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Ann Thorac Surg 2005;80:918-921
© 2005 The Society of Thoracic Surgeons

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Original article: Cardiovascular

Long-Term Physical Activity and Neurologic Function After Harvesting of the Radial Artery as T-Graft or Free Graft in Coronary Revascularization

^a Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
^b Department of Trauma Surgery, Hannover Medical School, Hannover, Germany

Accepted for publication March 18, 2005.

^_* Address reprint requests to Dr Knobloch, Trauma Surgery, Hannover Medical School, Carl-Neuberg-Str 1, Hannover, 30625 Germany (Email: kknobi{at}yahoo.com).

	Abstract

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 
BACKGROUND: Radial artery grafts in coronary revascularization are frequently used, either as a T-graft or as a free radial graft such as a saphenous venous graft. Besides the neurologic function of the hand after radial artery harvesting, which is questioned especially in the long-term perspective, no data on patients’ lifestyle are available in this special cohort. Therefore we focused on both the patients’ neurologic function as well as level of physical activity, along with their body mass index and smoking habits in this prospective, long-term study.

METHODS: Two hundred eleven patients (187 males; 64 ± 8 years; mean Canadian coronary scale, 2.4 ± 0.7; ejection fraction, 59 ± 15%) were enrolled and scheduled for elective radial artery harvesting in an open conventional technique. Follow-up of 26 ± 5 months (range, 13 to 37 months) was performed by a direct telephone interview with patients, which was 100% complete. The majority of radial arteries were used in the T-graft technique (73.9%), 24.2% were used as a free graft, and 1.4% as a jump graft.

RESULTS: One hundred sixty-five patients (78.2%) did not complain of any neurologic deficit at all. Numbness was distributed among the thumb (5.2%), the wrist (4.3%), and the incision site (3.3%). Hyposensitivity was predominantly at the wrist, followed by the thumb. Pain was distributed at the wrist (1.9%) and the thumb (1.5%). Aggravated sense of cold at the donor hand was evident in 11 patients (5.2%). No patient was compromised in their daily activities, such as piano playing or writing. Subjective well being improved in 147 patients (69.7%), was unchanged in 39 patients (18.5%), and was worse in 11 patients (5.3%) after radial artery harvesting. The mean Canadian coronary scale class improved significantly (1.3 ± 0.6; p < 0.05). There were patients (44.5%) who performed no sports activity after the procedure and patients (11.8%) who performed sports every day of the week. There were patients (80.1%) who did not participate in heart sport groups, with only 27 patients (12.8%) participating in such heart sport groups once a week. One hundred seventy-one patients (81.0%) attended a cardiac rehabilitation program after the procedure. Body mass index did not change at all. There were patients (29%) who stopped smoking as of the procedure, whereas 10% of patients were active smokers 25 months after the procedure.

CONCLUSIONS: Radial artery harvesting is associated with a minor number of neurologic complications such as numbness and hyposensitivity after a conventional pedicled harvesting technique without any compromise on patients’ daily activities. Further emphasis has to be taken in the promotion of lifestyle changes after coronary revascularization. About half of the patients did not perform any regular physical activity 2 years after surgery; mean body mass index did not change; and nearly 10% continued to smoke.

	Introduction

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Radial artery grafts in coronary revascularization, first used in 1971 by Carpentier and colleagues [1], are frequently used because of a number of potential advantages, such as the harvesting technique, a large diameter of the graft, a low rate of wound infections, and an improved survival versus vein conduits in the long-term perspective [2]. Concerns about the neurologic function of the hand after radial artery harvesting have been posted. Furthermore, as an arterial graft underlying graft atherosclerosis, we believe that there are no data available on the level of physical activity of patients after coronary revascularization using the radial artery in the long-term perspective. We analyzed a cohort of 211 patients undergoing elective coronary revascularization using the radial artery to assess neurologic function as well as lifestyle factors and physical activity after long-term follow-up.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 
Two hundred eleven patients (187 males [88.6%]; 64 ± 8 years) consecutively scheduled for elective coronary revascularization due to coronary heart disease using the radial artery as a bypass graft were included in this study. There were no exclusion criteria. Inclusion was performed in case of a radial artery harvesting and after informed, written consent of the patient to participate. Follow-up results were determined by direct telephone interview with the patients. Questions regarding personal assessment of their quality of life were asked in a trinomial fashion. All patients were informed and gave their written consent to participate in this study. Furthermore the local ethic committee was informed prior to the study and approved the study design.

