The radial artery: which place in coronary operation?

Radial artery vs right internal mammary artery as a second conduit during coronary artery bypass grafting

OBJECTIVE

To compare the clinical outcomes of radial artery (RA) grafts during CABG to those of right internal mammary artery (RIMA) grafts.

METHODS

This was a retrospective, single-institution cohort study of isolated CABG with multiple grafts between 2010-2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:1 match ratio. Long-term postoperative survival was compared among RA and RIMA groups. Similarly, major adverse cardiac and cerebrovascular events (MACCE) were compared among both cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for mortality, while cumulative incidence estimation was utilized for MACCE.

RESULTS

A total of 8,774 patients underwent CABG. Of those, 1,674 (19.1%) patients who underwent multiarterial CABG were included in this analysis. 326 (19.5%) patients received RA grafts and 1,348 (80.5%) received RIMA grafts. PSM yielded a cohort of 323 RA patients and 323 RIMA patients. After matching, groups were well-balanced across all baseline variables. No significant differences were observed in immediate postoperative complications or long-term survival, with 5-year survival estimates of 89.5% for the RA group vs 90.1% for the RIMA group. There was a nonsignificant trend toward a higher incidence of MACCE at 5 years in the RA group compared to the RIMA group (31.3% in the RA group vs 24.1% in the RIMA group), especially after 1-year follow-up (21.6% in the RA group vs 15.1% in the RIMA group). Specifically, for RA patients, there were higher rates of repeat revascularization in the 5-year postoperative period (14.7% in the RA group vs 5.3% in the RIMA group), particularly in the territory revascularized by the RA during the index operation (45.7% in the RA group vs 10.3% in the RIMA group).

CONCLUSION

Overall, RA and RIMA secondary conduits for CABG were associated with comparable immediate postoperative complications, 5-year MACCE, and 5-year survival after PSM. RA grafting was associated with significantly higher rates of repeat coronary revascularization at 5 years, specifically in the territory revascularized by the RA during the index operation.

Outcomes of Radial Artery Versus Saphenous Vein as A Second Conduit After Coronary Artery Bypass Grafting

Despite the advantages of multiarterial grafting, saphenous vein (SV) configurations predominate in coronary artery bypass grafting (CABG). In addition, the benefits of radial artery (RA) utilization in multivessel CABG remain unclear. This study aims to compare the clinical outcomes of patients who received RA grafts during CABG with those of patients who received SV grafts. A retrospective, single-institution cohort study was performed in 8,774 adults who underwent isolated CABG surgery with multiple grafts between 2010 and 2022. To balance graft cohorts, propensity score matching (PSM) was performed using a 1:2 (RA/SV) match ratio. Long-term postoperative survival was compared in RA and SV graft groups. Similarly, major adverse cardiac and cerebrovascular event (MACCE) rates were compared in the cohorts, with MACCE comprising death, myocardial infarction (MI), coronary revascularization, and stroke. Kaplan-Meier estimation was performed for both mortality and MACCE. A total of 7,218 patients (82.3%) who underwent multivessel CABG were included in this analysis. Of these patients, 341 (4.7%) received RA grafts, and 6,877 (95.3%) received SV grafts secondary to left internal mammary artery use. PSM yielded a cohort of 335 patients with RA and 670 patients with SV. After matching, groups were well balanced across all baseline variables. No significant differences were observed in either immediate postoperative morbidities or long-term survival. However, Kaplan-Meier estimates of long-term postoperative freedom from MACCE were significantly greater in matched patients with SV (73.3%) than in those with RA (67.4%) (p = 0.044, cluster log-rank), with patients with SV also possessing significantly greater freedom from coronary revascularization and MI. In conclusion, RA and SV secondary conduits for CABG were associated with comparable immediate postoperative complications and long-term survival after PSM. SV grafting was associated with significantly decreased rates of postoperative MACCE, likely owing to lower rates of coronary revascularization and MI than in RA grafting.

Endoscopic versus open harvesting of radial artery for CABG

Background

Endoscopic harvest of the radial artery avoids long forearm incisions and has better cosmesis compared to the open technique. The objective of this study was to compare the short-term results and wound-related complications of endoscopic radial artery harvest versus open technique.

Results

From 2013 to 2017, 800 patients had coronary artery bypass grafting; 88 patients of them had radial artery harvesting (11%). Two groups were included in the study according to the surgeon preference, endoscopic radial harvest (group 1, n = 30; 3.75% of total CABG patients) and open harvest (group 2, n = 58; 7.25% of total CABG patients). Group 1 had more males (25 (83.33%) vs. 35 (60.34%); p = 0.028). There was no difference in the preoperative comorbidities between both groups. The duration of the harvest was significantly longer in group 1 (median 40 min ranges from 38 to 42 min vs. 49 min ranges from 47 to 52 min in groups 1 and 2, respectively; p < 0.001). The operative time was longer in group 1 (median 302.5 min ranges from 295 to 310 min vs. 277 min ranges from 273 to 280 min in groups 1 and 2, respectively; p < 0.001). The hospital stay in the endoscopic radial artery harvest group was significantly shorter than that of open technique (median 7 days ranges from 6 to 7 days vs. 7.5 days ranges from 7 to 9 days; p < 0.001). There was no significant difference in the postoperative complications between both groups. One case (3.3%) was transformed from the endoscopic to open technique due to uncontrolled bleeding. Endoscopic technique was associated with more patients presenting with hand numbness (6 cases; 20% versus 3 cases 5.2%) and radial nerve injury (2 cases; 6.6% versus none), while open technique showed more cases of local hematoma (8 cases; 13.8% versus 1 case; 3.3%) and wound infection (6 cases; 10.34% versus none); p > 0.05.

Conclusion

Endoscopic radial artery harvest is associated with shorter harvest time and shorter hospital stay. Endoscopic radial artery harvest is a safe technique with good short-term outcomes. Longer follow-up is recommended.

Radial Artery Versus Saphenous Vein Grafts in Coronary Artery Bypass Surgery: a Literature Review

PURPOSE OF REVIEW

Coronary artery bypass grafting is a preferred strategy for complete coronary revascularization in patients who have multi-vessel coronary artery disease, left ventricular dysfunction, and/or diabetes. Both arterial (internal thoracic artery/radial artery) and venous grafts are utilized to bypass the obstruction in native vessels. Despite having radial arterial grafts as a preferred second conduit for bypass, venous grafts are more commonly used.

