HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sabine Bleiziffer Ruediger Lange Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bleiziffer, S. Articles by Lange, R. Search for Related Content PubMed Articles by Bleiziffer, S. Articles by Lange, R. Related Collections Minimally invasive surgery

J Thorac Cardiovasc Surg 2007;134:649-656
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Patency rates of endoscopically harvested radial arteries one year after coronary artery bypass grafting

^a Clinic for Cardiovascular Surgery, German Heart Center Munich, Munich, Germany
^b Clinic for Cardiology, German Heart Center Munich, Munich, Germany
^c Institute for Radiology, German Heart Center Munich, Munich, Germany
^d Department for Internal Medicine I, Clinical Center Rosenheim, Munich, Germany.

Received for publication September 21, 2006; revisions received April 2, 2007; accepted for publication April 11, 2007.

^_* Address for reprints: Sabine Bleiziffer, MD, Clinic for Cardiovascular Surgery, German Heart Center Munich, Lazarettstr. 36, 80636 Munich, Germany. (Email: bleiziffer{at}dhm.mhn.de).

	Abstract

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
Objectives: To improve patients’ acceptance of the radial artery as a graft for coronary revascularization, we introduced an endoscopic harvesting technique. The aim of this study was to assess graft quality 1 year after the operation.

Methods: In 50 patients who underwent endoscopic radial artery harvesting for coronary artery bypass grafting, 64-slice computed tomography, electrocardiography, and echocardiography were utilized to assess graft patency and left ventricle function at a 1-year follow-up. In addition, the influencing factors of radial artery graft patency were evaluated. Radial artery patency was compared with a control group from our database.

Results: Any patency of endoscopically harvested radial artery grafts was 78% (39/50) and perfect patency was 72% (36/50) 1 year after coronary revascularization. The implanting surgeon and graft harvester, patient factors, graft properties, medication, and target territory did not influence the patency rates of the radial artery graft. The only significant and strong parameter to predict perfect graft patency was the severity of the target vessel stenosis (P < .001). In patients with a target vessel stenosis of 90% or greater, radial artery graft patency was 90.3% (28/31). Patency rates of endoscopically (72%) and conventionally (74%) harvested radial arteries were not different (P = .822).

Conclusions: Patency rates 1 year after endoscopic radial artery harvesting are comparable to the open technique. On the basis of our results, we attempt to use the radial artery as a bypass graft only for target coronary arteries with 90% or greater stenosis. We recommend endoscopic harvesting as the technique of choice to harvest the radial artery.

	Introduction

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
Since the reintroduction of the radial artery (RA) as a coronary artery bypass graft in the 1990s, harvesting techniques and antispasmodic therapy have been advanced.^1-3 It has been hoped that the RA will maintain greater late patency than has the saphenous vein (SV).⁴ Consequently, we offer total arterial revascularization to patients aged less than 70 years. To further improve patients’ acceptance of the RA as a bypass graft, we established a method of endoscopic RA harvesting in March of 2004.⁵

To evaluate the graft patency of the endoscopic technique, we consecutively followed up our first series of patients who underwent endoscopic RA harvesting.

	Materials and Methods

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
Patients
Of 1403 patients who underwent coronary artery bypass grafting at our institution between March 2004 and July 2005, 397 received an RA graft. The RA was chosen as a bypass graft in patients aged less than 70 years and in the absence of contraindications such as carpal tunnel syndrome, Dupuytren disease, severe arterial obstructive disease, dialysis, pathologic Allen test or Doppler examination, small RA diameter, or visible calcification. A total of 71 patients underwent coronary artery bypass grafting with an endoscopically harvested RA during the above-mentioned time period. Twelve patients were lost to follow-up (10 patients live abroad and 2 patients refused follow-up). Of 59 patients, 6 refused the investigation with a multislice computed tomograph (MSCT), and 3 patients had contraindications for the application of the contrast agent (elevated creatinine or suppressed thyroid-stimulating hormone). Thus, evaluation of bypass patency after endoscopic RA harvesting at 1 year was performed in 50 patients. In these patients, a 12-lead electrocardiogram was recorded and an echocardiographic investigation was performed.

