CLINICIAN UPDATE
Should Radial Arteries Be Used Routinely for Coronary
Artery Bypass Grafting?
Subodh Verma, MD, PhD; Paul E. Szmitko, BSc; Richard D. Weisel, MD; Daniel Bonneau, MD;
David Latter, MD; Lee Errett, MD; Yves LeClerc, MD; Stephen E. Fremes, MD
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
C
ase Presentation: Mr P is a
57-year-old
construction
worker who has had Canadian
Cardiovascular Society class III angina
for the past 3 months. He has multiple
cardiovascular risk factors including
smoking, hypertension, dyslipidemia,
and diabetes. He is obese and has had
a previous laparotomy for a perforated
bowel. Coronary angiography revealed
triple vessel disease involving the left
anterior descending artery (LAD), the
first obtuse marginal branch, and the
right coronary artery (RCA), and an
akinetic inferior wall with an estimated
ejection fraction of 40%. The patient
was referred for consideration of coronary artery bypass graft (CABG) surgery. Is Mr P a candidate for CABG
and, if so, which vascular conduits
should be used?
CABG is the standard surgical procedure for the treatment of advanced
coronary artery disease. Since the first
successful
results
reported
by
Favaloro,1 CABG surgery has been
demonstrated to improve symptoms
and, in specific subgroups of patients,
to prolong life.2 Despite its success,
the long-term outcome of coronary
bypass surgery is strongly influenced
by the fate of the vascular conduits
used. Five to 7 years after surgery,
patients are at increased risk of suffering from ischemic complications coincident with graft failure.2 Furthermore,
as patients undergoing CABG surgery
become older with more preoperative
risk factors, and treated patients are
living longer and therefore requiring
reoperation, the optimal selection of
vascular grafts for bypass is essential.
Conduits Used in
Bypass Surgery
Conventional CABG surgery utilizes a
combination of arterial and venous
grafts. Saphenous vein (SV) grafts, the
first vascular conduits used in CABG,
are still widely utilized, primarily to
bypass vessels other than the LAD.
Despite being readily accessible, of
adequate length to access every vessel
on the heart, and the correct diameter
to facilitate coronary and aortic anastomoses, SV grafts are limited by poor
long-term patency. Because of a combination of intimal hyperplasia and
accelerated atherosclerosis, up to 15%
of SV grafts are occluded within 1
year,3 and by 10 years postoperatively,
at least 50% demonstrate significant
disease.4,5 To bypass the LAD, most
centers use the left internal thoracic
(mammary) artery (LITA or LIMA). In
contrast to SV grafts, the LITA displays excellent long-term patency, up
to 90% after 10 years, which is associated with improved survival.5–9 The
excellent results obtained with the
LITA anastomosed to the LAD have
added strength to the concept of complete arterial revascularization to improve clinical outcomes. Recently, a
prospective randomized trial demonstrated that total arterial revascularization with composite grafts improved
patient outcome in terms of freedom
from cardiac events, angina recurrence, and the need for percutaneous
transluminal coronary angioplasty reintervention when compared with conventional arterial and venous grafting.10 Additional arterial grafts are
being increasingly used in place of the
SV to avoid the late complications of
vein graft atherosclerosis and restenosis.
The use of arterial conduits has expanded beyond the LITA to include
the right internal thoracic artery
(RITA), the right gastroepiploic artery
(RGEA), the inferior epigastric artery
(IEA), and the radial artery (RA). Bi-
From the Division of Cardiac Surgery, Toronto General Hospital (S.V., P.E.S., R.D.W.), St. Michael’s Hospital (D.B., D.L., L.E., Y.L.), and
Sunnybrook and Women’s College Health Sciences Centre (S.E.F.), University of Toronto, Toronto, Canada.
Correspondence to Subodh Verma, MD, PhD, Division of Cardiac Surgery, Toronto General Hospital, 14 EN-215, 200 Elizabeth St, Toronto, ON, M5G
2C4, Canada. E-mail [email protected]
(Circulation. 2004;110:e40-e46.)
© 2004 American Heart Association, Inc.
Circulation is available at http://www.circulationaha.org
DOI: 10.1161/01.CIR.0000136998.39371.FF
e40
Verma et al
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lateral ITAs, using the RITA as a
pedicled or free graft, have been demonstrated to have long-term patency
exceeding SV grafts and result in improved patient survival.11–14 However,
no randomized trials have been done.
