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Retrospective Analysis of Local Sensorimotor Deficits After Radial Artery Harvesting for Coronary Artery Bypass Grafting
Journal of Surgical Research 139, 203–208 (2007) doi:10.1016/j.jss.2006.10.006
Retrospective Analysis of Local Sensorimotor Deficits After Radial Artery Harvesting for Coronary Artery Bypass Grafting Salman A. Shah, M.D.,*,1 Davin Chark, M.Sc.,* Judson Williams, B.A.,* Amelia Hessheimer, B.S.,* Jeannie Huh, M.Sc.,* Yi-Chen Wu, M.S.,† Paul A. Chang, B.S.,* Frank G. Scholl, M.D.,* and Davis C. Drinkwater, M.D.* *Department of Cardiac Surgery, and †Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee Submitted for publication June 29, 2006
Objectives. The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass. We analyze patient-based data to determine risk factors for long-term upper limb morbidities associated with RA harvest for coronary artery bypass grafting. Study design/methods. Between April 1997 and March 2004, a total of 1030 patients underwent RA harvesting for coronary artery bypass grafting for a total of 1704 harvest sites. Patients were contacted by telephone and asked to report any ongoing severe sensory and functional motor deficits for each harvest site since surgery. Retrospective chart review was performed and preoperative risk factors were evaluated. Patient-based risk factors were evaluated for development of significant long-term local sensorimotor deficits including gender, elderly age (>70 y), diabetes, smoking, and whether the RA was harvested from the dominant hand. Results. Successful evaluation of 629 patients for a total of 1048 RA harvest sites was completed. The mean follow-up time was 48.3 mo (range, 2 to 86 mo). The mean age of the patients analyzed was 62.2 y. On statistical analysis, diabetics and elderly did not report significantly greater functional or sensory deficits than nondiabetics and nonelderly, respectively. There was a significantly higher incidence of sensory deficits in smokers compared with nonsmoker patients (4.2% versus 1.4%; P ⴝ 0.005) but no difference in their functional impairment was noted. Harvesting from the dominant hand did not influence the occurrence of sensory or motor functional deficits. 1
To whom correspondence and reprint requests should be addressed at Department of Cardiac Surgery, Vanderbilt University Medical Center, 5247 Doctors Office Tower, Nashville, TN 372329292. E-mail: [email protected].
Conclusions. RA harvesting for coronary artery bypass grafting can be done with minimal serious longterm upper limb morbidity in higher risk patients. Based on our findings, harvesting of the RA from the dominant hand is not contraindicated in these patients. © 2007 Elsevier Inc. All rights reserved. Key Words: radial artery harvest; coronary artery bypass; sensorimotor changes. INTRODUCTION
The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass (CABG). Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis [1, 2]. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported [3– 6]. The RA has been described as having excellent patency rates and flow characteristics compared with saphenous veins [1, 2]. This, along with the emergence of the concept of total arterial revascularization, has led to an increase in the use of RA as a conduit for CABG [7]. The increased use of RA grafts has also been accompanied by various reports of morbidity associated with the harvesting of the RA [8]. The purpose of this study was to describe the technique for RA harvest and evaluate the upper limb sensory and motor morbidities occurring in the long-term period after RA harvesting. While studies have examined objective neurological signs of impairment [9], our study examines the patient’s perception. In addition, we evaluated preoperative patient characteristics to determine risk factors for developing complications with RA harvest.
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METHODS Between April 1997 and March 2004, a total of 1030 patients underwent unilateral or bilateral RA harvesting for elective CABG for a total of 1704 RA harvest sites. Included in this study were patients who also underwent concomitant saphenous vein procurements and other cardiac procedures. Patients undergoing redo CABG procedures were also included. Institutional review board approval and informed consent from the participating patients was obtained. Patients were contacted by telephone and administered a questionnaire to evaluate any severe sensory and motor deficits for each harvest site since surgery. Retrospective chart review was undertaken and preoperative risk factors including gender, elderly age (⬎70 y), diabetes (insulin dependent or noninsulin dependent), smoking, and hand dominance were evaluated and formatted into a structured database. Patients disqualified from analysis included those who reported upper limb impairments attributable to an interval cerebral vascular accident or an unrelated traumatic injury of the limb in question. Patients unable to complete the survey secondary to dementia were also excluded.
Preoperative Evaluation and Radial Artery Harvest Technique Patients underwent a modified Allen’s test in the preoperative evaluation using clinical evaluation and pulse oximetry of the middle finger to obtain digital oxygen saturations. Patients deemed to have radial dominant flow (Allen’s test ⬎6 s after ulnar pressure is released) or with inadequate saturations (⬍96% or change of ⬍4% from baseline) with RA compression were deemed unsuitable candidates for RA harvesting due to the increased risk of hand ischemia. Details of harvesting the RA have been extensively reported [10, 11]. Physician assistants or cardiac surgical residents performed RA harvesting. We used sharp dissection with limited use of the electrocautery, especially in the region of the radial nerve. Gentle handling of the conduit and the surrounding tissues was emphasized. We took care to avoid skeletonizing the artery and generally harvested the vessel with approximately 1 cm or more of associated fascia and muscle tissue. Branches were identified and ligated with silk ligature. The wound was closed in layers, and the skin reapproximated with subcuticular absorbable suture. The harvest site was typically closed without a drain and wrapped in a compressive dressing removed on the second postoperative day. The patient was given specific instructions regarding wound care and extremity elevation.