Endoscopic Radial Artery Harvesting
The nondominant arm was chosen for RA harvesting. Preoperative Allen test and Doppler examination were routinely performed to confirm adequate ulnar blood flow.

The RA was harvested through a single 3-cm skin incision. This technique is performed with an endoscope inserted into a retractor and a harmonic scalpel for the dissection of the artery. Transection of the artery is carried out with a pre-tied Endoloop. A detailed description of the technique has been published.⁵

Antispasmodic prophylaxis was carried out by intravenous application of 6 to 12 µg diltiazem/kg/min starting during extracorporeal circulation and continuing for 24 hours after the operation. We also recommended the administration of amlodipine as an antispasmodic agent in an oral dose of 5 mg/d for 3 months after the operation.

Intraoperative Assessment
Assessment of the bypass grafts was carried out after weaning from cardiopulmonary bypass and establishment of stable hemodynamic conditions with a transit time flowmeter (Medi-Stim ASA, Oslo, Norway). Mean graft flow and pulsatility index (PI) were obtained directly from the flowmeter.

Assessment of the Target Vessel Stenosis
Data concerning the severity of the target vessel stenosis for bypass grafting were collected from the preoperative angiograph, from which native coronary artery stenosis was determined by visual assessment.

Multislice Computed Tomographic Angiographic Analysis
A computed tomographic angiographic scan is routinely performed 1 year after coronary artery bypass grafting. Contrast-enhanced computed tomographic angiographic data (Sensation 64 Cardiac, Siemens Medical Solutions, New York, NY) were acquired with the use of a spiral scan with 32 x 0.6-mm collimation, 330 ms gantry rotation, pitch of 0.2, and tube voltage at 120 kV. The scanning range included the entire course of venous grafts and the most proximal part of internal thoracic artery grafts at their subclavian origin, if these arterial grafts had been used for bypass surgery.

All bypass grafts were independently evaluated by 2 investigators who were aware of the initial coronary artery bypass grafting procedure. The investigators independently evaluated the contrast-enhanced MSCT scans by assessment of the axial slices, multiplanar reformations, and 3 thin-slab maximum intensity projections. Lumen narrowings were classified by the maximal luminal diameter stenosis seen in any plane. Because localized bypass stenoses were not seen in the present cohort, the bypass grafts were classified as perfectly patent, patent, or occluded. All patients signed an informed consent.

Echocardiographic Analysis
All echocardiographic examinations were performed by an experienced investigator. Echocardiographic scanning was carried out under resting conditions using an image Point Hx ultrasound system with a 2.5-MHz transducer (Hewlett-Packard, Palo Alto, Calif). Measurements of left ventricular dimensions were performed in the long parasternal axis. Left ventricular function and wall motion abnormalities were evaluated by visual assessment.⁶

Control Group
To compare RA graft patency rate after endoscopic harvest (ENDO group) with the conventional open technique (OPEN group), 50 patients who had undergone coronary artery bypass grafting with a conventionally harvested RA in the above-mentioned time period were randomly and retrospectively selected from our database and served as controls. The patient characteristics and type of grafts implanted in the ENDO and OPEN groups are summarized in Tables 1 and 2. Assessment of the target vessel stenosis and antispasmodic prophylaxis were performed in the control group as described above. Assessment of bypass graft patency was performed by MSCT in 33 patients of the control group and by angiography in 17 patients who had been followed up in an external clinic.

We performed a logistic regression analysis for patency of the RA after endoscopic harvest. We used forward selection and the likelihood ratio test for model selection. Included were age, gender, and all variables with a P value less than .10 in the univariate tests. Because normal distribution and homogeneity of variances were not given, a P value of less than .01 was considered statistically significant. Data analysis was performed with the Statistical Package for the Social Sciences version 14.0.1 (SPSS Inc, Chicago, Ill).

