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Ann Thorac Surg 1995;60:102-109
© 1995 The Society of Thoracic Surgeons
Department of Cardiovascular Surgery, Geisinger Medical Center, Danville, Pennsylvania
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Methods. Between November 1992 and December 1994, the radial artery artery graft was used in 165 patients (mean age, 63.7 years) undergoing coronary revascularization. To prevent spasm, the radial artery was not skeletonized, and calcium-channel blockers were administered routinely.
Results. No ischemic or functional complications occurred in the hand after harvesting of the radial artery. Only 1 patient (0.6%) sustained a perioperative myocardial infarction in an area revascularized with a radial artery. The overall mortality was 3.0% (5 patients), but no deaths were caused by failure of the radial artery graft. During a mean follow-up of 14.0 months, angina recurred in 5 patients (3.0%), all of whom had widely patent radial artery grafts on angiography. Radionuclide exercise studies were performed 1 year after operation in 84 patients, 2 of whom (2.4%) had stress-induced defects in areas grafted with a radial artery.
Conclusions. Perioperative myocardial infarction, mortality, and recurrent angina usually were not related to failure of the radial artery graft. Our results suggest that the radial artery is an excellent alternative conduit for myocardial revascularization and may be used safely, especially in patients with poor-quality or unavailable saphenous veins.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Carpentier and associates [1] introduced in 1973 the radial artery as an alternative conduit for coronary artery bypass grafting. Two years later, however, Carpentier abandoned its use because of severe diffuse narrowing in 35% of the grafts, attributed to spasm of the denervated artery [2]. Other authors also observed early graft failure, caused by intimal hyperplasia [3–5].
In 1989, Carpentier's group in Paris revived the use of the radial artery because of unexpected good long-term results in several patients who had wide open radial artery grafts on angiography (more than 15 years later) and were initially presumed to have occlusion [6]. The improved results in the later series were attributed to the use of calcium-channel blockers to prevent arterial spasm, and also to a modified surgical technique, avoiding skeletonization and excessive dilatation of the graft [6].
These observations encouraged us to use the radial artery for coronary artery revascularization, starting with a patient who had previous stripping of bilateral varicose veins. Our early experience using the radial artery graft is reported, emphasizing important details in the harvesting technique and perioperative care, which may influence the long-term patency of this conduit.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Their mean age was 63.7 years (range, 34 to 82 years). There were 39 female (23.6%) and 126 male patients (76.4%). Other patient characteristics are listed in Table 1
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Altogether, 146 patients (88.5%) in this series underwent coronary revascularization using exclusively arterial grafts. In 19 patients (11.5%) a short segment of saphenous vein also was used because more than four distal anastomoses were indicated.
Contraindications for using the radial artery included Raynaud's disease or need for hemodialysis. Before the operation, the Allen test was performed routinely, with the patient's hand slightly flexed and relaxed, as recommended by Ejrup and colleagues [9], to avoid false-positive tests. Doppler studies were performed only if prolonged blanching persisted for more than 6 seconds when the ulnar artery was tested (while the radial artery was obliterated). So far, use of the radial artery was denied to only 1 patient, in whom the Doppler study showed a complete occlusion of the ulnar artery. During our study period, 8 additional patients had a positive Allen test before operation. However, dissection of the radial artery was not denied because their Doppler flow examination was considered normal.
Preoperative Preparations
All peripheral intravenous and arterial lines were placed in the dominant arm, before anesthetic induction. In patients with unstable angina, who were stabilized before operation with intravenous heparin and nitroglycerin, the infusions were continued until the patients were fully heparinized and cannulated. In patients who were not receiving intravenous heparin, an infusion was started and maintained at 1,000 U/h (preceded by a loading dose of 5,000 U).
To minimize the risk of arterial spasm, an intravenous infusion of diltiazem (125 mg/125 mL D5W) was administered during the entire operation, at a rate of 0.1 mg • kg-1 • h-1.