Follow-Up Questionnaire The follow-up questionnaire displayed in Fig. 1 was developed at our institution and is therefore a nonvalidated questionnaire. Patients were contacted by telephone and asked to report any ongoing subjectively severe sensory and/or functional motor deficits for each harvest site since surgery. Specifically, activities such as writing, using scissors, handling coins, lifting, and perceived arm strength were used as examples of gross and fine motor functions. Numbness, paresthesias, tingling sensations, and pain were used as examples to elicit sensory deficits. Preoperative hand dominance was also assessed. No formal neurovascular testing was conducted as a part of this follow-up. All patients had routine postoperative follow-up in the cardiothoracic surgical clinic and were examined in the clinic by the senior author in the study. Patients were contacted during the intermediate and late postoperative periods by the authors and trained personnel in the cardiac surgery department. Patients were called during the dates on the study period, and the time of follow-up varied from patient to patient.
Statistical Analysis The Fisher’s exact tests were performed to identify significant differences between proportions. A P value of less than 0.05 was deemed to be statistically significant. Statistical analyses were per-
formed via the Statistical Package R version 2.2.1 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Between April 1997 and March 2004, a total of 1030 patients underwent elective CABG with procurement of RA for use as a conduit. Of these, 755 (73.3%) were successfully contacted. Of the patients who were excluded from the study, 275 patients (26.7%) were lost to follow-up (disconnected phone number, moved away), while 98 patients (9.5%) were deceased. Sixteen patients (1.5%) had some form of a neurological event leading to a neurological impairment while three patients (0.3%) had suffered some form of trauma to the arm, which made sensorimotor assessment unreliable or impossible. Seven patients (0.67%) had progressive dementia such as Alzheimer’s disease and were unable to participate. One patient spoke no English and one patient did not want to answer the survey. These patients were not included, as they had a confounding variable or could not respond to the survey. Successful evaluation of 629 patients for a total of 1048 radial artery harvest sites was therefore completed. There were 453 (72%) males and 176 (28%) females in the interview group. The mean age at surgery was 62.2 y. Phone interviews were conducted between May and July 2004 with a mean follow-up time of 48.3 mo (range, 2 to 86 mo). A total of 1048 RA harvest sites (419 patients undergoing bilateral, 210 patients undergoing unilateral RA harvest) were successfully evaluated. When assessed in this site-specific manner, 283 (27%) sites were in patients greater than 70 y old at the time of surgery (elderly group). A total of 314 (30%) were from either insulin-dependent or noninsulin-dependent diabetics (diabetes group). A total of 382 (36.5%) sites were from patients who were active smokers at the time of harvest. Of the 1048 harvest sites, 464 (44.3%) were taken from the patient’s dominant hand and 584 (55.7%) from the nondominant hand. The results of functional gross and fine motor deficits are summarized in Table 1. A total of 22 harvest sites (2.1%) were reported to have developed ongoing severe motor deficits as perceived by the patient. Proposed preoperative risk factors for the development of significant long-term local sensorimotor deficits were individually evaluated. On statistical analysis, none of these (gender, elderly age, diabetes, smoking) were found to be a significant risk factor for developing major postoperative motor deficits. Also, harvesting the RA from the dominant hand did not carry any significant postoperative motor impairment. Major upper limb sensory deficits such as numbness, tingling, and pain were reported in 25 (2.39%) harvest sites. Of note, smokers, when compared to nonsmokers, were found to be at a greater risk for developing sig-
SHAH ET AL.: RETROSPECTIVE ANALYSIS OF LOCAL SENSORIMOTOR DEFICITS AFTER RADIAL ARTERY HARVESTING 205
FIG. 1.
Radial artery harvest site sensorimotor deficit assessment follow up questionnaire.
nificant postoperative sensory deficits (4.2% versus 1.4%; P ⫽ 0.005). The remaining risk factors (gender, elderly age, diabetes, and hand dominance) were not significant for developing major postoperative sensory deficits. These results are summarized in Table 2. DISCUSSION
Since the introduction of CABG into clinical practice, long-term benefits have been known to be strongly
influenced by the fate of the bypass conduit used. In 1973, Carpentier et al. reported using the radial artery as a conduit for CABG but discovered a strong tendency toward spasm and hence early postoperative occlusion [12]. After an initial decline, the use of the RA gained increased acceptance when Acar et al. published their results showing successful long-term patency [13]. Patency rates at 1 y were quoted as 90 to 95%, compared with long saphenous vein of 80 to 90% [13]. They attributed their success to the use of calcium
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TABLE 1 Functional Motor Deficits Reported by Various Risk Groups
Group
Number of RA harvest sites
Number with motor deficit
% With motor deficit
Male Female Elderly Nonelderly Diabetic Nondiabetic Smoker Nonsmoker Dominant hand Nondominant hand Total
754 294 283 765 314 734 382 666 464 584 1048
13 9 6 16 7 15 10 12 11 11 22
1.72 3.06 2.12 2.09 2.23 2.04 2.62 1.80 2.37 1.88 2.10
Fisher P-value 0.228 1 0.817 0.379 0.666
antagonists to prevent RA spasm and a modified harvesting and reanastomosis technique, which avoided endothelial damage [13]. With patency rates of internal mammary arterial graft conduits reaching 95% at 10 y postoperatively [14 –16], the conceptual benefit of total arterial revascularization has also contributed to the increased use of the RA as a conduit. Since then, other groups have encouraged the use of RA grafts based on excellent results [2, 17–20]. A point of concern when evaluating the use of RA conduits is the potential deleterious effect on the neurovascular supply of the forearm and hand. The complications resulting from RA harvesting for use as a bypass conduit have been extensively reported [8, 21, 22]. Altered temperature sensation, change in hand strength, paresthesias, and wound infections have been described as complications after RA harvesting [3, 23]. The morbidity associated with saphenous vein harvesting can also be significant, especially in those patients who are obese or have diabetes [24, 25]. This has resulted in attempts to decrease these complications by developing techniques such as skip incision and endoscopic vein harvesting. Our study was designed as a follow-up to a previous study by the senior author and coworkers [6]. We attempted to better define the late upper limb morbidities associated with RA harvesting as reported by patients themselves. The response rate of 629 patients (61.1%) formed a large, diverse database, did not alter the power of the study, and with the available responses the sensorimotor effects of radial harvesting could be assessed with statistical accuracy. We used a questionnaire designed to identify the patient’s subjective assessment of severe sensory and motor deficits after RA harvesting. This assessment did not rely on the use of formal neurovascular testing. We also analyzed patient-based data to determine preoperative risk factors for long-term upper limb morbidities, with