The use of bilateral ITAs is commonly
avoided in elderly, obese, or diabetic
patients, characteristics common to
CABG patients, because of higher
rates of sternal infection, dehiscence,
and mediastinitis.15 The RGEA, primarily used as an in situ graft to
bypass the RCA and its branches, has
shown reasonable long-term patency
that exceeds 90% up to 5 years postoperatively.16,17 Its use, however, has
been limited because of the fragile
quality of the artery, the small diameter of the vessel at the site of distal
anastomosis, concerns regarding vessel twisting, increased operative time,
and incisional discomfort with associated ileus. The IEAs, used in composite arterial conduits or as free
grafts,18 –20 are limited primarily by
their short usable length, only making
them suitable as grafts to diagonal or
intermediate branches. The principle
adverse events associated with IEA
harvesting are related to wound complications such as abdominal wall hematoma or infection, and relative contraindications to their use include
obesity, lower abdominal surgery, or
coexisting illness potentially requiring
abdominal surgery. Thus, despite improved graft patency, multiple arterial
conduits have not gained wider acceptance for myocardial revascularization
because of increased operative time,
limited access to distal coronary sites
because of graft length, and patient
factors that preclude their use. The
final arterial conduit used, the radial
artery, which is the focus of this review, overcomes many of these
disadvantages.
Radial Arteries for CABG:
Historical Perspective
The RA was first used for coronary
revascularization by Carpentier and
colleagues in 1971.21 However, 2 years
later, its use was abandoned because of
Radial Arteries for CABG Surgery
an occlusion rate that was greater than
that observed in SV grafts. A combination of graft spasm and severe intimal hyperplasia,22,23 likely the result of
endothelial denudation from mechanical dilation and trauma on skeletonized
harvesting, was thought to contribute
to the initial poor results obtained with
RA grafting. The discovery of a patent
RA graft 15 years postoperatively,
which was initially thought to be occluded, prompted the revitalization of
the RA as a bypass conduit.24
In 1992, Acar and colleagues24 reported the results from 104 patients
who received a RA graft as a bypass
conduit since 1989. The study showed
that the RA is a reasonable alternative
to other types of conduits to complement the LITA. Notably, in contrast to
initial attempts, early RA patency was
100% in this modern experience, likely
because of modifications that reduced
endothelial damage and graft spasm.
e41
Three major modifications are
now used to minimize RA spasm, the
primary cause of early graft failure.
First, the RA is harvested as a pedicle, including 2 satellite veins and
the surrounding fatty tissue, using an
atraumatic “no-touch” technique
similar to that used in the harvest of
other arterial conduits for coronary
surgery (see the Figure).25,26 During
harvesting, direct handling of the RA
is avoided. Second, mechanical dilation of the graft has been replaced by
pharmacological dilation with papaverine, a phosphodiesterase III inhibitor that enhances the nitric oxide
pathway, minimizing endothelial
damage and dysfunction. Third, in
hopes of minimizing postoperative
RA spasm, vasodilator therapy, most
commonly with calcium channel
blockers or nitrates, has been
adopted, despite limited clinical outcome data to support this practice.
The RA, harvested as a pedicle, is dissected through a skin incision starting 3 cm distal
to the elbow crease lateral to the biceps tendon, stopping 1 cm before the proximal
crease at the wrist level, centered over the radial pulsation, between the flexor carpi
radialis and the radial tubercle. Care is taken to avoid damaging the lateral antebrachial
cutaneous nerve (sensory), which crosses obliquely from medial to lateral. After incision
of the skin and fatty tissue, the RA can be seen in the distal third of the forearm
beneath the fascial layer and is completely exposed by lateral mobilization of the brachioradialis. All side branches are ligated and the artery is irrigated topically with dilute
papaverine solution during the dissection. Compared with the LITA, the RA has a much
thicker muscular media that likely contributes to its increased propensity to go into
spasm. The RA may be proximally anastomosed to the LITA, forming a composite graft,
or to the ascending aorta to bypass all coronary territories. Illustrated is the use of a
free RA graft anastomosed proximally to the ascending aorta to bypass a lesion in the
right coronary artery, the LITA anastomosed to the LAD, and a SV graft to the first
obtuse marginal branch. This operation is representative of those included in the RAPS.