Coronary artery disease was a single-vessel disease in 3 patients (1.4%), double-vessel disease in 43 (20.4%), and triple-vessel disease in 165 (78.2%). Left main stenosis was apparent in 17 patients with 50% to 75% stenosis (8.1%) and in 15 patients with stenosis greater than 75% (7.1%). Twenty-three patients had concomitant peripheral occlusive disease (10.9%). Thirty-seven patients had previous interventional treatment for coronary artery disease, such as percutaneous transluminal coronary angioplasty or coronary stent implantation (17.5%). Abdominal aortic aneurysms were apparent in 11 patients (5.2%) and carotid artery disease or a history of stroke in 20 patients (9.5%).

One hundred eighty-eight patients had a right dominant hand, 6 had a left dominant hand, and 2 were ambidextrous, and in 15 patients a dominant hand could not be evaluated because these patients were deceased at follow-up with no available record as to their orientation. Two hundred radial arteries (94.8%) were harvested on the patients’ left side, 9 (4.3%) on the right side, and in 2 patients (0.9%) both radial arteries were harvested. All radial artery grafts were harvested in the same technique from a forearm incision using an electric scalpel in a pedicled technique. No minimal invasive harvesting or radial skeletonized techniques were applied in this cohort. All grafts were perfused with Papaverin solution to prevent early vasospasm. Furthermore all patients received diltiazem (90 mg twice a day) for at least 14 days to prevent radial artery vasospasm during the immediate postoperative timeframe. The majority of radial arteries were used in the T-graft technique (73.9%), with 24.2% as a free graft, and 1.4% as a jump graft. Target vessel distribution of the radial artery is mentioned in Figure 1A. Eighty-seven percent (183 patients) had an additional left internal mammary artery graft in the same procedure, and 23% (79 patients) had an additional saphenous venous graft in the same procedure for coronary revascularization. Only 7 of 211 patients (3%) were operated on off-pump, all others (204 patients [97%]) were operated on using extracorporeal circulation with crystalloid cardioplegia. The mean aortic cross-clamp time was 48 ± 24 minutes, bypass time was 90 ± 42 minutes, and procedure time was 216 ± 58 minutes.

View larger version (14K): [in this window] [in a new window]   Fig 1. Target vessels of radial artery grafts in 211 patients. (CX = circumflex artery; LAD = left descending artery; PDA = posterior descending artery; RCA = right coronary artery; RIM = ramus intermedius.)

The statistical data are presented as median and range for continuous variables or number and percentages for dichotomous variables. Univariate analysis of categorical data was carried out using the ² test or Fisher exact test. A p value of less than 0.05 was considered to indicate statistical significance. The SPSS statistical software package 11.5 for Windows (SPSS Inc, Chicago, IL) was used for statistical analysis.

	Results

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 
Mean follow-up was 26 ± 5 months (minimum, 13 months; maximum, 37 months). Among the 211 patients, 14 died within the study period. Eight patients (3.8%) died within the first 30 days after the procedure, 5 patients (2.4%) between 30 days and 1 year after radial artery harvesting, and 1 patient (0.5%) died beyond the first year after the procedure. Regarding the causes of mortality, 2 patients (0.9%) died from sepsis and multiorgan failure, 10 patients (4.7%) died from cardiac failure, 1 patient (0.5%) died from pulmonary embolism, and 1 patient (0.5%) died from cancer.

Among the 197 patients alive at follow-up, 164 had no readmission to the hospital. Eight patients (3.8%) were readmitted due to angina, 6 patients (2.8%) due to arrhythmias, 6 patients (2.8%) were readmitted due to coronary angiography, 2 patients suffered a myocardial infarction (0.9%), 7 patients (3.3%) were readmitted due to peripheral vascular occlusive disease or carotid artery disease, and 3 patients (1.4%) had a pulmonary edema. Reoperations were performed in 5 patients (2.3%), and among them 2 patients had heart transplantations (0.9%), 2 had soft tissue revisions (0.9%, 1 radial artery harvesting site revision and 1 sternal revision), and 1 had a pulmonary thrombectomy (0.5%).