an attempt to identify any subgroups where RA harvest may be relatively contraindicated. This is of particular interest, considering that slower nerve regeneration rates, impaired wound healing, and underlying neuropathies are more readily seen in diabetics, smokers, and the elderly. In this study of 1048 RA harvest sites, none of the proposed preoperative risk factors (gender, elderly age (⬎70 y), diabetes, smoking) were associated with statistically significant ongoing gross or fine motor function deficits. The overall reported incidence of motor complications in our study group (2.1%) was slightly higher than in other references, which report weakness and limitation of hand activity in less than 1% of subjects 3 mo postoperatively [26, 27]. This can be attributed to the nature of the questionnaire, which failed to adhere to more rigid definitions of morbidities and, instead, considered patient perceptions of the degree of functional limitation. Even in cases of decreased motor function, patients may be inaccurately attributing difficulties to processes associated with normal aging as opposed to the RA harvest itself. Also, the exclusion criteria used in our study was very relaxed as we only eliminated patients who had neurological defects attributable to a cerebral vascular accident, trauma, or dementia preventing them from completing the questionnaire. Sensory deficits in the form of paresthesias and pain of the forearm and hand have been described as the most common complications following RA harvest (1.6 to 30.1%) [4, 28 –30]. These sensory symptoms largely disappear completely within days or weeks. The overall reported incidence of sensory complications in our study group (2.4%) was comparable to other references that report residual numbness (6.5%) and paresthesias (3%) 3 mo postoperatively [26]. In our analysis, only the preoperative risk factor of smoking contributed to a TABLE 2 Sensory Deficits Reported by Various Risk Groups
Group
Number of RA harvest sites
Number with sensory deficit
% With sensory deficit
Male Female Elderly Nonelderly Diabetic Nondiabetic Smoker Nonsmoker Dominant hand Nondominant hand Total
754 294 283 765 314 734 382 666 464 584 1048
17 8 5 20 9 16 16 9 11 14 25
2.25 2.72 1.77 2.61 2.87 2.18 4.19 1.35 2.37 2.40 2.39
Fisher P-value 0.655 0.502 0.512 0.005* 1
* Denotes group with statistically significant sensory deficits compared with the nongroup (⬍0.05).
SHAH ET AL.: RETROSPECTIVE ANALYSIS OF LOCAL SENSORIMOTOR DEFICITS AFTER RADIAL ARTERY HARVESTING 207
greater risk for developing significant postoperative sensory deficits. Numbness and residual pain had been previously reported as being a significant complication in elderly diabetics [6], a subgroup that was not analyzed in our study. Although using the nondominant arm as the initial procurement site is recommended, with a total arterial revascularization strategy the removal of bilateral RA has been shown to be safe and well tolerated [19, 31]. In our study, bilateral harvesting was performed in 419 patients and RA procurement from the forearm of the dominant hand did not result in any increased motor or sensory complaints when compared with harvesting from the nondominant forearm. The use of a modified preoperative and intraoperative Allen’s test was sufficient for preoperative assessment. There was no severe ischemic complication in any patient group. Postoperative hand ischemia after RA harvest is very rare regardless of the method used to assess ulnar artery adequacy, and only one occurrence of acute hand ischemia caused by congenital absence of the ulnar artery has been reported [32]. The use of RA as a conduit for CABG is increasing. Local harvest site complications occur with some frequency. The use of sharp dissection, harmonic scalpel, and endoscopic harvesting are refinements in the procurement technique that may lead to a further decrease in morbidities [5, 33–35]. Previously thought high-risk patients such as diabetics, smokers, and the elderly did not display an overwhelmingly higher occurrence of sensory or motor complications although significant upper limb morbidities may present if multiple risk factors are taken together. This study reflects upon the fact that although the morbidity of RA harvesting is not insignificant, it is still safely performed with good overall results. The vast majority of patients tolerate the RA harvesting without serious functional motor or sensory deficits. The study also allows improved counseling of patients regarding the validity of using the RA from the forearm of the patient’s dominant hand. In summary, RA harvesting for CABG can be done with minimal serious long-term upper limb morbidity in higher risk patients such as diabetics and elderly patients. Although smokers reported an increased incidence of sensory deficits after RA harvest, we believe that the radial artery should continue to be offered as a conduit for coronary artery bypass grafting to this group of patients. Lastly, based on our findings, we do not believe that harvesting the RA from the dominant hand is contraindicated. REFERENCES Acar C, Ramsheyi A, Pagny JY, et al. The radial artery for coronary artery bypass grafting: Clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981. 2. Possati G, Gaudino M, Alessandrini F, et al. Midterm clinical
and angiographic results of radial artery grafts used for myocardial revascularization. J Thorac Cardiovasc Surg 1998;116:1015. 3. Trick WE, Scheckler WE, Tokars JI, et al. Risk factors for radial artery harvest site infection following coronary artery bypass graft surgery. Clin Infect Dis 2000;30:270. 4. Saeed I, Anyanwu AC, Yacoub MH, et al. Subjective patient outcomes following coronary artery bypass using the radial artery: Results of a cross-sectional survey of harvest site complications and quality of life. Eur J Cardiothorac Surg 2001;20: 1142. 5. Greene MA, Malias MA. Arm complications after radial artery procurement for coronary bypass operation. Ann Thorac Surg 2001;72:126. 6.
