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Raval AJ, Parikh JK, Desai MA. A review on the treatment of intimal hyperplasia with perivascular medical devices: role of mechanical factors and drug release kinetics. Expert Rev Med Devices 2023; 20:805-819. [PMID: 37559556 DOI: 10.1080/17434440.2023.2244875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 08/02/2023] [Indexed: 08/11/2023]
Abstract
INTRODUCTION Intimal hyperplasia (IH) is a significant factor limiting the success of revascularization surgery for blood flow restoration. IH results from a foreign body response and mechanical disparity that involves complex biochemical reactions resulting in graft failure. The available treatment option utilizes either different pharmacological interventions or mechanical support to the vascular grafts with limited success. AREAS COVERED This review explains the pathophysiology of IH, responsible mechanical and biological factors, and treatment options, emphasizing perivascular devices. They are designed to provide mechanical support and pharmacology actions. The perivascular drug delivery concept has successfully demonstrated efficacy in various animal studies. Accurate projections of drug release mechanisms using mathematical modeling could be used to formulate prolonged drug elution devices. Numerical modeling aspects for the prediction of design outcomes have been given due importance that fulfills the unmet clinical need for better patient care. EXPERT OPINION IH could be effectively prevented by simultaneous mechanical scaffolding and sustained local drug delivery. Future perivascular medical devices could be designed to integrate these essential features. Numerical modeling for device performance prediction should be utilized in the development of next-generation perivascular devices.
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Affiliation(s)
- Ankur J Raval
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
- Research and Development Department, Sahajanand Medical Technologies Ltd, Surat, Gujarat, India
| | - Jigisha K Parikh
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
| | - Meghal A Desai
- Department of Chemical Engineering, Sardar Vallabhbhai National of Technology, Surat, Gujarat, India
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Zhang X, Hu Y, Friscia ME, Wu X, Zhang L, Casale AS. Perioperative diltiazem therapy was not associated with improved perioperative and long-term outcomes in patients undergoing on-pump coronary artery bypass grafting. BJA OPEN 2022; 3:100025. [PMID: 37588585 PMCID: PMC10430801 DOI: 10.1016/j.bjao.2022.100025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 06/17/2022] [Accepted: 06/23/2022] [Indexed: 08/18/2023]
Abstract
Background Diltiazem has been used during the perioperative period in patients undergoing coronary artery bypass grafting (CABG) to prevent arterial graft spasm. However, its long-term outcome effects remain unclear. Methods Patient records obtained from the Society of Thoracic Surgeons and the Geisinger Clinic electronic health records between October 2008 and October 2018 were screened. Adult patients who had isolated CABG with cardiopulmonary bypass were included. Cohorts of patients who received diltiazem (DILT) and those who did not (non-DILT) were matched by propensity scores based on age, gender, surgical year, Society of Thoracic Surgeons mortality and morbidity scores, and number of arterial grafts. Incidence rate ratios (IRRs) were estimated for DILT vs non-DILT on short-term adverse outcomes. Long-term survival over time was compared between DILT vs non-DILT using Kaplan-Meier curves. Results Among the 1004 patients included in the analyses, IRRs for the DILT group relative to the non-DILT group were: 30-day all-cause mortality, IRR: 2.33, 95% confidence interval (CI): 0.91-5.96, P=0.07; postoperative myocardial ischaemia, IRR: 1.10, 95% CI: 0.60-2.02, P=0.75; new onset atrial fibrillation, IRR: 1.06, 95% CI: 0.78-1.43, P=0.73; stroke/transient ischaemic attack, IRR: 0.76, 95% CI: 0.17-3.38, P=0.71. For long-term survival, Kaplan-Meier curves stratified by diltiazem revealed no differences in survival rates between DILT and non-DILT groups. Conclusion For patients undergoing on-pump CABG, perioperative diltiazem therapy did not show significant short- or long-term outcome advantages over those who did not receive diltiazem.
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Affiliation(s)
- Xiaopeng Zhang
- Department of Anaesthesiology, Geisinger Clinic, Danville, PA, USA
| | - Yirui Hu
- Department of Population Health Sciences, Geisinger Clinic, Danville, PA, USA
| | - Michael E. Friscia
- Department of Cardiovascular and Thoracic Surgery, Geisinger Clinic, Danville, PA, USA
- Geisinger Heart Institute, Danville, PA, USA
| | - Xianren Wu
- Department of Anaesthesiology, Geisinger Clinic, Danville, PA, USA
| | - Li Zhang
- Department of Anaesthesiology, Geisinger Clinic, Danville, PA, USA
| | - Alfred S. Casale
- Department of Cardiovascular and Thoracic Surgery, Geisinger Clinic, Danville, PA, USA
- Geisinger Heart Institute, Danville, PA, USA
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Tamim M, Alexiou C, Al-Hassan D, Al-Faraidy K. Prospective randomized trial of endoscopic vs open radial artery harvest for CABG: Clinical outcome, patient satisfaction, and midterm RA graft patency. J Card Surg 2020; 35:2147-2154. [PMID: 32652684 DOI: 10.1111/jocs.14706] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Endoscopic radial artery (RA) harvest (ERAH) is an alternative to open RA harvest (ORAH) technique. Our aim was to ascertain clinical outcomes, patent satisfaction, and 1-year angiographic patency rates after ERAH and ORAH. PATIENTS AND METHODS A total of 50 patients undergoing coronary artery bypass grafting were prospectively randomized to two groups. In the ERAH group (25 patients) the RA was harvested endoscopically and in the ORAH group (25 patients) openly. RESULTS There were not differences between the groups in preoperative characteristics. Length of skin incision was shorter in ERAH (P < .001) but there were not differences in the length of RA, harvest time, blood flow, and pulsatility index after ERAH and ORAH. Wound healing was uniformly smooth in ERAH and there were two hematomas and one infection in ORAH. Postoperatively, major neuralgias were present in five patients in ORAH and none in ERAH and minor neuralgias in 11 and 3 patients (P = .02) respectively. Twenty-four patients in ERAH and four in ORAH graded their experience as excellent (P < .001). One-year angiographic RA patency was 90% without intergroup difference. Target vessel stenosis less than 90% adversely affected RA patency (P < .0001). CONCLUSIONS In expert center, ERAH does not appear to have negative impact on the time harvest, the length, and quality of RA conduit, the wound healing, and the occurrence of hand and forearm complications. In addition, provides excellent cosmetic result and patient satisfaction. RA graft patency is gratifying when placed to a target coronary artery vessel with stenosis greater than 90%.