	Results

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
Clinical Outcome
All patients are alive at 11.1 ± 1.5 months after the initial operation. In the ENDO group, 33 of 50 patients (66%) are in New York Heart Association (NYHA) class I, 16 of 50 patients (32%) are in NYHA class II, and 1 patient (2%) is in NYHA class III. The mean ejection fraction was 56.5% ± 8% preoperatively and is 57.4% ± 6% at follow-up (P = .294).

In both groups, no cardiac reoperations have been performed. One patient has hemiparesis caused by postoperative apoplexy (ENDO group), and 1 patient underwent lateral thoracotomy for postoperative hematothorax (ENDO group). In 5 patients, sternal revision was performed (ENDO: n = 1, OPEN: n = 4). In 1 patient of the OPEN group, postoperative rethoracotomy was performed because of bleeding. No reinterventions have been necessary on the RA harvesting site in the ENDO group, whereas 1 patient in the OPEN group underwent wound revision. The surgical and catheter interventions performed in this series are summarized in Table 3.

View larger version (119K): [in this window] [in a new window]   Figure 1. Computed tomographic scan of a 3-dimensional reconstruction with a LITA graft to the left anterior descending artery (patent), an RA graft to the marginal branch (patent), and an SV graft to the RCA (occluded). LITA, Left internal thoracic artery; RA, radial artery.

Echocardiographic and Electrocardiographic Results (ENDO Group)
A total of 47 of 50 patients are in sinus rhythm, and 2 patients have an implanted pacemaker. One patient has multiple premature ventricular complexes, but his bypass grafts are patent. In 39 patients, left ventricular function is normal. Wall motion abnormalities are evident in 11 patients (n = 2 anterior wall hypokinesia, n = 1 posterior wall hypokinesia, n = 1 lateral wall hypokinesia, n = 6 septal dyskinesia and n = 1 diastolic dysfunction). Among the patients with wall motion abnormalities, 2 had an occluded RA graft.

Factors Influencing Radial Artery Graft Patency (ENDO Group)
To reveal factors affecting perfect RA graft patency after endoscopic RA harvesting, we tested the influence of patient characteristics, graft properties, postoperative medication, and target vessel properties (Table 4). Logistic regression revealed the severity of the target vessel stenosis as the only parameter indicating a significant and strong correlation with the patency rate (P < .001) (Table 5). In the group of patients with a target vessel stenosis of 90% or greater, 28 of 31 grafts (90.3%) were patent. The patency rate was 2.1 times higher in patients with a target vessel stenosis of 90% or greater. Mean target vessel stenosis had been 88.6% ± 16% in all patients with a perfectly patent RA graft versus 72.9% ± 15% in patients with an occluded graft (P = .003). Grafts with a flow rate of less than 55 mL/min seem to be more prone for occlusion (a flow of < 55 mL/min occurred in 13/36 patent grafts vs 11/14 occluded grafts, P = .007). However, graft flow was not detected as a significant factor influencing RA graft patency in the analysis of variances. Apparently, the learning curve of the first cases had no influence on patency; among our first 20 cases, only 1 RA graft was occluded.

Consequences in Patients with Occluded Radial Artery Graft (ENDO Group)
Among 14 of 50 patients with an occluded RA graft, 11 had no clinical symptoms. We recommended an exercise electrocardiogram to those patients to identify potential ischemia. Only 4 patients followed the recommendation, and all showed no signs of ischemia during exercise. Three patients with an occluded RA graft had angina during exercise. These patients had a target vessel stenosis of 80% to 100%. One of these patients had undergone stent implantation into the right coronary artery (RCA) because his RITA bypass was also occluded, resulting in an improvement of his symptoms. One patient refused angiography, and 1 patient with an occluded RA-RCA graft underwent stent implantation into the RCA.

