Despite wide spread use of the radial artery(RA) graft for coronary artery bypass grafting, thechange of hand circulation after RA harvest has notbeen fully clarified. Severe hand ischemia such asresting pain or gangrene is a rare complication andhas been reported in 4 patients. These casesresulted from occlusive artery disease in forearm,which should be carefully explored before RA har-vest. Incidence of mild hand ischemia such as handclaudication or fatigue is unknown, but our studysuggested that around 10% of the patients devel-oped mild hand ischemia after RA harvest. Theblood flow to the forearm territory was decreasedby 20% after RA harvest despite the compensatorydilatation of ulnar artery. The presence of low per-fusion in the affected hand has been pointed out insome studies. We reported the decreased tissueoxygenation of the affected hand during hand gripexercise. The Allen test is the most popular preop-erative screening method, but is associated withconsiderable numbers of false-positive and false-negative results. Full length scanning of ulnarartery by ultrasonography seems to have a lowerfalse-positive rate. But further clinical experience isnecessary to establish a more reliable screeningmethod.

Key words: coronary artery bypass grafting, radialartery

Introduction

The radial artery (RA) graft was first introduced forcoronary artery bypass grafting (CABG) byCarpentier et al.1 in the early 1970s, but use of the RAgraft was soon abandoned because of the poor short-term results2. Twenty years later, however, the tenden-cy of RA grafts to resist atherosclerotic changes wasreported by Acar et al.3, and use of RA grafts for CABGgained acceptance with a new protocol to overcomeseveral difficulties encountered during the initial expe-rience with these grafts. Recently, a prospective ran-domized study revealed that, in comparison to thesaphenous vein graft, the RA graft is associated with alower rate of graft occlusion4; therefore, many surgeonshave began to use the RA graft as the second arterialgraft in addition to the left internal mammary artery.

Early RA graft failure was attributed to spasm of theRA graft. Acar et al.3 introduced antispasm prophylax-is to prevent postoperative graft spasm. We investigat-ed the effect of such antispasm therapy on hemody-namics and renal function and confirmed that the anti-spasm therapy to prevent RA spasm is safe5.

In contrast, changes in hand circulation after RA har-vest have not been fully investigated. Although severehand ischemia after RA harvest is rare6-9, its etiology isnot clear. Several patients were reported to sufferfrom hand claudication after RA harvest10,11, but theability of patients to tolerate to hand exercise is yet tobe examined. The Allen test is the most popular pre-operative screening method for RA harvest, but this testis considered far from ideal because it is associatedwith considerable numbers of false-positive and false-negative results. Many studies have attempted toestablish more sensitive methods to detect the risk ofhand ischemia9,12-20, but further clinical experience isnecessary to establish the superiority of other test to

Review

Hand circulation after radial artery harvest for coronary artery bypass grafting

Susumu Manabe, Noriyuki Tabuchi, Hiroyuki Tanaka, Hirokuni Arai and Makoto Sunamori

Department of Cardiothoracic Surgery, Graduate School of Medicine, Tokyo Medical and Dental University

J Med Dent Sci 2005; 52: 101–107

Corresponding Author: Susumu ManabeGraduate School of Medicine, Department of CardiothoracicSurgery, Tokyo Medical and Dental University, 1-5-45, Yushima,Bunkyo-ku, Tokyo 113-8519, JapanTel: +81-3-5803-5270 Fax: +81-3-5803-0141E-mail: s-manabe@fb3.so-net.ne.jpReceived January 26; Accepted March 18, 2005

the Allen test.In the present paper, we provide a review of previous

reports discussing postoperative hand circulationafter RA harvest. All values in this paper areexpressed as mean ±SD.

Severe hand ischemia after RA harvest (Table 1)

Severe hand ischemia after RA harvest is a rarecomplication and has been reported in only fourpatients6-9. Tatoulis et al.6 reported that 2 of 6646CABG patients experienced severe hand ischemiaafter RA harvest, which suggests that the incidence ofsevere hand ischemia is approximately 0.03%. Weencountered one patient who suffered severe handischemia after RA harvest9. The Allen test was per-formed prior to surgery, and a normal result was con-firmed. According to preoperative ultrasonography,however, the diameter (1.7 mm/m2) and blood flow(33.4 ml/min/m2) in the patient’s ulnar artery (UA) wasmuch smaller than mean value in study patients(mean UA diameter, 2.54 mm/m2; mean UA bloodflow, 54.3 ml/min/m2). During surgery, good back-flowwas observed from the distal stump of the cut RA. Thepatient developed pneumonia a week after surgery andthen became critically ill with sepsis. The thumb of theaffected hand became cyanotic and then gangrenous.He died of sepsis several weeks after surgery, and no