Reddy VS, Parikh SM, Drinkwater DC, Jr., et al. Morbidity after procurement of radial arteries in diabetic patients and the elderly undergoing coronary revascularization. Ann Thorac Surg 2002;73:803.
7.
Uchikawa S, Nishida H, Endo M, et al. Early and mid-term results of all arterial graft coronary artery bypass grafting using bilateral internal thoracic and radial arterial conduits. Kyobu Geka 2002;55:1006.
8.
Arons JA, Collins N, Arons MS. Permanent nerve injury in the forearm following radial artery harvest: A report of two cases. Ann Plast Surg 1999;43:299.
9.
Grossebner M, Arifi A, Bourov Y, et al. No change in O2 saturation but measurable difference in thenar flexor power after radial artery harvest. Eur J Cardiothorac Surg 1999;16:160.
10.
Tatoulis J, Buxton BF, Fuller JA, et al. The radial artery as a graft for coronary revascularization: Techniques and follow-up. Adv Card Surg 1999;11:99.
11.
Levine AJ, Graham TR. Techniques in conduit harvesting. Hosp Med 1999;60:178.
12.
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.
13.
Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652.
14.
Fiore AC, Naunheim KS, Dean P, et al. Results of internal thoracic artery grafting over 15 years: Single versus double grafts. Ann Thorac Surg 1990;49:202.
15.
Kouchoukos NT, Karp RB, Oberman A, et al. Long-term patency of saphenous veins for coronary bypass grafting. Circulation 1978;58:I96.
16.
Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1.
17.
Hata M, Shiono M, Sezai A, et al. Comparative study of harvestsite complications following coronary artery bypass grafting between the radial artery and the saphenous vein in identical patients. Surg Today 2005;35:711.
18.
Ikizler M, Ozkan S, Dernek S, et al. Does radial artery harvesting for coronary revascularization cause neurological injury in the forearm and hand? Eur J Cardiothorac Sur 2005;28:420.
19.
Brodman RF, Frame R, Camacho M, et al. Routine use of unilateral and bilateral radial arteries for coronary artery bypass graft surgery. J Am Coll Cardiol 1996;28:959.
20.
Calafiore AM, Teodori G, Di Giammarco G, et al. Coronary revascularization with the radial artery: New interest for an old conduit. J Card Surg 1995;10:140.
21.
Manasse E, Sperti G, Suma H, et al. Use of the radial artery for myocardial revascularization. Ann Thorac Surg 1996;62:1076.
1.
208 22.
23. 24.
25.
26.
27.
28.
JOURNAL OF SURGICAL RESEARCH: VOL. 139, NO. 2, MAY 15, 2007 Pola P, Serricchio M, Flore R, et al. 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. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg 1986;39:176. Wong SW, Fernando D, Grant P. Leg wound infections associated with coronary revascularization. Aust N Z J Surg 1997;67: 689. Slaughter MS, Olson MM, Lee JT, Jr., et al. A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg 1993;56:1063. Meharwal ZS, Trehan N. Functional status of the hand after radial artery harvesting: Results in 3,977 cases. Ann Thorac Surg 2001;72:1557. Sankey RA, Rumian AP, Jackson W, et al. Harvesting the radial artery: Does it affect early postoperative hand function? Heart Surg Forum 2003;6:E12. Dietl CA, Benoit CH. Radial artery graft for coronary revascularization: Technical considerations. Ann Thorac Surg 1995;60:102.
29.
30.
31.
32.
33. 34. 35.
Denton TA, Trento L, Cohen M, et al. Radial artery harvesting for coronary bypass operations: Neurologic complications and their potential mechanisms. J Thorac Cardiovasc Surg 2001; 121:951. Sajja LR, Mannam G, Sompalli S. Neurologic hand complications after radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg 2002;123:585. Tatoulis J, Buxton BF, Fuller JA. Bilateral radial artery grafts in coronary reconstruction: Technique and early results in 261 patients. Ann Thorac Surg 1998;66:714. Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1998;66:929. Genovesi MH, Torrillo L, Fonger J, et al. Endoscopic radial artery harvest: A new approach. Heart Surg Forum 2001;4:223. Newman RV, Lammle WG. Radial artery harvest using endoscopic techniques. Heart Surg Forum 2003;6:E194. Wright CB, Barner HB, Gao A, et al. The advantages of the Harmonic Scalpel for the harvesting of radial arteries for coronary artery bypass. Heart Surg Forum 2001;4:226.