RECENT FINDINGS

We review the existing literature and report the preferred conduit based on a recently published meta-analysis of 6 randomized controlled trials. The analysis concluded that radial artery grafts are associated with fewer adverse cardiac events and better graft patency at 5 years of follow-up. Although saphenous vein grafting is the most commonly used conduit in addition to ITA, current data suggests that total arterial bypass (using RA conduit in addition to ITA) may be the better strategy. Both the US and European consensus guidelines advocate for the use of arterial over SV grafting for most patients.

Intraoperative chlorpromazine treatment for prevention of radial artery spasm in aortocoronary bypass grafting

A detailed description of intraoperative prevention of radial artery graft spasm using a solution of the calmodulin inhibitor chlorpromazine is presented. This method is used in direct myocardial revascularization and can reliably prevent perioperative spasm of radial artery grafts, as confirmed by intraoperative flow measurement, bypass angiography in the postoperative period, and in vitro experimental data.

Does vitamin C or its combination with vitamin E improve radial artery endothelium-dependent vasodilatation in patients awaiting coronary artery bypass surgery?

Background

We evaluated the vasodilatory effects of two antioxidants, vitamins C (ascorbic acid) and E (α-tocopherol), on radial artery and endothelium-dependent responses in patients awaiting coronary artery bypass surgery.

Methods

The study was performed in three groups. The first group took 2 g of vitamin C orally (n = 31, vitamin C group), the second group took 2 g of vitamin C with 600 mg of vitamin E orally (n = 31, vitamins C + E group), and the third group took no medication (n = 31, control group). After baseline measurements were taken of the radial artery lumen diameter, flow volume and lumen area in the non-dominant radial artery, occlusion was maintained for five minutes with a pressure cuff placed around the arm. The measurements were taken again at the time of deflating the cuff, and 60 seconds later. The measurements were repeated after medication in two of the groups and after placebo in the third group.

Results

We compared values of the vitamin C group with those of the vitamins C + E group, and found that the latter were higher than those of the vitamin C group but not statistically significant. In the control group, there was no statistical difference.

Conclusion

Vitamin C or its combination with vitamin E significantly enhanced endothelium-dependent vasodilatation in the radial circulation of patients with coronary artery disease. Its combination with vitamin E was superior to vitamin C administration alone for endothelial enhancement but this difference was not statistically significant. We hypothesised that vitamin C or its combination with vitamin E may be used as antioxidants for arterial graft patency in patients undergoing coronary artery surgery.

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

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

Effects of skeletonized versus pedicled radial artery on postoperative graft patency and flow

Background

Radial artery (RA) was the second arterial graft introduced in clinical practice for myocardial revascularization. The skeletonization technique of the left internal thoracic artery (LITA) may actually change the graft's flow capacity with potential advantages. This leads to the assumption that the behavior of the RA, as a coronary graft, is similar to that of the LITA, when skeletonized.

Objective

This study evaluated 'free' aortic-coronary radial artery (RA) grafts, whether skeletonized or with adjacent tissues.

Methods

A prospective randomized study comparing 40 patients distributed into two groups was conducted. In group I, we used skeletonized radial arteries (20 patients), and in group II, we used radial arteries with adjacent tissues (20 patients). After the surgical procedure, patients underwent flow velocity measurements.

Results

The main surgical variables were: RA internal diameter, RA length, and free blood flow in the radial artery. The mean RA graft diameters as calculated using quantitative angiography in the immediate postoperative period were similar, as well as the flow velocity measurement variables. On the other hand, coronary cineangiography showed the presence of occlusion in one RA graft and stenosis in five RA grafts in GII, while GI presented stenosis in only one RA graft (p = 0.045).

Conclusion

These results show that the morphological and pathological features, as well as the hemodynamic performance of the free radial artery grafts, whether prepared in a skeletonized manner or with adjacent tissues, are similar. However, a larger number of non-obstructive lesions may be observed when RA is prepared with adjacent tissues.

Endoscopic radial artery harvesting procedure for coronary artery bypass grafting

Development and adoption of endoscopic minimally invasive saphenous vein harvesting prompted its application to the radial artery in an effort to minimize surgical trauma. Recently, we reported that endoscopic radial artery harvesting was associated with better wound appearance and it proved to be safe and effective, with less pain and fewer wound complications than the open surgical technique. Based on this positive experience, our institution adopted endoscopic radial artery harvesting, hence the aim of this manuscript is to describe the minimally invasive endoscopic radial artery harvesting for coronary artery bypass grafting.

Endoscopic versus open radial artery harvesting for coronary artery bypass grafting

BACKGROUND AND AIM OF THE STUDY

The radial artery has become the artery of choice after both internal thoracic arteries for coronary artery bypass grafting (CABG). This study compares wound healing and arm complications after endoscopic versus open radial artery harvesting.

METHODS

From January 2002 to July 2004, 509 patients underwent CABG including a radial artery conduit. Thirty-nine had endoscopic and 470 conventional open radial artery harvesting. A propensity score was used to obtain 1:3 matching of all endoscopic to 117 open-harvesting patients. Postoperative wound healing, local neurologic deficits, wound infection, and pain scores were compared.

RESULTS

Wound healing: 34 of 39 endoscopic wounds exhibited a perfect Hollander score versus 339 of 470 open-harvest wounds (p = 0.01). Wound appearance was better for endoscopic harvesting (p = 0.004). Three incomplete neurologic deficits were observed after open harvesting versus one complete neurologic deficit after endoscopic harvesting that recovered prior to hospital discharge. Incidence of wound infection was similar in both groups (p = 0.7), although infection was more severe with open harvesting. Pain score was lower (p = 0.006) with endoscopic harvesting.

CONCLUSIONS

Endoscopic radial artery harvesting was associated with better wound appearance and less pain. Occurrence of neurologic deficits and wound infection was infrequent in both groups.

Late improvement in graft patency after coronary artery bypass grafting: Serial assessment with multidetector computed tomography in the early and late postoperative settings

OBJECTIVE

Grafts initially showing poor patency after coronary artery bypass grafting have occasionally shown improvement on serial multidetector computed tomography. This study analyzed possible factors associated with this phenomenon.

