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Ann Thorac Surg 2005;79:2180-2188
© 2005 The Society of Thoracic Surgeons

Review

Role of Radial Artery Graft in Coronary Artery Bypass Grafting

Lokeswara Rao Sajja, MCha,*, Gopichand Mannam, FRCS (CT)a, Narasinga Rao Pantula, MCha, Sriramulu Sompalli, MDb

a Division of Cardiothoracic Surgery, Care Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad, India
b Division of Cardiothoracic Anesthesiology, Care Hospital, The Institute of Medical Sciences, Banjara Hills, Hyderabad, India

* Address reprint requests to Dr Sajja, Care Hospital, The Institute of Medical Sciences, Road No 1, Banjara Hills, Hyderabad-500 034, AP, India (E-mail: sajjalr{at}yahoo.com).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
The use of the radial artery (RA) as a coronary artery bypass graft has assumed a revival and thus a multitude of issues have arisen surrounding the routine and widespread use of this conduit in myocardial revascularization. There has been no uniformity regarding harvest techniques, assessment of the adequacy of hand collateral circulation, antispasm protocols, selection of target vessels, and the site of proximal anastomosis. It is widely believed and practiced that the RA should be harvested as a pedicle graft and preferably be used to bypass critically stenosed (>70% stenosis) coronary arteries. It is used either as a free graft with proximal anastomosis to the ascending aorta or as a composite arterial graft along with the left or right internal thoracic artery. The patency of RA grafts depends on the severity of the target coronary artery stenosis and target artery location rather than its use as an aortocoronary conduit or composite graft. In this article, we reviewed the current knowledge regarding the use of RA grafts as a coronary bypass conduit in an attempt to suggest a few acceptable strategies concerning the above issues in a given clinical scenario.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Since its reintroduction by Acar and colleagues [1], the radial artery (RA) has generated considerable interest as an alternative arterial conduit for coronary artery bypass grafting (CABG). The resurgence of interest in the use of RA has been a sequelae to well-documented incidence of saphenous vein graft failure in the long-term [2]. In addition the exceptional results observed with arterial conduits, such as the left internal mammary artery (LIMA) anastomosed to the left anterior descending (LAD) artery, prompted the use of the RA as a second arterial conduit [3, 4]. The RA graft is rapidly gaining popularity because of its diameter, length, safety, and ease of harvest as well as the encouraging early and mid-to-long-term results [5–8]. It is being used as a conduit of choice over the right internal mammary artery (RIMA) by many surgeons because of the absence of additional risks regarding sternal wound infections, because no differences exist in perioperative or intermediate-term cardiac morbidity and mortality rates, and because the RA indicates equally favorable early and midterm patency rates [9].


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
We have reviewed the recent literature on the use of RA as a coronary artery bypass conduit. We searched the PubMed database using the following phrases: "RA graft in coronary artery bypass," "spasm of radial artery," and "forearm function after radial artery harvest." Articles published between 1978 and 2003 were analyzed to summarize the current knowledge regarding the use of this conduit with special reference to surgical anatomy, harvest techniques, antispasm protocols, selection of target arteries, and the site of proximal anastomosis. A few selected papers on each one of the abovementioned issues were analyzed and cited.

Historical Note
CABG using the RA was introduced clinically by Carpentier and colleagues in 1973 [10]. Despite early promising clinical outcomes, 2 years later in 1975 Carpentier himself recommended that this procedure be abandoned because of the higher incidence (35%) of narrowing or occlusion [11]. In 1989 Acar and colleagues reviewed the late angiograms performed on an early series of patients studied by Carpentier and to their surprise determined that the radial grafts were patent and functioning well at 15 years which were previously thought to be occluded. Acar attributed this early graft failure to the spasm of radial arteries and introduced pharmacological measures to minimize arterial spasms. In addition, Acar also refined the harvest techniques. Together, these changes resulted in the revival and interest regarding the use of this conduit for CABG [1].

