Arm complications after radial artery procurement for coronary bypass operation

Rationale and design of a single-center randomized trial to compare the graft patency between the radial artery and the no-touch saphenous vein in coronary artery bypass grafting surgery (GRAFT-CAB Study)

BACKGROUND

Previous studies suggested only the radial artery and the No-touch (NT) technique were effective in reducing graft occlusion after coronary artery bypass grafting (CABG) surgery. However, there is no randomized trial comparing these 2 graft conduits. The optimum second conduit for CABG remains undetermined.

MATERIALS AND METHODS

This study is a prospective, single-center randomized clinical trial, aiming to compare the graft patency between the radial artery and the NT vein graft. All patients undergoing isolated CABG with left internal mammary artery (LIMA) plus at least 2 additional grafts will be considered eligible. About 774 cases (516 in the radial artery group and 258 in the NT vein group) will be enrolled in over 1 to 2 years. Participants will be randomized and allocated to two bypass strategies: the LIMA plus 1 radial artery and 1 conventional vein graft, or the LIMA plus 2 NT vein grafts. The primary outcome is graft occlusion at 1 year after CABG evaluated by CT angiography. The secondary outcomes include graft occlusion at 3 and 5 years and major adverse cardiac or cerebrovascular events at 1, 3, and 5 years follow-ups.

DISCUSSION

This study will define whether or not the NT vein has a lower graft occlusion rate than the radial artery in short and mid-term follow-ups, and provide new evidence for the second conduit choice in CABG surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06014047. Registered on October 15th, 2023.

Clinical anatomy of the lateral antebrachial cutaneous nerve: Is there any safe zone for interventional approach?

INTRODUCTION

The lateral antebrachial cutaneous nerve (LACN) is a somatosensory nerve coursing in the lateral portion of the forearm. The nerve is located in a close proximity to the cephalic vein (CV) all along its course with a danger of being injured during venipuncture. The LACN also overlaps and communicates with the superficial branch of the radial nerve (SBRN) in the distal forearm and hand, making the awareness of their relationship of great importance in the treatment of neuroma. The aim of the study was to observe the relationship of the LACN to surrounding structures as well as its branching pattern and distribution.

MATERIALS AND METHODS

Ninety-three cadaveric forearms embalmed in formaldehyde were dissected. The relationship of the LACN to surrounding structures was noted and photographed, and distances between the structures were measured with a digital caliper. The cross-sectional relationships of the LACN and SBRN to the CV were described using heatmaps.

RESULTS

The emerging point of the LACN was found distally, proximally or at the level of the interepicondylar line (IEL). The LACN branched in 76 cases (81.7 %) into an anterior and posterior branch at mean distance of 47.8 ± 34.2 mm distal to the IEL. The sensory distribution was described according to the relationship of the LACN branches to the medial border of the brachioradialis muscle. The LACN supplying the dorsum of the hand was observed in 39.8 % of cases. The LACN and the SBRN intersected in 86 % of upper limbs with communications noticed in 71 % of forearms. The LACN was stated as the most frequent donor of the communicating branch resulting in neuroma located distal to the communication and being fed from the LACN. The relationship of the LACN and the CV showed that the IEL is the most appropriate place for the venipuncture due to maximal calibers of the CV and deep position of the LACN. The LACN was adjacent to the cubital perforating vein and the radial artery in all cases. The medial border of the brachioradialis muscle was observed less than 1.8 mm from the LACN.

CONCLUSION

The study provides morphological data on the LACN distribution, branching pattern and relationship to surrounding structures in a context of clinical use in different spheres of medicine. The branching pattern of the LACN appears to be more constant compared to data provided by previous authors. We emphasized the meaning of cross-sectional relationship of the LACN to the CV to avoid venipuncture outside the cubital fossa if possible. The posterior branch of the LACN was predicted as appropriate donor of the graft for a digital nerve. The LACN appeared to be in a close proximity within the whole length of the brachioradialis muscle what the orthopedic surgeons must be concerned of. The meaning of the donor-nerve of the communicating branch in neuroma treatment was also introduced.

Is endoscopic radial artery harvesting open for business?

