Radial artery grafts: surgical anatomy and harvesting techniques(1)

Safety and Effectiveness of Coronary Angiography or Intervention through the Distal Radial Access: A Meta-Analysis

Objectives

Searching the literature for coronary angiography (CAG) or intervention through distal radial access (DRA) and performing a meta-analysis.

Background

Coronary angiography (CAG) or intervention through distal radial access (DRA) may have a similar success rate, low radial artery occlusion rate, low radial artery spasm rate, and low rate of puncture site hematoma for patients with coronary heart disease. Therefore, the randomized controlled trials (RCTs) were searched, and the data were pooled for meta-analysis to evaluate the effectiveness and safety of DRA.

Methods

RCTs comparing the CAG or intervention through DRA vs. transradial access (TRA) published between January 1, 2017, and May 4, 2021, were searched in the PubMed, Embase, and Cochrane databases. The endpoints included the rate of access success and the number of radial artery occlusions, radial artery spasms, and puncture site hematomas. The data were extracted, and a random-effects model was used for analysis.

Results

Among 204 studies, 6 RCTs (with 2825 participants) met the inclusion criteria. Compared to TRA, the access success rate in DRA (p=0.1) and the lower rate of puncture site hematoma were not significantly different (p=0.646), while the radial artery occlusion rate (p < 0.001) and radial artery spasm rate (p=0.029) were significantly lower.

Conclusion

In summary, DRA has a similar access success rate and incidence of hematoma at the puncture site, but a lower incidence of RAO and spasm compared to TRA. These findings demonstrated that DRA is a safe and effective access for CAG or intervention.

Radial artery harvesting in coronary artery bypass grafting surgery-Endoscopic or open method? A meta-analysis

We analyzed the clinical outcomes of open radial artery harvesting (OAH) and endoscopic radial artery harvesting (EAH) undergoing coronary artery bypass grafting (CABG). We designed this meta-analysis conducted using Pubmed, Medline, the Cochrane Library, and EMBASE. Articles with comparisons of OAH and EAH undergoing CABG were included. Primary outcomes included the wound infection rate, the wound complication rate, neurological complications of the forearm, in-hospital mortality, long-term survival, and the patency rate. The results of our study included six randomized controlled trials (RCTs), two non-randomized controlled trials (NRCTs) with matching, and 10 NRCTs. In total, 2919 patients were included in 18 studies, while 1187 (40.7%) and 1732 (59.3%) patients received EAH and OAH, respectively. EAH was associated with a lower incidence of wound infection (RR = 0.29, 95% confidence interval (CI) = 0.14 to 0.60, p = 0.03), and neurological complications over the harvesting site (RR = 0.41, 95% CI = 0.27 to 0.62, p < 0.0001). There was no significant difference in 30-day mortality, long-term survival (over one year), and the graft patency rate. According to our analysis, endoscopic radial artery harvesting can improve the outcome of the harvesting site, without affecting the mortality, long-term survival, and graft patency.

Radial Artery Fascial Flow-Through Free Flap for Complex Cerebral Revascularization: Technical Notes and Long-Term Neurologic and Radiographic Outcomes

BACKGROUND

Surgical innovation is critical for the management of challenging cerebrovascular pathology. Flow-through free flaps are versatile composite grafts that combine viable tissue with a revascularization source. Neurosurgical experience with these flaps is limited.

OBJECTIVE

To provide an in-depth technical description of the radial artery fascial (and fasciocutaneous) flow-through free flap (RAFF and RAFCF, respectively) for complex cerebral revascularizations.

METHODS

An Institutional Review Board-approved, prospective database was retrospectively reviewed to identify patients that underwent extracranial-to-intracranial cerebral bypass with a RAFF or RAFCF. Patient demographics, underlying pathology, surgical treatment, complications, and outcomes were recorded.

