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Eur J Cardiothorac Surg 2004;26:110-117
© 2004 Elsevier Science NL

Is it better to use the radial artery as a composite graft? Clinical and angiographic results of aorto-coronary versus Y-graft

Division of Cardiovascular Surgery ‘L. Sacco Hospital’, Via G.B. Grassi 74, 20157 Milan, Italy

Received 19 October 2003; received in revised form 7 March 2004; accepted 15 March 2004.

^* Corresponding author. Tel.: +39-02-3904-2333; fax: +39-02-3904-2652
e-mail: massimo.lemma{at}fastwebnet.it
e-mail: m.lemma{at}hsacco.it

	Abstract

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Objective: We sought to evaluate whether the radial artery (RA) provides the same clinical and angiographic results when proximally anastomosed to the aorta or to the left internal thoracic artery (ITA) as a composite Y-graft. Methods: From February 1999 to December 2002, 512 patients underwent myocardial revascularization using the RA, the left ITA and, when required, the saphenous vein. According to the surgeons' preference the RA was proximally anastomosed to the aorta [336 patients (65.6%), Ao-Cor group] or to the left ITA as a composite Y-graft [176 patients (34.4%), Y-graft group]. There was a significant prevalence of three-vessel disease (86.8 versus 73.2%, P=0.000) and elderly age (60±9 versus 58±8 years, P=0.014) in the Y-graft group. Results: Patients in Y-graft group had longer aortic cross clamp time (P=0.001), more bypass grafts per patient (P0.001), more arterial bypass grafts per patient (P0.001) and more bypass grafts per patient with the RA (P0.001). There were no differences in terms of perioperative outcome. Mean follow-up time was 27.1±11.7 months in 322/333 (96.7%) patients of the Ao-Cor group and 14.9±10.2 in 165/172 (95.9%) patients of the Y-graft group. There was no difference in terms of overall survival (P=0.75), cardiac event-free survival (P=0.65), RA patency rate at postoperative angiography (P=0.59) and during follow-up (P=0.93). A preoperative coronary artery stenosis 70% was related with competitive flow (P=0.000) at postoperative angiography and with RA occlusion (P=0.001) at follow-up angiography. Conclusions: The RA provides the same clinical and angiographic results both as aorto-coronary and composite Y-graft with the left ITA. When the RA is used as Y-graft the procedure is more technically demanding and a greater number of distal coronary anastomoses is possible. RA grafts to targets with stenosis 70% appear to be at risk of failure.

Key Words: Composite arterial graft • Myocardial revascularization • Left internal thoracic artery • Radial artery • Graft patency

	1. Introduction

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Myocardial revascularization using the radial artery (RA) as a second arterial graft is receiving increasing acceptance because the RA is easy to use, can extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral internal thoracic artery harvesting (ITA) [1] and achieves both excellent early clinical results and short-term patency [2].

RA, being a free graft, can be used as a conventional aorto-coronary bypass or, in order to extend as much as possible the number of RA distal anastomoses, it can be proximally placed on the left ITA obtaining a composite Y- or T-graft.

The aim of this study was to retrospectively analyze the perioperative and mid-term outcomes of patients receiving an RA as aorto-coronary bypass versus those receiving an RA as a composite arterial graft.

	2. Material and methods

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
2.1. Patient population and criteria selection
This study retrospectively analyzed two groups of patients who were operated on consecutively between February 1999 and December 2002, receiving either the RA as aorto-coronary bypass (Ao-Cor group; n=336) or as composite graft (Y-graft group; n=176). The choice between the two different options was dependent on the surgeons' preference with either technique. All patients received a left ITA pedicle on the left anterior descending coronary artery and as many supplemental saphenous vein (SV) grafts as necessary. During this period of time general contraindications for arterial grafting using the RA were (1) age more than 70 years, (2) an emergency operation, (3) a left ventricular ejection fraction less than 30% and (4) a target coronary artery smaller than 1.5 mm in diameter and of poor quality. At the beginning of our experience the RA was used on coronaries with stenosis 50% but later on the limit moved to 70%. The RA was preferentially used on the circumflex system, less frequently on the right coronary artery and never on the left anterior descending coronary artery. Specific contraindications for the use of the RA were the presence of a positive Allen test, severe renal failure, a history of previous vascular trauma to the upper limbs and the presence of Raynaud's or Dupuytren's disease. The RA was always harvested from the non-dominant arm, and never bilaterally. The Allen test was routinely performed before the operation following the rules suggesting by Ejrup and colleagues [3] (patient's hand slightly flexed and relaxed to avoid false positive tests). We modified the standard Allen test by recording an oximetric plethysmography curve from the thumb during RA occlusion. Doppler examination of the upper extremity was only performed in presence of doubtful results.