METHODS

Between September 2003 and July 2007, 512 patients underwent multidetector computed tomography within 1 month of isolated coronary artery bypass grafting. Among them, 1720 distal anastomoses were made with 1042 arterial and 302 venous conduits. Of these, 95 grafts (in 73 patients) were faint (n = 67) or nonvisualized (n = 28). Seventy-three of these grafts (in 56 patients) had follow-up multidetector computed tomographic evaluation 1 year after surgery and comprised the study group.

RESULTS

Improvement in graft patency (faint to patent or nonvisualization to visualization) occurred in 44 grafts (60.3%). Multivariate analysis revealed proximal target vessel stenosis of at least 90% (relative risk, 3.81; P = .009), larger target coronary size (relative risk, 1.72; P = .002), and radial artery graft use (relative risk, 4.44; P = .003) to be significantly associated with the graft patency restoration. Graft patency restoration was most commonly observed in a group of 28 radial artery grafts that were anastomosed to target vessel with proximal stenosis of at least 90%; of these grafts, 24 (85.7%) showed improved graft patency on follow-up.

CONCLUSIONS

A large proportion of radial artery grafts initially showing poor opacification after coronary artery bypass grafting demonstrated patency restoration on serial multidetector computed tomography. Larger target vessel size and target vessel stenosis of at least 90% were significant correlative factors.

Impact of Transradial Coronary Procedures on Radial Artery

Objective: We evaluated the impact of transradial coronary procedures on the radial artery (RA). Methods: A total of 355 patients who underwent the transradial coronary procedures including transradial coronary angiography (CAG) and percutaneous coronary intervention (PCI) were enrolled. The right RA (RRA) was examined by ultrasound. Results: The mean RRA diameter was 2.37 ± 0.57, 1.95 ± 0.50, and 2.23 ± 0.41 mm, respectively, before the procedure, 1 day, and 1 month after the procedures (P < .01 at 1 day, P < .05 at 1 month). The mean intima-media thickness of RRA was 0.25 ± 0.12, 0.69 ± 0.31, and 0.38 ± 0.17 mm, respectively, before the procedure, 1 day and 1 month after the procedure (P < .01 at 1 day, P < .05 at 1 month). The incidence of RRA stenosis was 0%, 15.7%, and 7.6%, respectively; the incidence of RRA occlusion was 0%, 2.8%, and 1.7%, respectively, before the procedure,1 day and 1 month after the procedure. Conclusions: Transradial coronary procedures can lead to early RA injury, but this repairs later.

Open Clip-Free Radial Artery Harvesting With the Harmonic Shears

BACKGROUND

The Ultracision Harmonic Scalpel is associated with several advantages in radial artery (RA) harvesting. It allows fewer hemostatic clips to close the collateral branches, less thermal injury of the conduit, and reduced time of harvesting in comparison with the conventional RA harvesting technique with electrocautery and hemostatic clips. We recently started open RA harvesting with the harmonic shears (HSH). In this study, we aimed at evaluating the feasibility of this simplified ultrasonically activated harvesting technique, and report the results of RA harvesting with HSH.

METHODS

The RA harvesting with HSH was performed in 20 patients operated on for myocardial revascularization from July 2004 to December 2005.

RESULTS

The harvest of the RA was completed in little time, without any complication. Neither bleeding from the collateral branches nor spasm alongside the entire length of the RA was observed. No bleeding occurred from the muscles of the forearm.

CONCLUSION

This technique of RA harvesting with HSH is impressive in terms of short time of harvest, complete absence of clips for the collateral branches, and no thermal injury of the conduit.

Surgical treatment of coronary multivessel disease

Coronary artery bypass grafting has had a significant impact on the treatment of angina, and has been the 'gold standard' since 1969. Its use and efficacy has been increased by revascularization in cardiac arrest and the use of the internal mammary artery. In parallel, catheter techniques have evolved by means of balloon dilatation and additional stenting. This has effected the referral to surgery despite the development of new arterialization techniques and minimally invasive surgery. As competing techniques, an acceptable equilibrium between surgery and stenting will be found within the next years.

Predictive Factors of Hemodynamic Collapse After Coronary Artery Bypass Grafting: A Case-Control Study

OBJECTIVE

Sudden hemodynamic collapse after coronary artery bypass graft (CABG) surgery is a complication with high morbidity and mortality. The aim of this study was to explore factors possibly predictive of this major complication.

DESIGN

Retrospective case-control study.

SETTING

University hospital, department of cardiothoracic surgery.

PARTICIPANTS

Between 1988 and 1999, of 8,807 CABG patients, a total of 76 (0.9%) suffered hemodynamic collapse after CABG surgery unrelated to pericardial tamponade or bleeding. Preoperatively matched patients (by age, sex, New York Heart Association classification, number of diseased vessels, left ventricular ejection fraction, and diabetes) served as a control group (n = 76).

INTERVENTIONS

Patients with sudden cardiovascular collapse underwent emergency reopening of the sternotomy and open cardiac massage (OCM group). Several pre-, intra-, and postoperative variables were compared, and significant parameters in match-pair analysis were further tested with regression techniques.

MEASUREMENTS AND MAIN RESULTS

Of the 76 OCMs, 57 (75%) occurred during the first 5 postoperative hours. In-hospital mortality was 46% (35 of 76) versus 0% in controls; 5-year survival was 49% versus 95%. In the OCM group, cardiopulmonary bypass (CPB) time was significantly prolonged (p = 0.0024), and cardiac index (p = 0.05) and the first acid-base values after CPB were lower (pH, p = 0.0057; BE, p = 0.0014). Postoperative myocardial ischemia appeared in 33% of patients in the OCM group and in 8% of controls (p < 0.0001). OCM-group patients more frequently required postoperative inotropic (epinephrine, p = 0.0002) and mechanical support (intra-aortic balloon pump, p = 0.005). Regression analysis revealed a correlation between cardiopulmonary resuscitation risk and low cardiac index, postoperative ischemia, and low pH level.

CONCLUSION

Inadequate tissue perfusion, postoperative myocardial ischemia, and increased need for inotropic and mechanical support preceded hemodynamic collapse. Interventions to improve tissue perfusion and to prevent and treat myocardial ischemia may result in a more favorable outcome.

