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Eur J Cardiothorac Surg 2001;20:1142-1146
© 2001 Elsevier Science NL

Subjective patient outcomes following coronary artery bypass using the radial artery: results of a cross-sectional survey of harvest site complications and quality of life

Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK

Received 14 February 2001; received in revised form 13 June 2001; accepted 31 August 2001.

Corresponding author. Department of Cardiac Surgery, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK. Tel.: +44-1895-828550; fax: +44-1895-828992
e-mail: mr.amrani{at}rbh.nthames.nhs.uk

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
Objectives: To assess patient-based outcomes following radial artery harvesting for coronary artery bypass surgery (CABG). Methods: A cross-sectional telephone survey of 127 patients who underwent radial artery grafting was undertaken. The parameters assessed included symptoms related to the radial artery harvest site (functional impairment, sensory symptoms, and wound infection) and health related quality of life. Results: A high percentage of patients (67.7%) reported altered sensation, in the hand, in particular around the thenar eminence, in the forearm, or in relation to the incision; this was self-limiting and clinically insignificant in the vast majority of patients. Twelve patients reported residual insignificant symptoms after a median follow-up of 17.5 months. Four patients reported a subjective decrease in grip strength. Patients reported a good quality of life, and there was no association between this and the presence or absence of symptoms related to radial artery harvest. Some patients volunteered a ‘preference’ for the radial artery harvest site when compared with concomitantly harvested long saphenous vein (LSV), and there was a lower wound infection rate at radial artery harvest sites compared with vein harvest sites (6 vs. 15%). Conclusions: Sensory symptoms following radial artery procurement occur more frequently than previously reported, but are largely self-limiting and are usually clinically insignificant. Patients appear to have a good quality of life following CABG using the radial artery. Radial artery harvest may be associated with lower wound infection rates and greater patient satisfaction than LSV harvest, however, the presence of residual sensory symptoms may be of relevance when obtaining informed consent.

Key Words: Radial artery • Sensory symptoms • Wound infection • Quality of life

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
The use of the radial artery is becoming increasingly accepted by surgeons favouring arterial revascularization, with groups reporting excellent short- and mid-term results [1–4].

Procurement of the radial artery is safe in patients who have a normal collateral circulation to the hand, and complications are reported to occur infrequently [3,5–10]. Studies looking specifically at motor and sensory function of the hand after radial artery procurement also report objective neurological deficits as being infrequent [4,11–13]. Few studies, however, have examined patient-based outcomes or reviewed problems that may occur outside routine or planned follow-up.

We have previously presented our clinical experience with the radial artery as a conduit for routine coronary artery bypass grafting (CABG) [14]. In this paper, we examine the morbidity associated with harvesting of the radial artery as reported by patients.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
2.1. Surgical technique
Our surgical technique has been described previously [14] and utilizes the use of low energy electrocautery for radial artery harvesting.

2.2. Study population and study design
Consecutive patients who underwent CABG using the radial artery between December 1997 and April 1999, and survived to discharge, formed the study population. Patient characteristics are shown in Table 1. The study took the form of a cross-sectional telephone survey. A single observer conducted scripted telephone interviews and also noted additional comments that were made by patients.

Patients were asked whether they had experienced any sensory symptoms (including paraesthesiae or numbness), wound complications (including wound infection), weakness or functional impairment in the forearm or hand since the time of surgery; and whether these had resolved or were improving or unchanged. All problems were recorded, even when patients volunteered that these were transient or ‘minor’. Wound infection was defined as clinical infection requiring antibiotic treatment.

A quality of life index was obtained using the EuroQol (EQ-5D), a generic instrument for measuring health status. The EQ-5D defines health in terms of five dimensions: mobility, self-care, usual activities, pain or discomfort, and anxiety or depression [15]. Associations between quality of life and the presence or absence of symptoms related to radial artery harvest were tested using the paired t-test.

Patients who reported persisting sensory symptoms or limitation in hand activity at the initial interview were re-interviewed again 10 months later (February 2000; median follow-up, 17.5 months; interquartile range, 14.2–20.3 months; range, 9.7–24.8 months). They were questioned about the persistence, improvement or deterioration of these symptoms.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
3.1. Patients
During the study period, 151 CABG procedures using the radial artery were performed under the care of a single surgeon (M.A.). There was one post-operative death, and of the 150 surviving patients, 130 were contactable for the initial survey.

