Long-term impact of radial artery harvest on forearm function and symptoms: A comparison with leg vein

Late Clinical Outcomes of Total Arterial Revascularization or Multiple Arterial Grafting Compared to Conventional Single Arterial with Saphenous Vein Grafting for Coronary Surgery

Coronary surgery provides better long-term outcomes than percutaneous coronary intervention. Conventional practice is to use a single arterial conduit supplemented by saphenous vein grafts. The use of multiple arterial revascularization (MAG), or exclusive arterial revascularization (TAR), however, is reported as having improved late survival. Survival is a surrogate for graft failure that may lead to premature death, and improved survival reflects fewer graft failures in the non-conventional strategy groups. The reasons for not using MAG or TAR may be due to perceived technical difficulties, a lack of definitive large-scale randomized evidence, a lack of confidence in arterial conduits, or resources or time constraints. Most people consider radial artery (RA) grafting to be new, with use representing approximately 2-5% worldwide, despite select centers reporting routine use in most patients for decades with improved results. In conclusion, the current body of evidence supports more extensive use of total and multiple arterial revascularization procedures in the absence of contraindications.

Detailed statistical analysis plan for the neurological complications in endoscopic versus open radial artery harvest (NEO) randomised clinical trial

INTRODUCTION

Coronary artery bypass grafting can be conducted using the radial artery as a bypass graft. However, it remains unclear which harvesting method is superior, i.e. endoscopic or open radial artery, and which site for proximal anastomosis of the radial artery has the greatest benefits?

METHODS

The NEO Trial is a single site randomised clinical trial with a 2 × 2 factorial design. The first comparison assesses endoscopic versus open radial artery harvest with a primary outcome of hand function and secondary outcomes of neurological deficits through clinical exams and neurophysiological studies. The primary outcome is postoperatively hand function at three months. We anticipate a mean difference of 3 points with a standard deviation of 8 points, a power of 90%, and a type I error of 5%, resulting in a required sample size of 300 participants randomised 1:1. Secondary outcomes are neurological deficits (based on nerve conduction measurements, algometry test and von Frey hair test), clinical neurological examination of cutaneous sensibility, and registration of complications in the donor arm (haematoma formation, wound dehiscence, and/or infection). The second comparison assesses two different proximal anastomotic sites, i.e. aorto-radial anastomosis versus mammario-radial anastomosis. The primary outcome is a composite of cerebrovascular events and the secondary outcome is graft patency evaluation by multi-slice computer tomography-scan. These outcomes will be assessed at 1 year postoperatively, and the results of this comparison will be exploratory only. Both comparisons will be analysed using intention-to-treat and intervention groups will be compared using linear regression, logistic regression, or Mann-Whitney U test depending on data type. Two independent statisticians will follow the present plan and conduct the analyses which will hereafter be fused into a final analysis based on consensus.

CONCLUSION

This detailed analysis plan will increase the validity of the NEO trial results by predefining the statistical analysis in detail.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01848886 . Registered 25 February 2013. Danish Ethics committee number: H-3-2012-116. Danish Data Protection Agency: 2007-58-0015/jr. n:30-0838.

Off-Pump Coronary Artery Bypass Grafting; is it Still Relevant?

Off-pump Coronary Artery Bypass Grafting (OPCAB) experienced a resurgence in the 1980s -2000s and developed steadily with improvement of the instrumentation and techniques. However questions about graft patency and long-term survival of OPCAB patients still exist. This review attempts to explore the current relevance of OPCAB.

Short-term assessment of radial artery grafts with multidetector computed tomography

BACKGROUND

The clinical use of the radial artery (RA) in coronary artery bypass grafting (CABG) is still limited worldwide, although it has been recommended by several guidelines. Multidetector computed tomography (MDCT) is widely used to evaluate graft patency, as invasive coronary angiography could cause potentially serious risks including bleeding, dissection and stroke. This study aims to report the short-term results of the RA in CABG with MDCT.

METHODS

The study population consists of 41 consecutive patients undergoing elective CABG with the RA graft between 2017 to 2018, with MDCT performed to evaluate graft patency during follow-up, and target vessels for the RA were non-left anterior descending coronary arteries with > 70% stenosis.

RESULTS

A total of 150 grafts were assessed by MDCT during follow-up (mean, 8.9 ± 5.1 months). MDCT could clearly show the structure and patency of grafts, even for complex coronary artery revascularization. Graft patency of the left internal mammary artery was 92.9% (39/42), with the RA patency of 84.4% (38/45) and the patency of the saphenous vein graft of 81.1% (30/37). And the RA anastomosed to the left coronary artery system might have better patency than the RA anastomosed to the right coronary artery system (25/29, 86.2% vs 13/16, 81.3%, p = 0.686).

