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J Thorac Cardiovasc Surg 2005;130:9-12
© 2005 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass

^a Departments of Cardiac Surgery and Angiology, Rome, Italy
^b Catholic University, Rome, Italy.

Received for publication October 18, 2004; revisions received January 18, 2005; accepted for publication February 10, 2005.

^_* Address for reprints: Mario Gaudino, MD, Divisione di Cardiochirurgia, Policlinico Universitario, A. Gemelli, Largo A. Gemelli 8, 00168 Rome, Italy. (Email: mgaudino{at}tiscali.it).

	Abstract

Top Abstract Introduction Patients and Methods Results Discussion References

 
BACKGROUND: Only scant information is available on the chronic consequences of radial artery removal for coronary artery bypass surgery on forearm circulation.

METHODS: Twenty-five patients submitted to radial artery removal for coronary artery bypass were submitted to serial Doppler echocardiographic evaluation of the flow and morphology of the forearm arteries.

RESULTS: The peak systolic velocity of the ulnar artery of the operated side was significantly higher than that of the control site. The intimal-medial thickness of the ulnar artery was always significantly higher on the operated side, and this difference reached statistical significance at 10 years’ follow-up. There was a significantly higher prevalence of atherosclerotic plaques in the ulnar artery of the operated versus control arm (7/25 vs 0/25, P = .03).

CONCLUSION: Radial artery removal for coronary artery bypass surgery leads to a chronic increase in ulnar flow accompanied by increased intimal-medial thickness and accelerated atherosclerotic disease. These findings might have potentially important implications for surgical indications and patient management.

	Introduction

Top Abstract Introduction Patients and Methods Results Discussion References

Although acute ischemic forearm complications caused by insufficient ulnar flow have been minimized with the adoption of various methods of preoperative assessment of the adequacy of UA compensation, ^3–6 only scant information is available on the long-term consequences of RA removal on the forearm circulation, ⁷ and no data on the effect of the long-term flow increase on the UA have to date been reported.

This study examines the midterm to long-term modifications of UA flow and structure in a series of 25 nonconsecutive patients at a mean interval of 10 years after RA removal for coronary artery bypass grafting.

	Patients and Methods

Top Abstract Introduction Patients and Methods Results Discussion References

 
Patient Population
Our institutional experience with the use of the RA as a coronary artery bypass conduit started in 1993; a detailed description of the operative technique used in the operation, perioperative management, follow-up methods, and midterm to long-term clinical and angiographic results has been previously published. ^1,6–10

Bilateral RA harvesting was never performed in our series, and the artery was always harvested from the nondominant arm. ⁸

This study includes the first 25 nonconsecutive patients who have reached the 10-year follow-up point at the time of enrollment and agreed to forearm examination. All these patients had already undergone a similar study protocol 5 years after the operation, and detailed results of that study have been published. ⁷ The main clinical data of these cases are depicted in Table 1.

Echogenic foci in the arterial wall with posterior acoustic shadowing were recorded as calcification. Those without posterior acoustic shadowing were recorded as atherosclerotic plaques. Stenosis was defined as a focal increase in peak systolic velocity compared with that seen in the proximal arterial segment.

Statistical Analysis
Data are expressed as means ± 1 standard deviation. For statistical analysis, the paired and unpaired t test was used.

	Results

Top Abstract Introduction Patients and Methods Results Discussion References

 
No patient reported having forearm ischemic symptoms at any time during the follow-up.

Detailed results of the Doppler echocardiographic examination are summarized in Table 2. The peak systolic velocity of the UA of the operated side was higher than that of the control arm, testifying to the ulnar compensation to RA removal. The IMT of the UA was always significantly higher on the operated side, and this difference reached statistical significance at 10 years’ follow-up (Table 2 and Figure 1 ). Moreover, there was a significantly higher prevalence of atherosclerotic plaques in the UA of the operated versus control arm (7/25 vs 0/25, P = .03; Figure 2), whereas no difference in atherosclerotic involvement was found between the brachial arteries of the 2 sides (2/25 vs 1/25, P = .97).

View larger version (10K): [in this window] [in a new window]   Figure 1. Variations of IMT with time in the operated versus control arm.

View larger version (88K): [in this window] [in a new window]   Figure 2. Atherosclerotic plaques in the UA of the operated arm 10 years after surgical intervention.

	Discussion

Top Abstract Introduction Patients and Methods Results Discussion References

Actually, the good clinical and angiographic results reported have ruled out the perplexities related to the long-term durability of this conduit, ^1,2 and the immediate consequences of RA harvesting on the forearm blood supply and the methods to minimize the incidence of acute hand ischemia have been clearly established. ^3–6 However, to date, only limited information is available on the long-term modifications of the forearm vasculature and circulation after RA harvesting.

After RA removal, the forearm blood supply becomes totally dependent on the UA. This compensation leads to the significant increase in flow of the UA of the operated site that is evident from the early postoperative period and, according to our data, remains unchanged at 5 and 10 years of follow-up. ⁷

Surprisingly, we found that in the years after surgical intervention, the IMT of the UA of the operated arm become progressively higher than that of the control side (Table 2). This difference was already evident at midterm follow-up and increased until reaching significance in the successive years (Figure 1).

Although it is not possible to exclude that the increase in IMT is the result of a remodeling of the arterial wall of the UA in response to the chronic flow increase without any detrimental consequences, the alarmingly high incidence of overt atherosclerosis reported in the UAs of the operated side seems to deny this favorable hypothesis and to suggest that the UA of the operated arm is more susceptible to the development of atherosclerosis compared with the nonoperated site (Table 2). This observation is concordant with the reported value of IMT as a marker of early atherosclerosis in other vascular districts. ^13–15

These findings remain to be confirmed in the longer term and in studies with larger sample sizes but open a new and alarming perspective on the possible chronic ischemic consequences of RA removal on the forearm circulation.

For the moment, our data must be kept in mind when selecting the appropriate arterial conduits for surgical myocardial revascularization and have particular relevance in young patients with a long life expectancy (to whom total arterial coronary revascularization is most often offered).

	References

Top Abstract Introduction Patients and Methods Results Discussion References

 

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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 Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mario Gaudino Gianfederico Possati Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gaudino, M. Articles by Possati, G. Search for Related Content PubMed PubMed Citation Articles by Gaudino, M. Articles by Possati, G. Related Collections Related Article