3.2. First interview
Of the 130 patients contacted, one patient refused to answer questions, one was unable to answer questions because of ill health, and another patient had died of lung carcinoma. Data from these 127 patients (a response rate of 85%) form the cohort for this analysis. Of these patients, 81 had also undergone concomitant long saphenous vein (LSV) harvest.

3.3. Second interview
Of 64 patients reporting persistent symptoms related to radial artery harvest at the initial interview, 50 (a response rate of 78%) were contactable 10 months later (February 2000).

3.4. Results of first interview
3.4.1. Summary of neurological complications
A total of 89 patients (70%) had experienced symptoms in the forearm, wound or hand at some point following radial artery harvest. Seventy-five experienced sensory symptoms only, 11 experienced sensory symptoms and some weakness in the hand (this was mild and self-limiting for the majority; only four of these patients reported any functional impairment related to this — see below), and three experienced mild (self-limiting) weakness only. No ischaemic hand complications were reported.

3.4.2. Functional impairment
Four patients (3%) reported mild limitation in hand activity following radial artery harvest. Three of these patients reported a subjective decrease in grip strength, but with no impact on the activities of daily living. The fourth patient (who had the radial artery harvested from his dominant arm) also complained of a subjective decrease in grip strength. In addition, this patient felt that radial artery harvest had, in general, decreased his ability to perform many activities, in particular throwing darts. On further questioning, there were other co-morbidities and associated clinical problems due to diabetes.

3.4.3. Sensory symptoms
Sensory symptoms were reported by 86/127 (67.8%) patients. Table 2 shows the distribution of these symptoms. Fourteen of the 29 (48.3%) patients who experienced sensory symptoms on the palmar surface of the hand located their symptoms in the region of the thenar eminence. Other patients (including those reporting symptoms on the dorsum of the hand) also reported sensory symptoms involving different parts of the thumb and the tips of their fingers. No patients reported any limitation of their daily activities, and none had sought medical advice regarding them. Of the 86 patients who had experienced sensory symptoms, 24/87 (27.9%) reported that these symptoms had not changed since their onset, 40/86 (46.5%) patients said their symptoms were resolving, and 22/86 (25.6%) reported that their initial symptoms had resolved completely.

3.4.4. Health related quality of life
The median health utility score (on a scale of 0–1; 0 representing death and 1 representing the best possible health state) as determined by the EQ-5D method was 0.86 (interquartile range, 0.80–1.00).

Fig. 1 shows the percentage of respondents reporting problems in the EuroQol dimensions. The vast majority of patients reported no problem in most of the dimensions. Pain/discomfort was the most frequently reported problem in 46/127 (36.2%). Some patients reported discomfort and dysthaesia in relation to median sternotomy, but in some patients, the discomfort was related to a non-cardiac disease, such as orthopaedic disorders and peripheral vascular disease.

View larger version (20K): [in this window] [in a new window]   Fig. 1. Percentage of patients reporting a problem in each EuroQol dimension.

3.4.5. Wound infection
Six percent (7/127) of patients reported that they were given a short course of antibiotics by their family doctor for presumed infection of the radial harvest wound. Fifteen percent (12/81) of patients who had the saphenous vein harvested received antibiotics for leg wound infections.

3.5. Results of second interview
3.5.1. Functional symptoms
Of the four patients with functional impairment, we were able to contact two. Both reported no change in their symptoms, but reported no interference with their activities of daily living.

3.5.2. Sensory symptoms
Seventy-four percent (37/50) of patients reported that their symptoms had resolved. Twenty-four percent (12/50) reported no change in symptoms. These patients stated that they had become used to the altered sensation and that it did not interfere with the activities of daily living. One patient reported that his sensory symptoms had become worse. On further questioning, this patient revealed that his symptoms (experienced mainly around his fingertips) were in fact experienced bilaterally and therefore unlikely to be related to the radial harvest.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
We have recently compared the morbidity of radial artery grafting with that of conventional saphenous vein grafting and observed no increase in morbidity attributable to use of the radial artery [14]. The present study based on the same cohort, reinforces our opinion that use of the radial artery does not predispose to major morbidity. While this study suggests that the prevalence of sensory symptoms is higher than previously reported, most sensory symptoms reported were mild and self-limiting.