OM indicates first obtuse marginal branch.
e42
Circulation
August 3, 2004
Potential Advantages of
Radial Artery Use
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The RA possesses several anatomical
features that make it an excellent candidate for use in coronary revascularization.27 The average length of the
RA, ⬎20 cm, makes it suitable to
bypass all coronary artery territories,
and its inner diameter, which is between 2 to 3 mm, closely matches that
of the coronary arteries. Both coronary
and aortic anastomoses are technically
less demanding to construct with the
RA when compared with other arterial
conduits because of its thick muscular
wall. On a practical basis, harvesting
of the RA may occur concurrently with
harvesting of all other conduits, reducing the duration of the surgical
procedure.26
When compared with other vascular
conduits, the RA provides additional
benefits. According to observational
studies, relative to SV grafts, RAs can
be harvested without interfering with
ambulation and their use has been
shown to be protective against both
early and late mortality and morbidity,28 resulting in enhanced late survival.29 Also, unlike SV grafts, RA grafts
are adapted to higher arterial pressures
and have a homogeneous caliber free
from internal valves, characteristics
possibly contributing to the RA’s superior results. Compared with other
arterial grafts, contraindications such
as obesity, diabetes mellitus, or previous laparotomy do not apply to RA
harvesting, allowing this conduit to be
harvested in a majority of patients.
TABLE 1.
When comparing the RITA to the RA
as a second arterial graft, patients receiving a RA have a lower incidence
of sternal wound infection and decreased transfusion requirement,
though there is no difference in perioperative or intermediate-term cardiac
morbidity or mortality rates.30 Furthermore, RA use is safe in patients with
moderate to severe left ventricular dysfunction31 and in patients over the age
of 6532 (see Table 1).
Potential Disadvantages of
Radial Artery Use
Before harvesting the RA, it is mandatory to assess the adequacy of the ulnar
collateral circulation to the hand to
avoid ischemia. Methods to detect adequate forearm collateral flow include
the Allen test, static and dynamic
Doppler testing, direct digit pressure
measurement during RA compression,
and oxymetric plethysmography, together with the computation of a perfusion index.33 If concerns with the
adequacy of the forearm collateral circulation are raised by the preoperative
testing method, RA harvesting is contraindicated. Other contraindications to
RA harvesting include a radial artery
plaque on ultrasound, damage to the
RA due to trauma or previous cannulation, the presence of an arteriovenous fistula for hemodialysis, vasculitis, or Raynaud’s disease.26,34 If there
are no contraindications before harvesting, removal of the RA does not
result in any symptoms of hand ische-
The Advantages and Disadvantages of Using the RA as a Bypass Conduit
Advantages
Anatomical
Length (ⵑ20 cm)
Luminal diameter (2 to 3 mm)
Thick muscular wall/easy to work with
Clinical
Excellent short-, mid-, and long-term patency
Obesity, diabetes, and previous laparotomy
are not contraindications
Decreased transfusion requirement
Lower rate of sternal wound infection
Practical
Decreased operating time since harvested
concurrently with other grafts
Disadvantages
Increased propensity to spasm
Contraindications include poor forearm collateral
circulation, plaque on ultrasound, damage due to
trauma or previous cannulation, presence of an
arterio-venous fistula for hemodialysis, vasculitis,
or Raynaud’s disease
Risk of hand sensory or motor dysfunction
mia or motor dysfunction.35 Although
rare, complications after RA harvesting may occur. The most common
complications noted, occurring in
2.6% to 15.2% of patients, are sensory
abnormalities, especially cutaneous
paresthesias in the radial distribution
of the lateral antebrachial cutaneous
nerve or superficial branch of the radial nerve, likely secondary to nerve
injury from direct trauma, edema, or
carpal tunnel hematoma.35,36 Other disadvantages of the RA include a
slightly higher degree of atherosclerosis as compared with the LITA and its
increased chance of being subject to
previous iatrogenic vascular trauma.33,37 However, the inability to use
the RA because of severe calcification
or chronic dissection from prior cannulation is relatively rare, occurring in
less than 2% of candidates for RA
harvest34 (see Table 1).