With the resurgence of the radial artery in coronary artery bypass grafting, the debate on the optimal harvesting technique continues. Here, we comment on a randomized series in which the authors conclude that endoscopic harvesting techniques offer the benefit of improved cosmetic outcomes and decreased neurological complications with comparable graft-related outcomes when compared with open harvesting. We conclude that although this study is well designed and conducted, there are several areas of concern including surgical technique and statistical power.

Using bilateral radial arteries in coronary artery bypass grafting is safe

BACKGROUND

Recent studies have revealed that radial artery grafts have excellent patency rates. However, harvesting of the radial artery is generally limited to the non-dominant forearm. We would like to demonstrate the effectiveness and safety of bilateral radial artery harvesting.

METHODS

We enrolled 173 patients undergoing coronary artery bypass. Bilateral RA were used in 64 cases and unilateral in 109. The primary endpoint was post-harvest forearm and hand complications.

RESULTS

Forearm and hand complications occurred immediately postoperatively in 28.1% of the bilateral radial artery group, significantly more than in the unilateral radial artery group (8.3%). During follow-up, no overall difference was found in post-harvest forearm and hand complications. However, the forearm and hand perception score in the bilateral radial artery group was higher: 8.78 ± 1.45 vs. 8.35 ± 0.84 in the unilateral radial artery group. Subgroup analysis in the bilateral radial artery group revealed no significant difference in forearm and hand perception score between the dominant and non-dominant donor forearms (8.78 ± 1.45 in non-dominant and 8.66 ± 1.00 in dominant forearms). The bilateral radial artery group had more arterial coronary anastomoses, longer operative times, and longer cardiopulmonary bypass times. However, a backward multiple linear regression model revealed that only two factors related to operative time, these were the number of arterial distal coronary anastomosis and cardiopulmonary bypass time.

CONCLUSIONS

This study demonstrated that bilateral radial artery conduits can be used effectively and safely with no difference in persistent complications related to the hands and forearms.

The History and Evolution of Internal Maxillary Artery Bypass

Internal maxillary artery (IMA) bypass has gained momentum in the last 5 years for the treatment of complex cerebrovascular disorders and skull base tumors. However, some issues regarding this treatment modality have been proposed. As one of the most experienced neurosurgical teams to perform internal maxillary artery bypass in the world (>100 clinical cases), we reviewed the literature in aspects of basic anatomy of maxillary artery with its variations to the lateral pterygoid muscle, initial anastomosis modalities, and subsequent exposure techniques in cadaver studies, preoperative arterial evaluation methods, optimal interposed graft selections, and surgical outcome in the management of complex aneurysms, skull base tumors, and steno-occlusive disorders.

Risk Factors for Chronic Saphenous Neuralgia Following Coronary Artery Bypass Graft Surgery Utilizing Saphenous Vein Grafts

OBJECTIVES

The aim of this trial was to determine risk factors for chronic saphenous neuralgia (SN) following harvesting of the great saphenous vein (GSV) for coronary artery bypass graft (CABG) surgery.

METHODS

In a prospective observational trial, 526 patients with no history of chronic painful disorders or surgery in the lower limbs were followed up for 13 weeks after undergoing CABG surgery in which GSV grafts were used. The primary outcome measure was persistence of clinically significant pain of neuropathic type in the territory supplied by the saphenous nerve beyond 12 weeks after surgery.

RESULTS

Eighty-one (15.4%) patients consistently had probable neuropathic pain of clinically significant severity throughout the follow-up period and were labeled as suffering from chronic SN. Multivariable binary logistic regression analysis showed that younger age (OR, 0.92; 95% CI, 0.88-0.95; P-value, < 0.0001), female gender (OR, 2.28; 95% CI, 1.21-4.29; P-value, 0.011), higher body mass index (OR, 1.25; 95% CI, 1.17-1.35; P-value, < 0.0001), diabetes mellitus (OR, 2.13; 95% CI, 1.13-4.01; P-value, 0.020), distal-to-proximal dissection of the GSV (OR, 7.28; 95% CI, 3.62-14.66; P-value, < 0.0001), and closure of the leg wound in two layers (OR, 3.28; 95% CI, 1.81-5.95; P-value, 0.0001) were independent risk factors for chronic SN.

CONCLUSIONS

Chronic SN after CABG surgery utilizing GSV grafts is not uncommon. Risk factors identified in this trial are younger age, female gender, higher body mass index, diabetes mellitus, distal-to-proximal dissection of the GSV, and closure of the leg wound in two layers.