	Discussion

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
In addition to the favorable features of the RA as a bypass graft, such as optimal length, easy handling because of the thick muscular wall, and availability even in patients with varicosis, the endoscopic harvesting technique offers additional benefits. A scar of only 3 cm at the wrist provides excellent cosmetic results, leading to higher acceptance by the patient than a scar of 25 to 30 cm across the forearm, which is permanently visible in everyday life. Minor complications, such as hematomas or wound infections, are also reported to be reduced with the endoscopic technique.⁷ However, there is no consensus about RA patency at mid-term and long-term follow-up, although most studies report encouraging RA patency. Therefore, we sought to assess the patency of the RA bypass grafts in our first series of patients after endoscopic graft harvesting.

Patency rates published in the literature range from 51.3% (204/398) after 1.6 ± 1.4 years⁸ to 99.0% (100/101) after 2.9 ± 2.3 years.⁹ Most studies lack a prospective randomized design and must be interpreted with caution.¹⁰ A prospective randomized study showed no superiority of the RA over the SV graft when anastomosed randomly to the largest available coronary artery.¹¹ In contrast, the prospective randomized Radial Artery Patency Study trial showed a significantly lower occlusion rate for the RA versus the SV graft at 1-year angiography.⁴ A recent prospective randomized trial also showed superior patency of the RA (95%) over SV (79%) grafts at a 5-year follow up in 101 patients. In this study, all grafts were anastomosed to the circumflex territory with a target vessel stenosis greater than 75%.¹² A recent review article from Manabe and Sunamori¹³ describes a graft patency of 78.5% when the RA was anastomosed to the left circumflex territory and of 74.1% when anastomosed to the RCA territory. These data are comparable to our results with perfect patency rates of 67% (left circumflex territory) and 80% (RCA territory) with an overall rate of any patency of 78% and a perfect patency rate of 72%. Concerning mortality after coronary artery bypass grafting, Zacharias and associates¹⁴ found a significantly better cumulative 0- to 6-year survival in patients with RA versus SV grafts.

To our knowledge, we are the first to describe a prospective investigation of the patency rate 1 year after endoscopic RA harvest in a cohort of 50 patients. Some studies report early results. Miles and colleagues¹⁵ describe no readmission for postoperative angina that would have required recatheterization in their first 50 patients after endoscopic RA harvesting at a 30-day follow-up. Yoshizaki and colleagues¹⁶ describe patent RA grafts in 5 patients who underwent endoscopic RA harvesting and postoperative angiography. In the series of Massetti and colleagues,¹⁷ 15 of 15 RA grafts were patent postoperatively, also assessed by angiography. The perfect patency rate of 72% 1 year after endoscopic RA harvesting in our series seems comparable to patency rates after conventional RA harvest published in the literature; however, no randomized data are available. To explore whether the RA patency is influenced by the endoscopic technique, we compared our data with a retrospective control group of patients who underwent conventional open RA harvest during the same time period. We could not demonstrate a difference between perfect RA patency after endoscopic (72%) versus open RA harvest (74%, P = .822), whereas the 2 groups did not differ in baseline characteristics and target territories. Presumably, the use of the harmonic scalpel versus electrocautery may influence the patency more than the endoscopic or conventional technique. Endoscopic and conventional harvesting systems are available with the harmonic scalpel or with electrocautery. A study from Onorati and colleagues¹⁸ indicates better flowmetry and PI of the RA harvested with the harmonic scalpel versus electrocautery, whereas Cikirikcioglu and colleagues¹⁹ and Shapira and colleagues²⁰ found no alterations in vasoreactivity or endothelial integrity for either technique.