CONCLUSIONS

The short-term patency rate of RA grafts is good, and the RA might be associated with better patency when anastomosed to the left but not the right coronary artery. MDCT could provide excellent visualization of grafts in CABG.

Long-Term Results of the RAPCO Trials

Background:

An internal thoracic artery graft to the left anterior descending artery is standard in coronary bypass surgery, but controversy exists on the best second conduit. The RAPCO trials (Radial Artery Patency and Clinical Outcomes) were designed to compare the long-term patency of the radial artery (RA) with that of the right internal thoracic artery (RITA) and the saphenous vein (SV).

Methods:

In RAPCO-RITA (the RITA versus RA arm of the RAPCO trial), 394 patients <70 years of age (or <60 years of age if they had diabetes mellitus) were randomized to receive RA or free RITA graft on the second most important coronary target. In RAPCO-SV (the SV versus RA arm of the RAPCO trial), 225 patients ≥70 years of age (or ≥60 years of age if they had diabetes mellitus) were randomized to receive RA or SV graft. The primary outcome was 10-year graft failure. Long-term mortality was a nonpowered coprimary end point. The main analysis was by intention to treat.

Results:

In the RA versus RITA comparison, the estimated 10-year patency was 89% for RA versus 80% for free RITA (hazard ratio for graft failure, 0.45 [95% CI, 0.23–0.88]). Ten-year patient survival estimate was 90.9% in the RA arm versus 83.7% in the RITA arm (hazard ratio for mortality, 0.53 [95% CI, 0.30–0.95]). In the RA versus SV comparison, the estimated 10-year patency was 85% for the RA versus 71% for the SV (hazard ratio for graft failure, 0.40 [95% CI, 0.15–1.00]), and 10-year patient survival estimate was 72.6% for the RA group versus 65.2% for the SV group (hazard ratio for mortality, 0.76 [95% CI, 0.47–1.22]).

Conclusions:

The 10-year patency rate of the RA is significantly higher than that of the free RITA and better than that of the SV.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier: NCT00475488.

Persistent postoperative pain after cardiac surgery: a systematic review with meta-analysis regarding incidence and pain intensity

Persistent postoperative pain (PPP) has been described as a complication of cardiac surgery (CS). We aimed to study PPP after CS (PPPCS) by conducting a systematic review of the literature regarding its incidence, intensity, location, and the presence of neuropathic pain, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The review comprised 3 phases: a methodological assessment of 6 different databases identifying potential articles and screening for inclusion criteria by 2 independent reviewers; data extraction; and study quality assessment. Meta-analysis was used to estimate the pooled incidence rates using a random effects model. We have identified 442 potentially relevant studies through database searching. A total of 23 studies (involving 11,057 patients) met our inclusion criteria. Persistent postoperative pain affects 37% patients in the first 6 months after CS, and it remains present more than 2 years after CS in 17%. The reported incidence of PPP during the first 6 months after CS increased in recent years. Globally, approximately half of the patients with PPPCS reported moderate to severe pain. Chest is the main location of PPPCS followed by the leg; neuropathic pain is present in the majority of the patients. This is the first systematic review and meta-analysis to provide estimates regarding incidence and intensity of PPPCS, which elucidates its relevance. There is an urgent need for adequate treatment and follow-up in patients with PPPCS.

Major adverse cardiac and cerebrovascular event and patients' quality of life after endoscopic vein harvesting as compared with open vein harvest (MAQEH): a pilot study

Background

This is a prospective, comparative, pilot and follow-up (2-year postoperatively) study in patients undergoing coronary artery bypass graft surgery where the long saphenous vein was harvested either by the endoscopic vein harvest (EVH) technique or open vein harvest (OVH) technique. Quality of life (QOL) and major adverse cardiac and cerebrovascular events (MACCE) were assessed.

Methods

Alive patients who were initially part of a pilot study when EVH was introduced in our institution were included (n=48 EVH, n=49 OVH). Patients were sent a QOL questionnaire (SF12v2; 12-item medical outcomes study short form health survey version 2.0), and their cardiologist and general practitioner were contacted to assess MACCE.