Retrospective Analysis of Local Sensorimotor Deficits After Radial Artery Harvesting for Coronary Artery Bypass Grafting Salman A. Shah, M.D.,*,1 Davin Chark, M.Sc.,* Judson Williams, B.A.,* Amelia Hessheimer, B.S.,* Jeannie Huh, M.Sc.,* Yi-Chen Wu, M.S.,† Paul A. Chang, B.S.,* Frank G. Scholl, M.D.,* and Davis C. Drinkwater, M.D.* *Department of Cardiac Surgery, and †Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee Submitted for publication June 29, 2006
Objectives. The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass. We analyze patient-based data to determine risk factors for long-term upper limb morbidities associated with RA harvest for coronary artery bypass grafting. Study design/methods. Between April 1997 and March 2004, a total of 1030 patients underwent RA harvesting for coronary artery bypass grafting for a total of 1704 harvest sites. Patients were contacted by telephone and asked to report any ongoing severe sensory and functional motor deficits for each harvest site since surgery. Retrospective chart review was performed and preoperative risk factors were evaluated. Patient-based risk factors were evaluated for development of significant long-term local sensorimotor deficits including gender, elderly age (>70 y), diabetes, smoking, and whether the RA was harvested from the dominant hand. Results. Successful evaluation of 629 patients for a total of 1048 RA harvest sites was completed. The mean follow-up time was 48.3 mo (range, 2 to 86 mo). The mean age of the patients analyzed was 62.2 y. On statistical analysis, diabetics and elderly did not report significantly greater functional or sensory deficits than nondiabetics and nonelderly, respectively. There was a significantly higher incidence of sensory deficits in smokers compared with nonsmoker patients (4.2% versus 1.4%; P ⴝ 0.005) but no difference in their functional impairment was noted. Harvesting from the dominant hand did not influence the occurrence of sensory or motor functional deficits. 1
To whom correspondence and reprint requests should be addressed at Department of Cardiac Surgery, Vanderbilt University Medical Center, 5247 Doctors Office Tower, Nashville, TN 372329292. E-mail: [email protected].
Conclusions. RA harvesting for coronary artery bypass grafting can be done with minimal serious longterm upper limb morbidity in higher risk patients. Based on our findings, harvesting of the RA from the dominant hand is not contraindicated in these patients. © 2007 Elsevier Inc. All rights reserved. Key Words: radial artery harvest; coronary artery bypass; sensorimotor changes. INTRODUCTION
The radial artery (RA) has gained widespread acceptance as a conduit for coronary artery bypass (CABG). Advantages include minimal donor site discomfort, ease of handling, excellent early patency rates, and the possibility of freedom from late conduit atherosclerosis [1, 2]. Although most series describe minimal morbidity, a significant incidence of radial sensory neuropathy and isolated instances of hand claudication and ischemia have been reported [3– 6]. The RA has been described as having excellent patency rates and flow characteristics compared with saphenous veins [1, 2]. This, along with the emergence of the concept of total arterial revascularization, has led to an increase in the use of RA as a conduit for CABG [7]. The increased use of RA grafts has also been accompanied by various reports of morbidity associated with the harvesting of the RA [8]. The purpose of this study was to describe the technique for RA harvest and evaluate the upper limb sensory and motor morbidities occurring in the long-term period after RA harvesting. While studies have examined objective neurological signs of impairment [9], our study examines the patient’s perception. In addition, we evaluated preoperative patient characteristics to determine risk factors for developing complications with RA harvest.
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0022-4804/07 $32.00 © 2007 Elsevier Inc. All rights reserved.
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JOURNAL OF SURGICAL RESEARCH: VOL. 139, NO. 2, MAY 15, 2007
METHODS Between April 1997 and March 2004, a total of 1030 patients underwent unilateral or bilateral RA harvesting for elective CABG for a total of 1704 RA harvest sites. Included in this study were patients who also underwent concomitant saphenous vein procurements and other cardiac procedures. Patients undergoing redo CABG procedures were also included. Institutional review board approval and informed consent from the participating patients was obtained. Patients were contacted by telephone and administered a questionnaire to evaluate any severe sensory and motor deficits for each harvest site since surgery. Retrospective chart review was undertaken and preoperative risk factors including gender, elderly age (⬎70 y), diabetes (insulin dependent or noninsulin dependent), smoking, and hand dominance were evaluated and formatted into a structured database. Patients disqualified from analysis included those who reported upper limb impairments attributable to an interval cerebral vascular accident or an unrelated traumatic injury of the limb in question. Patients unable to complete the survey secondary to dementia were also excluded.
Preoperative Evaluation and Radial Artery Harvest Technique Patients underwent a modified Allen’s test in the preoperative evaluation using clinical evaluation and pulse oximetry of the middle finger to obtain digital oxygen saturations. Patients deemed to have radial dominant flow (Allen’s test ⬎6 s after ulnar pressure is released) or with inadequate saturations (⬍96% or change of ⬍4% from baseline) with RA compression were deemed unsuitable candidates for RA harvesting due to the increased risk of hand ischemia. Details of harvesting the RA have been extensively reported [10, 11]. Physician assistants or cardiac surgical residents performed RA harvesting. We used sharp dissection with limited use of the electrocautery, especially in the region of the radial nerve. Gentle handling of the conduit and the surrounding tissues was emphasized. We took care to avoid skeletonizing the artery and generally harvested the vessel with approximately 1 cm or more of associated fascia and muscle tissue. Branches were identified and ligated with silk ligature. The wound was closed in layers, and the skin reapproximated with subcuticular absorbable suture. The harvest site was typically closed without a drain and wrapped in a compressive dressing removed on the second postoperative day. The patient was given specific instructions regarding wound care and extremity elevation.
