Asian Cardiovasc Thorac Ann 2008;16:43-46
© 2008 Asia Publishing EXchange Ltd
Endoscopic Radial Artery Harvesting: Patient Satisfaction and Complications
Satoru Nishida, MD,
Yujiro Kikuchi, MD,
Go Watanabe, MD,
Munehisa Takata, MD,
Shigeki Ito, MD,
Kenji Kawachi, MD
Division of Cardiac Surgery, Tokyo Medical University, Tokyo, Japan
For reprint information contact: Satoru Nishida, MD, Tel: 81 3 3342 6111 Ext. 2104, Fax: 81 3 3349 2950, Email: snishida{at}k6.dion.ne.jp, Division of Cardiac Surgery, Tokyo Medical University, 6-7-1 Nishi-shinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
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ABSTRACT
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Endoscopic radial artery harvesting was recently introduced to reduce the morbidity associated with conventional open harvesting and improve cosmetic outcomes. From January 2004 through December 2006, 25 radial arteries were harvested endoscopically from 25 patients using the VasoView endoscopic system. Bilateral radial arteries were harvested from 6 patients by both the endoscopic and open techniques, and postoperative patient satisfaction was assessed using a visual analogue scale. Mean harvesting time was 61.9 ± 16.0 min (range, 44–105 min), and mean harvested conduit length was 16.8 ± 2.0 cm (range, 15–19 cm). Objective dorsal thenar numbness remained in 2 patients (8%); none complained of forearm numbness. All patients expressed marked satisfaction with the endoscopic technique and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 vs 5). Postoperative angiography revealed occlusion of a graft that had been anastomosed to a small diagonal branch. The overall graft patency was 96.6%. Endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly regarding the cosmetic outcome.
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INTRODUCTION
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The use of radial artery for coronary artery revascularization has been steadily increased since the first report by Acar and colleagues1 in 1993. In patients with triple-vessel disease or risk factors for sternal wound complications, use of the radial artery allows the number of arterial anastomoses to be increased. Studies have demonstrated short-term patency and superior mid to long-term results with radial artery grafts compared to saphenous vein grafts.2–5 We developed a less-invasive method of coronary artery revascularization, which includes minimally invasive direct coronary artery bypass grafting and beating-heart endoscopic coronary artery surgery.6,7 However, we made long skin incisions from the wrist to the antecubital fossa to harvest the radial artery. Many patients who have undergone conventional open harvesting express cosmetic dissatisfaction. Furthermore, open harvesting is associated with several problems, particularly neurologic complications.8–15 In an attempt to improve cosmetic outcomes and reduce the incidence of complications, we began performing endoscopic radial artery harvesting with the VasoView Endoscopic Vessel Harvesting System (Guidant, Santa Clara, CA, USA). Our initial endoscopic harvesting experience and short-term clinical results are described herein.
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METHODS AND PATIENTS
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From January 2004 through December 2006, 25 patients underwent endoscopic harvesting for elective primary coronary revascularization at our institution. Their mean age was 66 ± 8.0 years (range, 53–79 years), and 3 were women. Six patients had diabetes mellitus, 3 had peripheral vascular disease, and one had chronic renal failure. Twenty-five radial arteries were harvested endoscopically from the nondominant arm. Bilateral radial arteries were harvested from 6 patients with both the endoscopic technique for the nondominant arm and the conventional open technique for the dominant arm. Before surgery, all patients gave written informed consent and underwent an Allen’s test to check the integrity of the palmar arch. Postoperative satisfaction of those who underwent bilateral radial artery harvesting was assessed by the patients themselves using a visual analogue scale on postoperative day 7. We set the score for the open technique at 5 points as the standard to compare the two procedures. All patients underwent postoperative angiography during their hospital stay to evaluate graft patency.