Results

Median follow-up was 32 and 33 months, respectively. Three patients died (2 EVH, 1 OVH). Of the remaining 97 patients who were sent a questionnaire, 76% patients returned the form. More patients from the EVH group returned the QOL questionnaire (82% vs 71%). Time taken to return to normal daily activities was much shorter in EVH (median 6 (2–30) weeks) compared with OVH (median 9 (2–50) weeks) (P<0.05). QOL questionnaire revealed significant difference in physical score at follow-up: 45.3 (10.2) for EVH group and 40.7 (11.0) for OVH group (P<0.05). There was no difference in mental scores (46.9 (10.5) vs 49.2 (9.1), P=0.4). There were no significant differences in MACCEs including death between the two groups (12.2% vs 13.9%, P=0.5).

Conclusion

EVH patients returned to normal daily activities faster than OVH patients and experienced better physical QOL even after 2 years postoperatively with no increase in MACCE during follow-up.

Randomized comparison of the clinical outcome of single versus multiple arterial grafts: the ROMA trial-rationale and study protocol

SUMMARY

The primary hypothesis of the ROMA trial is that in patients undergoing primary isolated non-emergent coronary artery bypass grafting, the use of 2 or more arterial grafts compared with a single arterial graft (SAG) is associated with a reduction in the composite outcome of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization.

The secondary hypothesis is that in these patients, the use of 2 or more arterial grafts compared with a SAG is associated with improved survival. The ROMA trial is a prospective, unblinded, randomized event-driven multicentre trial comprising at least 4300 subjects. Patients younger than 70 years with left main and/or multivessel disease will be randomized to a SAG or multiple arterial grafts to the left coronary system in a 1:1 fashion. Permuted block randomization stratified by the centre and the type of second arterial graft will be used. The primary outcome will be a composite of death from any cause, any stroke, post-discharge myocardial infarction and/or repeat revascularization. The secondary outcome will be all-cause mortality. The primary safety outcome will be a composite of death from any cause, any stroke and any myocardial infarction. In all patients, 1 internal thoracic artery will be anastomosed to the left anterior descending coronary artery. For patients randomized to the SAG group, saphenous vein grafts will be used for all non-left anterior descending target vessels. For patients randomized to the multiple arterial graft group, the main target vessel of the lateral wall will be grafted with either a radial artery or a second internal thoracic artery. Additional grafts for the multiple arterial graft group can be saphenous veins or supplemental arterial conduits. To detect a 20% relative reduction in the primary outcome, with 90% power at 5% alpha and assuming a time-to-event analysis, the sample size must include 845 events (and 3650 patients). To detect a 20% relative reduction in the secondary outcome, with 80% power at 5% alpha, the sample size must include 631 events (and 3650 patients). To be conservative, the sample size will be set at 4300 patients. The primary outcome will be tested according to the intention-to-treat principle. The primary analysis will be a Cox proportional hazards regression model, with the treatment arm included as a covariate. If non-proportional hazards are observed, alternatives to Cox proportional hazards regression will be explored.

Forearm Cephalic Vein Graft for Short, “Middle”-Flow, Internal Maxillary Artery to Middle Cerebral Artery Bypass

BACKGROUND

The cervical carotid system has been used as a source of donor vessels for radial artery or saphenous vein grafts in cerebral bypass. Recently, internal maxillary artery to middle cerebral artery bypass has been described as an alternative, with reduction of graft length potentially correlating with improved patency.

OBJECTIVE

To describe our experience using the forearm cephalic vein grafts for short segment internal maxillary artery to middle cerebral artery bypasses.

METHODS

All vein grafts were harvested from the volar forearm between the proximal cubital fossa where the median cubital vein is confluent with the cephalic vein and the distal wrist.

RESULTS

Six patients were treated with internal maxillary artery to middle cerebral artery bypass. In 4, the cephalic vein was used. Postoperative angiography demonstrated good filling of the grafts with robust distal flow. There were no upper extremity vascular complications. All but 1 patient (mortality) tolerated the procedure well. The other 3 patients returned to their neurological baseline with no new neurological deficit during follow-up.

CONCLUSION

The internal maxillary artery to middle cerebral artery “middle” flow bypass allows for shorter graft length with both the proximal and distal anastomoses within the same microsurgical field. These unique variable flow grafts represent an ideal opportunity for use of the cephalic vein of the forearm, which is more easily harvested than the wider saphenous vein graft and which has good match size to the M1/M2 segments of the middle cerebral artery. The vessel wall is supple, which facilitates handling during anastomosis. There is lower morbidity potential than utilization of the radial artery. Going forward, the cephalic vein will be our preferred choice for external carotid-internal carotid transplanted conduit bypass.