Graft harvesting for revascularization in the head and neck

The techniques for revascularization in the neurocranium, skull base, and neck continue to evolve at an exciting pace. In this body of literature, however, techniques for harvesting radial artery and saphenous vein grafts are mainly reported using traditional open techniques. Minimally invasive procedures are fast becoming an alternative to open techniques in many fields and have the potential to become the standard of care. The cardiovascular literature is replete with reports of endoscopically harvested vascular grafts. This article reviews both methods, since the current state of the art involves knowledge of open and endoscopic harvesting techniques.

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.

Can the Use of the Radial Artery Be Expanded to All Patients with Different Surgical Grafting Techniques? Early Clinical and Angiographic Results in 600 Patients

OBJECTIVE

The use of the radial artery (RA) as a conduit for coronary artery bypass grafting (CABG) is gaining in popularity worldwide and is being increasingly adopted by many cardiac surgeons. Encouraged by our satisfactory early experience with the use of the RA conduit, we have expanded its use to more than 90% of all coronary surgery patients. The aim of the present study was to review our clinical and angiographic results when the use of the RA conduit was expanded to all patients including those aged 65 years and older and diabetics with different surgical grafting techniques.

METHODS

The records of 600 consecutive patients who underwent isolated CABG using the RA graft at Harefield Hospital between January 1999 and August 2002 were reviewed retrospectively. Ninety-three (15.5%) patients consented and underwent angiography before discharge at the earliest on the fourth postoperative day, aiming to look at the quality of anastomoses and the patency of the RA grafts.

RESULTS

The 600 patients had 613 RA grafts to perform 652 distal RA anastomoses. The proximal ends of 515 (84%) RA grafts were anastomosed to the aorta, 98 (16%) RA grafts were constructed as Y-grafts with 49 (8%) RA off a vein graft hood, and 49 (8%) RA grafts were constructed as T- or Y-grafts off an internal thoracic artery (ITA) graft. The proximal ends of 19 (19/294 or 6.5%) vein grafts were constructed as Y-grafts off the RA grafts. Two hundred and sixty-one (43.5%) patients were above the age of 65 years and 111 (18.5%) patients were diabetics. There were four in-hospital deaths (0.6%) among the study patients. Six (1%) patients developed forearm hematoma/seroma postoperatively. The operation time, the hospital stay, and the incidence of conduit harvest site infection for the patients who had vein grafts in addition to the RA grafts were significantly higher than those of patients who had RA grafts only. On postoperative angiography, 86 out of 93 (92.5%) RA grafts were found to be patent with good quality distal anastomoses. The maximum stenosis of the coronary arteries bypassed by the patent 86 RA grafts was 82.6 +/- 6.2%, while it was 56.3 +/- 15.4% for the coronary arteries bypassed by the occluded seven RA grafts, p < 0.001.

CONCLUSION

The use of the RA can be expanded to all patients with different surgical grafting techniques and provides satisfactory clinical and angiographic outcomes.

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.

A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts

BACKGROUND

In the past decade, the radial artery has frequently been used for coronary bypass surgery despite concern regarding the possibility of graft spasm. Graft patency is a key predictor of long-term survival. We therefore sought to determine the relative patency rate of radial-artery and saphenous-vein grafts in a randomized trial in which we controlled for bias in the selection of patients and vessels.

METHODS

We enrolled 561 patients at 13 centers. The left internal thoracic artery was used to bypass the anterior circulation. The radial-artery graft was randomly assigned to bypass the major vessel in either the inferior (right coronary) territory or the lateral (circumflex) territory, with the saphenous-vein graft used for the opposing territory (control). The primary end point was graft occlusion, determined by angiography 8 to 12 months postoperatively.

RESULTS

Angiography was performed at one year in 440 patients: 8.2 percent of radial-artery grafts and 13.6 percent of saphenous-vein grafts were completely occluded (P=0.009). Diffuse narrowing of the graft (the angiographic "string sign") was present in 7.0 percent of radial-artery grafts and only 0.9 percent of saphenous-vein grafts (P=0.001). The absence of severe native-vessel stenosis was associated with an increased risk of occlusion of the radial-artery graft and diffuse narrowing of the graft. Harvesting of the radial artery was well tolerated.

CONCLUSIONS

Radial-artery grafts are associated with a lower rate of graft occlusion at one year than are saphenous-vein grafts. Because the patency of radial-artery grafts depends on the severity of native-vessel stenosis, such grafts should preferentially be used for target vessels with high-grade lesions.

Initial experience with an endoscopic radial artery harvesting technique

OBJECTIVE

The purpose of the study was to investigate the feasibility of an endoscopic radial artery harvesting technique to improve esthetic results and possibly reduce the incidence of neurologic complications observed with the open method.

METHODS

Between July 1, 2002, and October 1, 2003, a total of 54 patients underwent endoscopic radial artery harvesting at our institution. Standard endoscopic equipment and a Harmonic Scalpel (Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) were used. Mean age of the patients was 63 +/- 8.1 years, and 16% were female. All patients underwent a preoperative Allen test and duplex ultrasonography to demonstrate adequate ulnar collateral flow. The nondominant arm was used for radial artery harvesting. Mean clinical follow-up was 13 +/- 4.6 months.

RESULTS

The artery was harvested through a 3-cm incision at the wrist and was divided at the elbow either through a small counterincision (n = 16) or endoscopically with the use of clips, Endoloop, and endoscopic scissors (n = 38). Mean harvest time was 42.2 +/- 16.9 minutes but decreased from 85 minutes for the first cases to 25 minutes for the last 5 cases. Mean harvested length was 19.6 +/- 1.7 cm. Harvesting complications included 1 conversion, 2 postoperative hematomas, 1 injury, 8 endoscopically controlled bleedings, and 15 cases of at least some superficial radial nerve paresthesia at 6 weeks (clinically relevant in 4 cases). Selective postoperative angiography revealed 1 occluded graft and 1 stenotic graft requiring percutaneous transluminal coronary angioplasty of the native vessel. Eighty-seven percent of the patients were enthusiastic about this new procedure.

