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Outcome assessment of hand function after radial artery harvesting for coronary artery bypass1
Outcome Assessment of Hand Function After Radial Artery Harvesting for Coronary Artery Bypass Robert H. Allen, MD, Robert M. Szabo, MD, MPH, James L. Chen, MPH, Sacramento, CA
The radial artery has gained widespread acceptance as a conduit for coronary artery bypass. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported. We performed an outcome study utilizing the Short Form-36, the Upper Limb-Disabilities of Arm, Shoulder and Hand, and a modified self-administered hand diagram to compare 288 patients undergoing coronary artery bypass utilizing the radial artery with a control group of 174 patients undergoing coronary artery bypass without the radial artery. The data were analyzed by the t test for continuous variables and the chi-square test for categorical variables, and subsequently a multivariate regression model was constructed. No patients developed hand claudication or ischemia. Although there was an incidence of radial sensory neuropathy of 9.9% associated with radial artery harvest, it was not significantly higher than the incidence in the control group (5.2%, p ⫽ .16). Intrinsic patient factors such as obesity, age, diabetes, and peripheral vascular disease were the principal determinants of overall health and quality of life issues. (J Hand Surg 2004;29A: 628 – 637. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Radial artery, outcome measures, sensory neuropathy.
Since its reintroduction to coronary artery surgery in 19921 the radial artery has gained widespread accep-
From the Department of Orthopaedics, University of California, Davis, Sacramento, CA. Received for publication February 16, 2004; accepted in revised form April 8, 2004. Supported by a 2002 Outcome Studies Grant from the American Society for Surgery of the Hand. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert M. Szabo, MD, MPH, Professor and Chief, Hand, Upper Extremity and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, Davis, 4860 Y St, Suite 3800, Sacramento, CA 95817. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A04-0013$30.00/0 doi:10.1016/j.jhsa.2004.04.013
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tance as a state-of-the-art bypass conduit. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility that this conduit, similar to the internal thoracic artery, will have relative freedom from late atherosclerosis.2–5 Although most series have described minimal adverse consequences to hand function, an incidence of peripheral neuropathy as high as 18% has been reported and there have been a few cases of isolated severe complications such as ischemia requiring revascularization, and complex regional pain syndrome.6 –9 Additionally there has been documentation of exercise-induced hand ischemia with sustained grip.10 We performed an outcome study on a large group of patients undergoing radial artery grafting, comparing them with a concurrent group of patients undergoing bypass surgery with-
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Figure 1. Adapted from the Katz14 hand diagram. Patients were instructed to mark this diagram in the areas where they felt pain, tingling, numbness, and decreased sensation.
out the radial artery, to see whether an outcome measure would detect any differences between the 2 groups. Outcome measures chosen for this study were the Short Form (SF)-36, the Upper Limb Disabilities of the Arm, Shoulder and Hand (DASH), and a modified self-administered hand diagram. The SF-36 is a general health status measure but is not designed to measure the outcome of specific conditions.11 The Upper Limb–DASH is a questionnaire designed to measure the symptoms and functional status of patients with upper-extremity disorders and it has been shown to have validity, reliability, and responsiveness.12,13 The self-administered hand diagram has been shown to be valid, reliable, and responsive in the diagnosis of carpal tunnel syndrome (Fig. 1).14 We modified the scoring of the hand diagram so that ulnar and radial sensory neuropathy could be evaluated in addition to median neuropathy (Fig. 2). An example of a positive hand diagram in the median and radial sensory distributions is shown (Fig. 3). These outcome measures were chosen to evaluate the effect of
radial artery harvest on overall health and upper-extremity symptoms and function while at the same time focusing on the most common known complication of radial artery harvest (ie, radial nerve dysesthesia).7 Because this was a retrospective study no patients had sensory testing before surgery.
Materials and Methods Patient Selection Patient selection during the study period largely was dictated by surgeon preference and the availability of personnel trained in radial artery harvest. Contraindications to the use of the radial artery included a positive modified Allen’s test, renal insufficiency requiring hemodialysis, a history of previous upper-extremity vascular injury, and emergency procedures.
Surgical Technique Either a cardiovascular surgeon performed radial artery harvesting during the study period or a physician assis-
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Figure 2. Scoring criteria for median, radial, and ulnar nerve deficits in study participants. Each hand diagram was evaluated and classified as either a classic, probable, possible, or unlikely neuropathy.
tant who was trained in the technique as described by Reyes et al.15 All patients had a preoperative modified Allen’s test supplemented using thumb plethysmography to assess in a qualitative manner the adequacy of the ulnar circulation. Quantitative reporting, such as a digital/brachial index, was not performed. Radial artery harvest was performed through an incision from 3 cm below the elbow flexion crease to 3 cm above the wrist crease. Care was taken to dissect at the medial border of the brachioradialis, avoiding the radial sensory and the lateral antebrachial cutaneous nerves. Branches of the radial artery were controlled with clips and electrocautery. After harvest the radial artery was distended gently with He’s solution.16 Closure was performed with 3-0 polyglactin (Vicryl; Ethicon, Johnson & Johnson, Somerville, NJ) in the subcutaneous tissue and 4-0 poly-
glecaprone (Monocryl; Ethicon) in the skin. The arm was wrapped and tucked at the side during the cardiac revascularization.
Subjects The potential study group for this analysis included all 1,694 patients undergoing coronary artery grafting in the year 2000 at Mercy General Hospital in Sacramento by a single surgical group. This year was chosen because it represented a transition year in which 609 patients (36%) of the overall group received 1 or 2 radial artery grafts. Before that time the internal thoracic artery and the saphenous vein had been the conduits of choice, and at the present time virtually all patients have a radial artery graft for coronary artery revascularization.