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Affiliation(s)
- Muhammed Tamim
- Department of Cardiac Surgery, King Fahd Military Medical Complex, Dhahran, KSA
| | - Christos Alexiou
- Department of Cardiac Surgery, King Fahd Military Medical Complex, Dhahran, KSA
| | - Donya Al-Hassan
- Department of Radiology, King Fahd Military Medical Complex, Dhahran, KSA
| | - Khalid Al-Faraidy
- Department of Cardiology, King Fahd Military Medical Complex, Dhahran, KSA
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4
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Technical Aspects of the Use of the Radial Artery in Coronary Artery Bypass Surgery. Ann Thorac Surg 2018; 108:613-622. [PMID: 30552888 DOI: 10.1016/j.athoracsur.2018.10.066] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Revised: 09/14/2018] [Accepted: 10/23/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND The radial artery has been used for coronary artery bypass surgery for more than 25 years. The recent confirmation of the clinical benefits associated with the use of the artery is likely to drive a new interest toward this conduit in the next few years. METHODS A group of surgeons with extensive experience in the systematic use of the radial artery summarize here the key technical aspects of the use of the conduit for coronary bypass operations. RESULTS Preoperative evaluation of the ulnar collateral circulation and attention to the characteristics of the target vessel are keys for the successful use of the radial artery. Open or endoscopic harvesting can be used, preferentially with the aid of the harmonic scalpel. The use of vasodilatory and antispastic protocols is probably important but poorly supported by the current evidence. The radial artery can be used for multiple grafting strategies with a variable degree of technical complexity. CONCLUSIONS With attention to few technical key points, the radial artery is a versatile conduit that can be easily introduced in the everyday practice of coronary artery bypass surgery.
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Leonard JR, Abouarab AA, Tam DY, Girardi LN, Gaudino MFL, Fremes SE. The radial artery: Results and technical considerations. J Card Surg 2018; 33:213-218. [DOI: 10.1111/jocs.13533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
- Jeremy R. Leonard
- Department of Cardiothoracic Surgery; Weill Cornell Medicine; New York New York
| | - Ahmed A. Abouarab
- Department of Cardiothoracic Surgery; Weill Cornell Medicine; New York New York
| | - Derrick Y. Tam
- Division of Cardiac Surgery; Schulich Heart Centre; Sunnybrook Health Sciences Centre; University of Toronto; Toronto Ontario Canada
| | - Leonard N. Girardi
- Department of Cardiothoracic Surgery; Weill Cornell Medicine; New York New York
| | - Mario F. L. Gaudino
- Department of Cardiothoracic Surgery; Weill Cornell Medicine; New York New York
| | - Stephen E. Fremes
- Division of Cardiac Surgery; Schulich Heart Centre; Sunnybrook Health Sciences Centre; University of Toronto; Toronto Ontario Canada
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Engin E, Alp Yildirim Fİ, Kalelі Durman D, Ömeroğlu SN, Göksedef D, Teskіn Ö, Balkanay OO, İpek G, Uydeş Doğan BS. Relaxant effect of the prostacyclin analogue iloprost on isolated human radial artery: An approach for the reversal of graft spasm. Prostaglandins Other Lipid Mediat 2017; 133:35-41. [PMID: 29107024 DOI: 10.1016/j.prostaglandins.2017.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 10/10/2017] [Accepted: 10/17/2017] [Indexed: 10/18/2022]
Abstract
Radial artery graft spasm in the perioperative or postoperative period of coronary bypass surgery necessitates urgent treatment due to risk of graft failure and mortality. Herein, we evaluated the effect of iloprost, a prostacyclin (PGI2) analogue, against the contractions produced by noradrenaline and potassium chloride on isolated human radial artery. Following the determination of endothelial and vascular relaxing capacities of the arteries, iloprost (10-9M-10-6M) was cumulatively applied on rings precontracted submaximally with the spasmogens. In some rings, the response to iloprost was assessed following pretreatment with nitric oxide (NO) synthase inhibitor, l-NAME (3×10-4M,30min). Iloprost produced complete relaxations on radial artery rings precontracted with noradrenaline whereas, only moderate relaxations against the contractions induced by potassium chloride. Notably, the relaxation to iloprost was remarkably blunted in radial arteries with impaired endothelial function. Moreover, the relaxation to iloprost was unchanged in rings pretreated with l-NAME. Our results demonstrated that iloprost could be a potent relaxant agent in reversing radial artery spasm, particularly initiated by noradrenaline, possibly acting via an endothelium-mediated mechanism unrelated to NO.
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Affiliation(s)
- Ersoy Engin
- Department of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey; Department of Cardiovascular Surgery, Şişli Hamidiye Etfal Education and Research Hospital, Istanbul, Turkey
| | - F İlkay Alp Yildirim
- Department of Pharmacology, Faculty of Pharmacy, Istanbul University, Istanbul, Turkey
| | - Deniz Kalelі Durman
- Department of Pharmacology, Faculty of Pharmacy, Istanbul University, Istanbul, Turkey
| | - Suat Nail Ömeroğlu
- Department of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Deniz Göksedef
- Department of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Önder Teskіn
- Biruni University, Faculty of Medicine, Department of Cardiovascular Surgery, Istanbul, Turkey
| | - Ozan Onur Balkanay
- Department of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - Gökhan İpek
- Department of Cardiovascular Surgery, Cerrahpaşa Medical Faculty, Istanbul, Turkey
| | - B Sönmez Uydeş Doğan
- Department of Pharmacology, Faculty of Pharmacy, Istanbul University, Istanbul, Turkey.
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He GW, Taggart DP. Antispastic Management in Arterial Grafts in Coronary Artery Bypass Grafting Surgery. Ann Thorac Surg 2016; 102:659-68. [PMID: 27319987 DOI: 10.1016/j.athoracsur.2016.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 01/19/2016] [Accepted: 03/07/2016] [Indexed: 10/21/2022]
Abstract
Arterial grafts have long-term patency superior to vein grafts but have a tendency to develop spasm that can lead to potentially life-threatening complications. A perfect antispastic protocol should include advanced surgical technique and adequate pharmacologic methods. All pharmacologic vasodilator drugs relax the vessel through specific mechanisms, and therefore, there is no perfect, single best vasodilator to prevent or treat spasm of the arterial graft against all mechanisms of contraction. One of the choices is to use a combination of pharmacologic vasodilators targeting different mechanisms of spasm to obtain the reliable and best effect.