Surgical Anatomy of the RA
The RA is the smaller of the two terminal branches of the brachial artery. It ascends from the brachial artery in the cubital fossa approximately 1.0 cm below the bend of the elbow opposite the neck of the radius and is a more direct continuation of the brachial artery. After its origin it traverses through the lateral aspect of the forearm approaching its lower end where it enters the palm to anastomose with the deep branch of the ulnar artery to complete the formation of the deep palmar arch. The proximal RA courses underneath the muscle belly of the brachioradialis muscle and, at this junction, prudence is required to identify and spare the lateral antebrachial cutaneous nerve that lies over the belly of the brachioradialis muscle. Damage to this nerve is associated with parasthesias of the radial side of the ventral aspect of the forearm [12]. The other important structure in proximity to RA is the median nerve, which is positioned near the most proximal part of the RA and distal part of the brachial artery and should be safeguarded during the harvest. The mid-part of the RA lies near the superficial branch of the radial nerve that is situated under the brachioradialis muscle. In its distal third, the artery becomes superficial and is positioned anterior to the radius and pronator quadratus muscle between the tendons of the brachioradialis and flexor carpi radialis. The structural relationships of RA are indicated in Figure 1.



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  		Fig 1. Frontal view of the right forearm after partial excision of the flexor carpi radialis and palmaris longus. Diagrammatic representation of structures on which the radial artery is positioned and the structures in the vicinity of radial artery that are at risk of injury at the time of radial artery harvest.

 
Several variations regarding the termination of the radial and ulnar arteries are common. Although the classic type of superficial palmar arch occurs relatively infrequently, there are always considerable anastomoses between the radial and ulnar arteries in the hand. Two types of deep palmar arches (complete and incomplete) and two types of superficial palmar arches (complete and incomplete) and their variants were described in detail in a study by Ruengsakulrach and colleagues [13].

Histologic and Pharmacological Properties of the RA
RA was classified as a type 3 arterial graft with higher propensity to spasm [14]. The medial thickness of RA is substantially greater than other arterial conduits such as the internal mammary artery (IMA) or the gastroepiploic artery (GEA) [15]. The RA exhibits a greater contraction force to potassium chloride than the IMA or GEA and a higher contraction force to norepinephrine and serotonin than the IMA but not the GEA [16]. In patients with coronary artery disease, RA atherosclerotic involvement is more frequent than that of the internal thoracic artery (ITA), but far less than of the common carotid artery. The early atherosclerotic changes observed in the RA do not seem to exhibit the potential to influence RA graft patency and endothelial function [17]. Hagiwara and associates reported that structural changes rarely develop in RA grafts even at midterm [18].

Assessment of Collateral Circulation Adequacy of the Hand Before RA Harvest
It is mandatory to assess the adequacy of the ulnar collateral circulation of the hand before harvesting RA. The Allen test is the most frequently used screening method for the evaluation of the adequacy of collateral hand circulation. The Allen test is considered positive if the reperfusion of thenar eminence, thumb, and index finger does not occur even at 10 seconds after the release of occlusion of the ulnar artery while maintaining the occlusion of the RA at the wrist joint. An intraoperative Allen test may be useful in the presence of the high origin of the superficial palmar branch or an anomalous anterior interosseous artery when a preoperative Allen test can be falsely negative [19]. Another method employed to assess the adequacy of hand collateral circulation includes use of a continuous wave Doppler placed on the superficial palmar arch to observe whether RA compression results in a decrease in the audibility of palmar arch signals. A decrease in audible Doppler signals with RA compression is considered to be a positive modified Allen test. No change or increase in the signals is considered as a negative test [20]. Another modification of the Allen test is the measurement of the first and second digit pressures before and during RA compression with a 2.5 cm digit pressure cuff placed on the proximal phalanx. Decrease in the systolic digit pressure of 40 mm Hg or more (digit {delta} p) in either digit with RA compression is considered a positive test [21]. Oxymetric plethysmographic waveform analysis is also used to assess the adequacy of ulnar collateral circulation. Furthermore a combination of these methods can be used to assess the adequacy of the ulnar collateral system to avoid hand ischemia after RA harvest [22].

