Ann Thorac Surg 2009;87:e21-e22. doi:10.1016/j.athoracsur.2008.10.063
© 2009 The Society of Thoracic Surgeons
Case Reports
Late Presentation Digital Ischemia After Radial Artery Harvest for Coronary Artery Bypass
Matthew Liava'a, MBCHBa,*,
Sanjay Theodore, MCha,
Timothy Wagner, FRACSb,
James Tatoulis, FRACSa
a Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Victoria, Australia
b Department of Vascular Surgery, Royal Melbourne Hospital, Victoria, Australia
Accepted for publication October 21, 2008.
* Address correspondence to Dr Liava'a, Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Grattan St, Parkville, Victoria, 3051, Australia (Email: mattliavaa{at}gmail.com).
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Abstract
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The radial artery is increasingly being used as a coronary artery bypass graft. Morbidity from harvesting is rare, yet it does occur. We present a case of digital ischemia presenting late after surgery and suggest that although preoperative assessment may be normal, comorbidities such as collagen vascular disease in conjunction with atherosclerotic peripheral vascular disease should be carefully considered as a contraindication to radial artery harvest.
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Introduction
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Use of the radial artery for coronary artery bypass surgery is becoming increasingly popular with excellent long-term patency and minimal morbidity [1, 2]. The experience with this conduit at our institution is that we have had few hand and forearm complications [3]. Wound infection or hematoma requiring exploration numbered approximately five per thousand, whereas digital ischemia has only been encountered twice [4]. A third example of digital ischemia has come to our attention, and we present the case here.
A 72-year-old woman initially presented to a peripheral hospital with an anterior myocardial infarction. After thrombolysis and transfer to our institution, coronary angiography revealed 80% ostial left main disease and a 95% left anterior descending coronary artery stenosis. Ongoing angina after angiography was treated with intra-aortic balloon pump insertion and the patient was brought forward for coronary artery bypass grafting 2 days after her initial infarct.
The left internal mammary artery was grafted to the left anterior descending coronary artery and the left radial artery was grafted to the left circumflex artery. The radial artery was harvested in a "no touch" fashion using sharp dissection and electrocautery. Preoperative modified Allen's test, double-checked with digital plethysmographic waveform review in the operating room, was negative. The harvested radial artery diameter measured 2.5 mm proximally and 2 mm distally without macroscopic disease or spasm. Initial intensive care notes report a cool left hand; however this improved daily and the limb was never believed to have critical ischemia.
Two years later the patient was referred to the vascular surgery department by her rheumatologist with nonhealing digital ulceration of the left fore and middle fingers, despite intermittent prostaglandin infusions (Fig 1). Duplex ultrasound investigations of the arm arteries revealed the left radial artery ligated and an ulnar artery with diffuse minor atheromatous disease and occlusion (3 cm proximal to the wrist), and in the right arm a heavily diseased radial artery that occluded at the level of the wrist with a patent ulnar artery. She was also found to have an asymptomatic 80% right internal carotid artery stenosis.
Angiography confirmed that the ulnar supply to the palmar arches was minimal and the hand was supplied by collaterals from the posterior interosseous artery to the previously ligated stump of the distal radial artery (Fig 2). The patient underwent brachial to radial artery stump bypass using ipsilateral cephalic vein. This provided excellent symptomatic relief with clinically well-perfused digits and healed digital ulceration at 3 weeks.
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Comment
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The initial case reports of digital ischemia after radial artery harvest for coronary artery bypass grafting by Nunoo-Mensah [5] and Fox and colleagues [6] (presenting the same patient) describe acute postoperative ischemia secondary to a congenitally absent ulnar artery [5, 6]. Our institution has previously had two cases of late postoperative radial artery harvest hand ischemia. Both patients had scleroderma, Raynaud's phenomenon, and significant peripheral vascular disease. Ca channel blockers were used to treat one patient, whereas the other required partial digital amputation. This third patient has similar characteristics; she had a known diagnosis of systemic lupus erythematosus after one episode of polyarthritis 8 years previously. Specific questioning with regard to the Raynaud's phenomenon was omitted preoperatively; however subsequent questioning elicited a 4-year history of Raynaud's phenomenon. Postoperative coronary artery bypass grafting investigations have also revealed multiple sites of peripheral vascular disease that were unknown at the time of initial surgery.
Most institutions would agree that prior surgery or major injury to the forearm, a positive Allen's test, or a severe collagen vascular disorder precludes radial artery harvesting. Also, although there is a plethora of literature about the use of Allen's test and suggestions that newer techniques, including duplex ultrasonography and digital plethysmography and pressure should be used routinely, little is written with regard to other contraindications [7, 8]. The knowledge that ulnar artery blood flow increases after radial artery harvest [9], and that there is always an anatomic connection between the radial and ulnar circulations [10], has encouraged our use of this conduit based simply on the modified Allen's test and digital plethysmography of the index finger during temporary radial artery occlusion when positioning the patient in the operating room.
Selection of the radial artery as a bypass conduit is at the surgeon's discretion and most generally does not harvest the radial artery in patients with connective tissue disorders. However, our database does not enable identification of those patients with connective tissue disorders who may have received a radial graft without complications. We believe our three cases of digital ischemia were all related to poor patient selection regarding medical comorbities. We suggest that the surgeon should refrain from harvesting the radial artery in the presence of a collagen vascular disorder, and the Raynaud's phenomenon, with or without a clear history of peripheral vascular disease. However, if digital ischemia is found postoperatively then radial artery bypass using vein conduit provides a satisfactory treatment option.
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References
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- Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years Ann Thorac Surg 2004;77:93-101.[Abstract/Free Full Text]
- Collins P, Webb C, Chong C, Moat N. Radial artery versus saphenous vein patency randomized trial—five-year angiographic follow-up Circ 2008;117:2859-2864.[Abstract/Free Full Text]
- Royse A, Royse C, Shah P, Williams A, Kaushik S, Tatoulis J. Radial artery harvest technique, use and functional outcome Eur J Cardiothorac Surg 1999;15:186-193.[Abstract/Free Full Text]
- Tatoulis J, Royse A, Buxton B, et al. The radial artery in coronary surgery: a 5-year experience—clinical and angiographic results Ann Thorac Surg 2002;73:143-148.[Abstract/Free Full Text]
- Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting Ann Thorac Surg 1998;66:929-931.[Abstract/Free Full Text]
- Fox A, Whiteley M, Phillips-Hughes J, Roake J. Acute upper limb ischemia: a complication of coronary artery bypass grafting Ann Thorac Surg 1999;67:535-537.[Abstract/Free Full Text]
- Kohonen M, Teerenhovi, Terho T, Laurikka J, Tarkka M. Is the Allen test reliable enough? Eur J Cardiothorac Surg 2007;32:902-905.[Abstract/Free Full Text]
- Rodriguez E, Ormont M, Lambert E, et al. The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting Eur J Cardiothorac 2000;19:135-139.
- Royse A, Royse C, Maleskar A, Garg A. Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm Ann Thorac Surg 2004;78:539-542.[Abstract/Free Full Text]
- Ruengsakulrach P, Eizenberg N, Fahrer C, Fahrer M, Buxton B. Surgical implications of variations in hand collateral circulation: Anatomy revisited J Thorac Cardiovasc Surg 2001;122:682-686.[Abstract/Free Full Text]
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Abstract
Introduction