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Affiliation(s)
- Guo-Wei He
- Department of Cardiovascular Surgery and Center for Basic Medical Research, TEDA International Cardiovascular Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin and Zhejiang University and The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China, and Department of Surgery, Oregon Health and Science University, Portland, Oregon.
| | - David P Taggart
- Department of Cardiothoracic Surgery, Oxford University, United Kingdom
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Erdem O, Memetoğlu ME, Tekin Aİ, Arslan Ü, Akkaya Ö, Kutlu R, Gölbaşı İ. Effects of intraoperative diltiazem infusion on flow changes in arterial and venous grafts in coronary artery bypass graft surgery. Braz J Cardiovasc Surg 2016; 30:459-65. [PMID: 27163420 PMCID: PMC4614929 DOI: 10.5935/1678-9741.20150045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 06/22/2015] [Indexed: 11/20/2022] Open
Abstract
Objective This study aimed to show the effects of intra-operative diltiazem infusion on
flow in arterial and venous grafts in coronary artery bypass graft
surgery. Methods Hundred fourty patients with a total of 361 grafts [205 (57%) arterial and
156 (43%) venous] underwent isolated coronary surgery. All the grafts were
measured by intraoperative transit time flow meter intra-operatively. Group
A (n=70) consisted of patients who received diltiazem infusion (dose of 2.5
microgram/kg/min), and Group B (n=70) didn't receive diltiazem infusion. Results Mean graft flow values of left internal mammary artery were 53 ml/min in
Group A and 40 ml/min in Group B (P<0.001). Pulsatility
index (PI) values of left internal mammary artery for Group A and Group B
were 2.6 and 3.0 respectively (P<0.001). No
statistically significant difference was found between venous graft
parameters. Conclusion We recommend an effect of diltiazem infusion in increasing graft flows in
coronary artery bypass graft operations.
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Affiliation(s)
- Ozan Erdem
- School of Medicine, Akdeniz University, Antalya, Turkey
| | | | | | - Ümit Arslan
- School of Medicine, Akdeniz University, Antalya, Turkey
| | - Özgür Akkaya
- School of Medicine, Akdeniz University, Antalya, Turkey
| | | | - İlhan Gölbaşı
- School of Medicine, Akdeniz University, Antalya, Turkey
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Technical Issues in the Use of the Radial Artery as a Coronary Artery Bypass Conduit. Ann Thorac Surg 2014; 98:2247-54. [DOI: 10.1016/j.athoracsur.2014.07.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/06/2014] [Accepted: 07/09/2014] [Indexed: 11/20/2022]
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Izgi C, Feray H. Is Radial Access and Transradial Cardiac Catheterization Feasible without the Use of Any Vasodilator? Int J Angiol 2014; 23:41-6. [PMID: 24627616 DOI: 10.1055/s-0033-1358384] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
This is a "proof of concept" study to assess feasibility of transradial access without use of vasodilators. Radial artery spasm (RAS) is an important cause of patient discomfort and procedural failure with use of radial access. Vasodilators are routinely used to prevent RAS. However, the use of vasodilators may not be appropriate in substantial groups of patients. These include patients with myocardial infarction and low blood pressure who will benefit from radial access the most. No specific recommendations about use of vasodilators in these settings are stated on consensus documents on radial access. During a short period of shortage of verapamil in our country, 15 consecutive patients underwent cardiac catheterization by transradial route without the use of vasodilators. Procedural success, and pain perceived by the patients along with radial occlusion after the procedure were assessed. In 14 of the 15 patients, the procedure was completed successfully without the use of vasodilators. In one patient, RAS developed and the procedure could be completed after injection of verapamil. Mean pain score was 5.3 on a scale of 0 to 10. No radial occlusion was detected early after the procedure. In three of the patients, a reason that would otherwise preclude use of a vasodilator was identified. Radial access can safely and effectively be performed without the use of vasodilators. Consideration of this approach when use of vasodilators is not appropriate should be formally discussed by the interventional cardiology community.
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Affiliation(s)
- Cemil Izgi
- Department of Cardiology, International Hospital, Istanbul, Turkey
| | - Hasan Feray
- Department of Cardiology, Acibadem Maslak Hospital, Istanbul, Turkey
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Watanabe G, Yamaguchi S, Takagi T, Tomita S, Tuan PM. Potent vasodilatory effect of fasudil on radial artery graft in coronary artery bypass operations. Ann Thorac Surg 2013; 97:845-50. [PMID: 24286636 DOI: 10.1016/j.athoracsur.2013.10.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Revised: 10/03/2013] [Accepted: 10/07/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND The radial artery (RA) is a useful conduit for coronary artery bypass grafting (CABG) but is susceptible to vasospasm during harvesting. We evaluated the usefulness of fasudil, a Rho kinase inhibitor, in dilating the RA graft and increasing graft free flow (GFF) compared with the conventional graft-dilating agents papaverine and verapamil-nitroglycerin (VG). METHODS Between June 2012 and January 2013, 45 patients with ischemic heart disease who underwent isolated CABG using the RA were enrolled and randomly assigned to fasudil (n = 15), papaverine (n = 15), or VG (n = 15). Fasudil (2.67 mmol/L), papaverine (1.0 mmol/L) mixed with heparinized blood, or VG (30 μmol/L each of verapamil and nitroglycerin) was injected intraluminally into the RA graft after harvesting. Main outcome measures were RA GFF, hemodynamic changes, and histopathologic examination of the RA. RESULTS In the fasudil group, GFF increased significantly (p < 0.001) from 36.8 ± 20.4 at baseline to 148.0 ± 88.3 mL/min after injection. GFF increased significantly (p < 0.001) from 36.0 ± 19.0 to 72.3 ± 36.7 mL/min in the papaverine group and increased significantly (p < 0.001) from 39.5 ± 23.3 to 64.3 ± 29.9 mL/min in the VG group. The GFF was significantly higher (p = 0.001) in fasudil-treated RA than in papaverine- or VG-treated RA. Histopathologically, RA graft diameter was markedly increased after fasudil injection, and the structure of the multiple elastic lamellae was intact. Blood pressure did not change significantly after drug injection in all groups. CONCLUSIONS Fasudil exhibited a very potent vasodilatory effect on the RA compared with conventional papaverine or VG, resulting in increased GFF. This agent is useful for dilating RA grafts in CABG.
