Tissue perfusion in non-donor and donor forearm/hand after radial artery harvest: 1- and 5-year follow-up
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《交互式心脏血管和胸部手术》
a Department of Cardiothoracic Surgery, The Yorkshire Heart Centre, D-Floor, Jubilee Wing, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
b Department of Medical Physics, The Yorkshire Heart Centre, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
Radio-labeled red cell perfusion scan of the non-donor/donor forearm/hand was undertaken, 1- and 5-years post operation, in 12 patients who had received a radial artery graft during myocardial revascularisation. Results were analysed using a Wilcoxon Signed Rank test (P-value <0.05 was taken as statistically significant). Mean tissue perfusion (in milliliters/100 ml tissue/min) declined in the non-donor (–10.06%, P=0.07) and donor (–6.65%, P=0.15) forearm, respectively, compared to 1 year post radial artery harvest. The statistically significant observed difference in tissue perfusion between the non-donor (21.9±5.1) and donor (17.5±3.7) forearm (P=0.0007) at 1 year was maintained at 5 years, non-donor and donor, 19.5±3.7 and 16.2±3.4 (P=0.001), respectively. The same pattern in tissue perfusion was observed in the non-donor/donor hand. This study demonstrates that, over time, there is little recovery in perfusion in the donor forearm/hand from ulnar artery collateral circulation. There is a significant and persistent difference in tissue perfusion between the non-donor/donor forearm/hand at 5 years post radial artery harvest. Although no functional deficit or overt ischaemic events were recorded, these findings may influence the choice of conduit and the information given when obtaining consent in patients undergoing myocardial revascularisation.
Key Words: Radial artery; Limb perfusion; Coronary artery bypass
1. Introduction
There remains a concern about forearm and/or hand ischaemia of the donor arm following the harvest of the radial artery and the ability of the ulnar artery to maintain adequate collateral blood flow thus preventing this potentially devastating complication.
This study aims to address this concern by examining the tissue perfusion of the donor and non-donor forearm and hand using radiolabelled autologous red blood cells in patients 5 years following harvesting of the radial artery.
2. Materials and methods
This study was conducted with Institutional Ethics Committee approval and a license from the Administration of Radioactive Substances Advisory Committee.
Twenty patients who had undergone elective first-time coronary artery bypass surgery, using the radial artery as one of the conduits, underwent upper limb tissue perfusion studies 1 year following the operation [1]. The same group of patients was invited to participate in the re-evaluation of upper limb tissue perfusion 5 years after surgery.
The study protocol was comparable and the end points included absolute tissue perfusion in the donor forearm/hand (radial artery harvested) and the non-donor forearm/hand, together with the change in forearm/hand perfusion between 1 and 5 years after the original coronary artery bypass surgery.
The technique of limb blood flow measurement in the hand and forearm is well established and has been described previously [2]. The patients were placed in front of a gamma camera fitted with a high-sensitivity collimator. The hands and forearms are placed on the collimator with pneumatic cuffs wrapped around the arms immediately above the elbow. The cuffs are rapidly inflated to 300 mmHg to isolate the blood in the arms and produce a hyperemic response. Once the cuffs are inflated, 10 ml of blood containing autologous technetium-99 m radiolabelled red blood cells are injected into a vein in the dorsum to the foot and flushed with 20 ml of saline. After 3 min 55 s of occlusion, the acquisition of 100x1 s frames into a 64x64 matrix begins. The cuffs are released at 4 min resulting in a rapid influx of radiolabelled blood.
Time–activity curves are created from regions of interest defined around the forearm and hand. The gradient from a least squares fit to the initial linear phase of each curve is directly proportional to the hyperemic blood flow expressed in millilitre/100 ml of tissue/min. The results for donor forearm/hand were compared with the non-donor forearm/hand.
Although the original study included data on the clinical assessment of hand function [1], none of the patients in the present study consented to undergo any functional testing.
In the original operation, the harvesting of the radial artery was standardised. The artery was mobilised using a combination of sharp dissection and diathermy, with hemo-clips applied to the branches of the artery. An atraumatic vascular clamp was placed on the radial artery proximally at the elbow and the presence of pulsatile flow in the distal segment was confirmed prior to the division and removal of the artery.
Analysis of the results was performed using the Wilcoxon-Rank Signed test with a P-value <0.05 taken as statistically significant.
3. Results
Twelve out of the original group of 20 patients consented to undergo re-evaluation of the upper limb tissue perfusion. The remainder declined for a variety of reasons, including personal circumstances (4 patients), lost to follow-up (3 patients) and death (1 patient).
