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J Thorac Cardiovasc Surg 1999;118:563-565
© 1999 Mosby, Inc.

BRIEF COMMUNICATIONS

EXTERNALLY SUPPORTED RADIAL ARTERY GRAFT FOR MYOCARDIAL REVASCULARIZATION: A NEW TECHNIQUE TO AVOID VASOSPASM

Luís A. O. Dallan, MD, Sérgio A. Oliveira, MD, Luiz F. Poli de Figueiredo, MD, Luiz A. Lisboa, MD, Fernando Platania, MD, Adib D. Jatene, MD, São Paulo, Brazil

From the Division of Cardiac Surgery, Heart Institute (InCor), Department of Cardiopneumology, University of São Paulo Medical School, São Paulo, Brazil.

Address for reprints: Luís A. O. Dallan, MD, Rua Inhambu, 917 Apt 191, São Paulo—SP—CEP 04520-013, Brazil (E-mail: expluiz{at}incor.usp.br).

The radial artery was proposed as a conduit for coronary artery bypass many years ago,Go 1 but its use was abandoned some years later because of a high incidence of arterial spasm, leading to narrowing or early graft occlusion. The development of new antispasmodic drugs led some surgeons, including us, to reevaluate the use of the radial artery for coronary artery bypass grafting, because arterial grafts are know to be more resistant to atherosclerosis than are autogenous vein grafts.Go Go 2,3 However, despite significant advances, such as improvements in radial artery removal technique and the use of calcium channel blockers, arterial spasm still may occur, causing concern for several surgeons.Go 4 The aim of this report is to present a new technique that eliminates radial artery spasm when the artery is used as a coronary artery bypass graft.

Patients and methods.
The Biocompound-graft (Alpha Research GmbH, Berlin, Germany) was developed as a new type of hybrid prosthesis, consisting of a highly flexible mesh tubing and the patient’s own vein. Its primary indication is for coronary artery bypass, using venous bypass grafting, in patients with irregularly shaped veins.Go 5 To our knowledge, this is the first report of this technique being used for an arterial graft. Detailed information and instructions for making and implanting the Biocompound-graft are available from the manufacturer.

The radial artery was harvested in a standard manner with topical application of warm saline solution and papaverine (1 mL/100 mL 0.9% NaCl). The harvested artery was then prepared with the external support. In brief, the composite graft, consisting of a mesh tubing and the radial artery, is constructed with a fibrin adhesive. The Biocompound-graft is extremely pliable, made of individual filaments, 32 µm thick, manufactured from a high-grade steel alloy (Phynox; Vena Tech, Evanston, Ill). After removal of the radial artery, a long, thin balloon catheter is carefully inserted through the distal end of the radial artery up to the proximal end. The applicator set with the Biocompound-graft mesh tubing is slipped over the radial artery, and the applicator is gently pushed off, leaving the mesh over the entire radial artery. The balloon is then gently inflated with isotonic solution, and the Biocompound-graft mesh is smoothed out starting at the middle of the balloon catheter and working toward both ends of the artery. A fibrin glue (human fibrinogen, bovine aprotinin, and human thrombin [Tissucol]; Immuno, Rio de Janeiro, Brazil) is applied in 2 steps. First, the fibrinogen component is applied along the entire length of the graft, followed by the thrombin component in a similar manner, to assure completion of the adhesion process. This process is repeated 3 times, rotating the graft to give uniform coating. The balloon is then deflated and carefully removed. After a few minutes, the radial artery graft has good consistency and elasticity and is uniformly dilated. Finally, the radial artery with the expanded mesh incorporated to its external wall is handled like a standard internal thoracic artery (ITA) or vein graft. We did not use calcium channel blockers in the postoperative period.

Clinical summaries
PATIENT 1.
A 45-year-old man with unstable, multivessel coronary artery disease underwent myocardial revascularization. The externally supported radial artery was used with its distal anastomosis to the posterior ventricular branch of the circumflex artery. The proximal anastomosis was performed to the aorta(Fig 1). Additional grafts used were the left ITA to the left descending anterior artery and a saphenous graft to the first diagonal branch.



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  		Fig. 1. Patient 1. Postoperative angiogram with a selective injection at the externally supported radial artery (RA) graft, demonstrating its proximal anastomosis to the aorta and its distal anastomosis to the posterior ventricular branch of the circumflex artery.

 
PATIENT 2.
A 68-year-old man with unstable, multivessel coronary artery disease underwent myocardial revascularization. The distal anastomosis between the externally supported radial artery was to the second marginal branch of the circumflex artery, and the proximal anastomosis was to the proximal portion of the left ITA, which was used to revascularize the left anterior descending coronary artery(Fig 2). The descending posterior artery received a saphenous graft.



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  		Fig. 2. Patient 2. Postoperative angiogram with a selective injection at the left internal thoracic artery (LITA), demonstrating its distal anastomosis to the left anterior descending coronary artery. LITA anastomosis with the externally supported radial artery (RA) graft and distal anastomosis between the radial artery and the second marginal branch of the circumflex artery can also be identified.

 
Both patients had an event-free postoperative course and were discharged after 1 week. There were no hemodynamic, enzymatic, or electrocardiographic alterations. Angiography, performed on the fourth postoperative day, showed that, in both patients, all grafts were patent. The radial artery grafts showed a good diameter, with no signs of spasm or constrictions(Figs 1Go and2Go).

Discussion.
Although the pedicled ITA remains the primary arterial conduit for myocardial revascularization, the externally supported radial artery, as we have prepared it, seems to be an excellent alternative as a bypass conduit, with all the advantages inherent in arterial compared with venous grafts. The technique for external support has been successfully used to improve varicose veins for coronary artery bypass grafting.Go 5 To our knowledge, this is the first report of its use in the radial artery to avoid spasm. The technique is easy to perform and results in excellent diameters, similar to good saphenous vein grafts(Fig 1Go, A). For women or patients with a small radial artery diameter, a smaller-diameter biocompound system will need to be developed. Long-term follow-up is required to establish the benefits of this technique and to better define whether the external support of the radial artery can be added to the armamentarium of surgeons dealing with coronary artery disease.

Acknowledgments

We thank Dr Danton Rocha Loures, from the Federal University of Paraná, for help with the technical aspects of the use of the Biocompound-graft.

References

  1. Carpentier A, Guermonprez JL, Deloche A, Frechette C, Dubost A. The aorto-to-coronary radial artery bypass graft: a technique avoiding pathological changes in grafts. Ann Thorac Surg 1973;16:111-21.[Medline]
  2. Acar C, Jebara VA, Portoghese M, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-9.[Abstract]
  3. Dallan LA, Oliveira AS, Lisboa LA, et al. Complete myocardial revascularization with exclusive use of arterial grafts. Rev Bras Circ Cardiovasc 1998;13:187-93
  4. Barner HB. Defining the role of the radial artery. Semin Thorac Cardiovasc Surg 1996;8:3-9.[Medline]
  5. Zurbrügg HR, Hetzer R. The use of Biocompound-grafts together with varicose veins: first clinical experience. J Cardiovasc Surg 1996:37(6 Suppl 1):143-6.
Received for publication May 7, 1999. Accepted for publication May 26, 1999.



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