CONCLUSIONS

Endoscopic radial artery harvesting is a feasible procedure that requires a definite learning curve. Although nerve paresthesias were not completely eliminated in our experience, the technique provided ample patient satisfaction. Further clinical follow-up is required to determine long-term patency rates.

Skeletonized Radial Artery Grafting: One-Year Patency Rate

BACKGROUND

The skeletonized radial artery harvesting technique has routinely been used in our institute. Its clinical outcome is acceptable; however, the graft patency rate at 1 year has not been reported.

METHODS

Between July 1, 2003, and October 31, 2002, 50 consecutive patients underwent isolated coronary artery bypass using skeletonized radial artery grafts in our hospital. There were no hospital deaths or perioperative myocardial infarctions. All patients completed follow-up by November 2003. Twenty of these patients (18 asymptomatic volunteers and 2 symptomatic patients) underwent coronary angiography at 1 year, and the results were analyzed.

RESULTS

At a mean (+/-SD) follow-up period of 1.2 +/- 0.2 years, there were no deaths. Two patients developed angina due to graft occlusion (1 in the radial artery and another in the gastroepiploic artery). Twenty-one radial artery grafts and 36 distal anastomoses with radial artery grafts were evaluated by angiography at 1 year (0.9 +/- 0.1 years). There was 1 radial artery graft occlusion affecting 1 distal anastomosis, giving a perfect graft patency rate of 95.2% (20/21) and a perfect anastomosis patency rate of 97.2% (35/36). The patient with the occluded radial artery graft had a history of peripheral vascular disease and diabetes. There were no graft stenoses or string signs.

CONCLUSION

At our limited follow-up, the results of using skeletonized radial artery grafts are excellent. Extensive skeletonization will not affect the graft patency rate or early graft spasm. Careful examinations of the radial artery grafts in patients with a history of peripheral artery disease and diabetes are mandated.

Total arterial revascularization with composite skeletonized gastroepiploic artery graft in off-pump coronary artery bypass grafting

BACKGROUND

Total arterial revascularization in coronary artery bypass grafting has recently become of great interest to many surgeons. At the same time, off-pump coronary bypass grafting has also become a popular procedure because of its low morbidity and mortality. Here we report our recent series of off-pump coronary bypass grafting performed with a grafting technique we developed by using the skeletonized gastroepiploic artery and the radial artery composite graft to achieve total arterial revascularization.

METHODS

From September 2000 to April 2003, 98 patients underwent total arterial revascularization with the skeletonized gastroepiploic artery and radial artery composite graft on the beating heart. We used the gastroepiploic artery graft of choice in patients with a right coronary artery lesion. When multiple grafting was required in inferior, posterolateral, or lateral ventricular walls and the gastroepiploic artery graft was too short to cover these areas, we used the composite grafting technique.

RESULTS

There were no in-hospital deaths and there was no severe morbidity among the study patients. Postoperative angiography showed graft occlusion at the anastomosis site between the gastroepiploic and radial arteries. The patency rate of the gastroepiploic arterial composite graft was 98.3% (118/120 distal anastomoses).

CONCLUSIONS

A composite graft with the skeletonized gastroepiploic artery and the radial artery ensured sufficient caliber size and length for myocardial revascularization on inferior, posterolateral, and lateral ventricular walls. This composite graft can be used safely and effectively even in off-pump coronary bypass surgery with excellent early clinical and angiographic outcome in selected patients, although longer follow-up periods are necessary to draw definitive conclusions.

Patencies of 2127 arterial to coronary conduits over 15 years

BACKGROUND

Use of arterial grafts in coronary surgery is based on the excellent patency of the left internal thoracic artery (LITA) and an expectation that other arterial grafts-right internal thoracic artery (RITA) and radial artery (RA)-will give similar patencies, superior to saphenous vein. We examined patencies of arterial grafts in a practice with extensive use for more than 15 years.

METHODS

Consecutive postoperative angiograms of 2,127 arterial/coronary conduits were evaluated. Angiograms were performed for cardiac symptoms. Assessment was by two observers. String signs were considered as occlusions.

RESULTS

There were 2127 arterial conduits. Overall patencies were as follows: LITA, 96.4% (1296 of 1345); RITA, 88.3% (534 of 605); aortocoronary RA, 89.3% (158 of 177). The LITA patency to the left anterior descending artery was 97.1% (1131 of 1165); to the obtuse marginal artery it was 91.7% (165 of 180; p 0.01). The RITA pedicled graft patency was 86% (275 of 321) compared with free RITA, 91% (259 of 284; p = not significant). For RITA there was a hierarchy of patency for coronary territory grafted (left anterior descending artery best, right coronary/posterior descending artery worst) and for degree of coronary stenosis: if stenosis was less than 60%, patency was 65% (47 of 72); if stenosis was more than 60%, patency was 90.9% (485 of 533; p = 0.0001). Similarly for the radial artery there was higher patency with greater coronary stenosis. The LITA patency at 5 years was 98%, at 10 years it was 95%, and at 15 years it was 88%. The RITA patency at 5 years was 96%, at 10 years it was 81%, and at 15 years it was 65%. The radial artery patency at 1 year was 96% and at 4 years it was 89%. For 3,714 vein grafts also studied overall patency was 61% (2266 of 3214) with patencies of 95% at 5 years, 71% at 10 years, and 32% at 15 years.

CONCLUSIONS

Excellent long-term patencies of arterial grafts are noted, superior to those of vein grafts. Patencies were influenced by conduit, by distribution, and by coronary artery stenosis.