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Affiliation(s)
- Go Watanabe
- Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan.
| | - Shojiro Yamaguchi
- Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Takeshi Takagi
- Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Shigeyuki Tomita
- Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
| | - Pham Minh Tuan
- Department of General and Cardiothoracic Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan
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He GW. Arterial grafts: clinical classification and pharmacological management. Ann Cardiothorac Surg 2013; 2:507-18. [PMID: 23977630 DOI: 10.3978/j.issn.2225-319x.2013.07.12] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 07/16/2013] [Indexed: 01/08/2023]
Abstract
In comparison with standard saphenous vein grafts, use of the internal mammary artery (IMA) as a coronary artery bypass graft has achieved superior long-term results. This is related to the differences in the biological characteristics between the venous and arterial grafts. However, even arterial grafts are not uniform in their biological characteristics. The variation in the perioperative behavior of the grafts and in their long-term patency may be related to different characteristics. These factors should be taken into account in the use of arterial grafts, some of which are subjected to more active pharmacological intervention during and after the operation to obtain satisfactory results. To better understand the biological behavior of the grafts, their common features and their differences, a clinical classification may be useful for a practicing surgeon. Based on experimental studies of their vasoreactivity combined with anatomical, physiological and embryological considerations, we have proposed a functional classification for arterial grafts that may be useful clinically. Our classification suggests that there are three types of arterial grafts: Type I-somatic arteries; Type II-splanchnic arteries; and Type III-limb arteries. Type I arteries have enhanced endothelial function and release more nitric oxide and other relaxing factors. Type II arteries, such as the gastro-epiploic artery, and Type III arteries, such as the radial artery (RA), have higher pharmacological reactivity to vasoconstrictors. This classification explains why the IMA has the best long-term patency. Because Type II and III arteries are prone to spasms due to higher contractility, they require more active pharmacological interventions. Furthermore, the harvesting technique of the conduits, including the saphenous vein and IMA, are described and discussed in this article. Prevention of spasms using two cocktails of medications (verapamil + nitroglycerin and nicardipine + nitroglycerin) during harvesting of the conduits is described. These solutions have been demonstrated to be clinically effective.
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Affiliation(s)
- Guo-Wei He
- TEDA International Cardiovascular Hospital, Tianjin & The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China; ; Department of Surgery, Oregon Health and Science University, Portland, Oregon, USA
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Diagnóstico y alternativas terapéuticas en la isquemia miocárdica aguda perioperatoria en cirugía coronaria. Med Intensiva 2010; 34:64-73. [DOI: 10.1016/j.medin.2008.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2008] [Revised: 11/18/2008] [Accepted: 11/29/2008] [Indexed: 11/20/2022]
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A new antispastic solution for arterial grafting: nicardipine and nitroglycerin cocktail in preparation of internal thoracic and radial arteries for coronary surgery. J Thorac Cardiovasc Surg 2008; 136:673-80, 680.e1-2. [PMID: 18805271 DOI: 10.1016/j.jtcvs.2007.12.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2007] [Revised: 11/05/2007] [Accepted: 12/24/2007] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Antispastic protocols for arterial grafts are important in arterial grafting for coronary artery bypass grafting surgery. We designed a new nicardipine and nitroglycerin cocktail that is composed of a second-generation dihydropyridine calcium antagonist, nicardipine and nitroglycerin (30 micromol/L), and examined its effect in human internal thoracic and radial arteries. METHODS Human internal thoracic (n = 86) and radial (n = 74) artery segments from 72 patients undergoing coronary artery bypass grafting were studied. Relaxation against 3 classic vasoconstrictors (potassium chloride, thromboxane A(2) mimetic U46619, and alpha-adrenoceptor agonist norepinephrine) and prophylactic effect on contraction against these vasoconstrictors were examined. The effect of the nicardipine and nitroglycerin cocktail on the endothelial function in internal thoracic and radial arteries was studied in response to acetylcholine. RESULTS Nicardipine and nitroglycerin induced almost full relaxation (92.2% +/- 4.7% to 97.9% +/- 1.0%, P < .001 in internal thoracic arteries and 95.4% +/- 1.9% to 96.7% +/- 3.3%, P < .001 in radial arteries, n = 6-8) against 3 vasoconstrictors with significant prophylactic effect on contraction (maximal contraction was depressed to 32.5% to 76.4%, P < .05 or P < .001, and EC50s were increased to 5 to 42-fold more, P < .01). After treatment with the nicardipine and nitroglycerin cocktail, the acetylcholine-induced relaxation was unchanged (P > .05). CONCLUSION The use of the nicardipine and nitroglycerin cocktail provides a new antispastic protocol that has rapid onset, full relaxation, and excellent prophylactic effect against all known mechanisms of vasospasm and maximally protects the endothelial and smooth muscle function of the internal thoracic and radial arteries. The cocktail is therefore expected to provide a new method in treating grafts in coronary artery bypass grafting with the best antispastic effect and protection of the graft.
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Conant AR, Theologou T, Dihmis WC, Simpson AWM. Diadenosine polyphosphates are selective vasoconstrictors in human coronary artery bypass grafts. Vascul Pharmacol 2008; 48:157-64. [PMID: 18325842 DOI: 10.1016/j.vph.2008.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Accepted: 01/17/2008] [Indexed: 11/16/2022]
Abstract
Diadenosine polyphosphates (Ap(n)A) are released by degranulating platelets and high, local concentrations may form at sites of platelet activation. Radial artery grafts, now often used alongside the internal mammary artery in coronary artery bypass surgery, are particularly reactive to several vasoconstrictors but the response to Ap(n)A has not been investigated. This study compared the vasoconstrictor activity of Ap(n)A in human radial artery with other vessels commonly used as bypass grafts. Radial artery demonstrated robust concentration-dependent vasoconstriction to Ap(n)A (n=4-6) at concentrations in the micromolar range. In contrast, average responses in internal mammary artery were negligible. Cross-desensitization revealed that Ap(n)A-mediated vasoconstriction occurred via an alphabetamethyleneATP-sensitive receptor. Responses to both Ap(5)A and alphabetamethyleneATP were inhibited by suramin but were insensitive to the P2X(1) receptor antagonist 8,8'-[Carbonylbis(imino-4,1-phenylenecarbonylimino-4,1-phenylenecarbonylimino)]bis-1,3,5-naphthalenetrisulfonic acid (NF279). Pyridoxalphosphate-6-azophenyl-2',4'-disulphonic acid (PPADS) enhanced responses to Ap(5)A. Similar responses were obtained in saphenous vein. In conclusion, diadenosine polyphosphates contract radial artery and saphenous vein by an as yet uncharacterized P2X receptor but have only limited activity in internal mammary artery. The selective activity of diadenosine polyphosphates in radial artery would implicate them as potential mediators of post-operative contraction in this graft.
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Affiliation(s)
- Alan R Conant
- The Cardiothoracic Centre, Liverpool NHS Trust, Thomas Drive, Liverpool L14 3PE, UK.
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Canver CC, Yousafzai SM. Intraoperative in Situ Radial Artery Conduit Flow Assessment. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2008. [DOI: 10.1177/155698450800300106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Charles C. Canver
- Section of Cardiac Surgery, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Sajjad M. Yousafzai
- Section of Cardiac Surgery, King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
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Intraoperative in Situ Radial Artery Conduit Flow Assessment. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2008; 3:25-6. [DOI: 10.1097/imi.0b013e3181662c58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A technique is described for simple flow assessment of the in situ radial artery conduit during coronary bypass via a small incision. This technique allows morphologic and physiologic direct intraoperative assessment of radial artery quality and expands the use of radial artery during coronary artery surgery.