Follow-Up Questionnaire The follow-up questionnaire displayed in Fig. 1 was developed at our institution and is therefore a nonvalidated questionnaire. Patients were contacted by telephone and asked to report any ongoing subjectively severe sensory and/or functional motor deficits for each harvest site since surgery. Specifically, activities such as writing, using scissors, handling coins, lifting, and perceived arm strength were used as examples of gross and fine motor functions. Numbness, paresthesias, tingling sensations, and pain were used as examples to elicit sensory deficits. Preoperative hand dominance was also assessed. No formal neurovascular testing was conducted as a part of this follow-up. All patients had routine postoperative follow-up in the cardiothoracic surgical clinic and were examined in the clinic by the senior author in the study. Patients were contacted during the intermediate and late postoperative periods by the authors and trained personnel in the cardiac surgery department. Patients were called during the dates on the study period, and the time of follow-up varied from patient to patient.
Statistical Analysis The Fisher’s exact tests were performed to identify significant differences between proportions. A P value of less than 0.05 was deemed to be statistically significant. Statistical analyses were per-
formed via the Statistical Package R version 2.2.1 (R Foundation for Statistical Computing, Vienna, Austria).
RESULTS
Between April 1997 and March 2004, a total of 1030 patients underwent elective CABG with procurement of RA for use as a conduit. Of these, 755 (73.3%) were successfully contacted. Of the patients who were excluded from the study, 275 patients (26.7%) were lost to follow-up (disconnected phone number, moved away), while 98 patients (9.5%) were deceased. Sixteen patients (1.5%) had some form of a neurological event leading to a neurological impairment while three patients (0.3%) had suffered some form of trauma to the arm, which made sensorimotor assessment unreliable or impossible. Seven patients (0.67%) had progressive dementia such as Alzheimer’s disease and were unable to participate. One patient spoke no English and one patient did not want to answer the survey. These patients were not included, as they had a confounding variable or could not respond to the survey. Successful evaluation of 629 patients for a total of 1048 radial artery harvest sites was therefore completed. There were 453 (72%) males and 176 (28%) females in the interview group. The mean age at surgery was 62.2 y. Phone interviews were conducted between May and July 2004 with a mean follow-up time of 48.3 mo (range, 2 to 86 mo). A total of 1048 RA harvest sites (419 patients undergoing bilateral, 210 patients undergoing unilateral RA harvest) were successfully evaluated. When assessed in this site-specific manner, 283 (27%) sites were in patients greater than 70 y old at the time of surgery (elderly group). A total of 314 (30%) were from either insulin-dependent or noninsulin-dependent diabetics (diabetes group). A total of 382 (36.5%) sites were from patients who were active smokers at the time of harvest. Of the 1048 harvest sites, 464 (44.3%) were taken from the patient’s dominant hand and 584 (55.7%) from the nondominant hand. The results of functional gross and fine motor deficits are summarized in Table 1. A total of 22 harvest sites (2.1%) were reported to have developed ongoing severe motor deficits as perceived by the patient. Proposed preoperative risk factors for the development of significant long-term local sensorimotor deficits were individually evaluated. On statistical analysis, none of these (gender, elderly age, diabetes, smoking) were found to be a significant risk factor for developing major postoperative motor deficits. Also, harvesting the RA from the dominant hand did not carry any significant postoperative motor impairment. Major upper limb sensory deficits such as numbness, tingling, and pain were reported in 25 (2.39%) harvest sites. Of note, smokers, when compared to nonsmokers, were found to be at a greater risk for developing sig-
SHAH ET AL.: RETROSPECTIVE ANALYSIS OF LOCAL SENSORIMOTOR DEFICITS AFTER RADIAL ARTERY HARVESTING 205
FIG. 1.
Radial artery harvest site sensorimotor deficit assessment follow up questionnaire.
nificant postoperative sensory deficits (4.2% versus 1.4%; P ⫽ 0.005). The remaining risk factors (gender, elderly age, diabetes, and hand dominance) were not significant for developing major postoperative sensory deficits. These results are summarized in Table 2. DISCUSSION
Since the introduction of CABG into clinical practice, long-term benefits have been known to be strongly
influenced by the fate of the bypass conduit used. In 1973, Carpentier et al. reported using the radial artery as a conduit for CABG but discovered a strong tendency toward spasm and hence early postoperative occlusion [12]. After an initial decline, the use of the RA gained increased acceptance when Acar et al. published their results showing successful long-term patency [13]. Patency rates at 1 y were quoted as 90 to 95%, compared with long saphenous vein of 80 to 90% [13]. They attributed their success to the use of calcium
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TABLE 1 Functional Motor Deficits Reported by Various Risk Groups
Group
Number of RA harvest sites
Number with motor deficit
% With motor deficit
Male Female Elderly Nonelderly Diabetic Nondiabetic Smoker Nonsmoker Dominant hand Nondominant hand Total
754 294 283 765 314 734 382 666 464 584 1048
13 9 6 16 7 15 10 12 11 11 22
1.72 3.06 2.12 2.09 2.23 2.04 2.62 1.80 2.37 1.88 2.10
Fisher P-value 0.228 1 0.817 0.379 0.666
antagonists to prevent RA spasm and a modified harvesting and reanastomosis technique, which avoided endothelial damage [13]. With patency rates of internal mammary arterial graft conduits reaching 95% at 10 y postoperatively [14 –16], the conceptual benefit of total arterial revascularization has also contributed to the increased use of the RA as a conduit. Since then, other groups have encouraged the use of RA grafts based on excellent results [2, 17–20]. A point of concern when evaluating the use of RA conduits is the potential deleterious effect on the neurovascular supply of the forearm and hand. The complications resulting from RA harvesting for use as a bypass conduit have been extensively reported [8, 21, 22]. Altered temperature sensation, change in hand strength, paresthesias, and wound infections have been described as complications after RA harvesting [3, 23]. The morbidity associated with saphenous vein harvesting can also be significant, especially in those patients who are obese or have diabetes [24, 25]. This has resulted in attempts to decrease these complications by developing techniques such as skip incision and endoscopic vein harvesting. Our study was designed as a follow-up to a previous study by the senior author and coworkers [6]. We attempted to better define the late upper limb morbidities associated with RA harvesting as reported by patients themselves. The response rate of 629 patients (61.1%) formed a large, diverse database, did not alter the power of the study, and with the available responses the sensorimotor effects of radial harvesting could be assessed with statistical accuracy. We used a questionnaire designed to identify the patient’s subjective assessment of severe sensory and motor deficits after RA harvesting. This assessment did not rely on the use of formal neurovascular testing. We also analyzed patient-based data to determine preoperative risk factors for long-term upper limb morbidities, with