Indications and Contraindications for RA Harvest
Indications
Currently RA is accepted as a secondarily preferred arterial conduit for coronary revascularization subsequent to the left internal thoracic artery (LITA). The usual target arteries for its usage are obtuse marginal branches of the circumflex artery, ramus intermedius, and right coronary artery (RCA). RA has been increasingly used as a composite arterial conduit to achieve total arterial revascularization. The advantages of composite radial arterial graft include greater conduit length and minimizing aortic manipulation particularly so when coronary revascularization is performed on beating heart [7, 23].

Contraindications
A positive Allen test is a contraindication for the RA harvest from the ipsilateral forearm. Approximately 11.6% of patients indicate a unilateral positive Allen test [24]. A prior operation for carpal tunnel syndrome leads to periarterial fibrosis of the distal segment of the RA and may preclude its use. A previous RA cannulation at the wrist may cause periarterial fibrosis. However these RA conduits may still be useful as a conduit after discarding the few distal centimeters. The use of the RA as a bypass conduit after transradial catheterization should be managed cautiously, as intimal damage may have occurred during catheter manipulations [25]. Diffuse arteriosclerosis and medial calcification observed in the elderly is a contraindication for its use. However specks of calcium seen in the RA do not preclude its use. It is reported that RA is not an ideal conduit to bypass target arteries that indicate less critical (< 70%) stenosis because of the possibility of competitive flow that results in either complete occlusion or formation of "string sign" [26, 27].

Harvest of RA
Most surgeons perform the RA harvest from the nondominant forearm [1, 28] although others harvest bilateral radial arteries routinely [24, 29]. Occasionally a long length of RA can be divided into two segments to graft two separate targets [24] or to construct multiple distal anastomoses in a sequential fashion [30, 31]. The RA has been used as an effective conduit in coronary reoperations [32].

Surgical Techniques
The common technique of harvesting RA is along with venae committantes using low strength electrocautery as an open method [33, 34]. The extrafascial technique of harvesting has also been reported [28]. Other methods include harvesting the RA in a skeletonized fashion [35]. Connolly and associates [36] have popularized the endoscopic technique. The hemostasis during harvest is achieved with either low strength cautery [37] or an ultrasonically activated scalpel [38]. Locker and associates reported that the compound effect of RA harvesting with a harmonic scalpel and topical treatment with the {alpha}-blocking agent, regitine, increases RA free flow and markedly decreases intraoperative spasticity [39]. Rukosujew and colleagues reported that skeletonization of the RA using scissors and clips is more time-consuming and technically more difficult, but yields considerably longer graft. Skeletonization with an ultrasonic scalpel did not result in additional length and was more frequently associated with severe endothelial damage [40]. Pedicle preparation using scissors or an ultrasonic scalpel is much simpler and faster and does not jeopardize endothelial integrity [40]. Usually the distal end of the RA is used for coronary anastomosis and the proximal end of the RA to the aorta or internal mammary artery. At times when the RA becomes sclerosed at the level of the wrist, this end may be used to create the proximal anastomosis and the healthy proximal part (elbow end) of the RA may be used for coronary anastomosis [41].

Distal Anastomosis of RA Conduit
The RA is preferably grafted to the native coronary artery with stenosis greater than 70% to avoid the risk of competitive flow and the development of string sign. The usual targets are the left circumflex (LCx), ramus intermedius, or RCA. Numerous published studies indicate decreased RA patency rates when grafted to bypass the RCA [26, 27]. If sequential grafting is required, the intermediate anastomoses can exhibit lower degree stenosis albeit that the last territory is severely stenosed [26].