Nevertheless, we had expected superior RA patency rates and thus aimed to identify factors influencing patency after endoscopic RA harvesting. Personnel factors such as the graft harvester or the graft implanting surgeon, as well as the learning curve, did not influence the RA patency. Furthermore, patient gender and age also did not influence the patency. Visible spasm of the RA after the harvest occurred in 1 case, and this graft was patent after 1 year. Intraoperatively assessed graft flow and PI tended to be better in RA grafts that were patent after 1 year, but this difference was not significant. It was not possible to evaluate a PI threshold value to predict graft occlusion. With regard to flow rate, grafts with a flow of less than 55 mL/min seemed to be more prone for occlusion (P = .007). Calcium-channel antagonists show proven antispasmodic effect on the RA,²¹ with dihydropyridine derivatives such as nifedipine or amlodipine being the most potent calcium antagonists. Therefore, we recommend the oral administration of amlodipine for at least 3 months after the operation. The length of amlodipine application (3 months or 1 year) did not correlate with RA patency in our series. Although the RA is more prone to vasoconstriction in the presence of norepinephrine,²² the postoperative amount of norepinephrine application did not affect RA patency as well. In our series, we could not demonstrate an impact of diabetes mellitus, smoking history, peripheral vessel disease, or hyperlipidemia on 1-year RA patency. This might be, at least in part, attributable to the low incidence of these risk factors in our patient population (Table 1). Also, the coronary territory to which the RA was anastomosed had no influence, which has also been described by Tatoulis and colleagues.²³ In our cohort, the only significant and strong predictor of 1-year RA perfect patency was the severity of target vessel stenosis (Table 5). In the group of patients with a target vessel stenosis of 90% or greater, RA graft perfect patency was as high as 90.3% (28/31). With a target vessel stenosis of less than 90%, perfect patency was only 42% (8/19), indicating that RA grafts are prone to occlusion in the presence of competitive coronary flow. In our retrospective control group, this relation was also present, because perfect patency was 92% (22/24) in RA grafts anastomosed to target vessels with a stenosis of 90% or greater versus 58% (15/26) when target vessel stenosis was less than 90% (P = .006). In our series, this effect was distinct. Desai and colleagues²⁴ speculate "that progressive auto-regulated adaptive narrowing of the RA conduit in the setting of competitive flow" may be the mechanism of graft occlusion. Royse and colleagues²⁵ defined 70% coronary stenosis as a "cut-off" point. Below this degree of stenosis, the long-term patency of the RA was found to be significantly decreased. In accordance with our findings, Desai and associates⁴ described a significantly lower RA patency even when target vessel stenosis is less than 90% and recommend RA grafting to severely stenotic targets (>90%) to improve patency in a recent article.²⁴ Fortunately, most of our patients with an occluded RA graft have no clinical symptoms, indicating that the rate of silent occlusion is high. Freedom from angina or dyspnea does not implicate RA graft patency.

In our cohort, the patency rates of LITA grafts (98%, 47/48) and RITA grafts (86%, 12/14) were satisfactory, whereas SV graft patency was less than expected (69%, 11/16). This may be because the SV was chosen as the graft of third choice after the LITA and a second arterial graft in this patient population.

	Conclusions

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
Patency rates 1 year after endoscopic RA harvesting are comparable to those of a control group with conventional harvest and to reports in the literature. In view of the advantages of the endoscopic technique, we recommend this approach as the technique of choice to harvest the RA. The target coronary artery for RA grafts must be selected with caution. On the basis of our results, we attempt to use the RA as a bypass graft only for target coronary arteries with stenosis of 90% or greater. A high intraoperative RA graft flow and low PI are not appropriate parameters for the prediction of RA patency.

	Limitations

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 
The present study is a consecutive 1-year follow-up of our first series of patients undergoing endoscopic RA harvesting. We compared patency rates with those of a control group selected retrospectively from our database and literature data. However, to prove the superiority of either technique, a prospective randomized study is needed. The resolution of the computed tomography angiography limits the differentiation between a complete graft occlusion and a functional occlusion with a minimal residual flow. The target vessel stenosis was visually assessed. However, this method may be affected by the individual investigator. Because our study population consisted of only 50 patients, only large effects were identified.