There were 11 males and 1 female. The mean age was 63.6 years (range 44–76 years). None of the patients had a history of smoking. One patient had recently been diagnosed with diet-controlled diabetes mellitus. Apart from one patient with a history of a single transient ischaemic attack attributable to non-surgically significant carotid artery disease, no patients had symptoms or signs of peripheral vascular disease. The mean number of bypass grafts was 3.3 per patient.
Although no objective functional assessment was performed, questioning at the time of the tissue perfusion study revealed that none of the 12 patients reported any significant functional deficit or any overt ischaemic events.
There was a reduction in mean tissue perfusion in the non-donor (–10.06%, P=0.07) and donor (–6.65%, P=0.15) forearm, respectively, at 5 year follow-up compared to 1 year post radial artery harvest.
In comparing the non-donor and donor side, the statistically significant difference observed in tissue perfusion of the forearm at 1 year, 21.9±5.1 and 17.5±3.7 (P=0.0007), was maintained at 5 years, 19.5±3.7 and 16.2±3.4 (P=0.001), respectively.
The same pattern was found in hand perfusion. There was a reduction in the tissue perfusion between the non-donor and donor hands, –11.5% (P=0.03) and –8.4% (P=0.15), respectively. Again, the significant difference between the two was maintained at 5-year post coronary artery bypass surgery: 26.5±4.7 and 22.5±5.1 (P=0.0004) at 1 year, and, 23.2±5.4 and 19.7±4.2 (P=0.005) at 5 years, respectively.
4. Discussion
In 1973, Carpentier first used the radial artery as a conduit in myocardial revascularisation [3]. Although the initial response to this development was equivocal, the use of the radial artery has since increased in popularity, principally as it is an easy conduit to harvest with excellent mid- to long-term patency rates [4,5]. The conduit has also been important in the trend towards performing coronary artery bypass surgery by total arterial revascularisation [6].
The effect of removing the radial artery and the possibility of ischaemia of the donor forearm and hand has remained the subject of much discussion. Historically, the adequacy of the ulnar collateral circulation has been established clinically using a test that is both subjective and observer-dependent, namely the modified Allen's test. More objective methods of assessment have superseded the Allen's test [7,8] and whilst these techniques have aided the decision-making process in choosing conduit for coronary artery bypass surgery, there is little information available on the long-term effects of removing the radial artery.
Apart from the study by Lee et al. [9], which reported on the long-term digital blood flow (at 3 years) after radial artery harvest, the present study is the only investigation that has quantified the actual long-term effects (at 5 years) on forearm and hand perfusion of removing the radial artery and thus leaving the tissue perfusion on the operated side reliant on ulnar artery collateral flow.
The technique used in the present investigation has a considerable advantage compared with other techniques in that it provides an absolute measurement of blood flow per unit volume of tissue and thus is a direct measurement of tissue perfusion [2]. This contrasts with the previous studies on this subject which have tended to rely on indirect surrogate markers of perfusion, such as blood velocity through digital arteries and hand function using pulse wave Doppler or plethysmography [9–13].
It is important to note that although certain results reach statistical significance, any conclusions should be tempered by the fact that the number of patients investigated in the original and the present study are small – 20 patients and 12 patients at 1 year and 5 years, respectively. Nonetheless, the number of patients investigated is comparable with other studies on this subject [9–13].
The results show that removing the radial artery results in a significant difference in the tissue perfusion between the non-donor and the donor forearm/hand. Furthermore, this difference does not improve with time and is present up to 5 years following the harvest of the radial artery. This, coupled with the fact that there is an overall reduction in the mean tissue perfusion between 1- and 5-years in both the non-donor and donor limbs, has important implications. Patients undergoing myocardial revascularisation tend to suffer to a variable extent from generalised arteriopathy. The development of changes consistent with atherosclerosis in the operated arm has been supported by a recent study that showed a higher incidence of intimal-medial thickness in the residual ulnar artery in the operated arm when compared to the non-operated arm. This pathological change appears to be due to the compensatory increase in flow in the ulnar artery. Crucially, although this finding is apparent early after removal of the radial artery, it reaches statistical significance at 10 years [14]. As the data from the present study suggest, a progressive reduction in overall tissue perfusion in both the donor and non-donor forearm and hand over 5 years, we would recommend caution in utilising the radial artery in patients with significant clinical evidence of peripheral vascular disease at the time of the operation.
