HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gaudino, M. Articles by Possati, G. Search for Related Content PubMed PubMed Citation Articles by Gaudino, M. Articles by Possati, G. Related Collections Coronary disease

Eur J Cardiothorac Surg 2006;29:71-73
© 2006 Elsevier Science NL

Ten-year Echo-Doppler evaluation of forearm circulation following radial artery removal for coronary artery bypass grafting

^a Department of Cardiac Surgery, Catholic University, Rome, Italy
^b Department of Angiology, Catholic University, Rome, Italy
^c Divisione di Cardiochirurgia, Policlinico Uniersitario A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy

Received 5 September 2005; received in revised form 13 October 2005; accepted 25 October 2005.

^_* Corresponding author. Tel.: +39 06 30154639; fax: +39 06 30 55 53 5. (Email: mgaudino{at}tiscali.it).

	Abstract

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

 
Objective: To investigate the chronic consequences of radial artery removal for coronary artery bypass surgery on the forearm circulation. Methods: Thirty-nine patients submitted to radial artery removal for coronary artery bypass were submitted to serial Echo-Doppler evaluation of the flow and morphology of the forearm arteries until 10 years follow-up. Results: The peak systolic velocity of the ulnar artery of the operated side was significantly higher than the control site. The intima-media thickness of the ulnar artery was always significantly higher on the operated side, and this difference reached statistical significance at 10 years follow-up. There was a significantly higher prevalence of atherosclerotic plaques in the ulnar artery (UA) of the operated versus control arm (11/39 vs 0/39; p = 0.005). Conclusions: Radial artery removal for coronary artery bypass surgery leads to a chronic increase in ulnar flow accompanied by increased intima-media thickness and accelerated atherosclerotic disease. These findings may have potentially important implications for surgical indications and patients management.

Key Words: Radial artery • Ulnar artery • Atherosclerosis

	1. Introduction

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

 
Removal of the radial artery (RA) for myocardial revascularization reduces forearm blood supply by half, leaving it completely dependent on the collateral circulation from the ulnar artery (UA). To date, only limited information on the chronic consequences of RA removal on the forearm circulation have been reported and no data on the effect of the chronic flow increase on the UA exist, although we have previously shown in a limited group of cases how this artery can have a tendency towards accelerated atherosclerotic disease [1].

The present study expands our previous observations in a larger group of cases with extended follow-up.

	2. Patients and methods

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

 
2.1 Patients population
Our institutional experience with the use of the RA as coronary artery bypass conduit started in 1993; detailed description of the operative technique used at surgery, perioperative management, follow-up methodology and mid- to long-term clinical and angiographic results have been previously published [2–7].

Bilateral RA harvesting was never performed in our series and the artery was always harvested from the non-dominant arm.

This study includes 39 non-consecutive cases who have reached the 10 years follow-up at the time of enrolment and accepted to undergo the forearm examination. All these patients had already undergone a similar study protocol 5 years after surgery; detailed results of this study have been published [5]. Main clinical data of these cases are resumed in Table 1 .

Echogenic foci in the arterial wall with posterior acoustic shadowing were recorded as calcification. Those without posterior acoustic shadowing were recorded as atherosclerotic plaques. Stenosis was defined as a focal increase in peak systolic velocity compared with the proximal arterial segment.

Twenty-one cases also underwent forearm stress test and transcutaneous oxymetry according to our previously described method [1].

2.3 Statistical analysis
Data are expressed as mean ± 1SD. For statistical analysis, the paired and unpaired t-test was used; a p-value < 0.05 was considered significant.

	3. Results

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

 
No patient complained of forearm ischemic symptoms at any time during the follow-up either at rest or during hand exercise. Transcutaneous oxymetry demonstrated a small degree of exercise-induced ischemia in the operated arm (see Fig. 1 ) in the absence of clinical symptoms.

View larger version (13K): [in this window] [in a new window]   Fig. 1. Results of transcutaneous oxymetry in the operated and control arm at rest and in stress condition (R: recovery time; data expressed as O2 mmHg).

The IMT of the UA was always significantly higher on the operated side, and this difference reached statistical significance at 10 years follow-up (see Table 2).

Moreover, there was a significantly higher prevalence of atherosclerotic plaques in the UA of the operated versus control arm (11/39 vs 0/39; p = 0.005), whereas no difference in atherosclerotic involvement was found between the brachial arteries of the two sides (3/39 vs 1/39).

	4. Discussion

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

 
The acute consequences of RA removal on the forearm circulation and the methods to minimize the incidence of hand ischemia have been clearly established.

However, only limited information is available on the effect of RA harvesting on the anatomic and functional aspects of the forearm vasculature.

Following RA removal, forearm blood supply becomes totally dependent on the UA.

This compensation leads to the significant increase in flow of the UA on the operated site. This increase become evident from the early postoperative period and, according to our data, remain unchanged at 5 and 10 years follow-up [5].

In a previous report we have shown how in a limited group of cases in the years after surgery the IMT of the UA of the operated arm become progressively higher than that of the control side and, more importantly, how the incidence of overt atherosclerosis of the UA was significantly higher in the operated arms [1].

However, the small sample size and limited follow-up limited the value of our previous observations and made us cautious in drawing conclusions.

