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J Thorac Cardiovasc Surg 2008;135:1389-1390
© 2008 The American Association for Thoracic Surgery
Brief Communication |
a Raja Isteri Pengiran Anak Saleha Hospital, Brunei, Darussalam
b Department of Cardiac Surgery, Royal Brompton and Harefield NHS Trust, London, England
Received for publication September 29, 2007; accepted for publication November 15, 2007. * Address for reprints: Chee Fui Chong, PO Box 529, Bandar Seri Begawan BS8671, Brunei Darussalam. (Email: chong_chee_fui{at}hotmail.com).
Radial artery (RA) grafts have been reported to have significantly better early graft patency and endothelial function than long saphenous vein grafts.1
With increasing RA harvesting, knowledge of anatomic anomaly of RA can be useful for surgeons involved in harvesting RAs. We present a case of a rare RA anatomic anomaly in the forearm of a patient undergoing coronary artery bypass graft surgery.
A 45-year-old man with severe triple-vessel coronary artery disease affecting the left anterior descending (proximal stenosis > 90%), circumflex (proximal > 75%), and small nondominant right coronary arteries was referred for coronary artery bypass graft surgery. The preoperative bilateral modified Allen's test result was negative.
During surgery, the patient's left RA was harvested simultaneously with the internal thoracic artery and a segment of the long saphenous vein. A longitudinal curvilinear skin incision was made on the left forearm and the brachioradialis muscle reflected to expose the RA. The RA was harvested with the 2 adjacent venae comitantes by sharp dissection beginning from the elbow end. All side branches were clipped and divided. Two thirds of the way down the forearm, a large branch exiting posteriorly from the pedicle and diving deep to the pronator teres muscle was noted (
Figure 1). This large branch was clipped and divided.
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7 cm) and was grafted onto the first diagonal 1 instead of the intended obtuse marginal 1 under cardiopulmonary bypass and intermittent cold blood cardioplegic arrest. The long saphenous vein grafts were anastomosed to the posterolateral circumflex and obtuse marginal arteries with the internal thoracic artery to mid-left anterior descending artery. The patient made an uneventful recovery and was discharged on the sixth postoperative day. He was reviewed in the outpatient clinic 1 month later and had normal subjective sensation and grip power in his left forearm and hand.
Forearm morbidity associated with RA harvesting has been reportedly low at 5%.1 Ischemic complications after RA harvesting are rare and usually result from insufficient ulnar collateralization of the palmar arch.2 Such congenital anomalies of forearm arteries are rare, but a knowledge of the different patterns of congenital anomalies of the ulnar and RA arteries is vital for surgeons involved in harvesting RAs.3
We have reported an abnormal anatomic course of the RA in the left forearm. Its deviation through the pronator teres muscle proximally resulted in a shortened RA that was just sufficient to bypass the diagonal 1. The formation of a "Y" graft to the left internal thoracic artery may have just reached the obtuse marginal artery.
Different variations in RA anatomy have been described.3 The most common RA abnormality is the high RA origin from the axillary artery in the upper limb, reported in approximately 15% limbs examined.4 This variation is usually associated with a normal anatomic course in the forearm. The anomaly we have described has not been previously reported. The closest description is by Funk and colleagues4 of a rare anomaly arising from a distal division of the brachial artery into the ulnar and RA arteries under the pronator teres muscle with the RA pedicle assuming its normal position in the distal forearm through the pronator teres muscle. In our case, the venae comitantes had a normal anatomic course above the pronator teres. The RA in its aberrant course was not accompanied by the venae comitantes.
The development of a congenital anomaly, such as a high-origin RA, has been attributed to an arrest in stage V of upper limb vascular development (embryos of 23 mm C-R length).5 The proximal venae comitantes pedicle with the band may represent a developmental regression of the proximal part of the RA.5 As reported by Funk and colleagues,4 we believed that this anomaly would not be identifiable on routine preoperative examination of the forearm. Other forearm arterial anomalies have been described that are associated with hand vascular anomalies.2,5
A knowledge of the major arterial variation of the upper arm should be consider essential for anyone involved in harvesting of RA conduits to help avoid unnecessary difficulties or complications.
References
This article has been cited by other articles:
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  E. W.K. Peng and P. K. Sarkar Preoperative and intraoperative considerations for radial artery anomalies in coronary artery bypass grafting. J. Thorac. Cardiovasc. Surg., March 1, 2009; 137(3): 785 - 785. [Full Text] [PDF]
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