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.

Radial artery as graft for coronary artery bypass surgery: Advantages and disadvantages for its usage focused on structural and biological characteristics

Radial artery (RA) is the most popular arterial graft after the left internal thoracic artery in both low- and high-risk patients undergoing coronary artery bypass grafting. Various arterial grafts such as the right internal thoracic artery, the right gastroepiploic artery, and the inferior epigastric artery have also gained ground over the past 30 years because of the intimal hyperplasia and atherosclerosis of the saphenous vein leading to late graft occlusion. In this review article we would like to present the utility of the RA as a graft, focused mainly on its structural and biological characteristics.

Endoscopic radial artery harvesting: patient satisfaction and complications

Endoscopic radial artery harvesting was recently introduced to reduce the morbidity associated with conventional open harvesting and improve cosmetic outcomes. From January 2004 through December 2006, 25 radial arteries were harvested endoscopically from 25 patients using the VasoView endoscopic system. Bilateral radial arteries were harvested from 6 patients by both the endoscopic and open techniques, and postoperative patient satisfaction was assessed using a visual analogue scale. Mean harvesting time was 61.9 +/- 16.0 min (range, 44-105 min), and mean harvested conduit length was 16.8 +/- 2.0 cm (range, 15-19 cm). Objective dorsal thenar numbness remained in 2 patients (8%); none complained of forearm numbness. All patients expressed marked satisfaction with the endoscopic technique and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 vs 5). Postoperative angiography revealed occlusion of a graft that had been anastomosed to a small diagonal branch. The overall graft patency was 96.6%. Endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly regarding the cosmetic outcome.

Applied anatomy of the superficial branch of the radial nerve

The superficial branch of the radial nerve (SBRN) is highly vulnerable to trauma and iatrogenic injury. This study aimed to map the course of the SBRN in the context of surgical approaches and identify a safe area of incision for de Quervain's tenosynovitis. Twenty-five forearms were dissected. The SBRN emerged from under brachioradialis by a mean of 8.31 cm proximal to the radial styloid (RS), and remained radial to the dorsal tubercle of the radius by a mean of 1.49 cm. The nerve divided into a median of four branches. The first branch arose a mean of 4.92 cm proximal to the RS, traveling 0.49 cm radial to the first compartment of the extensor retinaculum, while the main nerve remained ulnar to it by 0.64 cm. All specimens had branches underlying the traditional transverse incision for de Quervain's release. A 2.5-cm longitudinal incision proximal from the RS avoided the SBRN in 17/25 cases (68%). In 20/25 specimens (80%), the SBRN underlay the cephalic vein. In 18/25 (72%), the radial artery was closely associated with a sensory nerve branch near the level of the RS (SBRN 12/25, lateral cutaneous nerve of the forearm (LCNF) 6/25.) A longitudinal incision in de Quervain's surgery may be preferable. Cannulation of the cephalic vein in the distal third of the forearm is best avoided. The close association between the radial artery and first branch of the SBRN or the LCNF may explain the pain often experienced during arterial puncture. Particular care should be taken during radial artery harvest to avoid nerve injury.

Retrospective analysis of local sensorimotor deficits after radial artery harvesting for coronary artery bypass grafting

OBJECTIVES

The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass. We analyze patient-based data to determine risk factors for long-term upper limb morbidities associated with RA harvest for coronary artery bypass grafting.

STUDY DESIGN/METHODS

Between April 1997 and March 2004, a total of 1030 patients underwent RA harvesting for coronary artery bypass grafting for a total of 1704 harvest sites. Patients were contacted by telephone and asked to report any ongoing severe sensory and functional motor deficits for each harvest site since surgery. Retrospective chart review was performed and preoperative risk factors were evaluated. Patient-based risk factors were evaluated for development of significant long-term local sensorimotor deficits including gender, elderly age (>70 y), diabetes, smoking, and whether the RA was harvested from the dominant hand.

RESULTS

Successful evaluation of 629 patients for a total of 1048 RA harvest sites was completed. The mean follow-up time was 48.3 mo (range, 2 to 86 mo). The mean age of the patients analyzed was 62.2 y. On statistical analysis, diabetics and elderly did not report significantly greater functional or sensory deficits than nondiabetics and nonelderly, respectively. There was a significantly higher incidence of sensory deficits in smokers compared with nonsmoker patients (4.2% versus 1.4%; P = 0.005) but no difference in their functional impairment was noted. Harvesting from the dominant hand did not influence the occurrence of sensory or motor functional deficits.

