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Eur J Cardiothorac Surg 2006;30:200-201
© 2006 Elsevier Science NL
Letter to the Editor |
Department of Cardiac Surgery, Gleneagles JPMC Sdn Bhd Cardiac Centre, Jerudong Park BG3122, Brunei Darussalam
Received 17 March 2006; accepted 29 March 2006.
* Tel.: +673 2 611883; fax: +673 2 611886. (Email: chong_chee_fui{at}hotmail.com).
Key Words: Radial artery • Ulnar artery • Allen's test • Atherosclerosis
I read with interest the article by Gaudino et al. [1] regarding their findings of increased intimal thickening and accelerated atherosclerosis in the ulnar artery secondary to chronic increase in blood flow following radial artery harvesting. However, first I must correct an error made by Guadino et al. in the first line of his introduction for the benefit of all readers and that is removal of the radial artery does not in anyway reduced the forearm blood supply by half. This is a misconception since the amount of blood flow will be determined by the individual cardiac output rather than the number of conductance vessels, in this case arteries. Our own findings of forearm blood flow showed no significant reduction 3 months after surgery. In fact there is a nonsignificant increase in flow through the ulnar artery in the harvested forearm [2].
Most of our knowledge of the radial artery, to date, are based on early or mid-term results such as the RAPs findings of significantly better early patency rates of radial artery grafts over long saphenous vein grafts at 1 year, and this has provided an impetus for the continual use of the radial artery [3]. Similarly, our own findings reported no significant clinical adverse effects of radial artery harvesting on forearm blood flow and function at 3 months after surgery [2].
What is lacking is the long-term patency data or the long-term effects on the donor forearm following radial artery harvesting. Gaudino et al.'s [1] findings indicated that at 10 years there is a significant increase in intimal-media thickness and also significant higher incidence of atherosclerosis in the ulnar artery, secondary to chronic increase in flow. However, there was no mentioning of any significant flow limiting lesions and also none of the patients assessed had any forearm ischaemic symptoms at rest or exercise. Still this finding of accelerated atherosclerosis is highly relevant. A report by Hosokawa et al. [4] in 1990 published in the Annals of Plastic Surgery reported an increasing incidence of positive Allen's test with age, suggesting that the ulnar collateral circulation may be compromised with age probably due to atherosclerosis formation in the ulnar artery. Thus, Gaudino et al.'s [1] findings suggested that harvesting of the radial artery may be accelerating this natural process further. Certainly, atherosclerosis is a progressive disease and whether circulatory insufficiency will develop resulting in forearm claudication is a question which time will answer. These findings and the awareness that ulnar collateral flow may be compromised with age may necessitate a careful and close follow-up of all patients who have had radial artery harvesting performed for any forearm ischaemia resulting from accelerated atherosclerosis in the ulnar artery.
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