Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

Schwann, Thomas A.; Gaudino, Mario; Baldawi, Mustafa; Tranbaugh, Robert F.; Schwann, Alexandra N.; Habib, Robert H.

doi:10.1111/jocs.13517

Cited by 10 publications

(10 citation statements)

References 75 publications

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“…Verapamil is the best of these to be used in a topical/local milieu and is best combined with NTG (previously discussed). 7,11,12 Milrinone. Another powerful local and systemic vasodilator with a half-life of 2 hours.…”

Section: Spasm Prophylaxismentioning

confidence: 99%

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The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest

Tatoulis

2021

JTCVS Techniques

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There is mounting evidence from large observational studies and randomized trials (RCTs) that coronary artery bypass grafting using multiple arterial grafts (MAG) results in superior graft patency and better long-term clinical outcomes without compromising perioperative mortality and morbidity. [1][2][3] The radial artery (RA) has emerged as the second arterial graft of choice. It has the same patency as the right internal thoracic artery (ITA) when placed to the same vessels under the same conditions, but is much more versatile and easier to use. 4 Introduced in 1971 by Carpentier, lack of knowledge about arterial graft spasm and management of this with mechanical dilatation was problematic. Observation of excellent, patent, atheroma-free RA grafts from the original series 2 decades later has prompted its reappearance as a coronary graft. Advantages include ease of procurement, length (18-22 cm), robustness, versatility, excellent diameter appropriate to the coronaries, ease of constructing sequential anastomoses, potential for total arterial revascularization when used with the left ITA, especially as a T or Y graft, few infections and wound problems, suitable for use in patients with diabetes, and suitable for use in all ages, including the elderly, facilitating early ambulation. Proximally, its size generally allows direct anastomosis to the aorta or to an ITA. 4 Crucial to successful RA use is optimal harvesting, preparation to maximize its perioperative and long-term efficacy, and minimizing harvest-related complications or impediments. These include wounds, cosmesis, neurologic (particularly sensory) abnormalities, finger/hand ischemia, graft damage (especially intimal), and spasm. Therefore, knowledge of RA anatomy, assessment of hand circulation, its morphologic and pharmacologic characteristics, relationships to relevant nerves, harvest strategies, and a reproducible technique to avoid these potential complications is mandatory. AnatomyThe brachial artery bifurcates into the ulnar artery (UA) and RA at the elbow. The RA is usually smaller and fortuitously is not accompanied by any major nerves-unlike the UA (median nerve). The RA runs deep to the brachioradialis muscle and emerges between it and the flexor muscles approximately two-thirds of the way down the forearm, becoming superficial and easily accessible just above the wrist before its termination in the superficial and deep palmar arches (Figure 1).Proximally, the recurrent RA arises 1 cm distal to the RA origin and runs laterally and proximally. The interosseous artery originates from the deeper aspect. In its proximal two-thirds, the RA lies in loose areolar tissue with few branches. The branches become more numerous in the distal third, particularly around the wrist. Branches on the

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Section: Spasm Prophylaxismentioning

confidence: 99%

“…Verapamil is the best of these to be used in a topical/local milieu and is best combined with NTG (previously discussed). 7 , 11 , 12 …”

Section: Anatomymentioning

confidence: 99%

The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest

Tatoulis

2021

JTCVS Techniques

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“…In planning the appropriate deployment of RA grafts, it is worth remembering that although RA graft patency may decline with decreasing levels of proximal target vessel stenosis, it appears at least comparable to SV for the same level of target vessel stenosis (20). An alternate strategy to guide the use of the RA may be to consider the RA's crosssectional area compared to the minimal cross-sectional area at the maximal target vessel stenosis (22), although external clinical validation remains pending.…”

Section: -Indications and -Contra-indicationsmentioning

confidence: 99%

Radial artery as a conduit for coronary artery bypass grafting: a state-of-the-art primer

Sousa-Uva

Gaudino

Schwann

et al. 2018

European Journal of Cardio-Thoracic Surgery

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“…The past 5 years has seen an increased emphasis on enhancing graft patency in order to improve long‐term survival following Coronary Artery Bypass Graft (CABG) surgery. This includes the increased use of multiple arterial grafts; especially the use of the radial artery (RA), intraoperative transit time flow measurements to detect technical anastomotic issues, and optimization of storage solutions for saphenous vein grafts to enhance endothelial cell preservation . In this issue of the Journal, Schwann et al studied the effect of the completeness of revascularization on long term survival following CABG and whether multiple arterial grafting would have any impact on the outcomes.…”

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confidence: 99%

“…The use of bilateral internal mammary artery (BIMA) grafts was only 2.6%; however, the use of RA grafts was 41%. RA grafts have been shown to have superior patency to saphenous vein grafts and in some series have been superior to right internal artery conduits …”

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confidence: 99%

Detrimental effects of incomplete revascularization following CABG-multiple arterial grafting may not solve the problem

Lazar

2018

J Card Surg

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The past 5 years has seen an increased emphasis on enhancing graft patency in order to improve long-term survival following Coronary Artery Bypass Graft (CABG) surgery. This includes the increased use of multiple arterial grafts; especially the use of the radial artery (RA), intraoperative transit time flow measurements to detect technical anastomotic issues, and optimization of storage solutions for saphenous vein grafts to enhance endothelial cell preservation. 1-4 In this issue of the Journal, Schwann et al 5 studied the effect of the completeness of revascularization on long term survival following CABG and whether multiple arterial grafting would have any impact on the outcomes. They analyzed 15 year mortality in 7157 CABG patients based on the completeness of revascularization. A completeness of revascularization index (CRI) was calculated based on the difference between the number of coronary grafts and the number of diseased coronary artery systems as reported in their institution's STS database.This resulted in three types of revascularization patterns: Incomplete, Complete, and two levels of Supra-Complete revascularization.Although the incidence of incomplete revascularization was only 4.5%, incomplete revascularization was associated with decreased late survival despite the use of multiple arterial grafting. Schwann et al

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Optimal management of radial artery grafts in CABG: Patient and target vessel selection and anti-spasm therapy

Abstract: The current literature on radial artery grafting is reviewed focusing on the optimal deployment of radial artery grafts in coronary artery bypass surgery with specific attention to the selection of patients and target vessels for radial artery grafting.

Cited by 10 publications

References 75 publications

The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest

The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest

Radial artery as a conduit for coronary artery bypass grafting: a state-of-the-art primer

Detrimental effects of incomplete revascularization following CABG-multiple arterial grafting may not solve the problem

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