2.2. Operative techniques
The RA was harvested simultaneously with the left ITA and SV. Oximetric plethysmography was continuously recorded from the thumb. Electrocautery was exclusively used to cut the subcuticular tissue to prevent any thermal injury to the RA that was carefully dissected with its accompanying veins and the connective tissue to preserve its blood supply as much as possible. After systemic heparinization a small atraumatic vascular clamp (Fogarty Soft-jaw 6-mm spring clip, model 614-06; Baxter Healthcare Corp, Irvine, CA) was temporarily applied to occlude the RA. The confirmation of adequate collateral flow from the ulnar artery was obtained assessing oxygen saturation and pulse volume recorded by the pulse oximetric probe placed on the thumb. The RA was then tied, taken out and flushed carefully with diltiazem (50 mg of diltiazem per 50 ml of lactated Ringer's solution) avoiding any hydrostatic dilatation. It was than stored in a papaverine hydrochloride solution (100 mg of papaverine diluted in 100 ml of lactated Ringer's solution).

Coronary anastomoses were performed using continuous 7-0 polypropylene (Ethicon, Johnson–Johnson; Brussels, Belgium) sutures. Sequential diamond anastomoses were used preferentially. Aortic anastomoses were performed on the beating heart with continuous 6-0 polypropylene sutures using a 4.0-mm aortic punch (Pilling Weck Surgical Fort; Washington, PA) for RA graft and a 4.5-mm punch for SV. Y- or T-graft anastomoses between the RA and the left ITA were performed, according to surgeon's preference, either on the pleural or thoracic aspect of the left ITA at the level of entry into the pericardial space adjacent to the left atrial appendage, using continuous 7-0 or 8-0 polypropylene sutures, after coronary anastomoses and preferably during ischemic time.

To minimize the risk of arterial spasm patients receiving an RA graft were administered with a continuous intravenous infusion of diltiazem throughout the operation (0.25–0.50 µg/kg min^–1). Continuous infusion was maintained until patients were able to take medications orally. In presence of side effects diltiazem was replaced with intravenous nitroglycerin. Diltiazem was prescribed after discharge for a period of 6 months postoperatively at a dosage of 180 mg/day.

2.3. Postoperative complications: definitions
Operative mortality was defined as death occurring within 30 days from operation. Low cardiac output syndrome was defined as the presence of a mean blood pressure less than 60 mmHg or a cardiac index less than 2 l/min m^–2 lasting for more than 30 min and requiring inotropic support or intraortic ballon pumping despite adequate preload and appropriate afterload reduction. Postoperative myocardial infarction was defined by the appearance of new Q waves on the ECG and/or by an increase in the creatine kinase MB isoenzime fraction of >100 UI/l and/or >10% of the total creatine kinase level. The need of chest reopening for bleeding was defined as the presence of bleeding from the chest tubes >500 ml during the 1st hour, >400 ml during the 2nd hour and >300 ml during the 3rd hour or a total bleeding >1000 ml within the 4th hour [4]. The length of intensive care unit (ICU) stay was defined as the number of hours from patient arrival in ICU to patient transfer to the ward. Hospital length of stay was defined as the number of days from the operation to patient discharge.