Endothelial and Smooth Muscle Cell Dysfunction in Human Atherosclerotic Radial Artery

The radial artery (RA) is increasingly used as coronary artery bypass graft. In rare cases, however, it is macroscopically atherosclerotic at time of harvest. We examined how the regulation of vascular tone is altered under such circumstances. Macroscopically evident atherosclerotic lesions were observed in 3 of 429 RA (0.7%) isolated within 2 years. Histology revealed severe plaque formation; however, von Willebrand Factor staining showed a morphologically intact endothelium (n = 3). Endothelium-dependent relaxations to acetylcholine (10(-5) M) were reduced in atherosclerotic RA (32 +/- 6%; n = 3) as compared with control (78 +/- 4%; n = 10; P = 0.0001). Receptor-independent contractions to KCl (100 mM) were reduced in atherosclerotic RA (33.19 +/- 5.06 mN; n = 3) as compared with control (108.02 +/- 15.76 mN; n = 9; P < 0.05). Similarly, contractions to thrombin (1 U/ml) were reduced in atherosclerotic RA (3.02 +/- 1.58 mN; n = 3) as compared with control (10.97 +/- 5.12 mN; n = 8). Likewise, receptor-mediated contractions to norepinephrine were reduced in atherosclerotic RA (27.64 +/- 12.48 mN; n = 3) as compared with control (82.74 +/- 11.36 mN; n = 9; P < 0.05). Atherosclerosis is rare in RA of patients with coronary artery disease, but it does occur. Atherosclerotic RA exhibits a dysfunction of both endothelium and vascular smooth muscle. This dysfunction may favor thrombus formation and accelerated atherogenesis. Therefore, atherosclerotic RA should not be used for coronary artery bypass grafting.

Use of the radial artery graft after transradial catheterization: is it suitable as a bypass conduit?

BACKGROUND

The suitability of the radial artery after transradial catheterization as a bypass conduit has been of great concern to surgeons.

METHODS

A total of 67 patients underwent isolated coronary artery bypass grafting using the radial artery: 22 patients received preoperative transradial catheterization (group 1) and 45 patients did not receive transradial catheterization (group 2). Those patients were retrospectively reviewed.

RESULTS

Patient characteristics, operative procedures, and early clinical outcome were not different between groups. The stenosis-free graft patency rates in groups 1 and 2 were 88% (16 of 18 patients) and 90% (38 of 42 patients) in the left internal thoracic artery (p = 0.87); 77% (17 of 22 patients) and 98% (48 of 49 patients) in the radial artery (p = 0.017); and 87% (13 of 15 patients) and 84% (21 of 25 patients) in the saphenous vein (p = 0.42), respectively. Intimal hyperplasia of the radial artery was observed in 68% (11 of 16 patients) in group 1 and in 39% (14 of 34 patients) in group 2 (p = 0.046).

CONCLUSIONS

Transradial catheterization reduced early graft patency and caused intimal hyperplasia, although it did not affect early clinical outcomes. We suggest that the use of the radial artery as a bypass conduit after transradial catheterization should be undertaken cautiously.

Radial versus right internal thoracic artery as a second arterial conduit for coronary surgery: early and midterm outcomes

OBJECTIVE

We sought to compare early and midterm clinical outcomes in patients receiving a right internal thoracic artery or a radial artery as the second arterial conduit for myocardial revascularization.

METHODS

Data prospectively collected for all patients who underwent coronary artery bypass surgery between April 1996 and May 2001 and who received both a left internal thoracic artery graft and either a right internal thoracic artery (n = 336) or a radial artery graft (n = 325) were analyzed. Patients in the radial artery group were older, with a greater body mass index, poorer ejection fraction, greater prevalence of diabetes, and higher New York Heart Association class than those in the right internal thoracic artery group.

RESULTS

Odds ratios for perioperative myocardial infarction, atrial fibrillation, postoperative transfusion, and intensive care unit stay all showed a statistically significant benefit in the radial artery group compared with results in the right internal thoracic artery group (P <or=.05). Survival estimates at 18 months for patients who received right internal thoracic artery and radial artery grafts were 98.4% and 99.7%, respectively (hazard ratio, 0.25; 95% confidence interval, 0.06-1.10; P =.07). Estimates for survival free from any cardiac-related event or death in the right internal thoracic artery and radial artery groups were 92.3% and 97.8%, respectively (hazard ratio, 0.37; 95% confidence interval, 0.16-0.84; P =.02). A multivariate Cox regression model showed a stronger protective effect of a radial artery graft (hazard ratio, 0.25; 95% confidence interval, 0.12-0.51; P <.0001).

CONCLUSION

Early and midterm outcomes of myocardial revascularization with 2 arterial grafts are better if the radial artery is used for the second graft rather than the right internal thoracic artery, assuming that the left internal thoracic artery is used for the first arterial graft.

Intima-media thickening of the radial artery after transradial intervention. An intravascular ultrasound study

OBJECTIVES

We sought to assess the extent and nature of radial artery injury after transradial intervention (TRI) using intravascular ultrasound (IVUS).

BACKGROUND

Although TRI has been developed to minimize bleeding and improve the quality of life, radial artery injury is a problem.

METHODS

We studied 100 radial arteries in 100 consecutive patients who underwent coronary IVUS imaging. To assess the injury to the radial artery, we compared the radial artery findings between first-TRI patients (n = 48) and repeat-TRI patients (n = 52). Ten cross-sections at 5-mm intervals from the puncture site along a 50-mm distance were measured in each patient.

RESULTS

In repeat-TRI patients, the lumen area (LA) and minimal lumen diameter (MLD) were smaller than those in first-TRI patients (p = 0.032 and p = 0.028, respectively), whereas the intima-media cross-sectional area (IMcsa) and intima-media thickness (IMT) were significantly greater than those in first-TRI patients (p < 0.01). In the proximal radial artery, there were no significant differences in the vessel area (VA), LA, IMcsa, or MLD between the two groups. In the distal radial artery, both LA and MLD were significantly smaller in repeat-TRI patients than in first-TRI patients (p < 0.01), whereas IMcsa and IMT were greater in repeat-TRI patients than in first-TRI patients (p < 0.01). However, VA did not differ between the two groups.

CONCLUSION

The lumen diameters were smaller in repeat-TRI patients than in first-TRI patients due to intima-media thickening, especially in the distal radial artery. Care should be taken when the radial artery is used as a conduit in coronary artery bypass graft surgery, particularly in patients who have undergone TRI.

The radial artery is larger than the ulnar

BACKGROUND

The radial artery is presently widely used as a bypass graft for coronary artery reconstruction. However, the traditional opinion that the ulnar artery is the larger forearm artery has been questioned.

METHODS

The internal diameters of the radial and ulnar arteries were measured at the wrist in postmortem angiograms of 24 cadavers. Differences in mean values of variables between ulnar and radial arteries were analyzed using the Wilcoxon test.