further examination was conducted.One of the major factors leading to severe ischemia

has been thought to be abnormal continuity of the pal-mar arch with the peripheral arterial system of the dig-its. However, Ruengsakulrach et al.24 examined 50hands of 25 cadavers and observed arterial communi-cation between RA and UA in all the hands. In fact, anincomplete palmar arch has not been documented as acause of severe hand ischemia. Most cases of severehand ischemia due to surgical manipulation of the RA(RA harvest for CABG, hemodialysis shunt, or a radialforearm radial flap) resulted from occlusive disease inthe forearm artery (Table 1). Therefore, preoperativeexclusion of occlusive artery disease in the forearm isconsidered essential to avoid severe hand ischemia.

Mild hand ischemia after RA harvest (Table 2)

Hand claudication after RA harvest has beenreported in patients with particular professions such asdentist11 or accordionist10. The ability to tolerate handexercise after RA harvest has not been examined indepth. According to previous questionnaire-basedsurveys, the postoperative functional status of theaffected hand was considered acceptable by mostpatients. Hand weakness was present in fewer than 6%of the patients and decreased with time25,26. Fewer than6% of the patients complained of any limitations in hand

S. MANABE et al. J Med Dent Sci102

Table 1. Case reports about severe hand ischemia after surgical intervention on radial artery

RA; radial artery, CABG; coronary artery bypass grafting; HD; hemodialysis.*Forearm abnormality was detected preoperatively, and RA reconstruction with a vein graft was conducted simultaneously. Therefore, post-operative hand ischemia was avoided in this patient.** Cases with a hand complication caused by an HD shunt-specific problem such as the steal phenomena were excluded.

activity26-28.We conducted careful face-to-face interviews of 40

patients 1 year after surgery, and found that modestsymptoms suggestive of exercise intolerance werepresent in 5 (12.5%) patients29. Their symptoms con-sisted of hand fatigue when carrying a heavy bag (4patients), awareness of reduced grasping power (2patients) and numness of the thumb during handexercise (1 patient). However, no ischemic symptomswere recorded in these symptomatic patients duringroutine follow-ups in the outpatient clinic. Thesesymptoms did not seriously affect their daily life activi-ties. Some symptomatic patients unconsciouslyadopted a strategy to avoid frequent use of the affectedhand after RA harvest. Therefore, most symptomsmay have been overlooked or considered of non-ischemic origin in most of the conventional surveys.

Change of blood flow to the forearm territory after RA harvest

Compensatory dilatation of the UA was observedimmediately after RA harvest. Plethysmography indi-cated that the diameter of UA increased by 15.7%, and

the flow velocity increased by 17.4% after RA harvest20.We measured blood flow in RA and UA at the wrist

by Doppler ultrasonography before and after RA har-vest29. Before RA harvest, the forearm territory wassupplied with an average blood flow of 103.0±34.4ml/min/m2 through two major arteries (RA: 53.6±24.8ml/min/m2, and UA: 49.6±16.8 ml/min/m2). After RAharvest, blood flow through the remained majorartery, the UA, to the forearm territory was decreasedby 20.5% on average (UA: 81.9±36.3 ml/min/m2,p=0.011). Royse et al.30 measured blood flow in thebrachial artery (BA) immediately proximal to theelbow and compared flow between the arm where theRA was harvested and the opposite arm where therewas no harvest. BA blood flow of the harvested armshowed a 19.2% decrease on average compared withthat of control arm (harvested arm, 144±27 ml/min;control arm, 176±35 ml/min; P=0.167). However,they measured maximal BA blood flow (blood flowimmediately after ischemic exercise); which was similarbetween the two arms (harvested arm, 348± 50ml/min; control arm, 371±63 ml/min; P=0.679) andconcluded that arterial insufficiency is unlikely to pre-sent even during vigorous physical activity involving thearm.