CONCLUSIONS

RA harvesting for coronary artery bypass grafting can be done with minimal serious long-term upper limb morbidity in higher risk patients. Based on our findings, harvesting of the RA from the dominant hand is not contraindicated in these patients.

Forearm Muscle Necrosis After Radial Artery Harvesting for Coronary Artery Bypass Surgery

Donor site complications after radial artery harvesting for coronary revascularization have been primarily wound related and parasthesias. Forearm muscle compartment syndrome has only been reported once. A patient underwent successful coronary revascularization with a radial artery graft; however his forearm extensor muscles necrosed, possibly from a missed compartment syndrome, and he required tendon transfers to provide finger and wrist extension.

Harvesting radial artery and neurologic complications

BACKGROUND

Determination of the incidence, mechanisms, and diagnosis of hand complications after radial artery (RA) harvesting in coronary surgery (CABG).

METHODS

The study group (RA group) includes 54 patients who underwent RA harvesting in CABG operation. The control group (noRA group) consists of 131 patients who underwent CABG without the use of RA graft. The average follow-up time was 16.36 +/- 5.13 months. The patients were examined clinically, (a) for motor function abnormalities associated with radial and median nerve damage and (b) for sensory abnormalities, and the function of radial nerve was determined by eliciting the brachioradialis reflex. They answered in a formal scripted questionnaire to elicit symptoms and clinical points attributable to nerve damage during RA harvest, such as hand weakness, thumb weakness, sensation abnormalities on the back and on the palm side of the forearm, hand numbness, hand-reversible paresis or forearm infection postoperatively, and any other upper limb abnormality.

RESULTS

Of the patients in the RA group, 34.09% reported left-hand abnormality after operation. On the other hand, in the noRA group left-hand abnormality was reported in 18.68% of patients. In the RA group sensation abnormality was reported in 34.09% of patients and thumb weakness alone was reported in 6.82% of patients. There was a statistically significant difference between the two groups. Low EuroSCORE was the predicting factor for motor abnormalities.

CONCLUSIONS

More knowledge has been added about the neurologic complications after RA harvesting lately. We demonstrated the rate of motor and sensory abnormality, the potential mechanisms of these complications caused by surgical trauma or devascularization, and any predictive factors of complications. Optimal surgical techniques to avoid the damage of the responsible nerves are recommended.

Is it necessary to use a drain after harvesting radial artery? A randomized prospective study

BACKGROUND

Radial artery (RA) is a second choice after internal thoracic artery in coronary artery bypass operations. There are some complications in forearm after harvesting RA. We have prospectively compared the necessity of inserting drain in the forearm cavity after RA harvesting to prevent such complications.

METHODS

Eighty consecutive patients (younger than 65 years old, left ventricle ejection fraction >40%) undergoing coronary artery bypass operations were prospectively enrolled into study. Patients were divided into two groups by using, Table of Random Digit, for randomization. In group I patients (n = 40), we inserted drain during the forearm closing and in group II patients (n = 40), we did not use any drain. Patients in both groups evaluated for wound site complications such as hematoma, errythema, vascular complications, motor deficit, paresthesia, hand edema, and infection.

RESULTS

We found two hand edemas, one hematoma, five paresthesias, one infection, and three ecchymosis in Group I patients and one hematoma, four paresthesias, one infection, and four ecchymosis in Group II patients. There was no statistically significant difference between the groups in complications.

CONCLUSION

Placing of a drain into the forearm has not significant advantages but the cost and the complaints of patients could be reduced by not using the drain.

Subclinical Injury to Forearm Nerves During Radial Harvesting: Electrophysiologic Study

BACKGROUND AND AIM

There are few reports about injury to forearm nerves and its potential mechanisms during radial artery (RA) harvesting. We studied electrophysiologic changes in these nerves not sought until now.

METHODS

Among 152 consecutive patients who underwent coronary artery bypass surgery between February 2002 and August 2002, 20 were randomized for RA harvesting and formed the study group and 20 were randomized as control group. Neurologic examination and electrophysiologic studies were performed for sensory and motor impairment of the nerves in both groups pre- and postoperatively.