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Muriithi EW, Alphonso N, Barnard JB, Hyde JAJ, Pugsley WB, Trivedi UH, Forsyth AT. Early to midterm results with the radial artery in coronary artery bypass grafting following autotransplantation without pharmacological manipulation. J Card Surg 2007; 22:323-7; discussion 328-9. [PMID: 17661775 DOI: 10.1111/j.1540-8191.2007.00415.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND In our unit when the radial artery is used as a conduit for myocardial revascularization routine, postoperative calcium-channel blockade is not practised. To preserve the radial artery, it is freed from the surrounding structures together with its venae commitantes and then left, in situ, in circulation, until needed for grafting. We evaluated the early to midterm patency of the radial artery using this strategy in our patients. METHODS We analysed prospectively collected data on 690 consecutive patients who had isolated primary coronary artery bypass grafting performed between June 1999 and February 2003 with at least one conduit being a radial artery. RESULTS Radial arteries were used for 851 of 2150 distal anastomoses (39.6%). Median follow-up was 399 days (range 20-1323) and was 99.9% complete. Early mortality was 2.0% (14). Late mortality was 3.0% (21), 12 late deaths were not cardiac related. Nine patients (1.4%) had angiography on clinical grounds a mean of 238 days (range 0-511) postoperatively. Six coronary artery territories were inadequately supplied by their radial artery grafts. Kaplan-Meier event-free survival was 94% and 90% at 1 and 3 years, respectively. CONCLUSIONS The results of coronary artery bypass grafting using the radial artery in our institution compare favourably with those of other contemporary workers. It is safe to leave the radial artery in situ in the circulation until it is required for grafting. The absence of postoperative pharmacological manipulation of the radial artery does not appear to affect early or midterm outcome.
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Affiliation(s)
- E W Muriithi
- Sussex Cardiac Centre, Royal Sussex County Hospital, Brighton, United Kingdom
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19
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Oo AY, Conant AR, Chester MR, Dihmis WC, Simpson AWM. Temperature Changes Stimulate Contraction in the Human Radial Artery and Affect Response to Vasoconstrictors. Ann Thorac Surg 2007; 83:126-32. [PMID: 17184643 DOI: 10.1016/j.athoracsur.2006.08.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Revised: 08/17/2006] [Accepted: 08/18/2006] [Indexed: 11/26/2022]
Abstract
BACKGROUND Radial artery conduits are increasingly used in coronary artery bypass grafting as an additional arterial graft to the internal thoracic artery. Their reactive nature remains a concern, often necessitating the routine use of topically applied vasodilators, such as glyceryl trinitrate, papaverine, phenoxybenzamine, or calcium channel antagonists, in theatre. During preparation prior to surgery and grafting, radial artery conduits are exposed to cooling and rewarming. We investigated how these temperature changes would affect radial artery contractility and how commonly used topical treatments might be used to prevent this. METHODS Human radial artery was obtained excess to surgery and arterial sections used in organ bath tension experiments or for the culture of smooth muscle cells from medial explants. RESULTS The radial artery responded to rapid cooling by the addition of 22 degrees C buffer with contraction. Gradual cooling, over a 20 to 30 minute period, reduced basal tension and the response to potassium chloride (KCl) and noradrenaline. Subsequent rewarming from 22 degrees C to 37 degrees C reestablished contraction at precooled levels and led to an elevation of the basal tension. Increases in tension measured in the radial artery were paralleled by increases in intracellular calcium in smooth muscle cells. Contraction induced by rapid temperature changes could be blocked by glyceryl trinitrate but not by phenoxybenzamine. Papaverine and calcium channel blockers had only limited activity. CONCLUSIONS Temperature changes commonly encountered in theatre during the preparation of radial artery grafts are likely to cause contraction. If rapid temperature change cannot be avoided during graft preparation, then topically applied glyceryl trinitrate will block these responses.
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Affiliation(s)
- Aung Y Oo
- The Cardiothoracic Centre, University of Liverpool, Liverpool, United Kingdom
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Tarhan IA, Kehlibar T, Yapici F, Yilmaz M, Arslan Y, Saday G, Ozler A. Efficacy of Physiologic Temperature on the Spasm of Harvested Radial Artery. Heart Surg Forum 2006; 9:E765-9. [PMID: 16844635 DOI: 10.1532/hsf98.20051002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND The potential disadvantage of using the radial artery for coronary artery bypass grafting is its increased tendency to vasospasm. Therefore, different antispastic agents are being used in the perioperative and postoperative period. During the preparation of the radial artery, normal local and systemic temperatures are lost. METHODS We investigated the effects of topical normal saline solution at 20 degrees C (group SI), normal saline solution at 36 degrees C (group SII), diltiazem at 20 degrees C (group DI), and diltiazem at 36 degrees C (group DII) on radial artery free flow. Each group contained 10 patients undergoing coronary bypass surgery. Free flow and local temperature were measured at 3 stages: after the exploration and preparation of the distal 3 cm of the radial artery, after total preparation of the radial artery, and a median of 12 minutes after the pedicle had been sprayed with one of the agents. RESULTS Parallel to the significant decrease of the second local temperatures (P < .001), the second flow of the 4 groups decreased significantly (P < .001). CONCLUSION Hypothermia plays an important role in radial artery vasospasm, and normothermia may be the best perioperative vasodilating agent since the normal radial artery flows were reached with normothermia.