Proximal Anastomosis of RA Conduit
The RA can be used as an aortocoronary bypass graft (free graft) [30, 42, 43] or as a composite Y or T graft extending from the LITA [44]. Some groups have also described usage of the RA as an extension graft to the in situ right internal thoracic artery (RITA) or right gastroepiploic artery (RGEA) [45, 46]. Composite arterial grafts with RA extending from the LITA are more vulnerable to detrimental effects of chronic native competitive flow and should be used only for target vessels with a stenosis greater than 80% [26, 27]. In a recently published study Maniar and associates concluded that the site of the proximal anastomosis does not seem to influence the patency, but both the RA-to-aorta and composite conduits are sensitive to target location and stenosis [47]. Different patterns of RA use in total arterial revascularization has been described [7, 45, 46, 48–52] and illustrated in Figure 2.



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  		Fig 2. (A) Left internal thoracic artery (LITA) and radial artery (RA) as a Y or T graft. (B) RA and right internal thoracic artery (RITA) as a Y graft. (C) RITA, RA, and LITA as a sling. (D) RA to the side of LITA as an X graft. (E) RA as an extension graft of RITA.

 
Spasm of the RA
Concern exists regarding the theoretical possibility of RA spasm and many investigators have focused on the biological properties and behavior of this conduit in vitro to various chemical agents. It has been observed that the endothelial function of the RA, as it releases endothelial-derived relaxing factors in response to endogenous and exogenous agents, is similar to that of other arteries. Considerable basal and stimulated nitric oxide release have been reported in vivo [53], as well as maximal relaxation of the RA after acetylcholine administration [54]. He and Yang indicated that both endothelium-dependent and endothelium-independent vasorelaxation of the RA were similar to that of the ITA [55]. On the other hand, the RA can develop substantially higher maximal contractile force to vasoconstricting agents such as norepinephrine, serotonin, endothelin-I, and angiotensin II [55]. This can be explained based on the histology of the artery, which is more muscular in nature and thicker in media compared with ITA, GEA, and inferior epigastric arteries [15].

Protocols for Prophylaxis for Conduit Spasm
It is likely that the current success using the RA is related to the reduced trauma during harvest and the use of topical and intraluminal papaverine, which minimizes conduit spasm [34, 56]. It has been demonstrated that the use of verapamil and nitroglycerine solution to prepare RA grafts maximally preserves endothelial function [57]. In canine radial arteries, it has also been reported that pretreatment of the RA conduit with phenoxybenzamine completely inhibits vasoconstriction to phenyilephrine and norepinephrine for as long as 48 hours. It was proven clinically that topical treatment of the RA using regitine increases the RA free flow and is an effective intraoperative means of decreasing the RA spasticity [41].

Numerous surgeons worldwide [5, 7, 24] have empirically used the calcium-channel-blocker, diltiazem. However diltiazem usage is associated with negative inotropic and chronotropic effects [58]. Approximately 30%–40% of the patients treated with diltiazem potentially experience hypotension, bradycardia, or heart block requiring a decrease in dosage, a discontinuation of the drug, or temporary pacing [24, 59]. Moreover use of diltiazem does not completely eliminate spasm. Cable and colleagues demonstrated that diltiazem and verapamil exhibited little effect on RA receptor-dependent and receptor-independent contraction, whereas nifidipine and nitroglycerine proved to be much more effective [60]. In one comparative study that was initiated to assess the usefulness of diltiazem in patients with RA grafts for CABG, no difference was determined between the patients who received diltiazem and those who did not [61]. Shapira and associates reported that nitroglycerine should be strongly considered as the drug of choice to prevent conduit spasm after coronary bypass grafting [62]. Gurevitch and colleagues have used long-acting nitrates as an alternative to diltiazem for the prevention of composite arterial conduit spasm and reported satisfactory clinical results [63]. Myers and Fremes reported that prophylaxis against RA graft spasm is practiced in more than 95% of Canadian surgical centers despite the absence of clinical outcome data to support this approach [64]. The various protocols for prevention of RA graft spasm are listed in Table 1 [6, 7, 9, 34, 61, 65].