an attempt to identify any subgroups where RA harvest may be relatively contraindicated. This is of particular interest, considering that slower nerve regeneration rates, impaired wound healing, and underlying neuropathies are more readily seen in diabetics, smokers, and the elderly. In this study of 1048 RA harvest sites, none of the proposed preoperative risk factors (gender, elderly age (⬎70 y), diabetes, smoking) were associated with statistically significant ongoing gross or fine motor function deficits. The overall reported incidence of motor complications in our study group (2.1%) was slightly higher than in other references, which report weakness and limitation of hand activity in less than 1% of subjects 3 mo postoperatively [26, 27]. This can be attributed to the nature of the questionnaire, which failed to adhere to more rigid definitions of morbidities and, instead, considered patient perceptions of the degree of functional limitation. Even in cases of decreased motor function, patients may be inaccurately attributing difficulties to processes associated with normal aging as opposed to the RA harvest itself. Also, the exclusion criteria used in our study was very relaxed as we only eliminated patients who had neurological defects attributable to a cerebral vascular accident, trauma, or dementia preventing them from completing the questionnaire. Sensory deficits in the form of paresthesias and pain of the forearm and hand have been described as the most common complications following RA harvest (1.6 to 30.1%) [4, 28 –30]. These sensory symptoms largely disappear completely within days or weeks. The overall reported incidence of sensory complications in our study group (2.4%) was comparable to other references that report residual numbness (6.5%) and paresthesias (3%) 3 mo postoperatively [26]. In our analysis, only the preoperative risk factor of smoking contributed to a TABLE 2 Sensory Deficits Reported by Various Risk Groups
Group
Number of RA harvest sites
Number with sensory deficit
% With sensory deficit
Male Female Elderly Nonelderly Diabetic Nondiabetic Smoker Nonsmoker Dominant hand Nondominant hand Total
754 294 283 765 314 734 382 666 464 584 1048
17 8 5 20 9 16 16 9 11 14 25
2.25 2.72 1.77 2.61 2.87 2.18 4.19 1.35 2.37 2.40 2.39
Fisher P-value 0.655 0.502 0.512 0.005* 1
* Denotes group with statistically significant sensory deficits compared with the nongroup (⬍0.05).
SHAH ET AL.: RETROSPECTIVE ANALYSIS OF LOCAL SENSORIMOTOR DEFICITS AFTER RADIAL ARTERY HARVESTING 207
greater risk for developing significant postoperative sensory deficits. Numbness and residual pain had been previously reported as being a significant complication in elderly diabetics [6], a subgroup that was not analyzed in our study. Although using the nondominant arm as the initial procurement site is recommended, with a total arterial revascularization strategy the removal of bilateral RA has been shown to be safe and well tolerated [19, 31]. In our study, bilateral harvesting was performed in 419 patients and RA procurement from the forearm of the dominant hand did not result in any increased motor or sensory complaints when compared with harvesting from the nondominant forearm. The use of a modified preoperative and intraoperative Allen’s test was sufficient for preoperative assessment. There was no severe ischemic complication in any patient group. Postoperative hand ischemia after RA harvest is very rare regardless of the method used to assess ulnar artery adequacy, and only one occurrence of acute hand ischemia caused by congenital absence of the ulnar artery has been reported [32]. The use of RA as a conduit for CABG is increasing. Local harvest site complications occur with some frequency. The use of sharp dissection, harmonic scalpel, and endoscopic harvesting are refinements in the procurement technique that may lead to a further decrease in morbidities [5, 33–35]. Previously thought high-risk patients such as diabetics, smokers, and the elderly did not display an overwhelmingly higher occurrence of sensory or motor complications although significant upper limb morbidities may present if multiple risk factors are taken together. This study reflects upon the fact that although the morbidity of RA harvesting is not insignificant, it is still safely performed with good overall results. The vast majority of patients tolerate the RA harvesting without serious functional motor or sensory deficits. The study also allows improved counseling of patients regarding the validity of using the RA from the forearm of the patient’s dominant hand. In summary, RA harvesting for CABG can be done with minimal serious long-term upper limb morbidity in higher risk patients such as diabetics and elderly patients. Although smokers reported an increased incidence of sensory deficits after RA harvest, we believe that the radial artery should continue to be offered as a conduit for coronary artery bypass grafting to this group of patients. Lastly, based on our findings, we do not believe that harvesting the RA from the dominant hand is contraindicated. REFERENCES Acar C, Ramsheyi A, Pagny JY, et al. The radial artery for coronary artery bypass grafting: Clinical and angiographic results at five years. J Thorac Cardiovasc Surg 1998;116:981. 2. Possati G, Gaudino M, Alessandrini F, et al. Midterm clinical
and angiographic results of radial artery grafts used for myocardial revascularization. J Thorac Cardiovasc Surg 1998;116:1015. 3. Trick WE, Scheckler WE, Tokars JI, et al. Risk factors for radial artery harvest site infection following coronary artery bypass graft surgery. Clin Infect Dis 2000;30:270. 4. Saeed I, Anyanwu AC, Yacoub MH, et al. Subjective patient outcomes following coronary artery bypass using the radial artery: Results of a cross-sectional survey of harvest site complications and quality of life. Eur J Cardiothorac Surg 2001;20: 1142. 5. Greene MA, Malias MA. Arm complications after radial artery procurement for coronary bypass operation. Ann Thorac Surg 2001;72:126. 6.