RESULTS

A total of 4 patients were treated with RAFFs or RAFCFs (average age 40 ± 8.8 yr). Two patients with progressive moyamoya disease involving multiple vascular territories with predominantly anterior cerebral artery (ACA) symptoms and flow alterations underwent combined direct ACA and indirect middle cerebral artery (MCA) bypass with a RAFF. The third patient with moyamoya disease and concomitant proximal fusiform aneurysms requiring internal carotid artery sacrifice underwent dual direct ACA and MCA bypass and indirect MCA revascularization with posterior tibial artery and RAFF grafts. The fourth patient with a large MCA bifurcation aneurysm and recurrent wound complications underwent a direct MCA bypass and complex wound reconstruction using a RAFCF. Good neurologic outcomes (Glasgow Outcomes Scale score ≥4 at discharge) were achieved in all patients. There were no perioperative surgical complications, and graft patency was confirmed on long-term follow-up.

CONCLUSION

The RAFF and RAFCF are versatile grafts for complex cerebral revascularizations.

Patients' satisfaction and wound-site complications after radial artery harvesting for coronary artery bypass

The aim of the study was to establish patients' satisfaction and the incidence of wound-site complications after radial artery (RA) harvesting for bypass surgery. A telephonic quality of life questionnaire was performed in 306 consecutive patients who had undergone coronary artery bypass grafting with the use of RA with the open technique. A psychometric Likert scale was used to define the degree of patients' satisfaction. The questionnaire concerned arm pain, cosmesis and mobility, sensory and neurological complications, and patients' general health state. The median values and the modal scores achieved the maximal value of satisfaction for all site-related complications and the mean scores were >4 out of 5. The median patients' general health state was 4. Cosmetic result of the wound was considered at least acceptable by 98% of patients. The incidence of impairing peripheral neurological complications was 16.7%. The degree of patients' satisfaction after RA harvesting was more than satisfactory and the incidence of wound-site complications was acceptable. The incidence of neurological injuries was lower than previously described.

[Excision of the calcified mitral valve with ultrasound scalpel]

Mitral valve excision using ultrasound device has not been a routine procedure yet. We used an ultrasonic scalpel for the excision of the calcified mitral valves, which shorten operation time. Further, this technique permits an excision of the valve without applying traction or elevation of the valve from the level of the annulus. This method was first tested on twenty fresh porcine hearts. Subsequently, this technique was carried out with very good results in 15 consecutive patients with calcified or scarred, and distorted mitral valves. Histological samples were taken from the excised human and porcine valves. In porcine histological specimens the destructive effect of the ultrasonic scalpel was measured of an average of 0.7 mm (minimum 0.5 mms, maximum 0.8 mms). However, in the human heart, this effect was an average of 1.1 mms (minimum 0.6 mms, maximum 2.2 mms). There were no early or late complications observed in any case. The authors recommend this technique for excision of calcified mitral valves in cardiac surgery.

Endoscopic Radial Artery Harvest for Coronary Artery Bypass Surgery

BACKGROUND/PURPOSE

Coronary artery bypass grafting (CABG) provides better long-term patency than percutaneous intervention in patients with significant coronary artery disease. The radial artery is the second most common arterial conduit used for CABG in Western countries. However, radial artery harvesting necessitates a large surgical wound and has gained few patients' acceptance in subtropical areas. This study investigated the use of the minimally invasive approach of endoscopic radial artery harvest for CABG, and the surgical results at the harvest site.

METHODS

An endoscopic harvest program for radial arteries was implemented in this hospital in September 2003. During the first 12 months of the program until September 2004, 122 patients underwent the procedure. Preoperative evaluation included Allen's test and the modified palmar arch perfusion test. The age of patients ranged from 32 to 88 years old. Patients were excluded from participation if they had undergone recent transradial catheterization, had end-stage renal disease or documented peripheral artery occlusive disease. The VasoView system was utilized for the procedure. Details of the surgical techniques used were recorded and analyzed.

RESULTS

Using the endoscopic technique, 122 radial arteries were harvested successfully. The mean resting length of the harvested radial artery was 15.7 cm. No obvious arterial injury was visually confirmed. All radial arteries were used for CABG, except for two which were noted to have atherosclerotic plaques causing stenoses. Forty-seven patients presented with mild numbness over the dorsum of the thumb base, which improved significantly during the 3-month follow-up. No arterial insufficiency in the forearms or hands was noted.

CONCLUSION

Endoscopic harvest of the radial artery is technically demanding, but excellent results can be achieved. The endoscopic approach can provide suitable conduits in a less invasive way than the open harvest technique.

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.