2.4. Follow-up
After discharge from the hospital all patients underwent telephone interview every 6 months and yearly clinical review by a cardiac surgeon. At the time of contact were obtained data on patients survival, new onset of angina or myocardial infarction and further revascularization (surgical or percutaneous intervention).

2.5. Postoperative angiography
A few patients were asked to undergo postoperative coronary angiography for study purposes before discharge. During follow-up, angiography was carried out only for recurrence of symptoms or in presence of positive exercise stress test. The angiogram was obtained directly from the performing cardiologist or cath-lab and valued by the operating surgeon. Graft failure was defined as occlusion or stenosis of 70% or greater of one or more anastomotic sites and/or 70% or greater stenosis in any part along the graft. In the presence of uniform conduit narrowing greater than 50% (string sign) and delayed opacification of the target artery (TIMI 1 or 2 flow) the graft was considered functionally occluded and recorded as non-patent. Perfect patency was defined as (1) absence of any stenosis at the anastomotic sites and along the graft, (2) absence of competitive flow from the native coronary artery, and (3) presence of a TIMI 3 flow. At the time of postoperative angiography preoperative angiogram was reviewed and target vessels dimensions were retrospectively classified as moderately (70%) or severely (70%) stenosed.

2.6. Statistical analysis
All statistical analyses were performed using the SPSS^® 11.0 software (SPSS Inc., Chicago, IL, USA). Continuous data are presented as mean±standard deviation. Normal distribution was tested using both the Kolmogorov–Smirnov statistic with a Lilliefor's significance level and the Shapiro–Wilk statistics. Student's t test was used after evidence of normality. Nominal data are presented as the absolute frequency or as a percentage and were analyzed by ² test or Fisher's exact test where appropriate. Survival and freedom from cardiac events were determined using the Kaplan–Meier analysis. In order to have at least 80% of patients exposed to risk results of overall survival and cardiac event-free survival were considered at a follow-up length of 2.5 years. Variables defined as traditional predictors of cardiac morbidity and mortality that differed between groups at univariate analysis with a level of significance P<0.2 were selected to compose a Cox multivariate regression model. A P value <0.05 was considered to indicate significant statistical difference.

	3. Results

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
There was a significant prevalence of three-vessel disease (86.8 versus 73.2%, P=0.000) and elderly age (60±9 versus 58±8 years, P=0.014) in the Y-graft group. There was no significant difference in the prevalence of other traditional predictors of cardiac morbidity and mortality (Table 1) .

Analysis of perioperative outcome showed that there was no significant difference between the two groups of patients (Ao-Cor versus Y-graft group) considering the mortality rate (0.9 versus 2.3%, P=0.39), the incidence of perioperative myocardial infarction (6.6 versus 5.7%, P=0.86), the incidence of low cardiac output (1.5 versus 0%, P=0.25), the length of mechanical ventilation (14.2±20.4 versus 17.4±52.7 h, P=0.33), the length of intensive care unit stay (52.8±38.4 versus 47.6±38.2 h, P=0.14), the amount of bleeding (577±310 versus 632±542 ml, P=0.13), the incidence of chest reopening for bleeding (3.6 versus 3.4%, P=0.87) and the length of hospital stay (11.4±3.8 versus 10.9±1.7 days, P=0.09).

Mean follow-up time was 27.1±11.7 months (from 10 days to 49 months) in 322 of 333 patients (96.7%) of Ao-Cor group and 14.9±10.2 months (from 71 days to 47.8 months) in 165 of 172 patients (95.9%) of Y-graft group. One patient in Ao-Cor group died after 38 months. There were no deaths in the Y-graft group. After 2.5 years survival estimate was 100% for both groups of patients (Fig. 1) . Because there was only one death in Ao-Cor group, it was not possible to fit a multivariate Cox regression model to take account of all prognostic variables that differed between groups.

View larger version (16K): [in this window] [in a new window]   Fig. 1. Kaplan–Meier cumulative survival. Y-grafts vs Ao-Cor.

View larger version (20K): [in this window] [in a new window]   Fig. 2. Kaplan–Meier freedom from cardiac events. Y-grafts vs Ao-Cor.

