Eur J Cardiothorac Surg 2003;23:112-113
© 2003 Elsevier Science NL
Bifid proximal anastomosis technique of radial artery
Erkan Kuralay*,
Ertugrul Özal,
Nezihi Küçükarslan,
Harun Tatar
Cardiovascular Surgery Department, Gülhane Military Medical Academy, Etlik, Ankara, Turkey
Received 11 August 2002;
received in revised form 9 October 2002;
accepted 21 October 2002.
* Corresponding author. Yazanlar Sokak No: 31/11, A
a
i Ayranci, Ankara, Turkey. Tel.: +90-312-304-5206; fax: +90-312-232-3038
e-mail: ekural{at}gata.edu.tr
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Abstract
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We have modified proximal anastomosis of radial artery to reduce technical problems due to wall thickness disparity between radial artery and ascending aorta. Bifid proximal anastomosis of both radial arteries is done just after cannulation without cardiopulmonary bypass initiation. Proximal sides of two radial arteries are spatulated with thin incisions. Closer sides of radial arteries are sutured with 8/0 polypropylene suture. Then side clamp is applied on the ascending aorta. The proximal anastomosis is performed directly onto a 5-mm punched opening in the ascending aorta with continuous 6/0 polypropylene. Thus we create a graft with bifid proximal anastomosis.
Key Words: Radial artery • Proximal anastomosis • Coronary bypass
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1. Introduction
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The use of the radial artery (RA) as a graft for myocardial revascularization has become widely accepted because of good early and midterm results [1–3]. Some studies advocate that there is relatively lower patency rate when proximal anastomosis of RA is done on ascending aorta [2,3]. Proximal anastomosis on thick, calcified ascending aorta can be troublesome or impossible in these cases. We believe that tethering effect of especially thin or severely spastic RA graft on proximal anastomosis on ascending aorta may reduce blood flow of RA graft or may cause early graft occlusion. We have been performing modified proximal anastomosis technique for both RAs on ascending aorta.
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2. Materials and methods
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The RA is evaluated in all cases with the Allen test, which is considered negative when hand revascularization becomes normal in less than 5 s. RAs are harvested in both forearms in classical manner. Proximal sides of two RAs are spatulated with thin incisions. Closer sides of RAs are sutured with 8/0 polypropylene suture (Fig. 1)
. Then proximal anastomosis is performed directly onto a 5-mm punched opening in the ascending aorta with continuous 6/0 polypropylene (Fig. 2A)
just after cannulation without cardiopulmonary bypass (CPB) initiation. Thus we create two-orifice composite graft just before CPB (Fig. 2B). We have performed bifid proximal anastomosis in 25 cases. The average follow-up period is 26±4 months. Coronary angiographic studies are performed in all cases and all RA are found to be perfectly patent.
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Fig. 1. Proximal sides of two RAs are spatulated with thin incisions. Closer sides of RAs are sutured with 8/0 polypropylene suture.
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Fig. 2. (A) Proximal anastomosis of both radial arteries are performed directly onto 5-mm punched opening in the ascending aorta with continuous 6/0 polypropylene just after cannulation without cardiopulmonary bypass initiation. (B) Completed form of Bifid composite radial arteries.
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3. Discussion
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Although the early and midterm patency rates for free RA grafts have been reported to be good [2], early graft occlusion in 10% of RA grafts can be attributed to the technical difficulties encountered during the proximal anastomosis of RA to the ascending aorta [1,3]. This is probably caused by the disparity of luminal size and wall thickness between the aorta and the RA. This disparity can impose abnormal and potentially harmful shear stress on RA. Many techniques are being produced to eliminate disparity of luminal size and wall thickness. The radial artery can be anastomosed to the hood of an associated vein graft or to a pericardial patch placed in the aortic wall. Recently composite grafts have been constructed and the left internal mammary artery has been used for the inflow source. We have been performing RA graft individually instead of using a sequential technique. Sequential anastomosis with single RA can cause hypoperfusion syndrome so we avoid the sequential use of RA. Sequential anastomosis of spastic RA can also cause technical difficulties and unnoticed mistakes, which may reduce early and long-term patency of RA grafts. We have also used a large punch (no. 5) in our technique, which also provides a larger orifice in the ascending aorta. Both RAs are harvested in most cases but we have not found any forearm skin and nerve complications. We think harvesting of RA with careful sharp dissection and avoidance of excessive electrocautery reduces the risk of forearm nerve injury. Our bifid proximal anastomosis technique can reduce wall disparity between aorta and the RA and therefore can be used in thick ascending aorta wall conditions; thus the bifid proximal radial anastomosis technique should be part of the surgeon's armamentarium.
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References
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- Iaco A.L., Teodori G., Di-Giammarco G., DiMauro M., Storto L., Mazzei V., Vitolla G., Mostafa B., Calafiore A.M. Radial artery for myocardial revascularization: long-term clinical and angiographic results. Ann Thorac Surg 2001;72:464-469.[Abstract/Free Full Text]
- Tatoulis J., Buxton B.F., Fuller J.A. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998;66:714-719.[Abstract/Free Full Text]
- Calafiore A.M., Di-Giammarco G., Teodori G., D'Annunzio E., Vitolla G., Fino C., Maddestra N. Radial artery and inferior epigastric artery in composite grafts; Improved midterm angiographic results. Ann Thorac Surg 1995;60:517-524.[Abstract/Free Full Text]
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Abstract
1. Introduction