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Figure 3. Example of classic median, probable radial, and unlikely ulnar neuropathy.
Therefore the year 2000 offered a natural experiment with the opportunity to have 2 concurrent, though not randomly selected, groups of patients. After obtaining institutional review board approval from both Mercy Hospital and the University of California Davis School of Medicine attempts were made to contact all patients. Contact attempts included 2 mailings followed by 2 phone calls. With the individual patient’s approval to be enrolled they were sent the Upper-Limb DASH, the SF-36, and a self-administered hand diagram. Of the 609 patients who had received one or more radial artery grafts 3 patients were known to be deceased, 43 patients were lost to follow-up evaluation through change of address, 124 patients declined to participate, and 439 patients agreed to participate. Despite follow-up phone calls, however, only 288 completed surveys were returned from this group. Of the 1,085 patients who had not received a radial artery graft 29 patients were known to be deceased, 96 patients were lost to follow-up evaluation through change of address, 615 patients declined
to participate, and 345 patients agreed to participate. Despite follow-up phone calls only 174 patients returned the completed surveys. All demographic data were obtained from a national standardized cardiac surgery database compiled on all patients undergoing cardiac surgery in the practices of the surgeons involved in this study.
Data Analysis Data were entered into a database (Microsoft Access 2000 9.0; Microsoft Corporation, Redmond, WA) and imported into a statistical software program (SAS version 8.0; SAS Institute, Cary, NC) for analysis (J.L.C.). To compare the differences in baseline characteristics and outcomes between the treatment and control group the t test was applied to continuous variables and the chi-square statistic was applied to categoric variables. Baseline characteristics included age, gender, body mass index, ethnicity, smoking history, family history of coronary artery disease, diabetes, hypercholesteremia, hypertension, cerebrovascular accident, periph-
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eral vascular disease, cerebrovascular disease, and complications from surgery. Outcome variables included the DASH score, the SF-36 score, and the incidence of radial, ulnar, or median sensory neuropathy as determined from the hand diagram. The DASH outcome measure consists of 30 items scored from 1 to 5, with 1 indicative of no disability and 5 indicative of maximum disability. The raw score subsequently was converted to a 0 to 100 scale, in which 0 indicated no disability and 100 indicated maximum disability. The SF-36, which consists of 36 items, also was converted to a 0 to 100 scale in which a higher score was indicative of better health. The 8 subscales of the SF-36 are: physical functioning, limitations of physical health, pain, general health, emotional well-being, limitations owing to emotional health, energy/fatigue, and social functioning. The outcome of sensory neuropathy was analyzed at both the level of the patient as well as each upper extremity of the patient. For upper-extremity–level analyses the extremities were categorized as harvested or unharvested according to whether the radial artery was harvested for the coronary bypass surgery. A multivariate regression model was constructed using the separate outcomes of the DASH score, the SF-36 score for physical functioning, and pain subscales. Predictor variables were restricted to those that were significant at the p ⬍ .20 level in univariate analyses. The final model for the outcome of the DASH score included the following variables: diabetes, cerebrovascular accident, body mass index, peripheral vascular disease, age, family history of coronary artery disease, renal failure, and hypercholesteremia. The final model for the outcome of the SF-36 physical functioning subscale included body mass index, diabetes, age, peripheral vascular disease, and family history of coronary artery disease. The final model for the SF-36 pain subscale included body mass index, peripheral vascular disease, family history of coronary artery disease, and diabetes. A logistic regression model was constructed for the outcome of radial nerve sensory neuropathy. The final model included the variables of radial artery group, age, body mass index, smoking, hypercholesterolemia, hypertension, peripheral vascular disease, family history of coronary artery disease, cerebrovascular disease, diabetes, history of cerebrovascular accident, and renal failure.
Results Cohort Characteristics A total of 466 patients, 292 patients who had received a radial artery graft and 174 patients who had
not received a radial artery graft, completed the SF36, the Upper-Limb DASH, and the hand diagram. Patients in the radial artery group were significantly (p ⬍ .05) younger (average age, 65 y) than patients in the nonradial artery group (average age, 68 y). This selection bias during the early phase of our radial artery experience was related to our belief that younger patients with a greater life expectancy might obtain greater benefit from a graft that was potentially free from the complication of late vein graft atherosclerosis. The radial artery group had significantly fewer (p ⬍ .05) patients with a history of cerebrovascular accident (1%) than the nonradial artery group (5%). All other characteristics were not significantly different between the radial artery and nonradial artery group (Table 1).