RESULTS

There was no change on neurologic examinations before and after surgery. Electromyography (EMG) revealed significant reduction in sensory and motor conduction amplitudes of median, ulnar, and radial nerves and motor conduction velocities of median and ulnar nerves at the level of forearm in the study group. In the control group, ulnar nerve was mostly affected. When two groups are compared, sensory and motor amplitude drops of median and radial nerves and motor velocity impairment of median nerve in the study group are significant. Ulnar nerve impairments are identical in both groups.

CONCLUSIONS

Handling of tissues, minor hematoma or edema along with chest retraction best explains these impairments. Patients were asymptomatic after surgery showing that EMG is highly sensitive and is not predictive of clinical impairment.

Long-Term Physical Activity and Neurologic Function After Harvesting of the Radial Artery as T-Graft or Free Graft in Coronary Revascularization

BACKGROUND

Radial artery grafts in coronary revascularization are frequently used, either as a T-graft or as a free radial graft such as a saphenous venous graft. Besides the neurologic function of the hand after radial artery harvesting, which is questioned especially in the long-term perspective, no data on patients' lifestyle are available in this special cohort. Therefore we focused on both the patients' neurologic function as well as level of physical activity, along with their body mass index and smoking habits in this prospective, long-term study.

METHODS

Two hundred eleven patients (187 males; 64 +/- 8 years; mean Canadian coronary scale, 2.4 +/- 0.7; ejection fraction, 59 +/- 15%) were enrolled and scheduled for elective radial artery harvesting in an open conventional technique. Follow-up of 26 +/- 5 months (range, 13 to 37 months) was performed by a direct telephone interview with patients, which was 100% complete. The majority of radial arteries were used in the T-graft technique (73.9%), 24.2% were used as a free graft, and 1.4% as a jump graft.

RESULTS

One hundred sixty-five patients (78.2%) did not complain of any neurologic deficit at all. Numbness was distributed among the thumb (5.2%), the wrist (4.3%), and the incision site (3.3%). Hyposensitivity was predominantly at the wrist, followed by the thumb. Pain was distributed at the wrist (1.9%) and the thumb (1.5%). Aggravated sense of cold at the donor hand was evident in 11 patients (5.2%). No patient was compromised in their daily activities, such as piano playing or writing. Subjective well being improved in 147 patients (69.7%), was unchanged in 39 patients (18.5%), and was worse in 11 patients (5.3%) after radial artery harvesting. The mean Canadian coronary scale class improved significantly (1.3 +/- 0.6; p < 0.05). There were patients (44.5%) who performed no sports activity after the procedure and patients (11.8%) who performed sports every day of the week. There were patients (80.1%) who did not participate in heart sport groups, with only 27 patients (12.8%) participating in such heart sport groups once a week. One hundred seventy-one patients (81.0%) attended a cardiac rehabilitation program after the procedure. Body mass index did not change at all. There were patients (29%) who stopped smoking as of the procedure, whereas 10% of patients were active smokers 25 months after the procedure.

CONCLUSIONS

Radial artery harvesting is associated with a minor number of neurologic complications such as numbness and hyposensitivity after a conventional pedicled harvesting technique without any compromise on patients' daily activities. Further emphasis has to be taken in the promotion of lifestyle changes after coronary revascularization. About half of the patients did not perform any regular physical activity 2 years after surgery; mean body mass index did not change; and nearly 10% continued to smoke.

Palmar Microcirculation After Harvesting of the Radial Artery in Coronary Revascularization

PURPOSE

To evaluate real-time parameters of palmar microcirculation before and after harvesting of the radial artery in coronary revascularization using a laser Doppler flowmetry and remission spectroscopy system (O2C).

DESCRIPTION

Fifteen patients (11 males, 54 +/- 4 years, mean New York Heart Association [NYHA] class of 2.3 +/- 0.3) were prospectively scheduled with control measurements of the fingertips of D1, D3, and D5 at base line, after suprasystolic, and after selective radial or ulnar compression for tissue oxygen saturation (SO2), postcapillary venous recombinant hemoglobin (rHb) concentration, superficial (2 mm) blood flow, and deep (8 mm) blood flow.