It must be stated, however, that these findings would have added significance if there was a concomitant deterioration in donor forearm and hand function. Most studies have not shown this to be the case, although no study was identified that addressed this point beyond 18 months post-surgery [15].
Many surgeons are sufficiently concerned about the deleterious effects of harvesting the radial artery and will not only avoid bilateral radial arteries, but also, utilise the radial artery from the non-dominant arm only in circumstances where alternative conduit, namely the long saphenous vein, which can be taken without any attendant worry about lower limb ischaemia, is unavailable. Others also take the patient's occupation into account in the decision-making process.
Whilst this subject requires further investigation, this study provides additional information that may be of benefit when an appropriate choice of conduit is being considered and the preoperative consent is being obtained. This is particularly relevant in the younger patients, who are more likely to undergo total arterial revascularisation and thus may be more susceptible to any potential long-term deterioration in the vascular supply of the operated arm.
Appendix. Conference discussion
Dr A. Gaafar (Cairo, Egypt): How do you explain the decrease of blood supply in the nondonor arm?
Mr Shah: We all know that patients who have coronary artery disease are, for all intents and purposes, arteriopaths, and perhaps the explanation for the reduction in blood flow in the non-donor arm is progression of their atherosclerosis.
Dr Gaafar: Do you think it might have any relation to the invasive catheter placed at the time of the operation, radial artery cannulation by the anesthetist?
Mr Shah: It is possible.
Dr T. Elghobary (Nantes, France): Did these patients have any symptomatic problems or clinical manifestations when they came after five years?
Mr Shah: They didn't. At the first series of tests at one year, we performed functional studies as well and showed that there were no functional effects to harvesting the radial artery. In the current study, we only had 12 patients, and unfortunately, they had to spend the whole day in the department undergoing this particular study, and they did not consent to having the functional studies repeated. But, on cursory questioning there was no obvious functional deficit ascertained.
Dr Elghobary: Did they have any anatomical differences, I mean size differences, between the two forearms?
Mr Shah: Not obviously, no.
References
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.
Parkin A, Smye SW, Bishop N, Wilkinson D, Rees M, Vowden P, Kester RC. Forearm blood flow measurements using technetium-99 m human serum albumin following brachial arteriotomy. J Nucl Med 1989; 30:45–50.
Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg 1973; 16:111–121.
Cameron J, Trivedi S, Stafford G, Bett JHN. Five-year angiographic patency of radial artery bypass grafts. Circulation 2004; 110:II23–26.
Possati G, Gaudino M, Prati F, Alessandrini F, Trani C, Glieca F, Mazzari MA, Luciani N, Schiavoni G. Long-term results of the radial artery used for myocardial revascularisation. Circulation 2003; 108:1350–1354.
Tatoulis J, Buxton BF, Fuller JA. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998; 66:714–719.
Rodriguez E, Ormont ML, Lambert EH, Needleman L, Halpern EJ, Diehl JT, Edie RN, Mannion JD. The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting. Eur J Cardiothorac Surg 2001; 19:135–139.
Abu-Omar Y, Mussa S, Anastasiadis K, Steel S, Hands L, Taggart DP. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test. Ann Thorac Surg 2004; 77:116–119.
Lee HS, Heo YJ, Chang BC. Long-term digital blood flow after radial artery harvesting for coronary artery bypass grafting. Eur J Cardiothorac Surg 2005; 27:99–103.
Pola P, Serricchio M, Flore R, Manasse E, Favuzzi A, Possati GF. Safe removal of the radial artery for myocardial revascularisation: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996; 112:737–744.
Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg 1998; 102:1993–1998.
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.
Royse AG, Royse CF, Maleskar A, Garg A. Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm. Ann Thorac Surg 2004; 78:539–542.
Gaudino M, Serricchio M, Tondi P, Gerardino L, Di Giorgio A, Pola P, Possati G. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg 2005; 130:9–12.
Dumanian GA, Segalman K, Mispireta LA, Walsh JA, Hendrickson MF, Wilgis EF. Radial artery use in bypass grafting does not change digital blood flow or hand function. Ann Thorac Surg 1998; 65:1284–1287.(Samir S. Shaha, J. Rafael)
b Department of Medical Physics, The Yorkshire Heart Centre, The General Infirmary at Leeds, Great George Street, Leeds LS1 3EX, UK
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.
