Hand circulation after radial artery harvest for coronary artery bypass grafting

J Med Dent Sci 2005; 52: 101 107 Review Hand circulation after radial artery harvest for coronary artery bypass grafting Susumu Manabe, Noriyuki Tabuchi, Hiroyuki Tanaka, Hirokuni Arai and Makoto Sunamori Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University Despite wide spread use of the radial artery (RA) graft for coronary artery bypass grafting, the change of hand circulation after RA harvest has not been fully clarified. Severe hand ischemia such as resting pain or gangrene is a rare complication and has been reported in 4 patients. These cases resulted from occlusive artery disease in forearm, which should be carefully explored before RA harvest. Incidence of mild hand ischemia such as hand claudication or fatigue is unknown, but our study suggested that around 10% of the patients developed mild hand ischemia after RA harvest. The blood flow to the forearm territory was decreased by 20% after RA harvest despite the compensatory dilatation of ulnar artery. The presence of low perfusion in the affected hand has been pointed out in some studies. We reported the decreased tissue oxygenation of the affected hand during hand grip exercise. The Allen test is the most popular preoperative screening method, but is associated with considerable numbers of false-positive and falsenegative results. Full length scanning of ulnar artery by ultrasonography seems to have a lower false-positive rate. But further clinical experience is necessary to establish a more reliable screening method. Key words: coronary artery bypass grafting, radial artery Corresponding Author: Susumu Manabe Graduate School of Medicine, Department of Cardiothoracic Surgery, Tokyo Medical and Dental University, 1-5-45, Yushima, Bunkyo-ku, Tokyo 113-8519, Japan Tel: +81-3-5803-5270 Fax: +81-3-5803-0141 E-mail: s-manabe@fb3.so-net.ne.jp Received January 26; Accepted March 18, 2005 Introduction The radial artery (RA) graft was first introduced for coronary artery bypass grafting (CABG) by Carpentier et al. 1 in the early 1970s, but use of the RA graft was soon abandoned because of the poor shortterm results 2. Twenty years later, however, the tendency of RA grafts to resist atherosclerotic changes was reported by Acar et al. 3, and use of RA grafts for CABG gained acceptance with a new protocol to overcome several difficulties encountered during the initial experience with these grafts. Recently, a prospective randomized study revealed that, in comparison to the saphenous vein graft, the RA graft is associated with a lower rate of graft occlusion 4 ; therefore, many surgeons have began to use the RA graft as the second arterial graft in addition to the left internal mammary artery. Early RA graft failure was attributed to spasm of the RA graft. Acar et al. 3 introduced antispasm prophylaxis to prevent postoperative graft spasm. We investigated the effect of such antispasm therapy on hemodynamics and renal function and confirmed that the antispasm therapy to prevent RA spasm is safe 5. In contrast, changes in hand circulation after RA harvest have not been fully investigated. Although severe hand ischemia after RA harvest is rare 6-9, its etiology is not clear. Several patients were reported to suffer from hand claudication after RA harvest 10,11, but the ability of patients to tolerate to hand exercise is yet to be examined. The Allen test is the most popular preoperative screening method for RA harvest, but this test is considered far from ideal because it is associated with considerable numbers of false-positive and falsenegative results. Many studies have attempted to establish more sensitive methods to detect the risk of hand ischemia 9,12-20, but further clinical experience is necessary to establish the superiority of other test to

102 S. MANABE et al. J Med Dent Sci the Allen test. In the present paper, we provide a review of previous reports discussing postoperative hand circulation after RA harvest. All values in this paper are expressed as mean SD. Severe hand ischemia after RA harvest (Table 1) Severe hand ischemia after RA harvest is a rare complication and has been reported in only four patients 6-9. Tatoulis et al. 6 reported that 2 of 6646 CABG patients experienced severe hand ischemia after RA harvest, which suggests that the incidence of severe hand ischemia is approximately 0.03%. We encountered one patient who suffered severe hand ischemia after RA harvest 9. The Allen test was performed prior to surgery, and a normal result was confirmed. According to preoperative ultrasonography, however, the diameter (1.7 mm/m 2 ) and blood flow (33.4 ml/min/m 2 ) in the patient s ulnar artery (UA) was much smaller than mean value in study patients (mean UA diameter, 2.54 mm/m 2 ; mean UA blood flow, 54.3 ml/min/m 2 ). During surgery, good back-flow was observed from the distal stump of the cut RA. The patient developed pneumonia a week after surgery and then became critically ill with sepsis. The thumb of the affected hand became cyanotic and then gangrenous. He died of sepsis several weeks after surgery, and no further examination was conducted. One of the major factors leading to severe ischemia has been thought to be abnormal continuity of the palmar arch with the peripheral arterial system of the digits. However, Ruengsakulrach et al. 24 examined 50 hands of 25 cadavers and observed arterial communication between RA and UA in all the hands. In fact, an incomplete palmar arch has not been documented as a cause of severe hand ischemia. Most cases of severe hand ischemia due to surgical manipulation of the RA (RA harvest for CABG, hemodialysis shunt, or a radial forearm radial flap) resulted from occlusive disease in the forearm artery (Table 1). Therefore, preoperative exclusion of occlusive artery disease in the forearm is considered essential to avoid severe hand ischemia. Mild hand ischemia after RA harvest (Table 2) Hand claudication after RA harvest has been reported in patients with particular professions such as dentist 11 or accordionist 10. The ability to tolerate hand exercise after RA harvest has not been examined in depth. According to previous questionnaire-based surveys, the postoperative functional status of the affected hand was considered acceptable by most patients. Hand weakness was present in fewer than 6% of the patients and decreased with time 25,26. Fewer than 6% of the patients complained of any limitations in hand Table 1. Case reports about severe hand ischemia after surgical intervention on radial artery RA; radial artery, CABG; coronary artery bypass grafting; HD; hemodialysis. *Forearm abnormality was detected preoperatively, and RA reconstruction with a vein graft was conducted simultaneously. Therefore, postoperative hand ischemia was avoided in this patient. ** Cases with a hand complication caused by an HD shunt-specific problem such as the steal phenomena were excluded.