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Affiliation(s)
- Ibrahim Arif Tarhan
- Department of Cardiovascular Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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21
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Nisanoglu V, Battaloglu B, Ozgur B, Eroglu T, Erdil N. Topical Vasodilators for Preventing Radial Artery Spasm during Harvesting for Coronary Revascularization: Comparison of 4 Agents. Heart Surg Forum 2006; 9:E807-12. [PMID: 16893753 DOI: 10.1532/hsf98.20061070] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND There is still controversy about which vasodilator solution is best for storing radial artery (RA) conduits prior to coronary artery bypass grafting. The aim of this pilot study was to investigate how 4 different topical vasodilators applied during RA harvesting affect blood flow with the vessel in situ. MATERIALS AND METHODS The subjects were 85 patients who underwent RA harvesting in preparation for coronary artery bypass grafting. Each case was assigned to 1 of 5 groups (17 RAs each) that were treated with different solutions: normal saline (control), nitroglycerin, diltiazem, papaverine, and adenosine. Standard clinical concentrations were used. The RA was partially harvested (pedicle attached proximally) and flow rates and hemodynamic parameters (mean arterial pressure, heart rate, central venous pressure) were recorded at 2 time points: (1) pretreatment and (2) after 5 minutes of immersion in 60 mL of treatment solution. Results were compared within and between groups, and post-treatment-to-pretreatment ratios were calculated for each variable. RESULTS There were no significant differences among the groups' mean pretreatment flow rates (P = .979) or mean posttreatment flow rates (P = .069). All except the diltiazem group showed a significant rise in mean flow rate from pretreatment to posttreatment. The mean posttreatment-to-pretreatment ratios for RA flow rate were 1.28 +/- 0.39 in the saline group, 1.85 +/- 0.72 in the nitroglycerin group, 1.31 +/- 0.48 in the diltiazem group, 1.37 +/- 0.64 in the papaverine group, and 1.23 +/- 0.42 in the adenosine group. Only the mean flow ratio in the nitroglycerin group was significantly higher than that in the saline group (P = .003). The mean flow ratios in the other vasodilator groups were not statistically different from the flow ratio in the saline group. CONCLUSIONS These preliminary results indicate that topical application of nitroglycerin solution effectively prevents perioperative spasm of the RA in patients undergoing coronary artery bypass surgery. The authors recommend this solution for preparation and storage of RA grafts. Randomized controlled trials with power analysis will give more definitive information.
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Affiliation(s)
- Vedat Nisanoglu
- Department of Cardiovascular Surgery, Inonu University, Turgut Ozal Medical Center, Malatya, Turkey.
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Stojnic N, Bukarica LG, Peric M, Bumbasirevic M, Lesic A, Lipkovski JM, Heinle H. Analysis of Vasoreactivity of Isolated Human Radial Artery. J Pharmacol Sci 2006; 100:34-40. [PMID: 16404133 DOI: 10.1254/jphs.fpe05004x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Radial artery (RA) is increasingly used as graft for coronary artery bypass grafting due to its good long-term patency. However, the mechanism of peri- and post-operative spasm is still unclear. Because of that, the aim of our study is to analyze the contractility of RA and to determine whether the presence of functional endothelium alters its contractile properties. Contractions of isolated RA rings were provoked by exogenously applied vasoconstrictors or by electrical field stimulation (EFS, 20 Hz). The order of vasoconstrictors potency based on their EC50 values was as follows: angiotensin II > phenylephrine > 5-hydroxytriptamine. Presence of endothelium increased both EC50 and maximal contraction to phenylephrine and angiotensin II, but inhibited reactivity of RA to 5-hydroxytriptamine. Spontaneous rhythmic contractions (SRC, <4 mHz) and EFS-induced contractions of RA are endothelium-independent and weaker than contractions induced by exogenously applied vasoconstrictors. Our study concludes that RA shows marked sensitivity and reactivity to angiotensin II, phenylephrine, and 5-hydroxytriptamine. Further investigations are necessary to answer why angiotensin II and phenylepehrine induce stronger contractions in the presence of endothelium. In addition, SRC as well as contractions of neurogenic origin may take part in developing vascular spasm of RA.
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Affiliation(s)
- Natasa Stojnic
- Departement of Clinical Pharmacology, Pharmacology and Toxicology, Faculty of Medicine, University of Belgrade, Serbia and Montenegro
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Teskin O, Uydeş-Dogan BS, Enç Y, Alp FI, Kaleli D, Keser S, Iyigün T, Bilgen F, Dagsali S, Ozdemir O. Comparative Effects of Tolazoline and Nitroprusside on Human Isolated Radial Artery. Ann Thorac Surg 2006; 81:125-31. [PMID: 16368348 DOI: 10.1016/j.athoracsur.2005.07.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 07/04/2005] [Accepted: 07/06/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND The radial artery is increasingly being used in coronary revascularization as an alternative conduit to a saphenous vein graft. Its perfect endothelial capacity provides a high patency rate comparable with the internal mammary artery (IMA). However, its spastic characteristics cause difficulties during its intraoperative preparation and may lead to early postoperative graft failure. Thus, treatment and/or prevention of radial artery spasm with an effective vasodilator agent is essential for its longevity. Endogenous vasoconstrictors, including noradrenaline, endothelin-1, and thromboxane A2, are likely to play a role in the pathogenesis of graft spasm. In the present study, we evaluated the vasorelaxant effect of tolazoline, a nonselective alpha-adrenoceptor blocker, against the contractions induced by various spasmogenic agents in an isolated human radial artery. METHODS Tolazoline (10(-9)-10(-4) M) or sodium nitroprusside (SNP, 10(-9)-10(-4) M) were cumulatively applied on radial artery rings precontracted submaximally with noradrenaline, endothelin-1, thromboxane analogue, U46619, or potassium chloride. In addition, some rings were pretreated with tolazoline (4 x 10(-6) M) for 30 minutes and the contractile response curve to noradrenaline was assessed in its presence. RESULTS Tolazoline effectively reversed noradrenaline-induced contractions in the radial artery, whereas it failed to produce remarkable relaxations on rings contracted with other spasmogenic agents, while SNP overcame the contractions induced by all spasmogens to a similar extent. In addition, brief pretreatment of radial artery rings with tolazoline significantly inhibited the contractions to noradrenaline. CONCLUSIONS Tolazoline is not as broadly effective as SNP against all spasmogens investigated; however, it may be effective in counteracting alpha-adrenoceptor-mediated vasospasm in human radial arteries.
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Affiliation(s)
- Onder Teskin
- Department of Cardiovascular Surgery, Siyami Ersek Thoracic and Cardiovascular Surgery Education and Research Hospital, Istanbul, Turkey
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Manabe S, Sunamori M. Radial Artery Graft for Coronary Artery Bypass Surgery: Biological Characteristics and Clinical Outcome. J Card Surg 2006; 21:102-14; 115. [PMID: 16426364 DOI: 10.1111/j.1540-8191.2006.00182.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The radial artery (RA) is gaining popularity as a bypass conduit for coronary artery bypass grafting, and its impact on clinical practice has been extensively explored. In the present article, we provide a review of postoperative hand circulation, vascular biological characteristics of the RA graft, the efficacy of vasodilator therapies, and mid-term clinical results of use of the RA graft. Fundamental studies revealed excellent vascular biological characteristics of the RA graft as a living arterial conduit, making it almost equivalent to the internal thoracic artery (ITA) graft. Clinical studies have yielded encouraging mid-term results. Most studies reported in favor of the RA graft over the saphenous vein graft with regard to patency rate, freedom from cardiac events, and survival. However, superiority of either the RA or right ITA graft has not been conclusively determined. The long-term results of RA grafts remain unknown, but at present, supplementary use of an RA graft with a left ITA graft appears feasible for CABG.