	References

Top Abstract Introduction Materials and Methods Results Discussion Conclusions Limitations References

 

1. Acar C, Jebara VA, Portoghese M, Beyssen B, Pagny JY, Grare P, et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-659discussion 659-60.[Abstract/Free Full Text]
   
2. Fremes SE, Christakis GT, Del Rizzo DF, Musiani A, Mallidi H, Goldman BS. The technique of radial artery bypass grafting and early clinical results. J Card Surg 1995;10:537-544.[Medline]
   
3. Reyes AT, Frame R, Brodman RF. Technique for harvesting the radial artery as a coronary artery bypass graft. Ann Thorac Surg 1995;59:118-126.[Abstract/Free Full Text]
   
4. Desai ND, Cohen EA, Naylor CD, Fremes SE. A randomized comparison of radial-artery and saphenous-vein coronary bypass grafts. N Engl J Med 2004;351:2302-2309.[Medline]
   
5. Bleiziffer S, Libera P, Lange R. Endoscopic radial artery harvesting through a single incision. Thorac Cardiovasc Surg 2006;54:208-209.[Medline]
   
6. McGowan JH, Cleland JGF. Reliability of reporting left ventricular systolic function by echocardiography: a systematic review of 3 methods. Am Heart J 2003;146:388-397.[Medline]
   
7. Patel AN, Henry AC, Hunnicutt C, Cockerham CA, Willey B, Urschel J, et al. Endoscopic radial artery harvesting is better than the open technique. Ann Thorac Surg 2004;78:149-153.[Abstract/Free Full Text]
   
8. Khot UN, Friedman DT, Pettersson G, Smedira NG, Li J, Ellis SG. Radial artery bypass grafts have an increased occurrence of angiographically severe stenosis and occlusion compared with left internal mammary arteries and saphenous vein grafts. Circulation 2004;109:2086-2091.[Abstract/Free Full Text]
   
9. Calafiore AM, Di Mauro M, D’Alessandro S, Teodori G, Vitolla G, Contini M, et al. Revascularization of the lateral wall: long-term angiographic and clinical results of radial artery versus right internal thoracic artery grafting. J Thorac Cardiovasc Surg 2002;123:225-231.[Abstract/Free Full Text]
   
10. Nezic DG, Knezevic AM, Milojevic PS, Dukanovic BP, Jovic, MD, Borzanovic, MD, et al. The fate of the radial artery conduit in coronary artery bypass grafting surgery. Eur J Cardiothorac Surg 2006;30:341-346Epub 2006 Jul 7.[Abstract/Free Full Text]
    
11. Buxton BF, Raman JS, Ruengsakulrach P, Gordon I, Rosalion A, Bellomo R, et al. Radial artery patency and clinical outcomes: five-year interim results of a randomized trial. J Thorac Cardiovasc Surg 2003;125:1363-1371.[Abstract/Free Full Text]
    
12. Webb CM, Collins P, Chong CF, DeSouza AC, Pepper JR, Moat NE. A randomized trial of radial artery and saphenous vein grafts: 5-year patency. Circulation Suppl 2006;114II-429.
    
13. Manabe S, Sunamori M. Radial artery graft for coronary artery bypass surgery: biological characteristics and clinical outcome. J Card Surg 2006;21:102-115.[Medline]
    
14. Zacharias A, Habib RH, Schwann TA, Riordan CJ, Durham SJ, Shah A. Improved survival with radial artery versus vein conduits in coronary bypass surgery with left internal thoracic artery to left anterior descending artery grafting. Circulation 2004;109:1489-1496.[Abstract/Free Full Text]
    
15. Miles RH, Kollpainter RE, Riveron FA, Johnkoski JA. The pneumatic tourniquet technique for endoscopic radial artery harvest. J Card Surg 2004;19:495-498.[Medline]
    