HAND CIRCULATION AFTER RADIAL ARTERY HARVEST 103 Table 2. Summary of previous reports about hand function after radial artery harvest activity 26-28. We conducted careful face-to-face interviews of 40 patients 1 year after surgery, and found that modest symptoms suggestive of exercise intolerance were present in 5 (12.5%) patients 29. Their symptoms consisted of hand fatigue when carrying a heavy bag (4 patients), awareness of reduced grasping power (2 patients) and numness of the thumb during hand exercise (1 patient). However, no ischemic symptoms were recorded in these symptomatic patients during routine follow-ups in the outpatient clinic. These symptoms did not seriously affect their daily life activities. Some symptomatic patients unconsciously adopted a strategy to avoid frequent use of the affected hand after RA harvest. Therefore, most symptoms may have been overlooked or considered of nonischemic origin in most of the conventional surveys. Change of blood flow to the forearm territory after RA harvest Compensatory dilatation of the UA was observed immediately after RA harvest. Plethysmography indicated that the diameter of UA increased by 15.7%, and the flow velocity increased by 17.4% after RA harvest 20. We measured blood flow in RA and UA at the wrist by Doppler ultrasonography before and after RA harvest 29. Before RA harvest, the forearm territory was supplied with an average blood flow of 103.0 34.4 ml/min/m 2 through two major arteries (RA: 53.6 24.8 ml/min/m 2, and UA: 49.6 16.8 ml/min/m 2 ). After RA harvest, blood flow through the remained major artery, the UA, to the forearm territory was decreased by 20.5% on average (UA: 81.9 36.3 ml/min/m 2, p=0.011). Royse et al. 30 measured blood flow in the brachial artery (BA) immediately proximal to the elbow and compared flow between the arm where the RA was harvested and the opposite arm where there was no harvest. BA blood flow of the harvested arm showed a 19.2% decrease on average compared with that of control arm (harvested arm, 144 27 ml/min; control arm, 176 35 ml/min; P=0.167). However, they measured maximal BA blood flow (blood flow immediately after ischemic exercise); which was similar between the two arms (harvested arm, 348 50 ml/min; control arm, 371 63 ml/min; P=0.679) and concluded that arterial insufficiency is unlikely to present even during vigorous physical activity involving the arm.

104 S. MANABE et al. J Med Dent Sci Hand perfusion after RA harvest (Table 3) Perfusion in the affected hand after RA harvest has been examined with various methods, and the presence of low perfusion has been observed in some 10,20,29,33-38 but not all 19,30-32 analyses. Several studies reported that perfusion in the affected hand was low, especially during exercise; this suggests the presence of exercise intolerance 29,36,38. We measured tissue oxygenation (TcPO 2 ) during grip exercise in 40 patients who had undergone RA harvest 29. TcPO 2 was lower in the affected hand than in the unaffected hand during exercise. Seven patients (17.5%) experienced a considerable drop (more than 10%) of TcPO 2 during exercise, and the severity of this decrease in TcPO 2 indicates leg ischemia as Fontaine class II. Symptomatic patients showed a significantly lower TcPO 2 than did asymptomatic patients (Table 4). Another concern is whether exercise intolerance is a temporary phenomenon after RA harvest. Serrichio et al. 36 documented similar decrease in TcPO 2 in the affected hand at 5 years after RA harvest. However, Lee et al. 39 measured digital blood flow using plethysmography and reported that the overall decrease in distal blood flow immediately after RA harvest was significantly improved in long-term by physiologic adaptation. Table 3. Results of the clinical assessment representing hand perfusion after radial artery harvest

