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Ann Thorac Surg 2006;81:1551
© 2006 The Society of Thoracic Surgeons

Correspondence

Angiographic Patency of the Radial Artery Conduit in Coronary Artery Bypass Grafting

Dusko G. Nezic, MD, PhD, Aleksandar M. Knezevic, MD, BCh, Miomir Dj. Jovic, MD, PhD, Sasa D. Borovic, MD

Dedinje Cardiovascular Institute, Milana Tepica 1, Belgrade, SE 11040

(Email: nezic{at}eunet.yu).

To the Editor:

We read with great interest the review by Sajja and colleagues [1] about the role of the radial artery (RA) graft in coronary artery bypass grafting (CABG). Although it is an outstanding review, the angiographic radial artery conduit patency data equal or even worse than saphenous vein graft (SVG) patency were only marginally mentioned or even omitted.

A note of caution has recently come from the Cleveland Clinic; Khot and colleagues [2] report a retrospective, symptom-directed angiographic study on RA graft patency. At an average follow-up of 1.6 ± 1.4 years, RA grafts had a patency rate of only 51.3%, which was significantly lower than that of SVGs (64.0%, P = 0.0016). Although their methodology is flawed, the article presents one of the largest angiographic (310 of 3,600 patients) follow-up studies of RA conduit patency [3]. The importance of the article is that it raises concerns about high RA graft failure at a time when use of RA conduits is increasing.

Zacharias and associates [4] reported that angiographic patency of RA conduits (1.8 ± 1.4 years to re-angiogram) was 68.2%, statistically not better than the patency rate (63.3%) of SVGs. Although the patency data were derived from symptomatic patients (worst-case scenario), the assumption that symptom-free patients are likely to have more patent grafts does not justify extrapolation of better patency rates to the entire cohort because of the possibility of silent graft occlusions.

The Radial Artery Patency and Clinical Outcome study, a prospective, randomized, single-center trial, compared angiographic patency of RA conduits with patency of free right internal thoracic arteries in the first group of patients, and compared with SVGs in the second group [5]. Protocol-directed angiography at 5 years did not support the hypothesis that the RA has superior patency (ie, RA vs free right internal thoracic arteries, 97.4% vs 100%; RA vs Svg, 87.5% vs 95.5%) or is associated with fewer clinical events than free right internal thoracic arteries or SVGs.

The prospective, randomized trial (ie, the Radial Artery Patency Study) comparing the patency of RA grafts with that of the SVGs has recently been reported by Desai and colleagues [6]. The RA was randomly assigned to bypass a major vessel in either the right coronary territory or the circumflex territory, with the SVGs used for the alternate vessel (control). The angiographic study performed at 1 year after surgery demonstrated an occlusion rate of 8.2% for RA conduits and 13.6% for SVGs (P = 0.009). However, 7% of RA grafts versus 0.9% of SVGs had the "string sign," which resulted in a total "bad graft" rate of 15.2% for the RA conduit versus 14.5% for the SVGs. Furthermore, perfect graft patency (thrombolysis in myocardial infarction flow grade 3), was similar (ie, 87.7% for the RA grafts vs 85.7% for SVGs; P = 0.37).

The most important data are still to come. If prospective, randomized angiographic studies or meta-analyses, or both, between 5 and 10 years after CABG surgery show that RA conduits are not subject to late graft failure, then RA grafts are likely to be a preferred substitute for right internal thoracic artery as well as for SVGs in future CABG surgery.


   References
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 References
 

  1. Sajja LR, Mannam G, Pantula NR, Sompalli S. Role of radial artery graft in coronary artery bypass grafting Ann Thorac Surg 2005;79:2180-2188.[Abstract/Free Full Text]
  2. Khot U, Friedman D, Petterson G, Smedira N, Li J, Ellis S. Radial artery bypass grafts have an increased occurence of angiographically severe stenosis and occlusion compared with left internal mammary arteries and saphenous vein grafts Circulation 2004;109:2086-2091.[Abstract/Free Full Text]
  3. Khot U, Friedman D, Pettersson G, Smedira N, Li J, Ellis S. Letters regarding article by Khot et al, "Radial artery bypass grafts have an increased occurrence of angiographically severe stenosis and occlusion compared with left internal mammary arteries and saphenous vein grafts" Response Circulation 2005;111(1):e8-e9.
  4. Zacharias A, Habib R, Schwann T, Riordan C, Durham S, 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]
  5. Buxton B, Raman J, Ruengsakulrach P, Gordon I, Rosalion A, Bellomo R. Radial artery patency and clinical outcomesfive-year interim results of a randomized trail. J Thorac Cardiovasc Surg 2003;125:1363-1371.[Abstract/Free Full Text]
  6. Desai N, Cohen E, Naylor D, Fremes E. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts N Eng J Med 2004;22:2302-2309.

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Lokeswara Rao Sajja and Gopichand Mannam
Ann. Thorac. Surg. 2006 81: 1551-1552. [Extract] [Full Text] [PDF]



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Ann. Thorac. Surg., April 1, 2006; 81(4): 1551 - 1552.
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