16. Yoshizaki T, Arai H, Igari T, Tabuchi N, Tanaka H, Sunamori M. Endoscopic radial artery harvesting: our initial experience and results of the first 25 patients. Ann Thorac Cardiovasc Surg 2005;11:391-396.[Medline]
    
17. Massetti M, Babatasi G, Bruno P, Le Page O, Neri E, Nataf P, et al. Less invasive radial artery harvest. Heart Surg Forum 2002;5(Suppl 4):S392-S397.[Medline]
    
18. Onorati F, De Feo M, Cristodoro L, Esposito A, Perrotti A, Mastroroberto P, et al. Can harvesting techniques modify postoperative results of the radial artery conduit?. Ital Heart J 2005;6:911-916.[Medline]
    
19. Cikirikcioglu M, Yasa M, Kerry Z, Posacioglu H, Boga M, Yagdi T, et al. The effects of the Harmonic Scalpel on the vasoreactivity and endothelial integrity of the radial artery: a comparison of two different techniques. J Thorac Cardiovasc Surg 2001;122:624-626.[Free Full Text]
    
20. Shapira OM, Eskenazi BR, Anter E, Joseph L, Christensen TG, Hunter CT, et al. Endoscopic versus conventional radial artery harvest for coronary artery bypass grafting: functional and histologic assessment of the conduit. J Thorac Cardiovasc Surg 2006;131:388-394.[Abstract/Free Full Text]
    
21. He GW, Yang CQ. Comparative study on calcium channel antagonists in the human radial artery: clinical implications. J Thorac Cardiovasc Surg 2000;119:94-100.[Abstract/Free Full Text]
    
22. Chamiot-Clerc P, Copie X, Renaud JF, Safar M, Girerd X. Comparative reactivity and mechanical properties of human isolated internal mammary and radial arteries. Cardiovasc Res 1998;37:811-819.[Abstract/Free Full Text]
    
23. Tatoulis J, Buxton BF, Fuller JA. Patencies of 2127 arterial to coronary conduits over 15 years. Ann Thorac Surg 2004;77:93-101.[Abstract/Free Full Text]
    
24. Desai ND, Naylor CD, Kiss A, Cohen EA, Feder-Elituv R, Miwa S, et al. Impact of patient and target-vessel characteristics on arterial and venous bypass graft patency: insight from a randomized trial. Circulation 2007;115:684-691.[Abstract/Free Full Text]
    
25. Royse AG, Royse CF, Tatoulis J, Grigg LE, Shah P, Hunt D, et al. Postoperative radial artery angiography for coronary artery bypass surgery. Eur J Cardiothorac Surg 2000;17:294-304.[Abstract/Free Full Text]
    

This article has been cited by other articles:

				B. F. Buxton, P. A. R. Hayward, A. E. Newcomb, S. Moten, S. Seevanayagam, and I. Gordon Choice of conduits for coronary artery bypass grafting: craft or science? Eur J Cardiothorac Surg, April 1, 2009; 35(4): 658 - 670. [Abstract] [Full Text] [PDF]

				G. Bisleri and C. Muneretto Endoscopic radial artery harvesting MMCTS, January 1, 2009; 2009(0907): mmcts.2008.003780 - mmcts.2008.003780. [Abstract] [Full Text] [PDF]

				S. Bleiziffer, I. Hettich, B. Eisenhauer, D. Ruzicka, B. Voss, R. Bauernschmitt, and R. Lange Neurologic sequelae of the donor arm after endoscopic versus conventional radial artery harvesting J. Thorac. Cardiovasc. Surg., September 1, 2008; 136(3): 681 - 687. [Abstract] [Full Text] [PDF]

				R. H. Habib Optimal target vessel stenosis for radial artery grafting. J. Thorac. Cardiovasc. Surg., February 1, 2008; 135(2): 463 - 463. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sabine Bleiziffer Ruediger Lange Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bleiziffer, S. Articles by Lange, R. Search for Related Content PubMed Articles by Bleiziffer, S. Articles by Lange, R. Related Collections Minimally invasive surgery