EVALUATION

Preoperatively during suprasystolic compression SO2 decreased significantly for the fingertips of D1, D3, and D5 by -58%, -74%, and -63%, respectively (p < 0.05). Radial compression reduced SO2 for all fingertips (-12%, -14%, and -16%), as did ulnar compression (-24%, -18%, and -10%). rHb did not change significantly for either compression type. Superficial and deep blood flow decreased significantly after suprasystolic and only slightly after radial and ulnar compression at either side. No side differences were noted. After radial artery harvesting, microcirculatory parameters did not change considerably versus preoperatively.

CONCLUSIONS

Radial artery harvesting does not remarkably change microcirculatory parameters of the hand. The O2C system is a safe and quantitative method to assess both preoperatively and postoperatively the palmar microcirculation and therefore adds further functional clinical information.

Preoperative Assessment of the Radial Artery for Coronary Artery Bypass Grafting: Is the Clinical Allen Test Adequate?

BACKGROUND

The clinical Allen test (AT) is widely adopted as the only preoperative assessment of the hand collateral circulation before radial artery (RA) harvest as a coronary artery bypass graft. Nevertheless, in some cases it may be misleading because of clinically undetectable anatomic anomalies of the forearm arteries.

METHODS

We evaluated the nondominant forearm arterial circulation by echo color Doppler (ECD) technique and by performing static and dynamic tests such as the AT, snuffbox test (SBT), and palmar arch test (PAT) in 150 patients who underwent elective coronary artery revascularization with a RA graft.

RESULTS

Although the clinical AT was normal in all patients, in 8 patients (5.3%) preoperative ECD AT, SBT, and PAT did contraindicate RA harvesting. We did not harvest the RA in these patients. In the remaining 142 patients the RA was harvested. We did not observe any case of postoperative forearm or hand ischemia. We examined the blood flow to the hand in all patients at both 5 days and 24 months after surgery. In all patients ECD showed adequate hand perfusion and a significant increase of the peak flow velocity in the ulnar artery at both follow-up times.

CONCLUSIONS

The clinical AT may be not sufficient to assess the hand collateral flow and the quality of the RA as a coronary artery bypass graft in at least 5% of patients. The ECD technique, performed during static and dynamic tests, does offer a safer and more objective preoperative noninvasive evaluation and it may have an important role also from the medicolegal point of view.

The radial artery for coronary artery bypass grafting

Coronary artery bypass grafting (CABG) is the standard surgical procedure for the treatment of advanced coronary artery disease. CABG surgery has been demonstrated to improve symptoms and, in specific subgroups of patients, to prolong life. Despite its success, the long-term outcome of coronary bypass surgery is strongly influenced by the fate of the vascular conduits used. Previous long-term studies have shown unsatisfactory patency of saphenous vein grafts used for myocardial revascularisation, compared with internal mammary artery grafts. Recently, the use of radial artery for CABG has enjoyed a revival, on the basis of the belief that it will help improving long-term results of coronary operations. The recent reports of encouraging mid-term and long-term patency rates of the radial artery, supports its continued use as a bypass conduit. In this paper, we review the current knowledge about the radial artery as a bypass graft, with special emphasis on the clinical results.

The Pneumatic Tourniquet Technique for Endoscopic Radial Artery Harvest

BACKGROUND

Endoscopic vessel harvest is viewed as a safe, reliable, and cost-effective method for greater saphenous vein removal. As the radial artery has more recently become a popular conduit choice in coronary artery revascularization, we describe herein an endoscopic technique for radial artery harvest in our first 50 patients as an alternative to the more traditional open technique.

METHODS

From November 2001 to July 2002, 54 radial arteries were harvested endoscopically in 50 patients utilizing the VasoView Endoscopic Vessel Harvesting System, an Esmark bandage, and a pneumatic cuff tourniquet.

RESULTS

No patients experienced symptoms of vascular compromise, or signs of infection in the donor arm. No adjunctive procedures were required during the vessel harvest, i.e., conversion to open technique. All radial arteries were successfully removed with endoscopic technique and 53 of the 54 radial arteries were successfully used as bypass conduits. Although the quality of the radial artery harvested remains subjective, we found less vasospasm than in our experience with the open technique. Thirty-day follow-up revealed no readmissions, no cardiac ischemic complications, no significant complications with the donor arm, and an excellent cosmetic result.