Abstract
Radio-labeled red cell perfusion scan of the non-donor/donor forearm/hand was undertaken, 1- and 5-years post operation, in 12 patients who had received a radial artery graft during myocardial revascularisation. Results were analysed using a Wilcoxon Signed Rank test (P-value <0.05 was taken as statistically significant). Mean tissue perfusion (in milliliters/100 ml tissue/min) declined in the non-donor (–10.06%, P=0.07) and donor (–6.65%, P=0.15) forearm, respectively, compared to 1 year post radial artery harvest. The statistically significant observed difference in tissue perfusion between the non-donor (21.9±5.1) and donor (17.5±3.7) forearm (P=0.0007) at 1 year was maintained at 5 years, non-donor and donor, 19.5±3.7 and 16.2±3.4 (P=0.001), respectively. The same pattern in tissue perfusion was observed in the non-donor/donor hand. This study demonstrates that, over time, there is little recovery in perfusion in the donor forearm/hand from ulnar artery collateral circulation. There is a significant and persistent difference in tissue perfusion between the non-donor/donor forearm/hand at 5 years post radial artery harvest. Although no functional deficit or overt ischaemic events were recorded, these findings may influence the choice of conduit and the information given when obtaining consent in patients undergoing myocardial revascularisation.
Key Words: Radial artery; Limb perfusion; Coronary artery bypass
1. Introduction
There remains a concern about forearm and/or hand ischaemia of the donor arm following the harvest of the radial artery and the ability of the ulnar artery to maintain adequate collateral blood flow thus preventing this potentially devastating complication.
This study aims to address this concern by examining the tissue perfusion of the donor and non-donor forearm and hand using radiolabelled autologous red blood cells in patients 5 years following harvesting of the radial artery.
2. Materials and methods
This study was conducted with Institutional Ethics Committee approval and a license from the Administration of Radioactive Substances Advisory Committee.
Twenty patients who had undergone elective first-time coronary artery bypass surgery, using the radial artery as one of the conduits, underwent upper limb tissue perfusion studies 1 year following the operation [1]. The same group of patients was invited to participate in the re-evaluation of upper limb tissue perfusion 5 years after surgery.
The study protocol was comparable and the end points included absolute tissue perfusion in the donor forearm/hand (radial artery harvested) and the non-donor forearm/hand, together with the change in forearm/hand perfusion between 1 and 5 years after the original coronary artery bypass surgery.
The technique of limb blood flow measurement in the hand and forearm is well established and has been described previously [2]. The patients were placed in front of a gamma camera fitted with a high-sensitivity collimator. The hands and forearms are placed on the collimator with pneumatic cuffs wrapped around the arms immediately above the elbow. The cuffs are rapidly inflated to 300 mmHg to isolate the blood in the arms and produce a hyperemic response. Once the cuffs are inflated, 10 ml of blood containing autologous technetium-99 m radiolabelled red blood cells are injected into a vein in the dorsum to the foot and flushed with 20 ml of saline. After 3 min 55 s of occlusion, the acquisition of 100x1 s frames into a 64x64 matrix begins. The cuffs are released at 4 min resulting in a rapid influx of radiolabelled blood.
Time–activity curves are created from regions of interest defined around the forearm and hand. The gradient from a least squares fit to the initial linear phase of each curve is directly proportional to the hyperemic blood flow expressed in millilitre/100 ml of tissue/min. The results for donor forearm/hand were compared with the non-donor forearm/hand.
Although the original study included data on the clinical assessment of hand function [1], none of the patients in the present study consented to undergo any functional testing.
In the original operation, the harvesting of the radial artery was standardised. The artery was mobilised using a combination of sharp dissection and diathermy, with hemo-clips applied to the branches of the artery. An atraumatic vascular clamp was placed on the radial artery proximally at the elbow and the presence of pulsatile flow in the distal segment was confirmed prior to the division and removal of the artery.
Analysis of the results was performed using the Wilcoxon-Rank Signed test with a P-value <0.05 taken as statistically significant.
3. Results
Twelve out of the original group of 20 patients consented to undergo re-evaluation of the upper limb tissue perfusion. The remainder declined for a variety of reasons, including personal circumstances (4 patients), lost to follow-up (3 patients) and death (1 patient).
There were 11 males and 1 female. The mean age was 63.6 years (range 44–76 years). None of the patients had a history of smoking. One patient had recently been diagnosed with diet-controlled diabetes mellitus. Apart from one patient with a history of a single transient ischaemic attack attributable to non-surgically significant carotid artery disease, no patients had symptoms or signs of peripheral vascular disease. The mean number of bypass grafts was 3.3 per patient.