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Affiliation(s)
- Susumu Manabe
- Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University, Yushima 1-5-45, Bunkyo-Ku, Tokyo 113-8519, Japan.
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Kharabsheh S, Al-Halees Z. The radial artery as a coronary bypass conduit: dealing with hypereactivity. Ann Saudi Med 2005; 25:70-2. [PMID: 15822501 PMCID: PMC6150573 DOI: 10.5144/0256-4947.2005.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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26
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Daneshmand MA, Keller RS, Canver MC, Canver AC, Canver CC. Histamine H1 and H2 receptor–mediated vasoreactivity of human internal thoracic and radial arteries. Surgery 2004; 136:458-63. [PMID: 15300215 DOI: 10.1016/j.surg.2004.05.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Although internal thoracic arteries (ITAs) and radial arteries (RAs) have been shown to have similar patency, RAs tend to be more vasospastic postoperatively compared with ITAs. Therefore, the purpose of this study was to examine the effect of histamine subclass 1 (H1) receptors and histamine subclass 2 (H2) receptors on vasoreactivity in human ITAs and RAs. METHODS Vessels were obtained from coronary artery bypass grafting patients. Human arterial rings (2 mm) were mounted in tissue baths, and baseline contractility was determined. Histamine concentration response curves (10(-9)-10(-3) mol/L) were performed in the absence or presence of diphenhydramine (H1 antagonist, 10(-4) mol/L) or famotidine (H2 antagonist, 10(-4) mol/L). Comparison of curves was performed by 2-way analysis of variance with repeated measures and a Bonferroni post-t test. RESULTS Maximal contraction to histamine was significantly greater in RA (8.3 +/- 0.8 g, n = 6) than in ITA (2.9 +/- 0.3, n = 6), (P < .05). However, there was no difference in sensitivity. Histamine-mediated responses of both RA and ITA were blocked by pre-exposure to H1 antagonist, whereas an H2 antagonist only partially inhibited RA responses while blocking most of the ITA response to histamine. CONCLUSION These studies suggest that H1 receptors alone cause contraction in RA but not in ITA, which may have potential linkage to patency and vasospasm. Further studies are necessary to identify the exact role of H2 receptors in ITA.
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Affiliation(s)
- Mani A Daneshmand
- Heart Institute and the Center for Cardiovascular Science, Albany Medical College, Albany, NY 12208, USA
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27
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Okon EB, Millar MJ, Crowley CM, Bashir JG, Cook RC, Hsiang YN, McManus B, van Breemen C. Effect of moderate pressure distention on the human saphenous vein vasomotor function. Ann Thorac Surg 2004; 77:108-14; discussion 114-5. [PMID: 14726044 DOI: 10.1016/j.athoracsur.2003.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
BACKGROUND Manual pressure distension, which is commonly applied to the human saphenous vein graft for coronary artery bypass, is believed to have detrimental consequences for the graft patency. The vasomotor function of the vein after distention during surgical preparation for grafting and after distention in laboratory conditions at pressure of 50 to 600 mm Hg was studied. The effect of a combination of vasodilative agents to prevent vasospasm was also tested. METHODS The contractile and dilatory responses of distended and undistended human saphenous veins and those after drug treatment were examined in organ baths under isometric conditions. RESULTS Distention at the pressure range 100 to 300 mm Hg resulted in an increased contractile response of the saphenous vein to both alpha-adrenergic activation with 50 micromol/L phenylephrine (153.73% +/- 15.69%) and depolarization with 80 mmol/L K(+) (141.03% +/- 15.13%) in comparison with the undistended vein and did not impair the relaxation. In contrast manual distention during surgical preparation abolished the contractile response and impaired the relaxation. The application of a combination of vasodilative drugs (alpha-adrenergic antagonist phenoxybenzamine, 10 micromol/L, Rho-kinase inhibitor HA-1077, 50 micromol/L, and calcium blocker nicardipine, 1 micromol/L) eliminated the contractile response of the vein to phenylephrine and 80 mmol/L K(+). This effect was sustained more than 20 hours after the washout of the drugs. CONCLUSIONS The distention of the human saphenous vein at moderate pressure combined with the application of the effective combination of vasodilative drugs before grafting into the arterial circulation could be a beneficial alternative to the current practice of uncontrolled pressure distension.
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Affiliation(s)
- Elena B Okon
- Department of Pathology and Laboratory Medicine, University of British Columbia and St Paul Hospital, Vancouver, British Columbia, Canada.
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28
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Connors JJ. Pharmacologic Agents in Stroke Prevention, Acute Stroke Therapy, and Interventional Procedures. J Vasc Interv Radiol 2004; 15:S87-101. [PMID: 15101518 DOI: 10.1097/01.rvi.0000112975.88422.5d] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Pharmaceutical agents have moved far beyond just the aspirin and heparin that were the mainstays of stroke and interventional therapy as recently as 10 to 15 years ago. Our understanding of the mechanisms of thrombus formation and vascular response to damage as well as our armamentarium has tremendously improved in the past decade. Direct thrombin inhibitors, powerful antiplatelet agents, new fibrinolytic agents, and statins now allow far greater manipulation of the intraprocedural and postprocedural clot cascade and atherogenesis. It is mandatory that current-day interventionists understand the correct and appropriate use of these agents to achieve the desired outcomes of therapy.
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Affiliation(s)
- J J Connors
- Department of Interventional Neuroradiology, Miami Cardiovascular Institute, Baptist Hospital, 8900 North Kendall Drive, Miami, Florida 33176, USA.
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Fazel S, Mallidi HR, Pelletier MP, Sever JY, Christakis GT, Goldman BS, Fremes SE. Radial artery use is safe in patients with moderate to severe left ventricular dysfunction. Ann Thorac Surg 2003; 75:1414-21. [PMID: 12735555 DOI: 10.1016/s0003-4975(02)04992-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Using radial artery grafts in patients with moderate to severe left ventricular dysfunction (LVD; ejection fraction < 35%) has been discouraged for the fear that postoperative vasopressor support may cause graft spasm and lead to ischemic complications. We, therefore, examined the safety of radial grafts in aortocoronary bypass (ACB) patients with LVD. METHODS Data were collected from 5,455 patients who underwent isolated ACB between January 1995 and September 2001. One thousand eight hundred three patients received a radial artery graft (RadACB), and 3,652 patients did not (NoRadACB). Three hundred seven RadACB, and 819 NoRadACB operations were performed in LVD patients. A matched (age, sex, urgency of operation, diabetes, and renal insufficiency) cohort analysis was performed in LVD patients. Univariate and logistic regression analyses were performed in the entire population and the unmatched RadACB and NoRadACB patient subgroups to examine the effect of radial artery use on postoperative death or myocardial infarction rate. RESULTS The matched cohort analysis revealed a similar rate of death or myocardial infarction (RadACB, 11 of 242 patients; NoRadACB, 16 of 242 patients; p = 0.32). Left ventricular dysfunction was associated with a higher rate of death or myocardial infarction in both unmatched groups (RadACB, odds ratio, 2.36; 95% confidence interval, 1.38 to 4.58; p = 0.004; NoRadACB, odds ratio, 1.62; 95% confidence interval, 1.18 to 2.24; p < 0.001) and in the entire population (odds ratio, 1.77; 95% confidence interval, 1.32 to 2.35; p = 0.003). An interaction term for patients with LVD and a radial artery graft, which was forced into the logistic regression model for the entire population, was not predictive of death or myocardial infarction (odds ratio, 1.52; 95% confidence interval, 0.75 to 3.10; p = 0.25). CONCLUSIONS Left ventricular dysfunction carries similar risk for postoperative death or myocardial infarction in RadACB and NoRadACB patients. The presence of LVD in isolation is not a contraindication to the use of radial grafting.