HAND CIRCULATION AFTER RADIAL ARTERY HARVEST 105 Table 4. Tissue oxygen pressure (TcPO2) during grip exercise in symptomatic and asymptomatic patients Table 5. Preoperative screening test for the safe removal of radial artery UA; ulnar artery, RA; radial artery. * This data is obtained from reference 45 Preoperative screening to prevent hand ischemia (Table 5) The Allen test has been the most popular preoperative screening method for RA harvest, but this test has significant numbers of false-positive and false-negative results. The Allen test usually excludes 5-10% of CABG candidates from eligibility for RA harvest, but RA could be safely harvested from most of these patients 40-43. Abu Omar et al. 40 reported that 88% of patients with a positive Allen test were free of any forearm arterial occlusive disease according to Doppler ultrasonographic studies and that RA could be harvested without any hand ischemic complications. Severe hand ischemia in patients with a negative Allen test has also been reported 6-9. A false-negative result can be caused by well-developed collateral circulation 44, a superficial dorsal branch of the RA, or a median artery 45. Many studies have attempted to establish more sensitive methods based on ultrasonography or plethysmography, compared to Allen test. We proposed that UA blood flow should be measured by ultrasonography during Allen s maneuver (manual compression of the RA at wrist) 9. Because preoperative UA blood flow during Allen s maneuver correlates well with postoperative UA blood flow after RA harvest, the postoperative perfusion to the forearm territory can be

106 S. MANABE et al. J Med Dent Sci estimated with this test. The aforementioned patient with severe hand ischemia would have been excluded as a candidate by this test because he had relatively low UA flow during Allen s maneuver (30.8 ml/min/m 2 ). We found that patients with modest symptoms of hand ischemia suggestive of exercise intolerance had lower preoperative UA flow during RA compression (symptomatic patients, 40.5 12.3 ml/min/m 2 ; asymptomatic patients, 81.0 22.9 ml/min/m 2, P= 0.0004) and that UA flow during Allen s maneuver of less than 60 ml/min/m 2 was predictive of postoperative exercise intolerance 29. However, most of these tests appear to have an even higher false-positive rate than Allen test. Abu Omar et al. 40 suggested ultrasonographic scanning of the full length of UA. A two-fold increase in Doppler velocity in the UA precludes RA harvest. This test appears to have the lowest false-positive rate and may increase the number of patients eligible for RA harvest. Conclusion Two types of postoperative hand ischemia have been reported after RA harvest for CABG (Table 6). Severe hand ischemia is a rare complication and results from occlusive disease in the forearm artery. Full-length scanning of the UA by Doppler ultrasonography is considered useful to avoid this type of hand ischemia, and it has the lowest false-positive rate. Mild hand ischemia suggestive of exercise intolerance may result from poor UA flow reserve. Its incidence rate remains unknown but is estimated to be less than 10%. The clinical significance of this type of hand ischemia has yet to be determined, but evaluation of preoperative UA flow during Allen s maneuver may be useful to predict postoperative mild hand ischemia. References 1. Carpentier A, Guermonprez JL, Deloche A, et al. The aorta-tocoronary radial artery bypass graft: a technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111-121 2. Carpentier A. Discussion of Geha AS, Krone RJ, McCormick JR, et al. Selection of coronary bypass: anatomic, physiologic, and angiographic considerations of vein and mammary artery grafts. J Thorac Cardiovasc Surg 1975;70:414-431 3. Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660 4. Desai ND, Cohen EA, Naylor CD, et al. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafs. N Engl J Med 2004;351:2302-2309 5. Manabe S, Tanaka H, Yoshizaki T, et al. Effects of postoperative administration of diltiazem on renal function following coronary artery bypass grafting. Ann Thorac Surg 2005;79:831-836 6. Tatoulis J, Royse AG, Buxton BF, et al. The radial artery in coronary surgery: 5-year experience-clinical and angiographic results. Ann Thorac Surg 2002;73:143-148 7. Fox AD, Whiteley MS, Phillips-Hughes J, et al. Acute upper limb ischemia: a complication of coronary artery bypass grafting. Ann Thorac Surg 1999;67:535-537 8. Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1998;66:929-931 9. Manabe S, Tabuchi N, Toyama M, et al. Measurement of ulnar flow is helpful in predicting ischemia after radial artery harvest. Thorac Cardiovasc Surg 2002;50:325-328 10. Fukada Y, Matsui Y, Yamauchi H, et al. An evaluation of the potential ischemia of the forearm after harvesting of radial artery by near infrared spectroscopy. (in Japanese, English abstract) Kyobu geka 2002;55:549-553 11. Coltharp W. Discussion of Acar C, Jebara VA, Portoghese M. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660 12. Pola P, Serricchio M, Flore R, et al. Safe removal of the radial artery for myocardial revascularization: Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996;112:737-744 13. Kochi K, Sueda T, Orihashi K, et al. New noninvasive test alternative to Allen s test: snuff-box technique. J Thorac Cardiovasc Surg 1999;118:756-758 Table 6. Summary of postoperative hand ischemia after radial artery harvest

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