Although no objective functional assessment was performed, questioning at the time of the tissue perfusion study revealed that none of the 12 patients reported any significant functional deficit or any overt ischaemic events.
There was a reduction in mean tissue perfusion in the non-donor (–10.06%, P=0.07) and donor (–6.65%, P=0.15) forearm, respectively, at 5 year follow-up compared to 1 year post radial artery harvest.
In comparing the non-donor and donor side, the statistically significant difference observed in tissue perfusion of the forearm at 1 year, 21.9±5.1 and 17.5±3.7 (P=0.0007), was maintained at 5 years, 19.5±3.7 and 16.2±3.4 (P=0.001), respectively.
The same pattern was found in hand perfusion. There was a reduction in the tissue perfusion between the non-donor and donor hands, –11.5% (P=0.03) and –8.4% (P=0.15), respectively. Again, the significant difference between the two was maintained at 5-year post coronary artery bypass surgery: 26.5±4.7 and 22.5±5.1 (P=0.0004) at 1 year, and, 23.2±5.4 and 19.7±4.2 (P=0.005) at 5 years, respectively.
4. Discussion
In 1973, Carpentier first used the radial artery as a conduit in myocardial revascularisation [3]. Although the initial response to this development was equivocal, the use of the radial artery has since increased in popularity, principally as it is an easy conduit to harvest with excellent mid- to long-term patency rates [4,5]. The conduit has also been important in the trend towards performing coronary artery bypass surgery by total arterial revascularisation [6].
The effect of removing the radial artery and the possibility of ischaemia of the donor forearm and hand has remained the subject of much discussion. Historically, the adequacy of the ulnar collateral circulation has been established clinically using a test that is both subjective and observer-dependent, namely the modified Allen's test. More objective methods of assessment have superseded the Allen's test [7,8] and whilst these techniques have aided the decision-making process in choosing conduit for coronary artery bypass surgery, there is little information available on the long-term effects of removing the radial artery.
Apart from the study by Lee et al. [9], which reported on the long-term digital blood flow (at 3 years) after radial artery harvest, the present study is the only investigation that has quantified the actual long-term effects (at 5 years) on forearm and hand perfusion of removing the radial artery and thus leaving the tissue perfusion on the operated side reliant on ulnar artery collateral flow.
The technique used in the present investigation has a considerable advantage compared with other techniques in that it provides an absolute measurement of blood flow per unit volume of tissue and thus is a direct measurement of tissue perfusion [2]. This contrasts with the previous studies on this subject which have tended to rely on indirect surrogate markers of perfusion, such as blood velocity through digital arteries and hand function using pulse wave Doppler or plethysmography [9–13].
It is important to note that although certain results reach statistical significance, any conclusions should be tempered by the fact that the number of patients investigated in the original and the present study are small – 20 patients and 12 patients at 1 year and 5 years, respectively. Nonetheless, the number of patients investigated is comparable with other studies on this subject [9–13].
The results show that removing the radial artery results in a significant difference in the tissue perfusion between the non-donor and the donor forearm/hand. Furthermore, this difference does not improve with time and is present up to 5 years following the harvest of the radial artery. This, coupled with the fact that there is an overall reduction in the mean tissue perfusion between 1- and 5-years in both the non-donor and donor limbs, has important implications. Patients undergoing myocardial revascularisation tend to suffer to a variable extent from generalised arteriopathy. The development of changes consistent with atherosclerosis in the operated arm has been supported by a recent study that showed a higher incidence of intimal-medial thickness in the residual ulnar artery in the operated arm when compared to the non-operated arm. This pathological change appears to be due to the compensatory increase in flow in the ulnar artery. Crucially, although this finding is apparent early after removal of the radial artery, it reaches statistical significance at 10 years [14]. As the data from the present study suggest, a progressive reduction in overall tissue perfusion in both the donor and non-donor forearm and hand over 5 years, we would recommend caution in utilising the radial artery in patients with significant clinical evidence of peripheral vascular disease at the time of the operation.
It must be stated, however, that these findings would have added significance if there was a concomitant deterioration in donor forearm and hand function. Most studies have not shown this to be the case, although no study was identified that addressed this point beyond 18 months post-surgery [15].
Many surgeons are sufficiently concerned about the deleterious effects of harvesting the radial artery and will not only avoid bilateral radial arteries, but also, utilise the radial artery from the non-dominant arm only in circumstances where alternative conduit, namely the long saphenous vein, which can be taken without any attendant worry about lower limb ischaemia, is unavailable. Others also take the patient's occupation into account in the decision-making process.