Outcomes No patient had either ischemia or hand claudication after surgery, although one patient in the radial artery group complained of new-onset cold intolerance in the harvested extremity after surgery. Radial artery group patients had a significantly (p ⫽ .002) lower mean DASH score (13.45) than control group patients (18.77) (Table 2). Radial artery group patients had significantly higher mean SF-36 scores for the subscales describing physical functioning (73; p ⫽ .0001), pain (74; p ⫽ .0005), and social functioning (83; p ⫽ .05) than the control group scores (61, 66, and 79, respectively). The remaining 5 SF-36 subscales showed no significant differences between the 2 groups. At the analytic level of the extremity the incidence of sensory neuropathy in any nerve (median, radial, or ulnar) did not differ significantly among harvested extremities (19%) and nonharvested extremities (16%) (Table 3). Similarly the median sensory neuropathy did not differ significantly among harvested extremities (10%) and nonharvested extremities (8%). The incidence of ulnar sensory neuropathy was approximately the same (11%) in both harvested and nonharvested extremities. The incidence of radial sensory neuropathy was higher in harvested (8%) than nonharvested extremities (6%) although this difference did not reach statistical significance (p ⫽ .16). At the analytic level of the patient assessment, the incidence of sensory neuropathy in any nerve (median, radial sensory, or ulnar nerve) was significantly (p ⬍ .05) higher in the radial artery group (23%) than in the nonradial artery group (16%) (Table 4). The incidence of radial sensory neuropathy was higher in
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Table 1. Baseline Characteristics of Cohort Variable
% Radial Artery Group (n ⴝ 292)
% Nonradial Artery Group (n ⴝ 174)
64.6 79 29.3
68.3 79 28.4
2 2 91 3 2 52 22 32 63 2 65 1 7 8 38
3 2 92 2 1 58 17 25 53 4 68 5 9 11 41
Age % Male Body mass index Ethnicity Asian African American Caucasian Hispanic Not applicable/other Smoking Coronary artery disease family history Diabetes Hypercholesterolemia Renal failure Hypertension Cerebrovascular accident Peripheral vascular disease Cerebrovascular disease Any complications
the radial artery group (10%) than in the nonradial artery group (5%), although this difference did not reach statistical significance (p ⫽ .07). The incidence of median sensory neuropathy did not significantly differ between the radial artery (11%) and nonradial artery (10%) group. The incidence of ulnar sensory neuropathy did not differ significantly between the radial artery (14%) and nonradial artery group (12%). Of the 29 patients with radial sensory neuropathy in the radial artery group 24 patients had sensory neuropathy in the harvested extremity and 5 patients had sensory neuropathy in the unharvested extremity.
Table 2. Outcomes of Hand Dysfunction
Variable DASH SF-36 Physical functioning Limitations of physical health Pain General health Emotional well-being Limitation owing to emotional problems Energy/fatigue Social functioning
Radial Artery (n ⴝ 292)
Control Group (n ⴝ 174)
p Value
13.45
18.77
.002
73
61
.0001
79 74 63 71
75 66 60 71
.14 .0005 .2 .72
87 58 83
87 56 79
.74 .16 .05
p Value .0001 .95 .11 .79
.24 .2 .13 .026 .13 .46 .03 .44 .21 .52
SF-36 scores for all subscales were significantly lower (p ⬍ .05) and DASH scores were all significantly higher (p ⬍ .05) for patients with any median, radial, or ulnar sensory neuropathy compared with patients without any neuropathy.
Multivariate Analyses In linear regression analyses patients with diabetes (p ⬍ .0001), history of a cerebrovascular accident (p ⫽ .0003), peripheral vascular disease (p ⫽ .015), higher body mass index (p ⫽ .014), older age (p ⫽ .019), family history of coronary artery disease (p ⫽ .04), and renal failure (p ⫽ .038) were significantly more likely to have higher DASH scores. Patients with higher body mass index (p ⬍ .0001), older age (p ⬍ .0001), diabetes (p ⫽ .0001), and peripheral vascular disease (p ⫽ .0011) were significantly more likely to have lower SF-36 physical functioning scores. Patients with higher body mass index (p ⬍
Table 3. Incidence of Peripheral Sensory Neuropathy Among Extremities
Variable
Harvested Extremities (n ⴝ 29)
Nonharvested Extremities (n ⴝ 63)
p Value
Any nerve Median nerve Radial nerve Ulnar nerve
18.6 9.5 8.1 10.8
15.7 7.9 5.7 10.7
.28 .41 .16 .96
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Table 4. Incidence of Peripheral Sensory Neuropathy Among Patients
Variable
Radial Artery Group (n ⴝ 292)
Nonradial Artery Group (n ⴝ 174)
p Value
Any nerve Median nerve Radial nerve Ulnar nerve
23.3 11.3 9.9 13.7
15.5 10.3 5.2 12.1
.04 .75 .07 .61
.0001) and peripheral vascular disease (p ⫽ .0015) were significantly more likely to have lower SF-36 pain scores. In stepwise logistic regression analyses patients with any radial sensory neuropathy were more likely to have peripheral vascular disease (odds ratio ⫽ 3.0; 95% confidence interval, 1.22–7.37). Patients with any sensory neuropathy (radial, median, or ulnar nerve) were more likely to have diabetes (odds ratio ⫽ 1.94; 95% confidence interval, 1.21–3.10). The variables of peripheral vascular disease and diabetes were found to be the only significant independent predictors associated with radial sensory neuropathy and any neuropathy, respectively.