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  		Table 1. Anti-Spasm Protocols for Radial Artery Graft
 
Donor Site Complications of RA Harvest
Complications related to RA harvest are few and of little consequence. Postoperative hand ischemia after RA harvest is very rare regardless of the method used to assess ulnar artery adequacy and only one occurrence of acute hand ischemia caused by congenital absence of the ulnar artery has been reported [66]. Neurologic complications may occur in the form of parasthesias of the forearm and hand from 1.6%–30.1% [37, 42, 67]. The sensory symptoms disappear completely within days or weeks. In a large study comprising 3977 patients who underwent RA harvest for coronary artery bypass determined that RA harvest is associated with low morbidity and favorable functional outcome of the hand [68]. Forearm surgical wound infection varies between 1%–4% and the development of forearm hematoma occurs in less than 4% of patients [12, 69]. We have encountered a patient who presented with a compartmental syndrome that was treated by opening the forearm wound and releasing the muscles and fascia of the forearm. Incidentally this patient had undergone fixation of fracture of the left humerus using a plate and screws 2 years before the CABG. Ipsilateral axillary vein thrombosis has also been reported as a rare complication after RA harvest [70].

Forearm Function After RA Harvest
Harvesting the RA does not adversely affect subsequent forearm function or blood flow to a clinically notable degree in patients who exhibited a negative Allen test. Preoperative and postoperative forearm blood flow at rest and exercise induced ischemic reperfusion were not significantly different in both forearms [71]. RA harvest was quite acceptable from the patients’ perception, although a few experienced numbness and pain during the 3 postoperative months. These complications improve considerably in the later postoperative phase [72]. In another study Brodman and colleagues identified a mild reduction with regard to digital perfusion and an increase in ulnar artery flow velocity and diameter with no clinical sequelae or compromise in hand function after RA harvest in properly selected patients [73]. In a comparative study of operated and nonoperated forearms Dumanian and associates ascertained no clinical differences for digital-brachia indices, cold response, grip or pinch strength, digital two-point discrimination, or the nine-hole peg test. Patients experienced an increased but minor incidence of forearm numbness and tingling, however there was no increase concerning pain or cold intolerance after RA harvest [74].


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
We have reviewed the data on RA usage in an attempt to summarize the current knowledge regarding this conduit in CABG. The in-hospital mortality rate ranges from 0%–4.8% among the published series [1, 6]. Postoperative myocardial infarction rates vary between 0%–5.5% and the myocardial infarction reported in the territory of the RA graft is no greater than one-third of these instances [6, 7]. The overall early patency rates of RA grafts in various series fluctuated from 76.9%–100% and is indicated in Table 2 [1, 7, 8, 21, 65, 75–77]. The early patency rates of RA grafts used for different coronary arterial territories varied significantly as indicated in Table 3 [8, 26, 27, 47, 65]. The patency rates of RA grafts were higher for LAD and LCx arterial territories. The patency rates of RA grafts used to bypass the RCA are reported to be lower in several series [26, 27, 47, 65]. This low patency rate for the RCA territory may be attributable to a large caliber of the RCA with less critical stenosis indicating the potential for competitive flow and the development of disease at the crux at a later date [34]. The midterm and long-term overall angiographic patency rates of RA grafts for CABG varied from 87.5%–96.5% and are indicated in Table 4 [5–8, 29, 34, 76, 78]. The midterm and long-term patency rates for different coronary artery territories are indicated in Table 5 [8, 34, 78]. Long-term angiographic results of lateral wall myocardial revascularization using RA graft is favorable and comparable with RIMA grafts [78].


