasoactive Challenges
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Since the reintroduction of the RA into clinical practice, major theoretical concerns have been expressed owing to the high vasoreactivity and propensity to spasm of this conduit [1, 7]. In fact, in contrast to almost all arteries used for surgical myocardial revascularization, the RA has a thick muscular wall and only a limited amount of elastic tissue in its media [7]. This abundant muscular component is the anatomic background of the hyperspastic attitude of the artery that has been well documented both in vivo and in vitro [1, 5, 6, 12].

Anatomic and histologic studies demonstrated that the histologic architecture of the RA varies along its course, and the muscular component of the media tends to be more represented in the distal portion [7]. On this basis, one could hypothesize that RA grafts obtained from the more proximal part of the conduit have a more favorable wall architecture and can possibly achieve better patency rates. However, to date no objective data on this issue have been published.

The present report was conceived to evaluate the angiographic patency and tendency to spasm of proximal versus distal RA grafts. For this purpose, we submitted to control reangiography a group of patients who received two RA grafts obtained by dividing in two the RA (so that one graft was taken from the proximal tract of the artery and the second graft derived from the more distal part of the conduit).

Angiographic results testified how distal RA grafts have an enhanced vasospastic tendency that results in a significantly higher incidence of string sign and lower perfect patency rate at midterm follow-up. It is extremely likely that the more abundant muscular component of the media of distal RA grafts is the histologic mechanism that explains the reported observations.

These data have major implications for conduit selection during coronary artery bypass operations. It seems, in fact, that the proximal part of the RA should be preferred to the distal one, and that efforts must be made to avoid as much as possible the use of the more distal portion of the conduit.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting Ann Thorac Surg 1992;54:652-660.[Abstract]
  2. Brodman RF, Frame R, Camacho M, Hu E, Chen A, Hollinger I. Routine use of unilateral and bilateral radial arteries for coronary artery bypass graft surgery J Am Coll Cardiol 1996;28:959-963.[Abstract]
  3. Da Costa FDA, da Costa IA, Poffo R, et al. Myocardial revascularization with the radial arterya clinical and angiographic study. Ann Thorac Surg 1996;62:475-480.[Abstract/Free Full Text]
  4. Chen AH, Nakao T, Brodman RF, et al. Early angiographic assessment of radial artery grafts used for coronary artery bypass grafting J Thorac Cardiovasc Surg 1996;111:1208-1212.[Abstract/Free Full Text]
  5. Tatoulis J, Buxton BF, Fuller JA. Bilateral radial artery grafts in coronary reconstructiontechniques and early results in 261 patients. Ann Thorac Surg 1998;66:714-720.[Abstract/Free Full Text]
  6. Acar C, Ramsheyi A, Pagny JY, et al. The radial artery for coronary artery bypass graftingclinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981-989.[Abstract/Free Full Text]
  7. Van Son JAM, Smedts F, Vincent JG, van Lier HJ, Kubat K. Comparative anatomic studies of various arterial conduits for myocardial revascularization J Thorac Cardiovasc Surg 1990;99:703-707.[Abstract]
  8. Manasse E, Sperti G, Suma H, et al. Use of the radial artery for myocardial revascularization Ann Thorac Surg 1996;62:1076-1082.[Abstract/Free Full Text]
  9. Possati G, Gaudino M, Alessandrini F, et al. Mid term clinical and angiographic results of radial artery grafts used for myocardial revascularization J Thorac Cardiovasc Surg 1998;116:1015-1024.[Abstract/Free Full Text]
  10. Gaudino M, Glieca F, Trani C, et al. Mid-term endothelial function and remodeling of radial artery grafts anastomosed to the aorta J Thorac Cardiovasc Surg 2000;120:298-301.[Abstract/Free Full Text]
  11. Possati G, Gaudino M, Prati F, et al. Long-term angiographic results of radial artery grafts used as coronary artery bypass conduit Circulation 2003;108:1350-1354.[Abstract/Free Full Text]
  12. Chardigny C, Jebara VA, Acar C, et al. Vasoreactivity of the radial artery. Comparison with the internal mammary and gastroepiploic arteries with implications for coronary artery surgery Circulation 1993;88(Suppl 2):115-127.



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Gianfederico Possati
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