J Thorac Cardiovasc Surg 2004;127:607-608
© 2004 The American Association for Thoracic Surgery
The radial artery: neither gold, nor silver, but bronze?
Teresa Kieser, MD, FRCSC, FACS
Department of Cardiac Sciences, Calgary Health Region Foothills Medical Centre, Calgary, Alberta, Canada
To the Editor:
I greatly appreciated reading Dr Lytle's insightful comments in his editorial on the radial artery (RA) versus the right internal thoracic artery (RITA) as a second arterial conduit for coronary surgery.1 All that he says is true: the RITA graft, when considering its historical older brother the left internal thoracic artery (LITA) graft, should have the same long-term potential but technically poses a bigger challenge. Hence surgeons opt for a more user-friendly arterial conduit, the RA. I would like to suggest a different comparison/substitute: the RA for the vein graft. Dr Lytle's comment in his editorial, "in my judgment, the RA graft is less predictable than the RITA graft in regard to patency," intrigued me. Over the past 15 years as a practicing cardiothoracic surgeon, I have become profoundly aware of the inadequacy of veins, and since my recent attendance at the enlightening and energy-invoking symposium "Arterial Conduits for Myocardial Revascularization" in Rome by Dr G. F. Possatti and Dr A. M. Calafiore, I believe the thrust should be to continue to use double ITA grafts whenever possible (especially in the young) but to substitute the RA for the vein graft. Since my return from this symposium, I have tried to do this; perhaps I did not see (or did not want to see) before, but many patients have serious venous disease of their legs precluding use of the saphenous vein. I think one of the turning points for me was when I recently (July 24, 2003) had to reoperate on an 83-year-old woman, on whom I had placed 2 grafts at age 81. Her LITA had gone down, I believe because I placed the graft inadvertently above a stenosis and her vein graft to a marginal artery occluded. If her vein graft had stayed open, she probably would not have needed reoperation at age 83. I used a sequential RA graft to the left anterior descending coronary artery and the marginal branch on-pump, and postoperatively she woke up stating that this was easier than her first operation. (Obviously this time both grafts were working!)
A second reason to substitute the vein for the RA graft could be the anticipated longer-lasting results of the drug-eluting stents used by interventional cardiologists. I know we are all interested in the same end—stamping out coronary artery disease effects—but it can be a little disconcerting for many surgeons currently in practice to see their favored coronary artery bypass grafts (LITA plus 2 veins) going the way of the dodo bird. I want to be so bold as to predict that the drug-eluting stents will rival our saphenous vein grafts (that is, by the time they figure out which drug, from which drug family, how much eluting, over what period of time, and so on, works; it might take 20 years). Although we should never be competitive with our interventional colleagues because we have the same end point in common, we must as surgeons find something ancillary to their work. I believe total arterial grafting (be it bilateral ITA, LITA/RA, RITA, bilateral ITA/gastroepiploic artery) may well be the answer. As Dr Lytle most wisely stated at the 2003 meeting of The American Association for Thoracic Surgery in Boston (and I quote him often in this): "Did you think you were going to be doing the same operation for 100 years!?" Dr Lytle continues to be a driving force leading all our quests for the best coronary artery bypass conduit.
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References
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- Lytle BW. Radial versus right internal thoracic artery as a second arterial conduit for coronary surgery: early and midterm outcomes. J Thorac Cardiovasc Surg. 2003;126:5–6[Free Full Text]
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