The present study expands and confirms our initial data and opens a new, alarming perspective on the possible chronic ischemic consequences of RA removal on the forearm circulation.

In fact, although one could speculate that the increase in IMT is the result of a remodeling of the arterial wall of the UA without any detrimental consequences, the alarming high incidence of overt atherosclerosis reported in the operated side seems to deny this "favorable" hypothesis.

Obviously, further confirmation in larger studies and, ideally, by others, remain desirable.

For the moment our data must be kept in mind when selecting the appropriate arterial conduits for surgical myocardial revascularization and have particular relevance in young patients with a long life expectancy (to whom total arterial coronary revascularization is most often offered).

Due to the excellent patency of the RA in the long term, for the moment this conduit is still regarded as an alternative arterial choice for CABG at our institution. However, watchful waiting and careful evaluation of the ulnar artery of the operated arm are mandatory in RA patients.

	Appendix A

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

 
Conference discussion

Dr A. Wahba (Trondheim, Norway): You focused on the vascular side of the long-term results. Did you do any neurological examinations in the long-term on these patients?

Dr Gaudino : Well, as I said, all of our patients were totally asymptomatic from a clinical point of view. When asked by an expert neurologist, a very small percentage I must say had some incidence of paresthesia or dysesthesia of the thumb. But they were mainly the first patients, and that was probably related to the excessive length of the incision.

Dr J. Galea (G’Mangia, Malta): Do you think that the increase in velocity that you observed could have increased the shear stress and caused the atherosclerosis, because we know that with increased shear stress, one will have more plaque formation and hence atherosclerosis.

Dr Gaudino : Well, our data obviously cannot answer this interesting question. One could probably speculate that the increase in peak systolic velocity had a role in the development of atherosclerosis, however, we know that in other vascular disease an increase in flow is followed only by a vascular remodeling without development of atherosclerosis. So for the moment we haven’t an answer. The subject must be studied in detail yet.

	Footnotes

 
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.

	References

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

 

1. Gaudino M, Serricchio M, Tondi P, Gerardino L, Di Giorgio A, Pola P, Possati G. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis following radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg 2005;130:9-12.[Abstract/Free Full Text]
2. Possati G, Gaudino M, Prati F, Alessandrini F, Trani C, Glieca F, Mazzari M, Luciani N, Schiavoni G. Long-term angiographic results of radial artery grafts used as coronary artery bypass conduit. Circulation 2003;108:1350-1354.[Abstract/Free Full Text]
3. Manasse E, Sperti G, Suma H, Canosa C, Kol A, Martinelli L, Schiavello R, Crea F, Maseri A, Possati G. Use of the radial artery for myocardial revascularization. Ann Thorac Surg 1996;62:1076-1082.[Abstract/Free Full Text]
4. Pola P, Serricchio M, Flore R, Manasse E, Favuzzi A, Possati GF. Safe removal of the radial artery for myocardial revascularization: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996;112:737-744.[Abstract/Free Full Text]
5. Serricchio M, Gaudino M, Tondi P, Gasbarrini A, Gerardino L, Santoliquido A, Pola P, Possati G. Hemodynamic and functional consequences of radial artery removal for coronary artery bypass grafting. Am J Cardiol 1999;84:1353-1356.[CrossRef][Medline]
6. Gaudino M, Glieca F, Trani C, Lupi A, Mazzari MA, Schiavoni G, Possati G. Mid-term endothelial function and remodeling of radial artery grafts anastomosed to the aorta. J Thorac Cardiovasc Surg 2000;120:298-301.[Abstract/Free Full Text]
7. Gaudino M, Alessandrini F, Pragliola C, Cellini C, Glieca F, Luciani N, Girola F, Possati G. Effect of target artery location and severity of stenosis on mid-term patency of aorta-anastomosed vs. internal thoracic artery-anastomosed radial artery grafts. Eur J Cardiothorac Surg 2004;25:424-428.[Abstract/Free Full Text]

This article has been cited by other articles:

				A. G. Royse, G. S. Chang, D. M. Nicholas, and C. F. Royse No Late Ulnar Artery Atheroma After Radial Artery Harvest for Coronary Artery Bypass Surgery Ann. Thorac. Surg., March 1, 2008; 85(3): 891 - 894. [Abstract] [Full Text] [PDF]

				W. J. Gomes Invited Commentary Ann. Thorac. Surg., March 1, 2008; 85(3): 894 - 895. [Full Text] [PDF]

				D. G. Nezic, A. M. Knezevic, P. S. Milojevic, B. P. Dukanovic, M. D. Jovic, M. D. Borzanovic, and A. N. Neskovic The fate of the radial artery conduit in coronary artery bypass grafting surgery. Eur. J. Cardiothorac. Surg., August 1, 2006; 30(2): 341 - 346. [Abstract] [Full Text] [PDF]

				C. F. Chong Long-term effects of radial artery harvesting on donor forearm - a cautionary tale. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 200 - 201. [Full Text] [PDF]

				M. Gaudino and G. Possati Reply to chong. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 201 - 201. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gaudino, M. Articles by Possati, G. Search for Related Content PubMed PubMed Citation Articles by Gaudino, M. Articles by Possati, G. Related Collections Coronary disease