Surgical Technique
The radial artery was harvested from the nondominant arm: the left arm was used in 151 patients (91.5%), the right arm in 13 patients (7.9%), and both arms in 1 patient (0.6%). The entire arm was prepared circumferentially and positioned over an arm-board. An incision was made from the wrist (over the radial artery pulse) to the mid-antecubital fossa (over the brachial artery pulse).
Unlike the diverse topography of the saphenous veins, the course of the radial artery was noted to be very constant and predictable. After the antebrachialis fascia was incised, the brachioradialis muscle was retracted laterally in its entire length before dissection of the radial artery. This maneuver allowed excellent exposure of the entire length of the radial artery. In our opinion, it is important to avoid using short incisions in the distal forearm, digging under the muscles, because the radial artery may be injured or undergo severe spasm. The two satellite veins and the surrounding adipose tissue were left attached to the radial artery to preserve its blood supply as much as possible.
The branches of the radial artery were divided with a scissors between hemostatic clips; electrocautery was not used, to prevent thermal injury to the artery. This is extremely important because patency of arterial grafts may be jeopardized by using the electrocautery [10]. A small atraumatic vascular clamp (Fogarty Soft-jaw 6-mm spring clip, model 614-06; Baxter Healthcare Corp, Irvine, CA) was applied temporarily to occlude the radial artery in its middle segment. A palpable pulse or even a visible pulsation distal to the vascular clamp was considered a reliable indication of adequate collateral blood flow provided by the ulnar artery (Fig 1).
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To avoid intimal trauma, no metallic probes or dilators were used. The radial artery graft was irrigated very gently with heparinized saline solution and stored in a solution containing papaverine until used. The administration of cardioplegic solution directly into the graft, and manipulation of the arterial wall with forceps, also were avoided.
Hemostasis was verified carefully before the arm incision was closed. The antebrachialis fascia was not closed, to prevent a compartment syndrome. After the arm incision was closed and dressings and elastic bandages were applied, the arm was repositioned parallel to the patient's body using an elbow pad. The arm and hand again were examined carefully before leaving the operating room.
The time required to harvest the radial artery graft ranged from 45 to 75 minutes. However, total operating time was not prolonged because the radial artery was harvested by a physician assistant while the attending surgeon opened the sternum and prepared the internal mammary artery (IMA) and the right gastroepiploic artery (RGEA) grafts.
Radial Artery Graft Characteristics
The length of the radial artery graft ranged from 15.2 to 23.5 cm (mean, 20.5 cm), and the internal diameter ranged from 1.5 to 3.0 mm (mean, 2.3 mm). The free blood flow, measured after dividing the distal end, ranged from 60 to 240 mL/min (mean, 125 mL/min).
Generalized intraoperative spasm precluded use of the radial artery in only 2 patients. In another 2 patients, the spasm was localized to the distal 5 cm, which were discarded, and the remaining segment was used.
Three of the 8 patients with a positive Allen test before operation had no palpable or visible pulsation in the radial artery distal to the clamp, indicating inadequate collateral blood supply. Although these patients had essentially normal Doppler studies of the upper extremity before operation, the radial artery was not removed, to avoid ischemic complications.
Distal Anastomoses
Using cardioplegic arrest or intermittent aortic cross-clamping with fibrillatory arrest, all distal anastomoses were performed using continuous 7-0 polypropylene suture. In 12 patients, however, no clamps were applied to the ascending aorta because it was heavily calcified.
A total of 587 distal anastomoses were performed (average, 3.56 per patient), including 161 left IMA (LIMA) grafts, 22 right IMA grafts, 109 RGEA grafts, 35 inferior epigastric artery grafts, and 34 vein grafts.
The remaining 226 distal anasatomoses were performed with radial artery grafts (mean, 1.37 per patient). The radial artery was used as a single graft in 105 patients (including 1 patient in whom both radial arteries were used), as a sequential graft in 48 patients, and as a Y graft in 12 other patients. The most frequent targets were the obtuse marginal branches of the circumflex artery (Table 2).