While several studies have looked at objective neurological signs [11], our study differs in that we have examined [3,5–10,13] the patient's perspective. An objective assessment of neurological symptoms would have complemented our telephone survey, but was not feasible.

This study has the limitations of any cross-sectional survey, namely non-responder bias, and information (interviewer and recall) bias. The open and broad case definition, including even ‘minor’ or transient symptoms, following radial artery harvest may have resulted in overestimation of the prevalence of sensory symptoms. Royse et al. reported that 15.5 and 11.3% of patients had a subjective loss in sensation compared with a 2.1 and 0.3% objectively measured loss of sensation in the distribution of the lateral cutaneous nerve of the forearm and superficial radial nerve, respectively [13]. Studies have also reported scar ‘hypersensitivity’ as occurring in around 20–33% patients [4,13]. The factors mentioned above, partly account for the difference between the prevalence of sensory symptoms in our cohort (67.7%; 86/127), and the above and other studies that report an even lower prevalence of sensory problems (ranging from 0 to 10%) [4–6,12].

Despite the frequency of sensory symptoms, patients ascribed little importance to them — no patients reported limitations to their activities of daily living. Nevertheless, it appears that a small percentage of patients have residual sensory symptoms at a median follow-up of 17.5 months; this may have relevance when obtaining informed consent.

The distribution of sensory symptoms is difficult to localize precisely with the survey method employed. We believe the occurrence of sensory symptoms is due to the often-unavoidable trauma or oedema around the superficial branch of the radial nerve or lateral cutaneous nerve of the forearm.

Motor symptoms are reported rarely. Four patients reported a subjective decrease in grip strength. Royse et al. have reported a decrease in both gross and finger pinch strength in operated compared with non-operated arms [13]. This was attributed to the expected difference between dominant and non-dominant arm strength.

A subjective decrease in grip strength may, however, be an expression of a decrease in thenar flexor power. The thenar musculature is supplied predominantly by the radial artery. Grossebner et al. have demonstrated a decrease in thenar flexor power following radial artery procurement [11]. This may account for the subjective decrease in grip strength experienced by these patients.

Wound infection rates of below 1% after radial harvest have been reported, but it has been suggested that higher rates will be found with increased surveillance [3–5,13,16]. Six percent of patients in this study required a short course of oral antibiotics for superficial wound infection around the radial artery harvest site, in comparison with 12% for LSV harvest site infections. This was despite the fact that most of these patients had a short leg incision, as only one length of LSV was harvested. It is also interesting to note that a high percentage of patients (35%) also report sensory symptoms related to LSV harvest, and although anecdotal, that some patients who underwent concomitant LSV and radial artery harvest volunteered their ‘preference’ for the radial artery harvest site over the LSV site. Radial artery harvesting may therefore be less morbid than sapneous vein harvesting.

Patients have a good overall health related quality of life (HRQOL) following CABG with the radial artery, with a utility score of 0.86 which falls within the range of an age-matched UK population [15]. Overall, the vast majority of patients had maximal scores in all dimensions of the EQ-5D questionnaire (Fig. 1). There was no association between quality of life and a history of symptoms related to radial artery harvest. Notably, quality of life was similar in patients who reported forearm or hand symptoms compared with those that did not.

	5. Summary

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 
This study suggests that the prevalence of sensory symptoms associated with radial artery harvest appears to be higher than previously reported, but these are largely self-limiting, non-restrictive, and do not interfere with patient quality of life or activities of daily living. However, a small percentage of patients appear to experience residual sensory symptoms and patients should be told about this possibility.

	Footnotes

 
Presented at the Annual Meeting of the Society of Cardio-thoracic Surgeons of Great Britain and Ireland, London, UK, March 12–15, 2000.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion 5. Summary References

 

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