Long-Term Neurological Data
One hundred sixty-five patients (78.2%) did not complain of any neurologic deficit. Distribution of numbness (Fig 2A), hyposensitivity (Fig 2B), and pain (Fig 2C) are shown in the figure as indicated. Numbness was nearly distributed equally among the thumb (5.2%), wrist (4.3%), and incision site (3.3%). Hyposensitivity was predominantly at the wrist, followed by the thumb. Pain was distributed at the wrist (1.9%) and the thumb (1.5%). Motor deficits were evident in 7 patients (3.3%). Aggravated sense of cold at the donor hand was evident in 11 patients (5.2%). None of the patients with neurologic sequelae were compromised in daily business activities, such as playing violin or piano or during writing. Furthermore, none of these patients were referred to either a neurologist or a neurophysiologist regarding nerve conduction velocities, because the neurologic defects in each patient were so minor in their subjective assessment that no further neurologic studies had to be introduced.

View larger version (18K): [in this window] [in a new window]   Fig 2. (A) Percent distribution of numbness at mean follow-up of 26 months after radial artery harvesting in coronary revascularization in 211 patients. (B) Percent distribution of hyposensitivity at mean follow-up of 26 months after radial artery harvesting in coronary revascularization in 211 patients. (C) Percent distribution of pain at mean follow-up of 26 months after radial artery harvesting in coronary revascularization in 211 patients.

Physical Activity After Radial Artery Harvesting
Ninety-four patients (44.5%) with coronary artery disease and after radial artery harvesting performed no sports activity at all 25.7 ± 5 months after the procedure (Fig 3A). Approximately 50% of the patients were physically active on a regular basis. Twenty-five patients (11.8%) performed sports every day of the week. In Germany, a large number of specialized sport groups meeting the needs of patients with coronary artery disease are available. At follow-up (25.7 ± 5 months after radial artery harvesting), 169 patients (80.1%, Fig 3B) did not participate in such heart sport groups. Only 27 patients (12.8%) participated in such heart sport groups once a week. Concerning any cardiac rehabilitation course performed, 25 patients (11.8%) did not participate in such a cardiac rehabilitation program at all, whereas 171 patients (81.0%) attended a cardiac rehabilitation program after the procedure.

View larger version (17K): [in this window] [in a new window]   Fig 3. (A) Physical activity in 211 patients 26 months after radial artery harvesting in coronary revascularization due to coronary artery disease. (B) Participation in specialized coronary sport groups ("Herzsportgruppe") in 211 patients 26 months after radial artery harvesting in coronary revascularization due to coronary artery disease.

Smoking Before and After Radial Artery Harvesting
Among the 211 patients, 66 patients (31.3%) never smoked at all. Forty-nine patients (23.2%) stopped smoking within the previous 10 years before the operation, 61 patients (28.9%) stopped smoking directly after radial artery harvesting. Twenty patients (9.5%) still smoked 25.7 ± 5 months after radial artery harvesting.

	Comment

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 
The major findings are that radial artery harvesting is associated with only minor neurologic complications such as numbness or hyposensitivity in about 10% to 15% of patients from a long-term perspective. Motor deficits or paresthesias were not evident and pain was apparent in approximately 5% of all patients. Regarding physical activity level 25.7 ± 5 months after radial artery harvesting, nearly 45% of patients did not perform any physical activity at all, which is in line with an unchanged body mass index at follow-up, indicating that lifestyle changes are mandatory for patients with coronary revascularization. In addition, approximately 10% of patients were still smoking after radial artery harvesting.

Neurological Complications After Radial Artery Harvesting
Different harvesting techniques of the radial artery seem to have an impact on the neurologic outcome. In a series in 197 patients 1 year after either traditional or minimally invasive harvesting of the radial artery, 16.5% of patients complained of temporary dysesthesia after traditional harvesting versus 2% after a minimally invasive harvesting technique [3]. The neurologic symptoms ceased at average after 3.8 months (range, 1 to 12 months). Others reported about 10.7% cutaneous paresthesias in the radial distribution of the lateral antebrachial cutaneous nerve or superficial branch of the radial nerve [4]. Short-term motor hand function, assessed as grip power and fine motor skills 5 days after radial artery harvesting, has been found not to be significantly reduced [5].