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Proximal Anastomoses
Using a partial occlusion clamp on the ascending aorta, the proximal anastomoses were performed, after excision of a thin fragment of aortic wall (approximately 2 x 12 mm), using continuous 6-0 polypropylene suture (Fig 2).
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Perioperative Medical Management
An intravenous infusion of diltiazem was administered during the operation, and continued until the second postoperative day, at 0.1 mg • kg-1 • h-1, as recommended by Acar and associates [6]. The diltiazem then was given orally (120 to 240 mg/day) during 6 to 12 months.
In patients with severe left ventricular dysfunction, amlodipine (5 to 10 mg/day) was preferred. Aspirin also was administered (325 mg/day), starting on the second postoperative day.
To minimize the risk of infection or hematomas, no intravenous lines were placed in the donor arm until discharge from the hospital.
Statistical Analysis
Univariate analysis and comparison of risk factors was carried out using the 
2 test, and the Fisher's exact test was used to compare results obtained with a similar population of patients who underwent nonemergency coronary artery bypass grafting at our institution from January 1991 to October 1994. Patients who underwent emergency coronary revascularization were excluded from this group to avoid a comparison of heterogeneous groups of patients, because the radial artery graft usually was avoided in emergency situations.
Our results also were compared with the results published by The Society of Thoracic Surgeons National Database. Calculated p values less than 0.05 were considered statistically significant.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Nine patients (5.5%) sustained a perioperative myocardial infarction. However, only 1 (0.6%) of these patients had a new Q-wave myocardial infarction in an area revascularized with a radial artery graft (with endarterectomy of the same vessel). The other 8 perioperative myocardial infarctions occurred in areas revascularized with other grafts.
Three of the patients who sustained a perioperative myocardial infarction (MI) died: in 2 of them, the MI was anterior and was caused by tension on the LIMA graft in 1 and possibly by spasm of the LIMA in the other. The third patient had a posterolateral MI caused by embolization of atherosclerotic debris from an old vein graft. There was no statistically significant difference in the prevalence of perioperative MI, or other complications, when our present series was compared with a group of 1,588 patients who underwent nonemergency coronary artery bypass grafting at our institution.
The overall 30-day mortality in the present series was 3.0% (5 patients). In addition to the three deaths caused by a perioperative MI, 1 patient with severe left ventricular dysfunction, a recent MI, and diffusely calcified coronary arteries died in the operating room in low cardiac output. Another death occurred in a patient who suffered a cerebrovascular accident. No deaths can be attributed to the use of the radial artery graft.
Tables 3 and 4 show that there was no significant difference in the prevalence of risk factors, or their related mortality, when our present series was compared with a group of patients who underwent coronary revascularization at our institution without using the radial artery. Actually, the 30-day mortality was slightly (but not significantly) lower in patients who had a radial artery graft.
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), in spite of a significantly higher prevalence of several risk factors in our present series (see Table 3).
Follow-up
During a mean follow-up of 14.0 months (range, 11 to 24 months), 1 patient died in congestive heart failure and 1 patient had a late myocardial infarction in an area grafted with a saphenous vein.
Angina recurred in 5 patients (3.0%), who underwent repeat coronary angiography within 6 months of the operation. Two of them were noted to have diffuse spasm of a free gastroepiploic artery graft, another patient showed no flow in the LIMA graft (due to competitive flow), and another had a moderate stenosis at the LIMA anastomosis. These 4 patients are being managed with medications. The fifth patient, who had an occluded vein graft, underwent early reoperation. In all 5 patients who were restudied, the radial artery graft was widely patent (Figs 4, 5).