Internal maxillary artery-middle cerebral artery bypass: infratemporal approach for subcranial-intracranial (SC-IC) bypass

BACKGROUND:

Internal maxillary artery (IMax)–middle cerebral artery (MCA) bypass has been recently described as an alternative to cervical extracranial-intracranial bypass. This technique uses a “keyhole” craniectomy in the temporal fossa that requires a technically challenging end-to-side anastomosis.

OBJECTIVE:

To describe a lateral subtemporal craniectomy of the middle cranial fossa floor to facilitate wide exposure of the IMax to facilitate bypass.

METHODS:

Orbitozygomatic osteotomy is used followed by frontotemporal craniotomy and subsequently laterotemporal fossa craniectomy, reaching its medial border at a virtual line connecting the foramen rotundum and foramen ovale. The IMax was identified by using established anatomic landmarks, neuronavigation, and micro Doppler probe (Mizuho Inc. Tokyo, Japan). Additionally, we studied the approach in a cadaveric specimen in preparation for microsurgical bypass.

RESULTS:

There were 4 cases in which the technique was used. One bypass was performed for flow augmentation in a hypoperfused hemisphere. The other 3 were performed as part of treatment paradigms for giant middle cerebral artery aneurysms. Vein grafts were used in all patients. The proximal anastomosis was performed in an end-to-side fashion in 1 patient and end-to-end in 3 patients. Intraoperative graft flow measured with the Transonic flow probe ranged from 20 to 60 mL/min. Postoperative angiography demonstrated good filling of the graft with robust distal flow in all cases. All patients tolerated the procedure well.

CONCLUSION:

IMax to middle cerebral artery subcranial-intracranial bypass is safe and efficacious. The laterotemporal fossa craniectomy technique resulted in reliable identification and wide exposure of the IMax, facilitating the proximal anastomosis.

ABBREVIATIONS:

EC-IC, extracranial-intracranial

IMax, internal maxillary artery

MCA, middle cerebral artery

SC-IC, subcranial-intracranial

STA, superficial temporal artery

Saphenous vein graft vs. radial artery graft searching for the best second coronary artery bypass graft

Coronary artery bypass grafting (CABG) was first used in the late 1960s. This revolutionary procedure created hope among ischemic heart disease patients. Multiple conduits are used and the golden standard is the left internal mammary artery to the left anterior descending artery. Although all approaches were advocated by doctors, the use of saphenous vein grafts became the leading approach used by the majority of cardiac surgeons in the 1970s. The radial artery graft was introduced at the same time but was not as prevalent due to complications. It was reintroduced into clinical practice in 1989. The procedure was not well received initially but it has since shown superiority in patency as well as long-term survival after CABG. This review provides a summary of characteristics, technical features and patency rates of the radial artery graft in comparison with venous conduits. Current studies and research into radial artery grafts and saphenous vein grafts for CABG are explored. However, more studies are required to verify the various findings of the positive effects of coronary artery bypass grafting with the help of radial arteries on mortality and long-lasting patency.

Endoscopic versus open radial artery harvest and mammario-radial versus aorto-radial grafting in patients undergoing coronary artery bypass surgery: protocol for the 2 × 2 factorial designed randomised NEO trial

Background

Coronary artery bypass grafting using the radial artery has, since the 1990s, gone through a revival. Observational studies have indicated better long-term patency when using radial arteries. Therefore, radial artery might be preferred especially in younger patients where long time patency is important. During the last 10 years different endoscopic techniques to harvest the radial artery have evolved. Endoscopic radial artery harvest only requires a small incision near the wrist in contrast to open harvest, which requires an incision from the elbow to the wrist. However, it is unknown whether the endoscopic technique results in fewer complications or a graft patency comparable to open harvest. When the radial artery has been harvested, there are two ways to use the radial artery as a graft. One way is sewing it onto the aorta and another is sewing it onto the mammary artery. It is unknown which technique is the superior revascularisation technique.

Methods/Design

The NEO Trial is a randomised clinical trial with a 2 × 2 factorial design. We plan to randomise 300 participants into four intervention groups: (1) mammario-radial endoscopic group; (2) aorto-radial endoscopic group; (3) mammario-radial open surgery group; and (4) aorto-radial open surgery group.

The hand function will be assessed by a questionnaire, a clinical examination, the change in cutaneous sensibility, and the measurement of both sensory and motor nerve conduction velocity at 3 months postoperatively. All the postoperative complications will be registered, and we will evaluate muscular function, scar appearance, vascular supply to the hand, and the graft patency including the patency of the central radial artery anastomosis. A patency evaluation by multi-slice computer tomography will be done at one year postoperatively.