CONCLUSIONS

Endoscopic harvest of the radial artery with the tourniquet technique may offer advantages over the more traditional open technique.

Radial artery graft for bypass of the maxillary to proximal posterior cerebral artery: an anatomical and technical study

OBJECTIVE

To examine the use of a radial artery graft for bypass of the maxillary artery (MA) to proximal posterior cerebral artery (PCA) as an alternative to the external carotid artery (ECA) to PCA anastomosis used in posterior circulation bypass surgery.

MATERIALS AND METHODS

The method was applied to five adult cadaver sides bilaterally. The MA was easily found 1-2 cm beneath the infratemporal crest after a frontotemporal craniotomy and a zygomatic arch osteotomy. Extradurally, 2-3 cm posterolateral to the foramen rotundum, a hole was drilled in the sphenoid bone with a 4-mm tipped drill. After sylvian fissure, the interpedincular and ambient cisternae were opened and the P2 segment of the PCA appeared. The graft was passed through the hole and dura to reach the P2 segment. Proximal to the infraorbital artery branch, the MA was freed from the surrounding tissue and transected. The proximal side of the radial artery graft was anastomosed end-to-end with the MA and the distal side was anastomosed end-to-side with the P2 segment of the PCA.

RESULTS

The average diameter of the MA proximal to the infraorbital artery branch was 2.6+/-0.3 mm. The average diameter of the P2 was 2.2+/-0.2 mm. The average length of the graft was 47+/-5.2 mm.

CONCLUSION

As MA to proximal PCA bypass uses a short radial graft and as the calibers of the MA and PCA are >2 mm such a bypass may provide sufficient blood flow and represents a reasonable alternative to "ECA to PCA" bypass.

Long-term neurologic hand complications after radial artery harvesting using conventional cold and harmonic scalpel techniques

BACKGROUND

The purpose of this study was to determine the incidence of neurologic hand complications after radial artery harvesting and to compare the harmonic scalpel versus conventional cold scalpel technique.

METHODS

From 1995 to 2000, 786 radial arteries were harvested from 782 patients for coronary artery bypass grafting. From 1995 to 1997, the conventional cold scalpel technique was used (422 patients), and from 1998 to 2000, the harmonic scalpel was used (360 patients). Mean follow-up was 4.2 +/- 2.1 years and was 90% complete. Symptoms included thumb weakness or numbness, tingling, or pain in the hand.

RESULTS

The incidence of neurologic hand complications was similar with both techniques (11.2% +/- 3.5% cold, 11.0% +/- 3.6% harmonic, p > 0.95), and in 19% (13 of 67 with symptoms) there was complete resolution within 1 year. Symptoms persisted long-term in 9.0% +/- 3.2% cold scalpel and 9.0% +/- 3.3% harmonic scalpel patients (p > 0.81), but were considered a "constant and significant source of discomfort" in only 0.6% +/- 0.9% cold scalpel and 1.4% +/- 1.3% harmonic scalpel patients (p > 0.41).

CONCLUSIONS

The incidence of adverse neurologic outcomes causing significant long-term discomfort in the hand was low using either the cold scalpel or harmonic scalpel technique. However, a significant number of patients had neurologic hand symptoms in both groups, and this should be included when discussing operative risks with the patient.

Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test

BACKGROUND

The Allen test is commonly used to assess collateral hand circulation before radial artery harvest for coronary artery bypass grafting. However there is no consensus as to whether an abnormal Allen test is an absolute or relative contraindication to radial artery harvesting. We assessed the safety of harvesting the radial artery using arterial duplex ultrasonography in patients with an abnormal Allen test.

METHODS

Two hundred and eighty-seven consecutive patients scheduled for total arterial coronary revascularisation underwent preoperative Allen tests over a 34-month period. Patients with an abnormal Allen test underwent duplex ultrasonography preoperatively to assess the adequacy of the ulnar collateral supply and the suitability of the radial artery for harvesting.

RESULTS

Two hundred and forty-four patients (85%) had a normal left Allen test and proceeded directly to radial artery harvest. Forty-three patients (15%) with an abnormal left Allen test underwent duplex ultrasonography scans and of those, 5 patients had an abnormal scan. These patients underwent scanning of the contralateral forearm. Three patients had a normal right forearm arterial duplex scan and the right radial artery was harvested. The mean diameter of the radial and ulnar arteries was not significantly different between the patients with normal and abnormal duplex ultrasonograms. There were no ischemic hand complications in this series.