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In our present series, there were no cases of radial artery graft failure requiring reoperation.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Patency rate of the RGEA, when used as a pedicled graft, is similar to that of the IMA, with approximately 95% to 97% patency after 2 to 5 years [16, 17]. Both the IMA and the RGEA have a low susceptibility to atherosclerosis, which may influence the higher long-term patency of these grafts [18]. The improved patency rates of the IMA and RGEA grafts also may be explained by the increased capacity of the arterial endothelium to secrete prostacyclin and endothelium-derived relaxing factor, which are potent vasodilators and inhibitors of platelet aggregation [19, 20].
However, the patency rate of free arterial grafts is suboptimal, because only 77% of the free IMAs studied after 18 months [21] and 75% of the free RGEAs remained patent [16]. Technical problems related to a small, thin-walled vessel anastomosed to a thicker aortic wall may produce stenosis and eventually thrombosis of free arterial grafts [16, 21]. We recommend modified techniques (see Figs 2, 3) to minimize kinking or stenosis at the proximal anastomosis.
Free arterial grafts also may fail because of spasm [22, 23]. Two possible explanations are that there is an increased reaction to norepinephrine, as a consequence of total denervation of free arterial grafts [22], and there is a total disruption of the vasa vasorum at both ends [5]. Early failure of the radial artery graft also has been attributed to generalized intimal hyperplasia [3]. Massa and co-workers [22] recently suggested a correlation between spasm and intimal hyperplasia in an experimental model.
The initial experience with the radial artery resulted in a high failure rate, which was attributed to a combination of spasm and intimal hyperplasia. To minimize these problems, Acar and associates [6] recommend the following modifications in the harvesting technique: the radial artery should be dissected en bloc, together with its pedicle, including the two satellite veins and the surrounding adipose tissue, to preserve the vasa vasorum as much as possible. They also advocate avoiding intraluminal dilation, to prevent intimal trauma, and the routine administration of calcium-channel blockers during and after operation, to prevent spasm. These important modifications resulted in considerably improved patency rates (93.5% at 1 year) in their recent experience [6].
In addition to these suggestions, we strongly recommend retracting the belly of the brachioradialis muscle before dissecting the radial artery pedicle, to minimize the risk of injury or spasm. We also emphasize that the use of electrocautery to divide the branches should be avoided, to prevent thermal injury of the graft [10].
The distal segment of the radial artery should be discarded in some patients because it may be more prone to spasm. A similar observation was made by He [24], when using the IMA graft, and by Grandjean and associates [17], when using the RGEA graft, that the distal segment of these arterial grafts is more reactive and should not be used for the anastomosis.
Another reason for concern when using the radial artery is the potential risk of ischemic complications in the hand and, consequently, the potential for litigation. However, the forearm and the hand mainly are vascularized by the ulnar artery and its collaterals [6]. Nevertheless, we recommend verifying the presence of a pulse in the radial artery distal to a clamp, in the operating room (see Fig 1), to assure adequate collateral blood flow, even if the preoperative Doppler study was normal. With these considerations in mind, ischemic complications did not occur in our present series.
In summary, use of the radial artery does not increase morbidity or mortality. In our experience, perioperative myocardial infarction, mortality, recurrent angina, and need for reoperation were not related to failure of the radial artery graft.
Our results suggest that the radial artery graft is an excellent alternative conduit for myocardial revascularization, and it can be used safely, especially in patients with unsuitable or unavailable saphenous veins. Emphasis should be made on using a proper harvesting technique, to prevent intimal damage, and minimizing the risk of spasm and intimal hyperplasia, to improve long-term patency. However, long-term follow-up is necessary before reaching any definitive conclusion.
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Acknowledgments |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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Address reprint requests to Dr Dietl, Department of Cardiovascular Surgery, Geisinger Medical Center, Danville, PA 17822-1343.
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentAcknowledgmentsReferences |
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2 mm), a rhombic segment of aortic wall (10 to 12 mm in each side) is excised and replaced with autologous pericardium (20 mm in each side) (A, B). The proximal end of the radial artery graft then is sutured to the pericardial patch (C, D).