Reddy VS, Parikh SM, Drinkwater DC, Jr., et al. Morbidity after procurement of radial arteries in diabetic patients and the elderly undergoing coronary revascularization. Ann Thorac Surg 2002;73:803.
7.
Uchikawa S, Nishida H, Endo M, et al. Early and mid-term results of all arterial graft coronary artery bypass grafting using bilateral internal thoracic and radial arterial conduits. Kyobu Geka 2002;55:1006.
8.
Arons JA, Collins N, Arons MS. Permanent nerve injury in the forearm following radial artery harvest: A report of two cases. Ann Plast Surg 1999;43:299.
9.
Grossebner M, Arifi A, Bourov Y, et al. No change in O2 saturation but measurable difference in thenar flexor power after radial artery harvest. Eur J Cardiothorac Surg 1999;16:160.
10.
Tatoulis J, Buxton BF, Fuller JA, et al. The radial artery as a graft for coronary revascularization: Techniques and follow-up. Adv Card Surg 1999;11:99.
11.
Levine AJ, Graham TR. Techniques in conduit harvesting. Hosp Med 1999;60:178.
12.
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.
13.
Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652.
14.
Fiore AC, Naunheim KS, Dean P, et al. Results of internal thoracic artery grafting over 15 years: Single versus double grafts. Ann Thorac Surg 1990;49:202.
15.
Kouchoukos NT, Karp RB, Oberman A, et al. Long-term patency of saphenous veins for coronary bypass grafting. Circulation 1978;58:I96.
16.
Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1.
17.
Hata M, Shiono M, Sezai A, et al. Comparative study of harvestsite complications following coronary artery bypass grafting between the radial artery and the saphenous vein in identical patients. Surg Today 2005;35:711.
18.
Ikizler M, Ozkan S, Dernek S, et al. Does radial artery harvesting for coronary revascularization cause neurological injury in the forearm and hand? Eur J Cardiothorac Sur 2005;28:420.
19.
Brodman RF, Frame R, Camacho M, et al. Routine use of unilateral and bilateral radial arteries for coronary artery bypass graft surgery. J Am Coll Cardiol 1996;28:959.
20.
Calafiore AM, Teodori G, Di Giammarco G, et al. Coronary revascularization with the radial artery: New interest for an old conduit. J Card Surg 1995;10:140.
21.
Manasse E, Sperti G, Suma H, et al. Use of the radial artery for myocardial revascularization. Ann Thorac Surg 1996;62:1076.
1.
208 22.
23. 24.
25.
26.
27.
28.
JOURNAL OF SURGICAL RESEARCH: VOL. 139, NO. 2, MAY 15, 2007 Pola P, Serricchio M, Flore R, et al. 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. Timmons MJ, Missotten FE, Poole MD, et al. Complications of radial forearm flap donor sites. Br J Plast Surg 1986;39:176. Wong SW, Fernando D, Grant P. Leg wound infections associated with coronary revascularization. Aust N Z J Surg 1997;67: 689. Slaughter MS, Olson MM, Lee JT, Jr., et al. A fifteen-year wound surveillance study after coronary artery bypass. Ann Thorac Surg 1993;56:1063. Meharwal ZS, Trehan N. Functional status of the hand after radial artery harvesting: Results in 3,977 cases. Ann Thorac Surg 2001;72:1557. Sankey RA, Rumian AP, Jackson W, et al. Harvesting the radial artery: Does it affect early postoperative hand function? Heart Surg Forum 2003;6:E12. Dietl CA, Benoit CH. Radial artery graft for coronary revascularization: Technical considerations. Ann Thorac Surg 1995;60:102.
29.
30.
31.
32.
33. 34. 35.
Denton TA, Trento L, Cohen M, et al. Radial artery harvesting for coronary bypass operations: Neurologic complications and their potential mechanisms. J Thorac Cardiovasc Surg 2001; 121:951. Sajja LR, Mannam G, Sompalli S. Neurologic hand complications after radial artery harvest for coronary artery bypass grafting. J Thorac Cardiovasc Surg 2002;123:585. Tatoulis J, Buxton BF, Fuller JA. Bilateral radial artery grafts in coronary reconstruction: Technique and early results in 261 patients. Ann Thorac Surg 1998;66:714. Nunoo-Mensah J. An unexpected complication after harvesting of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1998;66:929. Genovesi MH, Torrillo L, Fonger J, et al. Endoscopic radial artery harvest: A new approach. Heart Surg Forum 2001;4:223. Newman RV, Lammle WG. Radial artery harvest using endoscopic techniques. Heart Surg Forum 2003;6:E194. Wright CB, Barner HB, Gao A, et al. The advantages of the Harmonic Scalpel for the harvesting of radial arteries for coronary artery bypass. Heart Surg Forum 2001;4:226.