RESULTS

The mean diameter of the radial artery was 28% larger than that of the ulnar artery in the right arm (p < 0.001) and 26% larger in the left arm (p < 0.001). In the right arm the radial artery was dominant in 20 of 24 cadavers (83%), the ulnar artery in 3 of 24 (13%), and the arteries were equal in 1 of 24 (4%). In the left arm the figures were 17 of 24 cadavers (71%), 3 of 24 (13%), and 4 of 24 (17%), respectively.

CONCLUSIONS

In view of the present investigation the radial artery should be considered the larger forearm artery of the hand in most patients.

Is vitamin C superior to diltiazem for radial artery vasodilation in patients awaiting coronary artery bypass grafting?

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.

Midterm clinical results in myocardial revascularization using the radial artery

STUDY OBJECTIVES

The aim of this study was to evaluate the immediate and midterm results of coronary artery bypass grafting with the radial artery (RA) as a conduit.

PATIENTS

Two hundred forty-one patients underwent myocardial revascularization using the RA. In 78.5% of patients, three coronary vessels were involved, and in 25% of patients, the left main coronary artery was involved. The mean (+/- SD) preoperative ejection fraction was 58 +/- 13%.

INTERVENTIONS

The RA was implanted on branches of the circumflex artery in 81% of the cases, and the left internal mammary artery was implanted on the left anterior descending artery in 94% of patients. Total arterial myocardial revascularization was performed in 58% of patients.

MEASUREMENTS AND RESULTS

The in-hospital mortality rate was 0.8%. Two patients had acute myocardial infarction, and three patients experienced a transient low-cardiac output syndrome. We reviewed the records of all 171 patients who had undergone at least 6 months of follow-up after surgery. The late mortality rate in this group was 0.6% (one patient died 2 months after surgery because of cardiocirculatory arrest due to untreatable ventricular fibrillation). At a mean follow-up time of 545 +/- 253 days, two patients showed class 3 residual angina according to the Canadian Cardiovascular Society (CCS) guidelines. One patient required another hospital admission 6 months after undergoing surgery for PTCA/stenting on a circumflex artery that had not previously undergone bypass. The second patient, 8 months after undergoing coronary artery bypass grafting, underwent angiography and stenting on a stenosed anastomosis of a posterolateral branch of the circumflex artery that previously had been bypassed with the right internal mammary artery.

CONCLUSIONS

The routine use of the RA for coronary bypass grafting is a safe surgical technique, providing excellent clinical mid-term results in terms of cardiac event-free expectancy.

Triple arterial coronary revascularization using the radial artery and bilateral internal mammary arteries versus the gastroepiploic artery and bilateral internal mammary arteries

Arterial grafts are frequently used in modern coronary artery bypass grafting (CABG) and the benefit of the 2 internal mammary arteries (IMA) has already been established. However, the choice of the third arterial conduit, in addition to the IMA, is controversial. We have retrospectively analized perioperative and the follow-up results of patients who underwent CABG with triple arterial bypass using either the radial artery (RA) or the gastroepiploic artery (GEA) in conjunction with the bilateral IMA (BIMA). Between December 1995 and June 2001, 1,516 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. Among them the RA and BIMA were used in 96 patients (78 males, 18 females; mean age, 63.2+/-6.7 years, group R), and the GEA and BIMA in 123 patients (101 males, 22 females; mean age, 61.0+/-11.6 years, group G). Their perioperative and follow-up data were studied. The preoperative risk factors were similar between the 2 groups, except that there were significantly fewer patients with renal dysfunction in group R. The surgical results did not differ between the 2 groups; however, the GEA was more commonly used for revascularization of the right coronary artery, while the RA was used for the diagonal, circumflex or right coronary arteries. Surgical mortality and morbidity rates were not significantly different. During the follow-up period of 2.3+/-1.6 years, the event-free rates as well as the survival rates were not significantly different. CABG with either the RA or the GEA in conjunction with the BIMA can be performed safely. The surgical results as well as the follow-up results were acceptable and no significant differences between the 2 groups were observed.

Skeletonized radial artery grafting: improved angiographic results

BACKGROUND

The radial artery has been used for coronary artery bypass grafting (CABG) but its early angiographic results were relatively inferior to that of the internal mammary artery, most likely due to spasm of the graft. To avoid vasospasm we harvested the radial artery using a skeletonized technique and spasm was completely reversed before use. The graft patency of the skeletonized radial artery was compared with the radial artery graft harvested as a pedicle.

METHODS

A total of 112 patients underwent isolated CABG using a pedicled radial artery between September 1, 1999, and August 31, 2000 (group P), and a total of 131 patients with a skeletonized radial artery between September 1, 2000, and August 31, 2001 (group S). An ultrasonic scalpel (Harmonic Scalpel; Ethicon EndoSurgery, Cincinnati, OH) was used for skeletonization and removing satellite veins and surrounding tissue. CABG was performed by the standard technique. Perioperative results were prospectively collected and compared between the two groups. Early angiographic results performed within 3 months were also compared.

RESULTS

There were two hospital deaths in group S. Major complications were observed in 11 (8.4%) in group S and 3 (2.7%) in group P (p = not significant [NS]). None were related to the radial artery graft. Angiography was obtained in 96 patients of group S and 76 patients in group P and revealed that the stenosis free graft patency rate of group S (138 of 143, 96.5%) was superior to that of group P (73 of 86, 84.9%) with p < 0.005.

CONCLUSIONS

Skeletonization of the radial artery with the ultrasonic scalpel is safe and contributes to reducing the incidence of early graft stenosis.

Incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery

OBJECTIVE

To identify the incidence of coronary-subclavian steal syndrome in patients undergoing noncardiac surgery.

DESIGN

Prospective.

SETTING

Veterans Affairs Medical Center and university-affiliated medical center.

PARTICIPANTS

Adult patients with prior coronary artery bypass graft surgery and documented use of an internal mammary artery.

INTERVENTIONS

Bilateral simultaneous brachial blood pressures were determined noninvasively. The presumptive diagnosis of ipsilateral subclavian artery stenosis and coronary-subclavian steal syndrome was made if the systolic blood pressure differential was >20 mmHg.