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  		Table 2. Overall Early Angiographic Patency Rates of Radial Artery Graft
 

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  		Table 3. Early Patency Rates of Radial Artery Graft in Different Coronary Arterial Territories
 

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  		Table 4. Overall Midterm and Long-Term Patency of Angiography RA Grafts
 

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  		Table 5. Midterm and Long-Term Patency Rates of Radial Artery Graft in Different Coronary Arterial Territories
 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
The use of RA has been revived in conjunction with the availability of antispasm agents as well as improved harvesting techniques [1]. The RA has become the second preferred arterial conduit, which can be used along with LITA to achieve total arterial or extensive arterial revascularization [34]. Increasing interest in the use of the RA as a CABG has been based on the encouraging early, midterm, and long-term clinical and angiographic results as well as the well-documented long-term failure of the saphenous vein conduits. Several recently published studies determined similar RA patency rates regardless of the chosen grafting strategy [8, 26, 30] as either a free graft to the ascending aorta or as a composite graft to the LITA or RITA. However the RA is particularly sensitive to both the target artery location and the proximal target artery stenosis [27]. Iaco and associates published long-term clinical and angiographic results [8] for two different types of proximal anastomoses of the RA graft either to the side of LITA or to the ascending aorta indicating patency rates of RA to ITA of 95.6% (87 out of 91) and RA to aorta of 100% (26 out of 26). The rates were not statistically significant in either group at a mean of 48 ± 27 months (range 6–90 months) [8]. It was considered that proper target selection is potentially the principle determinant of RA patency rather than the grafting strategy chosen. It has been recommended by several authors that the RA should not be used for target arteries with less than 70% stenosis [26, 27, 78]. Similarly the impact of the target location has been addressed by several investigators with regard to arterial conduits [26, 79]. It was reported that despite the chosen grafting strategy, patency was significantly worse for the targets of the RCA (58% T graft: 67% RA-to-aorta) [30]. The advantages of composite grafting include greater conduit length and minimization of aortic manipulation at the expense of increased complexity and potential for hypoperfusion [30]. These factors should be considered when choosing the RA grafting strategy. Two important studies [9, 80] (nonrandomized and observational studies) demonstrated that the use of RA as a second arterial conduit subsequent to the use of LITA revealed several early and midterm clinical advantages compared with the use of RITA as a second arterial conduit.

RA could be harvested in the majority of patients because clinical contraindications were quite rare (positive Allen test, history of previous vascular trauma of the ipsilateral upper limb, Dupuytren disease). Diabetes, elderly age, chronic obstructive pulmonary disease, and obesity posed concerns with respect to sternal wound infection, which may therefore be considered a relative contraindication regarding the use of bilateral ITA harvesting in this group of patients and it may, therefore, be preferable to use RA instead of RITA. The RA is a versatile conduit and can be harvested easily, safely, and concomitantly with LITA. It has been noted by many surgeons that the RA graft patency rates decreased when grafted to coronary arteries that exhibited mild or moderate obstruction [81]. The advantages and disadvantages are dependent upon patient-related, conduit-related, coronary artery-related and surgeon-related variables [82]. Five-year interim results do not support the hypothesis that the RA exhibits superior patency to or is associated with fewer clinical events than the free RITA or saphenous vein grafts [83]. Another multicenter radial patency (RAP) study indicated that RA is a safe bypass conduit with angiographic patency similar to saphenous vein grafts at 1 year [84]. The long-term results of randomized control trials currently being assessed by Buxton and the RAPS investigators are anxiously anticipated in hopes that the role of RA grafting with regard to the long-term status of patients after CABG can be determined irrevocably.

In conclusion, the RA should preferably be harvested as a pedicle graft and should be used to bypass critically stenosed (≥70%) coronary artery or arteries. The patency of RA grafts depend on the severity of target coronary artery stenosis and target artery location rather than its use as an aortocoronary conduit or composite graft. The prophylaxis against spasm of RA graft is advocated by many investigators although no randomized trials are available to support this practice.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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