Discussion Increased use of the radial artery as a bypass conduit is a result of 3 decades of experience with the surgical treatment of arteriosclerotic coronary artery disease. Although saphenous vein grafting continues to enjoy widespread use, longitudinal studies have shown a high propensity of vein grafts to develop arteriosclerosis. In contrast the left internal thoracic artery rarely develops arteriosclerosis and patients who have received a left internal thoracic artery graft have a lower incidence of late ischemic events, reoperation, and death than those who receive vein grafts.4 The use of the right internal mammary as a second arterial graft has been associated with a further reduction in risks for late death, reoperation, and angioplasty.17–20 As experience in handling arterial grafts has grown the concept of the all-arterial graft procedure has become a more attainable goal, although convincing data that this will provide a still further reduction in late cardiac morbidity and mortality have not been published. It is this clinical environment that has prompted the widespread use of the radial artery graft, which over the past decade has evolved to become the standard of practice status. Originally introduced by Carpentier et al21 in 1973
and then abandoned for reasons of vasospasm and early graft closure, the procedure was resurrected in 1993 by Acar et al1,2 when it was discovered on restudy that some of the early patients had patent and nonatherosclerotic radial artery grafts 17 years after surgery. Although long-term patency rates are not yet available the short-term patency rates of 83% to 98% of the radial artery are superior to that of the saphenous vein.2,5,22–24 Moreover the problems of vasospasm can now be overcome by better surgical technique and newer pharmacologic agents.16,25,26 Additionally the radial artery may be used as a composite T graft with the left internal mammary artery.27–33 By using the technique of multiple sequential anastomoses the radial artery usually will reach to all target vessels, allowing the goal of total arterial revascularization to be achieved. The use of the radial artery in this fashion also avoids an aortic anastomosis, thereby minimizing the risk for aortic atheroembolism, and has been associated with low donor site morbidity, surgical mortality less than 1%, and radial artery graft patency between 83% and 98%.2,3,5,24,27,28,34 –38 Donor site morbidity is lower with the radial artery than with the saphenous vein, with fewer infections (4% vs 18%), less discomfort (5% vs 12%), and comparable concern about the cosmetic effects (5% vs 7%).39 In patients without significant peripheral vascular disease or a history of prior injury, hand collateral circulation is almost always adequate to supply the entire hand through an intact ulnar artery. Although classic anatomy is only present in 10% of hands and the superficial palmar arch is incomplete and fails to supply the thumb and index finger directly in 34% of hands, in virtually every hand there is at least one artery connecting the radial and ulnar arterial circulations.40 Careful Doppler evaluation of hand circulation in preoperative patients has shown that 4% to 8% will have inadequate collateral circulation to tolerate radial artery harvest safely.41– 43 The use of the modified Allen’s test, however, has proven to discriminate between patients who can and cannot tolerate radial artery harvest. Isotope measurement of arm and hand blood flow at rest in postoperative patients has shown a 15% decrement in the operative versus nonoperative arm, although functional tests such as grip and pinch strength show no difference.44 Chong et al45 performed measurements of forearm blood flow and grip strength both before and after surgery in patients undergoing radial artery harvest. Blood flow was unchanged and similar decreases in grip strength were seen in both the radial artery
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harvest extremity and the contralateral unoperated extremity. The most frequent upper-extremity complication after coronary bypass using the radial artery is peripheral neuropathy. Between 8% and 18% of patients report dorsal hand numbness at the 12-month follow-up evaluation,7,39,46 suggesting that there has been direct thermal or mechanical damage to the radial sensory nerve. Radial sensory neuropathy also may be seen with radial artery cannulation for hemodynamic monitoring or arterial blood gas analysis. The most frequent complication in a series47 of 1,080 radial artery harvests was transient dysesthesia in the distribution of the lateral antebrachial cutaneous nerve, although in this series there were no wound infections, no incidence of hand ischemia, and no incidence of motor disturbance in the hand. Ulnar neuropathy is a well-recognized complication of median sternotomy, with an incidence between 6% and 38%. The mechanism has been attributed to either traction or a pinching effect between the first rib and the clavicle, although a study in which preoperative patients were evaluated with electrophysiology studies suggests that the patients most commonly affected have underlying, asymptomatic ulnar neuropathy and that a double-crush phenomenon may be causative.48 Our results were quite consistent with the results reported by earlier investigators including the low incidence of hand ischemia (no patients), hand claudication (no patients), and new-onset cold intolerance (one patient). This again confirms that the modified Allen’s test is an effective screening method for determining patients who are appropriate candidates for radial artery harvest. Our incidence of radial sensory neuropathy in the radial artery harvest group (10%) is also consistent with the results in other reported series of patients undergoing radial artery harvest (8% to 18%).7,23,46 There was also an incidence of radial sensory neuropathy in the nonradial artery harvest group (5.2%) but it was not low enough to represent a significant difference (p ⫽ .16). Furthermore when the incidence of radial sensory neuropathy in harvested and unharvested extremities was examined there was again no significant difference (8% and 6%, respectively). Multivariate analysis suggests that it is the presence of peripheral vascular disease and not the radial artery harvest that is the important risk factor for developing radial sensory neuropathy after coronary artery bypass. Additional support for this concept is found in our
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incidence of ulnar neuropathy (14% and 12% in the radial and nonradial artery groups) and median neuropathy (11% and 10% in the radial artery and nonradial artery groups). These neuropathies, which almost certainly are unrelated to radial artery harvest, nonetheless occur at a higher frequency than do radial sensory neuropathy. Multivariate analysis again suggests that diabetes is the important risk factor. In summary peripheral neuropathy occurs in post– coronary bypass patients and the preponderance of our evidence would suggest that the important risk factors are intrinsic to the patient. It was a surprising finding that the DASH scores in the nonradial artery harvest group were higher, that is, there was more disability than in the radial artery group. The 2 groups of patients differed, however, in that the radial artery group was younger and had a lower incidence of prior stroke. Multivariate analysis again suggested that the patient variables (diabetes, prior stroke, peripheral vascular disease, obesity, and age) were more predictive for upper-extremity dysfunction after coronary artery bypass. These results confirmed the widely held view that radial artery harvest is safe and not likely to result in an increase in either specific upper-extremity complications or overall upper-extremity dysfunction. Our patients who received radial artery grafts had notably better overall health after surgery as measured by the SF-36 than those patients who did not receive a radial artery graft. Although it may be true that the avoidance of saphenous vein harvest and the use of more arterial grafts eventually will be shown to improve both short- and longterm results with coronary bypass surgery, presently we conclude that intrinsic patient risk factors, namely obesity, age, diabetes, and peripheral vascular disease, are the principal determinants of overall health and quality-of-life outcomes.