MEASUREMENTS AND MAIN RESULTS

The presumptive diagnosis of ipsilateral subclavian artery stenosis based on a blood pressure differential was made in 6 of 86 (5%) patients screened. The diagnosis of coronary-subclavian steal syndrome was confirmed at cardiac catheterization by observing retrograde internal mammary artery flow in 3 patients or lack of internal mammary artery flow in 1 patient (3.4%). All 4 patients with angiographic confirmation had either angina or silent ischemia. Three patients had successful carotid subclavian bypass, and 1 patient refused surgery. Two patients had no evidence of myocardial ischemia and underwent their planned procedure without incident.

CONCLUSION

Coronary-subclavian steal syndrome occurs with relative frequency in noncardiac surgery patients with prior coronary artery bypass graft surgery using internal mammary artery conduits. Bilateral blood pressure measurements should be routinely performed during the preoperative evaluation. A pressure differential >20 mmHg should suggest the possibility of coronary-subclavian steal syndrome.

Creative arterial bypass grafting can be performed on the beating heart

BACKGROUND

To demonstrate that compromise is unnecessary in either the design or performance of beating heart surgery, we report our experience, over 1 year, of total arterial revascularization where composite or creative grafting was utilized.

METHODS

We performed 321 off-pump coronary artery bypass operations, of which, 290 (90%) were done with only arterial conduits. The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses. One hundred eighty-nine patients (65%) were male, and 101 (35%) were female, with a mean age of 67 years. Comorbidities included chronic renal failure (CRF), 21 (7%); diabetes, 92 (32%); obesity, 68 (23%); hypertension, 212 (73%); chronic obstructive pulmonary disease, 189 (65%); cerebral vascular accident (CVA), 39 (13%); smoking, 164 (56%); and hypercholesterolemia, 151 (52%). The mean ejection fraction was 56%, with a range of 21% to 71%. All procedures were performed with external stabilizers with or without vacuum assist. The complete arterial revascularizations included a T-graft (internal thoracic [ITA]/radial arteries [RA]), 130 (45%); a sequential graft (ITA +/- RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or right gastroepiploic artery), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (12); and a Y-graft (ITA/RA), 31 (10%).

RESULTS

The postoperative incidence of atrial fibrillation was 80 of 290 (27%); CVA, 5 of 290 (2%); bleeding resulting in take-back, 5 of 290 (2%); CRF, 8 of 290 (3%); deep sternal infection, 4 of 290 (1%); and readmission (30-day) for angina, 4 of 290 (1%). The observed perioperative (30-day) mortality was 9 of 290 (3.1%), with the STS predicted rate of 3.82%.

CONCLUSIONS

Our experience indicates that once the operating surgeon has learned to safely expose the lateral and inferior walls of the heart, the type of conduit and the method of revascularization should be no different than that used with cardiopulmonary bypass. However, we still recommend conventional methods of revascularization (on-pump with saphenous vein conduits) for the ischemic patient.

Coronary artery bypass grafting using the radial artery: midterm results in a Japanese institute

BACKGROUND

To avoid remote cardiac events associated with graft occlusions, arterial conduits are being increasingly utilized in coronary artery bypass grafting (CABG). The development of antispasmic agents has enabled the use of the radial artery as a graft conduit in CABG.

METHODS

Between December 1995 and December 1998, 920 consecutive isolated CABG operations were performed at Shin-Tokyo Hospital. The radial artery was used for graft conduits in 475 of these patients, and their data were analyzed in this study. The patients were followed to determine midterm graft patency, cardiac events, and survival. All data are given as mean +/- standard deviation. The end points were patient death or occurrence of cardiac events.

RESULTS

The radial artery was used in 475 patients (366 males and 109 females, with a mean age of 64.5+/-8.5 years). The left internal mammary artery was used in 94.9% of patients, the right internal mammary artery in 17.5%, the gastroepiploic artery in 50.9%, the inferior epigastric artery in 0.2%, and the saphenous vein in 39.2%. The in-hospital morbidity and mortality rates of the studied group were 12.8% and 0.6%, respectively. A major complication related to radial artery harvesting, compartment syndrome of the arm due to postoperative bleeding, was observed in 1 patient. No postoperative myocardial infarction attributable to radial artery bypass was observed. During the late follow-up period of 3.5+/-0.9 years, cardiac events were observed in 63 patients, giving actuarial 2- and 3-year event-free rates of 92.8% and 89.6%, respectively. A total of 24 late deaths were noted, including seven cardiac deaths, giving actuarial 2- and 3-year survival rates of 98.1% and 97.2%, respectively. Postoperative angiography was performed in selected patients. The cumulative graft patency rate of the radial artery was 93.0% during the mean angiographical follow-up period of 1.5+/-1.1 years.

CONCLUSIONS

No adverse effects were noted after CABG using a radial artery graft in this short- and midterm follow-up period.

Myocardial revascularization with multiple arterial grafts: comparison between the radial artery and the right internal thoracic artery

BACKGROUND

Bilateral internal thoracic artery (ITA) harvesting is significantly underused, whereas the radial artery is being used with increasing frequency. We have retrospectively analyzed perioperative and short-term outcomes of patients receiving a radial artery versus those receiving a right ITA as a second arterial graft.

METHODS

Between February 1999 and May 2000, 250 patients underwent coronary artery bypass grafting using the radial artery (156 patients) or the right ITA (94 patients) in combination with the left ITA and, when required, the saphenous vein.

RESULTS

There was a higher prevalence of risk factors in the radial artery group. More coronary artery bypass graftings (p < 0.001) were performed with the radial artery. Operative mortality was not different (p = not significant). In the right ITA group there was more bleeding (p < 0.001) and a longer hospital stay (p < 0.001). Mean follow-up was 8.1 +/- 3.9 months. The probability of survival was similar (p = not significant).

CONCLUSIONS

The radial artery can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting because of multiple risk factors. Perioperative and short-term results are good.

Cardiopulmonary Complications Following Cardiac Surgery

There are numerous cardiac and pulmonary complications that can occur after operations that involve the use of cardiopulmonary bypass (CPB). We have chosen to focus on perioperative myocardial ischemia, left ventricular (LV) dysfunction, ventricular arrhythmias, atrial arrhythmias, and inflammation and pulmonary dysfunction as the most important. If left untreated, these complications can be life-threatening. Moreover, their presence is associated with higher hospital expenses due to therapies and longer inpatient stays.