	4. Discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

From the surgical point of view the RA is an attractive artery because its preparation is straightforward, can be harvested simultaneously with the left ITA, has thick vessel wall and large diameter facilitating performance of coronary anastomoses, has sufficient length to accommodate sequential grafting for even distal targets and avoids any increase in sternal wound complications associated with bilateral ITA grafting [1]. The RA may be either used as an aorta-coronary graft or, in order to extend as much as possible the number of distal targets, can be proximally anastomosed to the pedicled left ITA as a composite Y- or T-graft. Anastomosing the RA to the left ITA can bring the RA as much as 10 cm more closer to the coronary arteries, allowing it to reach most targets. This surgical strategy is more technically demanding than RA anastomosis to the ascending aorta. It must be performed with impeccable precision, usually on the pleural aspect of the left ITA avoiding any torsion of this graft. Particularly at the beginning of our experience the Y-anastomosis was performed after coronary anastomoses and during ischemic time. This allowed us to work in a more comfortable surgical field and to obtain a perfect RA and left ITA graft length between the Y-anastomosis and their first coronary target, avoiding both the risk of kinking of the grafts and traction on the coronaries. On the contrary RA anastomosis to the ascending aorta is quite simple because the thick vessel wall and the large diameter make the management of this graft easy, avoiding the technical problems related to anastomosis between a thin-walled vessel and a thicker aortic wall, which may produce stenosis and thrombosis of arterial grafts like the right ITA [11,12], the inferior epigastric artery [13] and the gastroepiploic artery [14]. The favorable anatomic characteristics of the RA explain our choice to perform sequential diamond anastomoses in both groups of patients in presence of two or more distal targets. This technique has been associated with the ITA to a 10% loss in patency [15] but is not particularly demanding using the RA, this graft having a diameter comparable to the SV.

The RA has shown good short- and mid-term results both clinically and angiographically [16,17]. The present observational study shows that the way of use of the RA do not influence perioperative, early and mid-term clinical results. Despite the higher prevalence of elderly patients and of triple-vessel coronary artery disease in the Y-graft group the incidence of perioperative mortality, myocardial infarction and low cardiac output was similar in both groups of patients. During follow-up there were no significant differences in survival and freedom from cardiac events. These results further highlight the reliability of the RA both as aorto-coronary graft and as Y-graft with the left ITA.

Supplying most of the coronary circulation through a single source of inflow may be worrisome and concerns about this technique center on the possible inefficiency of the left ITA to fully respond to the coronary system flow demand, particularly at short term after the operation. It has been shown however that soon after the operation the left ITA used as a Y-graft with the RA can efficiently adapt to an increase in flow demand, keeping normal the O₂ supply-to-demand ratio [18]. Moreover, there is evidence that the flow reserve of the left ITA used as a composite graft increases after 6 months from the operation [19]. Although others have cautioned against the potential dangerous effects of acute hypoperfusion resulting from inadequate left ITA flow, this was not a clinically evident problem in our experience. We believe that hypoperfusion is more likely related to technical errors, such us conduits injury or kinking than to inadequate flow reserve of the ITA.

Postoperative angiography showed a 100% patency rate for left ITA and RA in both groups of patients. During follow-up only patients with signs or symptoms of myocardial ischemia underwent angiography. LITA patency rate was 100% in both groups while RA patency rate was 53.5% (15/28) in Ao-Cor group and 60% (9/15) in Y-graft group (P=0.93). A coronary stenosis 70% was related with the presence of RA competitive flow at postoperative angiography (P=0.000) and with RA occlusion at follow-up angiography (P=0.001).

Only one patient of the Y-graft group showing competitive flow at postoperative angiography became symptomatic with further evidence at follow-up angiography of RA occlusion. Among arterial conduits the RA may be particularly sensitive to competitive flow given its propensity for graft spasm [20]. Several investigators [21–23] have demonstrated an association between grafting moderately stenosed vessels and a subsequent increase in the incidence of arterial graft occlusion or an angiographic ‘string sign’. A further angiography in all the asymptomatic patients of our groups with evidence of competitive flow at pre-discharge angiography should be necessary to better define the role of competitive flow on late RA patency rate.