In another cohort of 271 patients undergoing radial artery grafting, 0.7% patients reported donor arm weakness 8 weeks postoperatively and cutaneous paresthesia at 6-months follow-up in 3.7% of all patients [6]. The largest published series yet evaluating self-reported neurologic complications by telephone interview after radial grafting (n = 560) found 30.1% neurologic complications with 5.5% decreased thumb strength, and in 18.1% sensation abnormalities at a mean follow-up of 15 months [7]. They reported a high rate of symptom improvement during an average of 9 months. Our study revealed minor neurologic deficits such as numbness and hyposensitivity in as much as 15% of patients after conventional pedicled radial artery harvesting after 25.7 ± 5 months at follow-up.

Lifestyle Changes
Our study found an alarming high number of patients performing no regular physical activity at all after coronary revascularization. Furthermore, body weight at follow-up was still high with a body mass index of 27.8 indicating obesity likely due to physical inactivity and is an independent and strong predictor of death [8]. Another 10% of patients after radial artery grafting were active smokers at follow-up. Thus, lifestyle changes still have to be further implemented in patients with coronary artery disease, although there are large efforts aimed to inform patients, which are achieved during the rehabilitation program. More than 80% of the patients in this study participated in the rehabilitation program. Keeping in mind the expected beneficial effects of radial grafts, especially regarding long-term patency, one can not emphasize enough the need for concomitant lifestyle changes in patients after radial artery harvesting [9].

In conclusion, radial artery harvesting is a safe procedure with only minor number of neurologic complications such as numbness and hyposensitivity after conventional pedicled harvesting techniques. Further emphasis has to be taken to promote lifestyle changes after coronary revascularization, because 45% of patients did not perform any regular physical activity 2 years after the procedure associated with an obese body mass index and smoking habits.

	Footnotes

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 
^_* The first two authors contributed equally to this work.

	References

Top Abstract Introduction Patients and Methods Results Comment Footnotes References

 

1. Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass grafta technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111-121.[Abstract/Free Full Text]
2. Zacharias A, Habib RH, Schwann TA, Riordan CJ, Durham SJ, Shah A. Improved survival with radial artery versus vein conduits in coronary bypass surgery with left internal thoracic artery to left anterior descending artery grafting Circulation 2004;109:1489-1496.[Abstract/Free Full Text]
3. Galajda Z, Jagamos E, Maros T, Peterffy A. Radial artery graftssurgical anatomy and harvesting techniques. Cardiovasc Surg 2002;10(5):476-480.[Medline]
4. Greene MA, Malias MA. Arm complications after radial artery procurement for coronary bypass operation Ann Thorac Surg 2001;72(1):126-128.[Abstract/Free Full Text]
5. Sankey RA, Rumian AP, Jackson W, Osborne M, Stanbridge RD. Harvesting the radial arterydoes it affect early postoperative hand function?. Heart Surg Forum 2003;6(2):E12-E15.[Medline]
6. Budillon AM, Nicolini F, Agostinelli A, et al. Complications after radial artery harvesting for coronary bypass graftingour experience. Surgery 2003;133(3):283-287.[Medline]
7. Denton TA, Trento L, Cohen M, et al. Radial artery harvesting for coronary bypass operationsneurologic complications and their potential mechanisms. J Thorac Cardiovasc Surg 2001;121(5):951-956.[Abstract/Free Full Text]
8. Hu FU, Willet WC, Li T, Stampfer MJ, Colditz GA, Manson JAE. Adiposity as compared with physical activity in predicting mortality among women N Engl J Med 2004;351:2694-2703.[Medline]
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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): Artur Lichtenberg Christian Hagl Uwe Klima Axel Haverich Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Knobloch, K. Articles by Haverich, A. Search for Related Content PubMed PubMed Citation Articles by Knobloch, K. Articles by Haverich, A.