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circulation before radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg 1999;117:261– 266. Rafael Sadaba J, Conroy JL, Burniston M, Maughan J, Munsch C. Effect of radial artery harvesting on tissue perfusion and function of the hand. Cardiovasc Surg 2001;9: 378 –382. Chong WC, Ong PJ, Hayward CS, Collins P, Moat NE. Effects of radial artery harvesting on forearm function and blood flow. Ann Thorac Surg 2003;75:1171–1174. Hata M, Raman J, Seevanayagam S, Hare D, Buxton BF. Post radial artery harvest hand perception: postoperative 12-month follow-up results. Circ J 2002;66:816 – 818. Chen AM, Brodman RF, Frame R, Graver LM, Tranbaugh RF, Banks T, et al. Routine myocardial revascularization with the radial artery: a multicenter experience. J Card Surg 1998;13:318 –327. Casscells CD, Lindsey RW, Ebersole J, Li B. Ulnar neuropathy after median sternotomy. Clin Orthop 1993;291:259 – 265.
The radial artery has gained widespread acceptance as a conduit for coronary artery bypass. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported. We performed an outcome study utilizing the Short Form-36, the Upper Limb-Disabilities of Arm, Shoulder and Hand, and a modified self-administered hand diagram to compare 288 patients undergoing coronary artery bypass utilizing the radial artery with a control group of 174 patients undergoing coronary artery bypass without the radial artery. The data were analyzed by the t test for continuous variables and the chi-square test for categorical variables, and subsequently a multivariate regression model was constructed. No patients developed hand claudication or ischemia. Although there was an incidence of radial sensory neuropathy of 9.9% associated with radial artery harvest, it was not significantly higher than the incidence in the control group (5.2%, p ⫽ .16). Intrinsic patient factors such as obesity, age, diabetes, and peripheral vascular disease were the principal determinants of overall health and quality of life issues. (J Hand Surg 2004;29A: 628 – 637. Copyright © 2004 by the American Society for Surgery of the Hand.) Key words: Radial artery, outcome measures, sensory neuropathy.
Since its reintroduction to coronary artery surgery in 19921 the radial artery has gained widespread accep-
From the Department of Orthopaedics, University of California, Davis, Sacramento, CA. Received for publication February 16, 2004; accepted in revised form April 8, 2004. Supported by a 2002 Outcome Studies Grant from the American Society for Surgery of the Hand. No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert M. Szabo, MD, MPH, Professor and Chief, Hand, Upper Extremity and Microvascular Surgery, Department of Orthopaedic Surgery, University of California, Davis, 4860 Y St, Suite 3800, Sacramento, CA 95817. Copyright © 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A04-0013$30.00/0 doi:10.1016/j.jhsa.2004.04.013
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tance as a state-of-the-art bypass conduit. Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility that this conduit, similar to the internal thoracic artery, will have relative freedom from late atherosclerosis.2–5 Although most series have described minimal adverse consequences to hand function, an incidence of peripheral neuropathy as high as 18% has been reported and there have been a few cases of isolated severe complications such as ischemia requiring revascularization, and complex regional pain syndrome.6 –9 Additionally there has been documentation of exercise-induced hand ischemia with sustained grip.10 We performed an outcome study on a large group of patients undergoing radial artery grafting, comparing them with a concurrent group of patients undergoing bypass surgery with-
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Figure 1. Adapted from the Katz14 hand diagram. Patients were instructed to mark this diagram in the areas where they felt pain, tingling, numbness, and decreased sensation.
out the radial artery, to see whether an outcome measure would detect any differences between the 2 groups. Outcome measures chosen for this study were the Short Form (SF)-36, the Upper Limb Disabilities of the Arm, Shoulder and Hand (DASH), and a modified self-administered hand diagram. The SF-36 is a general health status measure but is not designed to measure the outcome of specific conditions.11 The Upper Limb–DASH is a questionnaire designed to measure the symptoms and functional status of patients with upper-extremity disorders and it has been shown to have validity, reliability, and responsiveness.12,13 The self-administered hand diagram has been shown to be valid, reliable, and responsive in the diagnosis of carpal tunnel syndrome (Fig. 1).14 We modified the scoring of the hand diagram so that ulnar and radial sensory neuropathy could be evaluated in addition to median neuropathy (Fig. 2). An example of a positive hand diagram in the median and radial sensory distributions is shown (Fig. 3). These outcome measures were chosen to evaluate the effect of
radial artery harvest on overall health and upper-extremity symptoms and function while at the same time focusing on the most common known complication of radial artery harvest (ie, radial nerve dysesthesia).7 Because this was a retrospective study no patients had sensory testing before surgery.
Materials and Methods Patient Selection Patient selection during the study period largely was dictated by surgeon preference and the availability of personnel trained in radial artery harvest. Contraindications to the use of the radial artery included a positive modified Allen’s test, renal insufficiency requiring hemodialysis, a history of previous upper-extremity vascular injury, and emergency procedures.
Surgical Technique Either a cardiovascular surgeon performed radial artery harvesting during the study period or a physician assis-
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Figure 2. Scoring criteria for median, radial, and ulnar nerve deficits in study participants. Each hand diagram was evaluated and classified as either a classic, probable, possible, or unlikely neuropathy.
tant who was trained in the technique as described by Reyes et al.15 All patients had a preoperative modified Allen’s test supplemented using thumb plethysmography to assess in a qualitative manner the adequacy of the ulnar circulation. Quantitative reporting, such as a digital/brachial index, was not performed. Radial artery harvest was performed through an incision from 3 cm below the elbow flexion crease to 3 cm above the wrist crease. Care was taken to dissect at the medial border of the brachioradialis, avoiding the radial sensory and the lateral antebrachial cutaneous nerves. Branches of the radial artery were controlled with clips and electrocautery. After harvest the radial artery was distended gently with He’s solution.16 Closure was performed with 3-0 polyglactin (Vicryl; Ethicon, Johnson & Johnson, Somerville, NJ) in the subcutaneous tissue and 4-0 poly-
glecaprone (Monocryl; Ethicon) in the skin. The arm was wrapped and tucked at the side during the cardiac revascularization.