We expect the nerve conduction studies and the standardised neurological examinations to be able to discriminate differences in hand function comparing endoscopic to open harvest of the radial artery. The trial also aims to show if there is any patency difference between mammario-radial compared to aorto-radial revascularisation techniques but this objective is exploratory.

Trial registration

ClinicalTrials.gov identifier: NCT01848886.

Danish Ethics committee number: H-3-2012-116.

Danish Data Protection Agency: 2007-58-0015/jr.n:30–0838.

Should the radial artery be used as a bypass graft following radial access coronary angiography

The radial artery (RA) is often selected as the next conduit of choice following the internal thoracic artery for coronary artery bypass grafting operations (CABG). Radial access coronary angiography (RA-CA) has grown in popularity among cardiologists and has been advocated as the access route of choice for coronary angiography and intervention by many groups. However, sheath insertion and instrumentation may lead to structural and functional damage to the RA, which may preclude its use as a bypass conduit. The increasing use of RA-CA may therefore have an adverse effect on the ability to use the RA as a bypass conduit at subsequent CABG. To review this, a best evidence topic in cardiothoracic surgery was written according to a structured protocol. The question addressed was: 'should the radial artery be used as a bypass conduit following radial access coronary angiography'? Altogether, 167 papers were found using the reported search; 11 papers were identified that provided the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these studies were tabulated. Acute RA occlusion occurs in 2.3-30.5% of patients undergoing RA-CA. While a significant number of occluded RA's show recanalization on early follow-up, markers of endothelial function such as intima-media thickening (IMT) and flow-mediated dilatation remain impaired. RA-CA causes structural injury to the RA with evidence of histological injury (including intimal hyperplasia, periarterial tissue/fat necrosis and adventitial inflammation) along with intimal tears and medial dissections evident along the entire length of the vessel. Only one paper directly assesses patency rates of RA's used as bypass grafts following RA-CA finding a significant adverse effect on graft patency (77% patency in RA-CA, compared with 98% in the control group). We recommend avoiding the RA as a bypass conduit if it has previously been used for RA-CA. In situations where conduit options are limited, if possible, the RA should be avoided for at least 3 months following RA-CA and it may be beneficial to assess the RA's patency and flow characteristics with Doppler ultrasound preoperatively.

Mid-term results of the Radial Artery Patency and Clinical Outcomes randomized trial

BACKGROUND

The radial artery (RA), as an alternative to the saphenous vein or the right internal thoracic artery (RITA) for coronary artery bypass grafting, has gained considerable interest over the years. A randomized controlled trial was undertaken to assess the suitability of the radial artery as a conduit.

METHOD

The Radial Artery Patency and Clinical Outcomes (RAPCO) trial is a double-armed randomized controlled trial comparing the RA with the free RITA in a younger cohort of patients undergoing elective coronary bypass surgery, and the RA with the saphenous vein in an older group. The trial conduit was grafted to the most important coronary target after the left anterior descending artery, which received the gold standard left internal thoracic artery. Clinical outcomes and angiographic patency up to 10 years was recorded during careful follow up, with annual clinical review and a program of randomly assigned, staggered angiography. The final trial results will be available in 2014.

RESULTS

Mid-trial results have shown equivalent survival and event-free survival and graft patency in both arms at median follow up of approximately 6 years. The demographic and clinical data, pre- and postoperative angiographic findings of the trial database have led to a number of substudies focusing on the role of lipid exposure in patency and disease progression, the fate of moderate lesions when grafted or left alone, patterns of disease regression, and patient satisfaction with graft harvest sites.

CONCLUSIONS

While the final analysis of the primary trial end points is eagerly awaited, the additional insight into the natural history of grafted coronary artery disease with modern secondary prevention will be of considerable interest.

The history of arterial revascularization: from Kolesov to Tector and beyond

Coronary artery bypass grafting (CABG) is the one of the most effective revascularization strategies for patients with obstructive coronary artery disease. Total arterial revascularization using one or both internal thoracic and radial arteries has been shown to improve early outcomes and reduce long-term cardiovascular morbidity. Although CABG has evolved from an experimental procedure in the early 1900's to become one of the most commonly performed surgical procedures, there is still significant variation in grafting strategies amongst surgeons. We review the history and development of CABG with a particular emphasis on the early pioneers and the evolution of arterial grafting.