The major disadvantage, which may
affect long-term performance, is the
propensity of the RA to go into spasm.
RA graft spasm is more intense and
more difficult to reverse compared
with spasm of the internal thoracic
artery.38 Basic science investigations
have elucidated the mechanism by
which RA spasm is mediated. Although nonreceptor-mediated spasm in
response to surgical trauma and local
tissue acidity is important, it is the
receptor-mediated response to catecholamines and platelet-derived factors, induced by endothelial damage
and platelet aggregation, which should
be abrogated in the setting of a coronary bypass graft. Endothelial function
of the RA, in terms of the release of
endothelium-derived relaxing factors
such as nitric oxide, is similar to that of
other arteries, as is its sensitivity to
vasoconstricting agents.38 Thus, the
propensity for the RA to go into spasm
is likely due to the higher density of
muscle cells in the media of this vessel
that are organized into multiple tight
layers, whereas the internal thoracic,
gastroepiploic, and epigastric arteries
have fewer muscle cells that are less
organized.27 Because of the more muscular nature of the RA, a significantly
Verma et al
TABLE 2.
Radial Arteries for CABG Surgery
e43
Relative Patency Rates of Radial Artery Grafts
Study
Timing
RA
LITA
RITA
FITA
early
56/56 (100%)
48/48 (100%)
11/11 (100%)
16/18 (89.9%)
early
26/26 (100%)
43/43 (100%)
35/35 (100%)
䡠䡠䡠
Calafiore et al20
early
75/76 (98.7%)
䡠䡠䡠
䡠䡠䡠
Chen et al48
early
90/94 (95.7%)
䡠䡠䡠
62/62 (100%)
da Costa et al49
early
59/61 (96.7%)
31/32 (96.8%)
䡠䡠䡠
12/13 (92.3%)
䡠䡠䡠
50
䡠䡠䡠
27/27 (100%)
Acar et al24/p
Calafiore et al
47
䡠䡠䡠
RGEA
䡠䡠䡠
5/5 (100%)
䡠䡠䡠
13/14 (92.8%)
䡠䡠䡠
48/50 (96.0%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
34/38 (89.5%)
䡠䡠䡠
䡠䡠䡠
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
86/90 (95.5%)
137/139 (98.6%)
䡠䡠䡠
99/100 (99%)
Acar et al24
mid
29/31 (93.5%)
28/28 (100%)
9/9 (100%)
Calafiore et al47
mid
16/17 (94.1%)
31/31 (100%)
22/23 (95.6%)
䡠䡠䡠
䡠䡠䡠
2/2 (100%)
Calafiore et al20
mid
33/35 (99.3%)
Manasse et al52
mid
43/49 (87.8%)
䡠䡠䡠
45/47 (95.8%)
䡠䡠䡠
1/2 (50%)
䡠䡠䡠
2/4 (50%)
䡠䡠䡠
5/5 (100%)
Tatoulis et al34
mid
21/22 (95.7%)
16/16 (100%)
䡠䡠䡠
1/1 (100%)
Bhan et al53
mid
60/62 (96.8%)
56/57 (98.2%)
Amano et al51
mid
213/229 (93.0%)
142/149 (95.3%)
䡠䡠䡠
27/27 (100%)
Acar et al24
late
54/64 (84.4%)
44/47 (93.6%)
Possati et al55
late
57/61 (91.9%)
58/60 (96.7%)
䡠䡠䡠
3/4 (75%)
Buxton et al45 group 1
late
38/39 (95%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
29/29 (100%)
Buxton et al45 group 2
late
21/24 (86%)
䡠䡠䡠
Possati et al56
late
䡠䡠䡠
79/82 (96.3%)
Totals:
early
529/542 (97.6%)
283/285 (99.3%)
mid
415/445 (93.3%)
318/328 (97.0%)
late
244/272 (89.7%)
181/189 (95.8%)
74/84 (88%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
early
䡠䡠䡠
䡠䡠䡠
67/70 (95.7%)
䡠䡠䡠
early
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
1/1 (100%)
Brodman et al
䡠䡠䡠
11/13 (84.6%)
SVG
8/9 (88%)
䡠䡠䡠
24/26 (92.3%)
Amano et al51
䡠䡠䡠
IEA
䡠䡠䡠
25/25 (100%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
35/46 (76.1%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
75/82 (91.4%)
䡠䡠䡠
䡠䡠䡠
71/79 (89.8%)
䡠䡠䡠
䡠䡠䡠
9/10 (90%)
䡠䡠䡠
䡠䡠䡠
43/58 (74.1%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
21/22 (95%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
39/73 (53.4%)
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
䡠䡠䡠
Early inidcates a mean follow-up of ⬍6 months; mid, a mean follow-up of 6 to 36 months; late, a mean follow-up exceeding 36 months; and SVG, saphenous
vein graft.