Subjects The potential study group for this analysis included all 1,694 patients undergoing coronary artery grafting in the year 2000 at Mercy General Hospital in Sacramento by a single surgical group. This year was chosen because it represented a transition year in which 609 patients (36%) of the overall group received 1 or 2 radial artery grafts. Before that time the internal thoracic artery and the saphenous vein had been the conduits of choice, and at the present time virtually all patients have a radial artery graft for coronary artery revascularization.
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Figure 3. Example of classic median, probable radial, and unlikely ulnar neuropathy.
Therefore the year 2000 offered a natural experiment with the opportunity to have 2 concurrent, though not randomly selected, groups of patients. After obtaining institutional review board approval from both Mercy Hospital and the University of California Davis School of Medicine attempts were made to contact all patients. Contact attempts included 2 mailings followed by 2 phone calls. With the individual patient’s approval to be enrolled they were sent the Upper-Limb DASH, the SF-36, and a self-administered hand diagram. Of the 609 patients who had received one or more radial artery grafts 3 patients were known to be deceased, 43 patients were lost to follow-up evaluation through change of address, 124 patients declined to participate, and 439 patients agreed to participate. Despite follow-up phone calls, however, only 288 completed surveys were returned from this group. Of the 1,085 patients who had not received a radial artery graft 29 patients were known to be deceased, 96 patients were lost to follow-up evaluation through change of address, 615 patients declined
to participate, and 345 patients agreed to participate. Despite follow-up phone calls only 174 patients returned the completed surveys. All demographic data were obtained from a national standardized cardiac surgery database compiled on all patients undergoing cardiac surgery in the practices of the surgeons involved in this study.
Data Analysis Data were entered into a database (Microsoft Access 2000 9.0; Microsoft Corporation, Redmond, WA) and imported into a statistical software program (SAS version 8.0; SAS Institute, Cary, NC) for analysis (J.L.C.). To compare the differences in baseline characteristics and outcomes between the treatment and control group the t test was applied to continuous variables and the chi-square statistic was applied to categoric variables. Baseline characteristics included age, gender, body mass index, ethnicity, smoking history, family history of coronary artery disease, diabetes, hypercholesteremia, hypertension, cerebrovascular accident, periph-
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eral vascular disease, cerebrovascular disease, and complications from surgery. Outcome variables included the DASH score, the SF-36 score, and the incidence of radial, ulnar, or median sensory neuropathy as determined from the hand diagram. The DASH outcome measure consists of 30 items scored from 1 to 5, with 1 indicative of no disability and 5 indicative of maximum disability. The raw score subsequently was converted to a 0 to 100 scale, in which 0 indicated no disability and 100 indicated maximum disability. The SF-36, which consists of 36 items, also was converted to a 0 to 100 scale in which a higher score was indicative of better health. The 8 subscales of the SF-36 are: physical functioning, limitations of physical health, pain, general health, emotional well-being, limitations owing to emotional health, energy/fatigue, and social functioning. The outcome of sensory neuropathy was analyzed at both the level of the patient as well as each upper extremity of the patient. For upper-extremity–level analyses the extremities were categorized as harvested or unharvested according to whether the radial artery was harvested for the coronary bypass surgery. A multivariate regression model was constructed using the separate outcomes of the DASH score, the SF-36 score for physical functioning, and pain subscales. Predictor variables were restricted to those that were significant at the p ⬍ .20 level in univariate analyses. The final model for the outcome of the DASH score included the following variables: diabetes, cerebrovascular accident, body mass index, peripheral vascular disease, age, family history of coronary artery disease, renal failure, and hypercholesteremia. The final model for the outcome of the SF-36 physical functioning subscale included body mass index, diabetes, age, peripheral vascular disease, and family history of coronary artery disease. The final model for the SF-36 pain subscale included body mass index, peripheral vascular disease, family history of coronary artery disease, and diabetes. A logistic regression model was constructed for the outcome of radial nerve sensory neuropathy. The final model included the variables of radial artery group, age, body mass index, smoking, hypercholesterolemia, hypertension, peripheral vascular disease, family history of coronary artery disease, cerebrovascular disease, diabetes, history of cerebrovascular accident, and renal failure.
Results Cohort Characteristics A total of 466 patients, 292 patients who had received a radial artery graft and 174 patients who had
not received a radial artery graft, completed the SF36, the Upper-Limb DASH, and the hand diagram. Patients in the radial artery group were significantly (p ⬍ .05) younger (average age, 65 y) than patients in the nonradial artery group (average age, 68 y). This selection bias during the early phase of our radial artery experience was related to our belief that younger patients with a greater life expectancy might obtain greater benefit from a graft that was potentially free from the complication of late vein graft atherosclerosis. The radial artery group had significantly fewer (p ⬍ .05) patients with a history of cerebrovascular accident (1%) than the nonradial artery group (5%). All other characteristics were not significantly different between the radial artery and nonradial artery group (Table 1).