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Affiliation(s)
- Shafie Fazel
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada
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Drossos GE, Toumpoulis IK, Katritsis DG, Ioannidis JPA, Kontogiorgi P, Svarna E, Anagnostopoulos CE. Is vitamin C superior to diltiazem for radial artery vasodilation in patients awaiting coronary artery bypass grafting? J Thorac Cardiovasc Surg 2003; 125:330-5. [PMID: 12579102 DOI: 10.1067/mtc.2003.3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES We aimed to measure the vasodilating effects of vitamin C on the radial arteries of healthy subjects and to assess whether vitamin C is superior in this regard to diltiazem, a commonly used vasodilator in coronary artery bypass using radial conduits. METHODS In a case-control study (study 1) oral single-dose vitamin C (2 g) was given to 15 healthy nonsmokers and 15 matched otherwise healthy smokers. In a randomized double-blind study (study 2) oral single-dose vitamin C (2 g, n = 15) and diltiazem (180 mg, n = 15) were compared in preoperative patients with coronary artery disease. We examined the dilation of the radial artery with high-resolution ultrasonography and measurement of the lumen surface and color Doppler images of the nondominant radial artery just before and 2 hours after drug administration. RESULTS In study 1 both smokers and nonsmokers showed a significant increase in the lumen surface at 2 hours compared with at baseline (P <.001 and P =.013, respectively). The increase was larger in smokers (median, 37.5% vs 14.3%; P =.004). In study 2 both groups showed statistically significant increases in the lumen surface at 2 hours compared with at baseline (P <.001 and P =.008 for vitamin C and diltiazem, respectively). Vitamin C achieved a larger increase than diltiazem (median, 33.3% vs 18.2%; P =.016). In multivariate modeling the increase in lumen surface was independently predicted by use of vitamin C over diltiazem (+21.2%, P =.007), diabetes mellitus (+14.5%, P =.085), increased cholesterol (+26.2%, P =.001), and smoking history (+20.8%, P =.017). CONCLUSIONS Vitamin C is a potent acute vasodilator in both smokers and nonsmokers and is superior to diltiazem in preoperative coronary patients who need protection from vasospasm of the radial conduit.
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Affiliation(s)
- George E Drossos
- Department of Cardiothoracic Surgery, University of Ioannina School of Medicine, Ioannina, Greece
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Saito S, Tanaka S, Hiroe Y, Miyashita Y, Takahashi S, Satake S, Tanaka K, Yamamoto M. Usefulness of hydrophilic coating on arterial sheath introducer in transradial coronary intervention. Catheter Cardiovasc Interv 2002; 56:328-32. [PMID: 12112884 DOI: 10.1002/ccd.10202] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Radial artery spasm is one of the major problems during transradial coronary intervention (TRI). The sheath introducer with hydrophilic coating may reduce the incidence of spasm and reduce the difficulty in removing it from the radial artery under the situation of spasm artery spasm. After we compared the friction resistance between the sheath introducer with hydrophilic coating and that without coating (nine samples each) in vitro, the sheath introducers with and without hydrophilic coating were randomly used in 37 and 36 patients, respectively, who underwent elective TRI with a 6 Fr introducer sheath. Hydrophilic coating of sheath introducer reduced friction resistance by 70% (P < 0.00001) in in vitro model and facilitated sheath removal after finishing TRI (P = 0.0003). Hydrophilic coating of sheath introducer is useful in TRI.
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Affiliation(s)
- Shigeru Saito
- Division of Cardiology and Catheterization Laboratories, Heart Center of Shonan, Kamakura General Hospital, Kamakura, Japan.
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Abstract
BACKGROUND To reverse preexisting coronary graft spasm, we investigated the vasodilative effect of the average therapeutic plasma concentration of nitroglycerin (NTG) alone and various calcium antagonists in combination with NTG in human arterial and venous conduits. METHODS Vasodilative effects of 2 x 10(-8) mol/L NTG alone and 10(-8) mol/L NTG in combination with 2.2 x 10(-7) mol/L diltiazem, 2.8 x 10(-7) mol/L nifedipine, 10(-7) mol/L verapamil, or 5.6 x 10(-8) mol/L nicardipine were assessed in human radial artery, internal thoracic artery, and saphenous vein segments precontracted with a mixture of ten times the maximum plasma concentrations of endothelin-1 (8.6 x 10(-13) mol/L), angiotensin II (36 x 10(-11) mol/L), 5-hydroxytryptamine (3.4 x 10(-7) mol/L), and norepinephrine (1.7 x 10(-8) mol/L). The studies were done in organ baths. RESULTS The therapeutic concentration of NTG alone or nifedipine, verapamil, diltiazem, or nicardipine in combination with NTG caused equal relaxation in a particular group of vascular segments (average vasodilation: radial artery, 83% to 95% [p = 0.7608 by analysis of variancel; saphenous vein, 47% to 70% [p = 0.3142]; internal thoracic artery, 54% to 79% [p = 0.27831). These combinations were not equally effective when compared between different groups of vascular segments (vasodilation; radial artery > internal thoracic artery > saphenous vein [p < 0.0001 by analysis of variance]). Although not significant, in comparison with NTG alone, NTG in combination with a calcium antagonist caused less vasodilation in any group of vascular segments. CONCLUSIONS Nitroglycerin alone or in combination with nifedipine, verapamil, diltiazem, or nicardipine effectively reverses preexisting vasospasm in coronary artery conduits.
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Affiliation(s)
- J Chanda
- Division of Cardiothoracic Surgery, Albany Medical College, New York 12208, USA
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