CONCLUSIONS

The Allen test is a quick, easy, and reliable screening test before radial artery harvesting in the majority of patients. Duplex ultrasonography predicts safe radial artery harvest in the majority of patients with an abnormal Allen test.

Complications after radial artery harvesting for coronary artery bypass grafting: our experience

BACKGROUND

The aim of this study was to evaluate the incidence of complications in the upper limbs as a new event after radial artery (RA) harvesting for coronary artery bypass grafting (CABG).

METHODS

From June 1997 to August 2001, the RA graft was used in 271 patients who underwent cardiac surgery at our department. These patients were prospectively reviewed. All patients were preoperatively examined to determine the presence of normal sensation and circulation in the upper limbs; then we evaluated the incidence of complications at discharge, 8 weeks, and 6 months.

RESULTS

No donor arms developed symptoms of ischemia or motor dysfunction. At 8 weeks 2 patients (0.7%) reported donor arm weakness, and cutaneous paresthesia was noted postoperatively in 10 upper limbs (3.7%). The univariate statistical analysis showed that significant risk factors for persistent cutaneous paresthesia were diabetes and smoking.

CONCLUSIONS

This study demonstrates that complications after harvesting the RA for CABG are a rare consequence. The main symptom is a persistent cutaneous paresthesia present in 10 patients at 6-month follow-up.

Use of percutaneous radial artery catheter for peripheral blood progenitor cell collection in pediatric patients

BACKGROUND

Leukapheresis procedures require adequate flow rates, which in children may frequently involve invasive vascular access placement.

STUDY DESIGN AND METHODS

A minimally invasive peripheral radial artery catheter was used for drawing blood in 85 leukapheresis procedures performed in 33 pediatric patients. Blood return to the patients was provided by either a central Broviac-type catheter or a peripheral venous access. The patients' age range was 1 to 18 years (median, 9.5) and the weight range was 9 to 73 kg (median, 29 kg). Vasocan Braunüle Luer Lock IV cannulas (22 gauge in 78 and 20 gauge in 7) were placed percutaneously under local anesthesia, and in 8 patients, catheter placement was carried out during general anesthesia for other procedures. A continuous flow cell separator was used in all cases (Fresenius AS104 in 23 and AS204 in 62).

RESULTS

Flow rates ranged from 18 to 45 mL per minute, the mean number of total blood volumes processed was 2.07 (range, 0.51-2.51), and the mean duration of the procedures was 150 minutes (range, 90-260). The 22-gauge cannulas provided adequate flow rates independently of patient age and weight. No significant thrombotic, embolic, hemorrhagic, ischemic, or infectious complications were observed.

CONCLUSION

Peripheral radial artery catheters are safe, are minimally invasive, and provide steady, high-flow rates, and they should be considered for patients requiring leukapheresis and lacking a suitable vascular access for drawing blood.

Post radial artery harvest hand perception: postoperative 12-month follow-up results

The 12-months' follow-up results for radial artery harvest in relation to complications are reported and compared with the postoperative 3-months' results. The postoperative wound problems of 155 patients who underwent coronary artery bypass grafting with radial artery harvesting were assessed using a questionnaire at 3 and 12 months after surgery. The questionnaire contained 9 statements concerning hand and forearm problems in daily life. The answers were graded in 7 levels. An answer of higher than grade 3 (mild symptoms) was regarded as a significant symptom. No hand ischemic complications was observed. In the 12 month-study, 152 patients (98.1%) were normal. Hand pain and numbness occurred in 25 patients (16.1 %) and 33 patients (21.3%), respectively, at 3 months and were markedly improved at 12 months (pain: 13 (8.4%), p = 0.045, numbness: 20 (12.9%), p = 0.069). Total scores for all questions also significantly decreased at 12 months (10.2 +/- 3.5) compared with 3 months (11.1 +/- 3.9) postoperatively (mean +/- SD, p = 0.0003). Radial artery harvest was quite acceptable from the patient's perception, although a few patients had numbness and pain in the 3 months after surgery. Those complications significantly improve in the later postoperative phase.