Outcomes No patient had either ischemia or hand claudication after surgery, although one patient in the radial artery group complained of new-onset cold intolerance in the harvested extremity after surgery. Radial artery group patients had a significantly (p ⫽ .002) lower mean DASH score (13.45) than control group patients (18.77) (Table 2). Radial artery group patients had significantly higher mean SF-36 scores for the subscales describing physical functioning (73; p ⫽ .0001), pain (74; p ⫽ .0005), and social functioning (83; p ⫽ .05) than the control group scores (61, 66, and 79, respectively). The remaining 5 SF-36 subscales showed no significant differences between the 2 groups. At the analytic level of the extremity the incidence of sensory neuropathy in any nerve (median, radial, or ulnar) did not differ significantly among harvested extremities (19%) and nonharvested extremities (16%) (Table 3). Similarly the median sensory neuropathy did not differ significantly among harvested extremities (10%) and nonharvested extremities (8%). The incidence of ulnar sensory neuropathy was approximately the same (11%) in both harvested and nonharvested extremities. The incidence of radial sensory neuropathy was higher in harvested (8%) than nonharvested extremities (6%) although this difference did not reach statistical significance (p ⫽ .16). At the analytic level of the patient assessment, the incidence of sensory neuropathy in any nerve (median, radial sensory, or ulnar nerve) was significantly (p ⬍ .05) higher in the radial artery group (23%) than in the nonradial artery group (16%) (Table 4). The incidence of radial sensory neuropathy was higher in
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Table 1. Baseline Characteristics of Cohort Variable
% Radial Artery Group (n ⴝ 292)
% Nonradial Artery Group (n ⴝ 174)
64.6 79 29.3
68.3 79 28.4
2 2 91 3 2 52 22 32 63 2 65 1 7 8 38
3 2 92 2 1 58 17 25 53 4 68 5 9 11 41
Age % Male Body mass index Ethnicity Asian African American Caucasian Hispanic Not applicable/other Smoking Coronary artery disease family history Diabetes Hypercholesterolemia Renal failure Hypertension Cerebrovascular accident Peripheral vascular disease Cerebrovascular disease Any complications
the radial artery group (10%) than in the nonradial artery group (5%), although this difference did not reach statistical significance (p ⫽ .07). The incidence of median sensory neuropathy did not significantly differ between the radial artery (11%) and nonradial artery (10%) group. The incidence of ulnar sensory neuropathy did not differ significantly between the radial artery (14%) and nonradial artery group (12%). Of the 29 patients with radial sensory neuropathy in the radial artery group 24 patients had sensory neuropathy in the harvested extremity and 5 patients had sensory neuropathy in the unharvested extremity.
Table 2. Outcomes of Hand Dysfunction
Variable DASH SF-36 Physical functioning Limitations of physical health Pain General health Emotional well-being Limitation owing to emotional problems Energy/fatigue Social functioning
Radial Artery (n ⴝ 292)
Control Group (n ⴝ 174)
p Value
13.45
18.77
.002
73
61
.0001
79 74 63 71
75 66 60 71
.14 .0005 .2 .72
87 58 83
87 56 79
.74 .16 .05
p Value .0001 .95 .11 .79
.24 .2 .13 .026 .13 .46 .03 .44 .21 .52
SF-36 scores for all subscales were significantly lower (p ⬍ .05) and DASH scores were all significantly higher (p ⬍ .05) for patients with any median, radial, or ulnar sensory neuropathy compared with patients without any neuropathy.
Multivariate Analyses In linear regression analyses patients with diabetes (p ⬍ .0001), history of a cerebrovascular accident (p ⫽ .0003), peripheral vascular disease (p ⫽ .015), higher body mass index (p ⫽ .014), older age (p ⫽ .019), family history of coronary artery disease (p ⫽ .04), and renal failure (p ⫽ .038) were significantly more likely to have higher DASH scores. Patients with higher body mass index (p ⬍ .0001), older age (p ⬍ .0001), diabetes (p ⫽ .0001), and peripheral vascular disease (p ⫽ .0011) were significantly more likely to have lower SF-36 physical functioning scores. Patients with higher body mass index (p ⬍
Table 3. Incidence of Peripheral Sensory Neuropathy Among Extremities
Variable
Harvested Extremities (n ⴝ 29)
Nonharvested Extremities (n ⴝ 63)
p Value
Any nerve Median nerve Radial nerve Ulnar nerve
18.6 9.5 8.1 10.8
15.7 7.9 5.7 10.7
.28 .41 .16 .96
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Table 4. Incidence of Peripheral Sensory Neuropathy Among Patients
Variable
Radial Artery Group (n ⴝ 292)
Nonradial Artery Group (n ⴝ 174)
p Value
Any nerve Median nerve Radial nerve Ulnar nerve
23.3 11.3 9.9 13.7
15.5 10.3 5.2 12.1
.04 .75 .07 .61
.0001) and peripheral vascular disease (p ⫽ .0015) were significantly more likely to have lower SF-36 pain scores. In stepwise logistic regression analyses patients with any radial sensory neuropathy were more likely to have peripheral vascular disease (odds ratio ⫽ 3.0; 95% confidence interval, 1.22–7.37). Patients with any sensory neuropathy (radial, median, or ulnar nerve) were more likely to have diabetes (odds ratio ⫽ 1.94; 95% confidence interval, 1.21–3.10). The variables of peripheral vascular disease and diabetes were found to be the only significant independent predictors associated with radial sensory neuropathy and any neuropathy, respectively.