higher maximal contractile force can
result in response to vasoconstricting
agents, such as norepinephrine, serotonin, endothelin I, and angiotensin II,
generated in response to endothelial
damage and dysfunction.33,38 Thus, use
of the RA as a bypass conduit in
patients at high risk of needing postoperative vasopressor support should
be avoided. Currently, the propensity
of the RA to spasm has been greatly
reduced by minimal touch harvesting,
pharmacological dilation, and the use
of both topical and systemic vasodilators, including calcium channel blockers,24,30 papaverine,24 the phosphodiesterase inhibitor milrinone,34 intravenous
nitroglycerin,39 and ␣-adrenergic receptor blockers.40 Finally, studies suggest
that the RA should be limited to grafting
native vessels with a high degree of
stenosis (⬎70%) because of graft sensitivity to competitive flow and its increased propensity to spasm.41
Patency Rates of Radial
Artery Conduits
The long-term success of CABG depends largely on graft patency. Based
on the perceived advantages from arterial revascularization, the RA was
increasingly used in the 1990s, either
as a separate graft or in composite
grafts.20,24,34,42–56 Several angiographic
observational studies have shown that
the RA achieves excellent short-, mid-,
and long-term patency when used as a
conduit for revascularization (see Table 2). Patency rates exceed that of SV
grafts at all time points and are comparable to those observed for other
arterial conduits. Similarly, the use of
the RA in composite grafts, as T or Y
grafts to the LITA, displays favorable
short- and long-term patency.42– 44 Recently, Possati and colleagues56 described the long-term (105⫾9 months)
angiographic patency of RA grafts in a
series of 90 consecutive CABG pa-
tients. They found that the long-term
patency rate of the RA, which was
grafted to either an obtuse marginal or
posterior descending branch, was 88%.
This was less than that of the LITA
(96.3%), but was significantly better
than the patency rate for saphenous vein
grafts (53.4%). Thus, the long-term patency of the RA appears to be superior to
that of the SV, supporting its proposed
role as a complementary arterial conduit
for myocardial revascularization. Although these results are encouraging,
there are few long-term studies assessing
the patency rates of RA grafts in
symptom-free patients in a randomized,
controlled setting. To address this concern, there are 3 ongoing randomized
trials to compare angiographic patency
of RA grafts versus other vascular conduits. These are the Radial Artery Patency and Clinical Outcome (RAPCO)
study,45 the Radial Artery Patency
Study (RAPS),46 and the VA Compara-
e44
Circulation
August 3, 2004
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tive Study (Dr Steven Goldman, personal communication, 2004).
The RAPCO study was undertaken
to compare elective angiographic patency and cardiac event-free survival
of the RA graft with that of the free
RITA or SV during a 10-year period
after primary CABG surgery. The RA
was compared with the free RITA in a
younger patient group (n⫽285, age
⬍70 years) and with the SV in an older
patient group (n⫽153, age ⱖ75 years).
Patients were randomly assigned to
receive either the RA, RITA, or SV
grafted to the largest available coronary artery other than the LAD. The
5-year interim results of this prospective, randomized, single-center trial
were recently reported.45 Buxton and
colleagues45 report that in the first 5
years after surgery, there were no differences in the angiographic failure
rates and major clinical outcomes,
namely survival and cardiac event-free
survival, of the RA compared with the
RITA or SV. However, these results
were based on only a small proportion
of the expected angiographic results.
Furthermore, in their study,45 SV graft
patency rates were much better than
those previously recorded or the nonstudy SVs. Also, the 5-year time point
may be too short to assess the true
difference in patency as SV grafts
begin to display accelerated graft atherosclerosis and increasing rates of
graft failure between 5 and 10 years
postoperatively. Thus, the final results
obtained after 10 years of follow-up
should help clarify the long-term RA
patency rates and whether the use of
this graft in CABG is superior to the
RITA or SV.