4.1. Limitation of the study
This is an observational study in which the selection criteria for patient allocation was the surgeon's preference for either technique. As a consequence two different groups of patients were selected, with a greater incidence of elderly patients and three-vessel coronary artery disease in the Y-graft group. However, the multivariate Cox regression model failed to identify between the preoperative differences any independent significant predictor for any of the cardiac-related events. The results of our experience show that despite the increased complexity of this approach it can be also used in elderly patients with severe coronary artery disease. Nevertheless prospective randomized trials are needed to confirm these data.

Two additional limitations are the shortness of the follow-up period, particularly in the Y-graft group, and the lack of a systematic protocol for postoperative angiograms. The rationale for using the RA as a Y-graft is predicated on long-term benefits. Our experience with Y-grafts is shorter than that with the aorto-coronary RA. Y-grafting is more technically demanding and represented for us the last step in the field of arterial myocardial revascularization. Coronary angiograms were collected in the postoperative period in a few patients for study purposes. During the follow-up coronary angiography was available only from patients with signs or symptoms of myocardial ischemia. This represents the worst scenario in the analysis of graft patency. Data concerning relative patency, however, should be minimally affected by this consideration.

In conclusion the incidence of perioperative cardiac morbidity and mortality was the same both for the Ao-Cor and the Y-graft groups. The RA, in whatever way used, provides reliable results and can safely extend the benefits of multiple arterial grafting to those patients who are usually excluded from bilateral ITA harvesting for advanced age, diabetes, chronic obstructive pulmonary disease and obesity. Thanks to its morphometric features the RA can be easily used as an aorto-coronary graft and to perform multiple distal anastomoses in sequential fashion. When used as a Y-graft it allows to reach any coronary artery making easier to get a more complete arterial revascularization. Late RA patency rate can be adversely affected by coronary artery with moderate stenosis (70%).

	Footnotes

 
Presented at the joint 17th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 11th Annual Meeting of the European Society of Thoracic Surgeons, Vienna, Austria, October 12–15, 2003.

	Appendix A. Conference discussion

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 
Mr R. Ascione (Bristol, UK): I was wondering if you could tell us whether the analysis was adjusted for potentially confounding variables like how do you actually do the top end when using radial artery, the extent of coronary disease, the run-off of the grafted coronary, and the experience of the surgeons.

And the second question is, how did you decide on which patient you were going to do the angiographic control at follow-up? Was this based on symptoms or was it based random selection?

Dr Lemma: No, the analysis was not adjusted for potentially confounding variables. During follow-up control angiograms were performed only in symptomatic patients. We did protocol-directed angiography for study reasons only in the postoperative period, before discharge from the hospital. At the beginning of our experience our policy was to use the radial artery in presence of coronary stenosis greater than 50% but later on, looking at our results and at the results reported in the literature, we moved to 70% or more.

Dr U. Giedrius (Vilnius, Lithuania): I would like to know if you take radial artery with concomitant veins, that is one question, or skeletonized manner, and in case you put at least more than three sequential grafts on radial artery, where you prefer to connect to, to aorta or to Y graft?

Dr Lemma: We used the saphenous vein (in order) to complete myocardial revascularization. This is not a prospective randomized trial so the choice between the two different options, ascending aorta or left internal mammary artery was depending on the surgeons' preference with either technique.

Dr Giedrius: Not the saphenous, but radial. I must use radial artery for sequential grafting, and in this case I suppose it is better to adjust to aorta, to put the anastomosis upon the aorta, and then you don't answer if you take it with concomitant veins or just as a fully skeletonized artery?

Dr Lemma: No, we routinely harvest the radial artery with its accompanying veins and the connective tissue to preserve its blood supply as much as possible.

	References

Top Abstract 1. Introduction 2. Material and methods 3. Results 4. Discussion Appendix A. Conference... References

 

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