Discussion Increased use of the radial artery as a bypass conduit is a result of 3 decades of experience with the surgical treatment of arteriosclerotic coronary artery disease. Although saphenous vein grafting continues to enjoy widespread use, longitudinal studies have shown a high propensity of vein grafts to develop arteriosclerosis. In contrast the left internal thoracic artery rarely develops arteriosclerosis and patients who have received a left internal thoracic artery graft have a lower incidence of late ischemic events, reoperation, and death than those who receive vein grafts.4 The use of the right internal mammary as a second arterial graft has been associated with a further reduction in risks for late death, reoperation, and angioplasty.17–20 As experience in handling arterial grafts has grown the concept of the all-arterial graft procedure has become a more attainable goal, although convincing data that this will provide a still further reduction in late cardiac morbidity and mortality have not been published. It is this clinical environment that has prompted the widespread use of the radial artery graft, which over the past decade has evolved to become the standard of practice status. Originally introduced by Carpentier et al21 in 1973
and then abandoned for reasons of vasospasm and early graft closure, the procedure was resurrected in 1993 by Acar et al1,2 when it was discovered on restudy that some of the early patients had patent and nonatherosclerotic radial artery grafts 17 years after surgery. Although long-term patency rates are not yet available the short-term patency rates of 83% to 98% of the radial artery are superior to that of the saphenous vein.2,5,22–24 Moreover the problems of vasospasm can now be overcome by better surgical technique and newer pharmacologic agents.16,25,26 Additionally the radial artery may be used as a composite T graft with the left internal mammary artery.27–33 By using the technique of multiple sequential anastomoses the radial artery usually will reach to all target vessels, allowing the goal of total arterial revascularization to be achieved. The use of the radial artery in this fashion also avoids an aortic anastomosis, thereby minimizing the risk for aortic atheroembolism, and has been associated with low donor site morbidity, surgical mortality less than 1%, and radial artery graft patency between 83% and 98%.2,3,5,24,27,28,34 –38 Donor site morbidity is lower with the radial artery than with the saphenous vein, with fewer infections (4% vs 18%), less discomfort (5% vs 12%), and comparable concern about the cosmetic effects (5% vs 7%).39 In patients without significant peripheral vascular disease or a history of prior injury, hand collateral circulation is almost always adequate to supply the entire hand through an intact ulnar artery. Although classic anatomy is only present in 10% of hands and the superficial palmar arch is incomplete and fails to supply the thumb and index finger directly in 34% of hands, in virtually every hand there is at least one artery connecting the radial and ulnar arterial circulations.40 Careful Doppler evaluation of hand circulation in preoperative patients has shown that 4% to 8% will have inadequate collateral circulation to tolerate radial artery harvest safely.41– 43 The use of the modified Allen’s test, however, has proven to discriminate between patients who can and cannot tolerate radial artery harvest. Isotope measurement of arm and hand blood flow at rest in postoperative patients has shown a 15% decrement in the operative versus nonoperative arm, although functional tests such as grip and pinch strength show no difference.44 Chong et al45 performed measurements of forearm blood flow and grip strength both before and after surgery in patients undergoing radial artery harvest. Blood flow was unchanged and similar decreases in grip strength were seen in both the radial artery
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harvest extremity and the contralateral unoperated extremity. The most frequent upper-extremity complication after coronary bypass using the radial artery is peripheral neuropathy. Between 8% and 18% of patients report dorsal hand numbness at the 12-month follow-up evaluation,7,39,46 suggesting that there has been direct thermal or mechanical damage to the radial sensory nerve. Radial sensory neuropathy also may be seen with radial artery cannulation for hemodynamic monitoring or arterial blood gas analysis. The most frequent complication in a series47 of 1,080 radial artery harvests was transient dysesthesia in the distribution of the lateral antebrachial cutaneous nerve, although in this series there were no wound infections, no incidence of hand ischemia, and no incidence of motor disturbance in the hand. Ulnar neuropathy is a well-recognized complication of median sternotomy, with an incidence between 6% and 38%. The mechanism has been attributed to either traction or a pinching effect between the first rib and the clavicle, although a study in which preoperative patients were evaluated with electrophysiology studies suggests that the patients most commonly affected have underlying, asymptomatic ulnar neuropathy and that a double-crush phenomenon may be causative.48 Our results were quite consistent with the results reported by earlier investigators including the low incidence of hand ischemia (no patients), hand claudication (no patients), and new-onset cold intolerance (one patient). This again confirms that the modified Allen’s test is an effective screening method for determining patients who are appropriate candidates for radial artery harvest. Our incidence of radial sensory neuropathy in the radial artery harvest group (10%) is also consistent with the results in other reported series of patients undergoing radial artery harvest (8% to 18%).7,23,46 There was also an incidence of radial sensory neuropathy in the nonradial artery harvest group (5.2%) but it was not low enough to represent a significant difference (p ⫽ .16). Furthermore when the incidence of radial sensory neuropathy in harvested and unharvested extremities was examined there was again no significant difference (8% and 6%, respectively). Multivariate analysis suggests that it is the presence of peripheral vascular disease and not the radial artery harvest that is the important risk factor for developing radial sensory neuropathy after coronary artery bypass. Additional support for this concept is found in our
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incidence of ulnar neuropathy (14% and 12% in the radial and nonradial artery groups) and median neuropathy (11% and 10% in the radial artery and nonradial artery groups). These neuropathies, which almost certainly are unrelated to radial artery harvest, nonetheless occur at a higher frequency than do radial sensory neuropathy. Multivariate analysis again suggests that diabetes is the important risk factor. In summary peripheral neuropathy occurs in post– coronary bypass patients and the preponderance of our evidence would suggest that the important risk factors are intrinsic to the patient. It was a surprising finding that the DASH scores in the nonradial artery harvest group were higher, that is, there was more disability than in the radial artery group. The 2 groups of patients differed, however, in that the radial artery group was younger and had a lower incidence of prior stroke. Multivariate analysis again suggested that the patient variables (diabetes, prior stroke, peripheral vascular disease, obesity, and age) were more predictive for upper-extremity dysfunction after coronary artery bypass. These results confirmed the widely held view that radial artery harvest is safe and not likely to result in an increase in either specific upper-extremity complications or overall upper-extremity dysfunction. Our patients who received radial artery grafts had notably better overall health after surgery as measured by the SF-36 than those patients who did not receive a radial artery graft. Although it may be true that the avoidance of saphenous vein harvest and the use of more arterial grafts eventually will be shown to improve both short- and longterm results with coronary bypass surgery, presently we conclude that intrinsic patient risk factors, namely obesity, age, diabetes, and peripheral vascular disease, are the principal determinants of overall health and quality-of-life outcomes.
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