Whilst this subject requires further investigation, this study provides additional information that may be of benefit when an appropriate choice of conduit is being considered and the preoperative consent is being obtained. This is particularly relevant in the younger patients, who are more likely to undergo total arterial revascularisation and thus may be more susceptible to any potential long-term deterioration in the vascular supply of the operated arm.
Appendix. Conference discussion
Dr A. Gaafar (Cairo, Egypt): How do you explain the decrease of blood supply in the nondonor arm?
Mr Shah: We all know that patients who have coronary artery disease are, for all intents and purposes, arteriopaths, and perhaps the explanation for the reduction in blood flow in the non-donor arm is progression of their atherosclerosis.
Dr Gaafar: Do you think it might have any relation to the invasive catheter placed at the time of the operation, radial artery cannulation by the anesthetist?
Mr Shah: It is possible.
Dr T. Elghobary (Nantes, France): Did these patients have any symptomatic problems or clinical manifestations when they came after five years?
Mr Shah: They didn't. At the first series of tests at one year, we performed functional studies as well and showed that there were no functional effects to harvesting the radial artery. In the current study, we only had 12 patients, and unfortunately, they had to spend the whole day in the department undergoing this particular study, and they did not consent to having the functional studies repeated. But, on cursory questioning there was no obvious functional deficit ascertained.
Dr Elghobary: Did they have any anatomical differences, I mean size differences, between the two forearms?
Mr Shah: Not obviously, no.
References
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.
Parkin A, Smye SW, Bishop N, Wilkinson D, Rees M, Vowden P, Kester RC. Forearm blood flow measurements using technetium-99 m human serum albumin following brachial arteriotomy. J Nucl Med 1989; 30:45–50.
Carpentier A, Guermonprez JL, Deloche A, Frechette C, DuBost C. The aorta-to-coronary radial artery bypass graft. A technique avoiding pathological changes in grafts. Ann Thorac Surg 1973; 16:111–121.
Cameron J, Trivedi S, Stafford G, Bett JHN. Five-year angiographic patency of radial artery bypass grafts. Circulation 2004; 110:II23–26.
Possati G, Gaudino M, Prati F, Alessandrini F, Trani C, Glieca F, Mazzari MA, Luciani N, Schiavoni G. Long-term results of the radial artery used for myocardial revascularisation. Circulation 2003; 108:1350–1354.
Tatoulis J, Buxton BF, Fuller JA. Bilateral radial artery grafts in coronary reconstruction: technique and early results in 261 patients. Ann Thorac Surg 1998; 66:714–719.
Rodriguez E, Ormont ML, Lambert EH, Needleman L, Halpern EJ, Diehl JT, Edie RN, Mannion JD. The role of preoperative radial artery ultrasound and digital plethysmography prior to coronary artery bypass grafting. Eur J Cardiothorac Surg 2001; 19:135–139.
Abu-Omar Y, Mussa S, Anastasiadis K, Steel S, Hands L, Taggart DP. Duplex ultrasonography predicts safety of radial artery harvest in the presence of an abnormal Allen test. Ann Thorac Surg 2004; 77:116–119.
Lee HS, Heo YJ, Chang BC. Long-term digital blood flow after radial artery harvesting for coronary artery bypass grafting. Eur J Cardiothorac Surg 2005; 27:99–103.
Pola P, Serricchio M, Flore R, Manasse E, Favuzzi A, Possati GF. Safe removal of the radial artery for myocardial revascularisation: a Doppler study to prevent ischemic complications to the hand. J Thorac Cardiovasc Surg 1996; 112:737–744.
Dumanian GA, Segalman K, Buehner JW, Koontz CL, Hendrickson MF, Wilgis EF. Analysis of digital pulse-volume recordings with radial and ulnar artery compression. Plast Reconstr Surg 1998; 102:1993–1998.
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.
Royse AG, Royse CF, Maleskar A, Garg A. Harvest of the radial artery for coronary artery surgery preserves maximal blood flow of the forearm. Ann Thorac Surg 2004; 78:539–542.
Gaudino M, Serricchio M, Tondi P, Gerardino L, Di Giorgio A, Pola P, Possati G. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg 2005; 130:9–12.
Dumanian GA, Segalman K, Mispireta LA, Walsh JA, Hendrickson MF, Wilgis EF. Radial artery use in bypass grafting does not change digital blood flow or hand function. Ann Thorac Surg 1998; 65:1284–1287.(Samir S. Shaha, J. Rafael)