The results of the second trial,
RAPS,46 were reported at the 2003
American Heart Association Scientific
Sessions.57 RAPS was a prospective,
multicenter, randomized clinical trial
comparing RA patency with that of the
SV when randomly allocated as the
graft to the right or circumflex coronary arteries. The primary objective of
the study was to determine the 8- to
12-month angiographic patency of the
RA relative to the SV, with each pa-
tient serving as his or her own control.
The long-term patency (5 to 10 years)
of the RA relative to SV grafts will be
assessed in follow-up studies. A total
of 561 patients were enrolled, of whom
440 underwent follow-up angiography.
Graft patency was greater in RA grafts
(91.8%) than in SV grafts (86.4%,
P⫽0.01; graft occlusion odds ratio
⫽0.53, 95% confidence interval 0.31
to 0.85). Perfect graft patency, defined as
grafts with Thrombolysis In Myocardial
Infarction (TIMI) 3 flow, was similar
(87.7% versus 85.7%, P⫽0.37). Perfect
patency of the radial artery was highly
dependent on the severity of the proximal native coronary artery stenosis (70%
to 89% coronary stenosis: 81.7%; ⱖ
90% coronary stenosis: 91.5%). Patency
of the RA graft was similar in the RCA
and circumflex territories.
The Future of the
Radial Artery as a
Vascular Conduit
The RA is becoming increasingly popular as a third arterial conduit in association with the LITA and RITA, or as
the second in patients with contraindications to bilateral ITA harvesting.
With the movement toward complete
arterial revascularization and more frequent off-pump surgery to avoid aortic
manipulation, the use of the RA to
form composite arterial grafts to the
LITA will become more common.58,59
Techniques simplifying the construction of anastomoses between vessels
and the aorta, by use of aortic connectors, may be extended to RA grafts.60
New pharmacological agents or gene
therapy strategies61 will be developed
to further decrease the potential for RA
spasm, which remains a problem that
may be most relevant in patients who
require postoperative vasopressor support. Furthermore, minimally invasive
approaches for the harvesting of the
RA are being developed, providing
desirable clinical and cosmetic outcomes.62 Finally, as more patients require reoperation, the RA will be one
of the few conduits still available for
use.
Mr P was deemed eligible for
CABG. Because of his age, the use of
arterial grafts was preferred. However,
his obesity, diabetes, and previous laparotomy prompted the surgeons to
avoid harvesting the RITA, IEA, and
RGEA. His right Allen test was sluggish; however, it was normal on the
left. Therefore, Mr P underwent
CABG with a LITA to the LAD, a left
radial artery graft to the distal RCA,
and a SV graft to the first obtuse
marginal branch, similar to the procedure illustrated in the Figure. His perioperative course was unremarkable
and he was discharged from hospital 5
days after surgery.
Note Added in Proof
During the review process, an important article on radial arteries was published by Zacharias et al.63 The authors
evaluated 6-year outcomes in
propensity-matched CABG-LITALAD patients (925 each) divided into
those with one radial graft and those
with vein-only grafting. Perioperative
outcomes, including death, were similar, although cumulative survival was
better for patients receiving the radial
artery graft. Angiography data in restudied symptomatic patients showed a
trend for greater radial artery graft
patency. Furthermore, the extent of
vein graft failure was significantly
worse than that of radial graft falure.
These data would support the use of
radial arteries as a second arterial conduit in CABG-LITA-LAD as opposed
to vein grafting.
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2. Kirklin JW, Akins CW, Blackstone EH, et al.
ACC/AHA Task Force report: guidelines
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543–589.
3. Fremes SE, Levinton C, Naylor CD, et al.
Optimal antithrombotic therapy following
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Should Radial Arteries Be Used Routinely for Coronary Artery Bypass Grafting?
Subodh Verma, Paul E. Szmitko, Richard D. Weisel, Daniel Bonneau, David Latter, Lee Errett,
Yves LeClerc and Stephen E. Fremes
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Circulation. 2004;110:e40-e46
doi: 10.1161/01.CIR.0000136998.39371.FF
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