103HAND CIRCULATION AFTER RADIAL ARTERY HARVEST

Table 2. Summary of previous reports about hand function after radial artery harvest

Hand perfusion after RA harvest (Table 3)

Perfusion in the affected hand after RA harvest hasbeen examined with various methods, and the pres-ence of low perfusion has been observed insome10,20,29,33-38 but not all19,30-32 analyses. Severalstudies reported that perfusion in the affected hand waslow, especially during exercise; this suggests thepresence of exercise intolerance29,36,38. We measuredtissue oxygenation (TcPO2) during grip exercise in 40patients who had undergone RA harvest29. TcPO2

was lower in the affected hand than in the unaffectedhand during exercise. Seven patients (17.5%) experi-

enced a considerable drop (more than 10%) of TcPO2

during exercise, and the severity of this decrease inTcPO2 indicates leg ischemia as Fontaine class II.Symptomatic patients showed a significantly lowerTcPO2 than did asymptomatic patients (Table 4).

Another concern is whether exercise intolerance is atemporary phenomenon after RA harvest. Serrichio etal.36 documented similar decrease in TcPO2 in theaffected hand at 5 years after RA harvest. However,Lee et al.39 measured digital blood flow using plethys-mography and reported that the overall decrease in dis-tal blood flow immediately after RA harvest was signif-icantly improved in long-term by physiologic adaptation.

S. MANABE et al. J Med Dent Sci104

Table 3. Results of the clinical assessment representing hand perfusion after radial artery harvest

Preoperative screening to prevent hand ischemia (Table 5)

The Allen test has been the most popular preopera-tive screening method for RA harvest, but this test hassignificant numbers of false-positive and false-negativeresults. The Allen test usually excludes 5-10% ofCABG candidates from eligibility for RA harvest, but RAcould be safely harvested from most of thesepatients40-43. Abu Omar et al.40 reported that 88% ofpatients with a positive Allen test were free of any fore-arm arterial occlusive disease according to Dopplerultrasonographic studies and that RA could be har-vested without any hand ischemic complications.

Severe hand ischemia in patients with a negativeAllen test has also been reported6-9. A false-negativeresult can be caused by well-developed collateral cir-culation44, a superficial dorsal branch of the RA, or amedian artery45.

Many studies have attempted to establish moresensitive methods based on ultrasonography orplethysmography, compared to Allen test. We pro-posed that UA blood flow should be measured by ultra-sonography during Allen’s maneuver (manual com-pression of the RA at wrist)9. Because preoperative UAblood flow during Allen’s maneuver correlates wellwith postoperative UA blood flow after RA harvest, thepostoperative perfusion to the forearm territory can be

105HAND CIRCULATION AFTER RADIAL ARTERY HARVEST

Table 4. Tissue oxygen pressure (TcPO2) during grip exercise in symptomatic and asymptomatic patients

Table 5. Preoperative screening test for the safe removal of radial artery

UA; ulnar artery, RA; radial artery. * This data is obtained from reference 45

estimated with this test. The aforementioned patientwith severe hand ischemia would have been excludedas a candidate by this test because he had relativelylow UA flow during Allen’s maneuver (30.8ml/min/m2). We found that patients with modest symp-toms of hand ischemia suggestive of exercise intoler-ance had lower preoperative UA flow during RA com-pression (symptomatic patients, 40.5±12.3 ml/min/m2;asymptomatic patients, 81.0± 22.9 ml/min/m2, P=0.0004) and that UA flow during Allen’s maneuver ofless than 60 ml/min/m2 was predictive of postoperativeexercise intolerance29. However, most of these testsappear to have an even higher false-positive rate thanAllen test. Abu Omar et al.40 suggested ultrasono-graphic scanning of the full length of UA. A two-foldincrease in Doppler velocity in the UA precludes RAharvest. This test appears to have the lowest false-pos-itive rate and may increase the number of patients eli-gible for RA harvest.

Conclusion

Two types of postoperative hand ischemia havebeen reported after RA harvest for CABG (Table 6).Severe hand ischemia is a rare complication andresults from occlusive disease in the forearm artery.Full-length scanning of the UA by Doppler ultrasonog-raphy is considered useful to avoid this type of handischemia, and it has the lowest false-positive rate. Mildhand ischemia suggestive of exercise intolerance mayresult from poor UA flow reserve. Its incidence rateremains unknown but is estimated to be less than 10%.The clinical significance of this type of hand ischemiahas yet to be determined, but evaluation of preoperativeUA flow during Allen’s maneuver may be useful to pre-dict postoperative mild hand ischemia.

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107HAND CIRCULATION AFTER RADIAL ARTERY HARVEST