For radial artery harvest, a tourniquet was placed on the upper arm and connected to an insufflation device, but not pressurized. The donor arm was prepared and draped, and the hand was covered with a sterile glove. A 3-cm longitudinal incision was made over the radial artery, just proximal to the wrist crease. An initial dissection was carried out to identify the radial artery and accompanying veins, and to create a space for insertion of the blunt-tip trocar port. After exposure of the radial artery, sodium heparin (3,000 units) was administered intravenously, and the entire forearm was wrapped with an Esmark bandage (Medline, Mundelein, IL, USA). The tourniquet was inflated to 250 mm Hg, and the Esmark bandage was released. A 5-mm 0-degree fiberoptic endoscope (Guidant) was inserted into a VasoView conical-tip dissection cannula (Guidant), and connected to a fiberoptic video system. The trocar port was inserted into the wound, and its balloon was inflated to the minimum degree necessary to seal the incision (no more than 10 cc of air was required). Standard gas tubing insufflation at was attached to the trocar port, and CO2 5 L·min–1 with a pressure of 15 mm Hg was utilized for tunnel expansion. The dissection cannula was inserted through the trocar port, and anterior dissection of the radial artery was continued to the antecubital fossa by slipping the cannula under the lateral intermuscular fascia and lifting the tip anteriorly so as not to put dissection pressure on the radial artery. The dissection was carried out to no further than the recurrent radial artery or the large venous plexus just proximal to the antecubital fossa. After posterior and lateral dissections were carefully performed without directly contacting the radial artery, branch exposure was carried out to clear the tissue and allow efficient branch cauterization and division with minimal tension. The fiberoptic scope was inserted into the VasoView Uniport Plus (Guidant) using the bipolar scissors and cradles. The Uniport Plus was inserted into the dissected tunnel through the trocar port, and a fasciotomy of the lateral intermuscular septum was performed over the length of the forearm. Any anterior tributaries were divided by bipolar electrocautery set to 30 Watt. The tissue and tributaries identified laterally on each side of the radial artery pedicle were also divided by bipolar electrocautery, maintaining the spatial distance between the artery and the bipolar scissors by using the cradle to stabilize the pedicle. The cradle was run along the radial artery and accompanying veins to confirm that all side branches had been divided. The Uniport Plus was advanced to the end of the tunnel, and a stab incision was made into the tunnel. A mosquito clamp was inserted into the stab incision, and the radial artery pedicle was grasped. The radial artery was divided with the bipolar scissors with no coagulation, and the radial stump was pulled through the stab incision and ligated with sutures. Dissection of the distal radial artery pedicle was performed under direct observation with electrocautery, in the same manner as the traditional open harvesting technique. The forearm was wrapped with an elastic bandage, and the tourniquet was released. The hand was immediately assessed for blood flow by pulse oximetry. The radial artery was gently flushed with diluted olprinone hydrochloride solution, and the side branches were ligated with hemoclips for confirmation. The radial artery was placed in diluted olprinone hydrochloride solution until use. After coronary artery revascularization and reversal of heparin, the wrist incision was closed with 3/0 Vicryl (Ethicon Inc., Somerville, NJ, USA) and 4/0 monofilament. The stab incision was closed with 4/0 monofilament only. The entire forearm was tightly wrapped with an elastic bandage, but continued to be assessed for blood flow by pulse oximetry. Administration of intravenous nitroglycerin was started after induction of anesthesia and continued until 24 hours after the operation, when oral nitrates were started.
Data are expressed as the mean ± standard deviation. The visual analogue scale showing patient satisfaction was analyzed using the unpaired t test. Differences with a value of p < 0.05 were considered statistically significant.
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RESULTS
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All radial arteries were successfully harvested with no conversion to the open technique. The first patient required a second 3-cm incision near the antecubital fossa to control bleeding from the venous plexus; none of the next 24 patients required a second proximal incision. In 5 patients, some bleeding occurred from side branches during dissection, but it could be managed endoscopically. Mean harvest time, including skin closure, was 61.9 ± 16.0 min (range, 44–105 min). Mean harvested conduit length was 16.8 ± 2.0 cm (range, 15–19 cm). Only 3 of the 25 conduits required more than a single 7/0 monofilament suture for repair of side branches that were transected too close for clipping. All radial arteries were grossly acceptable and used as bypass conduits. All coronary bypass grafting was performed off-pump. There were 83 anastomoses carried out, 29 of which used radial arteries harvested endoscopically. All radial artery grafts were identified as patent on the basis of intraoperative Doppler analysis.
Postoperatively, the first patient had a tunnel hematoma and complained of numbness in all digits. However, the hematoma resolved and no numbness was present at the 30-day follow-up. No ischemic complications of the hand occurred. None of the patients had neither cellulitis nor infection. Five patients experienced objective dorsal thenar numbness in the distribution of the superficial radial nerve. At 30-day follow-up, numbness remained in 2 patients (8.0%). None complained of forearm numbness or paresthesias in the distribution of the lateral antebrachial cutaneous nerve. All patients expressed great satisfaction with endoscopic harvesting and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 compared with 5, p = 0.0002; Figure 1
). Postoperative angiography revealed an occluded radial artery graft that had been harvested endoscopically and anastomosed to a small diagonal branch. The patient was treated conservatively because all other bypass conduits were patent. The overall patency of the radial artery grafts harvested endoscopically was 96.6%.
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Figure 1. Endoscopic harvesting from the left arm, and conventional open harvesting from the right arm. The patient expressed marked satisfaction with the endoscopic technique.
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DISCUSSION
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The less-invasive endoscopic harvesting technique was recently introduced to reduce the morbidity associated with conventional open radial artery harvesting, and to improve cosmetic outcomes. In open harvesting, wound infection and functional loss are infrequent; however, hand and forearm numbness or paresthesia and patient dissatisfaction are not uncommon. The reported incidence of neurologic complications in open harvesting has ranged from 9.5% to 67.7%.8–15
In our endoscopic harvesting series, objective dorsal thenar numbness in the distribution of the superficial radial nerve occurred in 8% of patients. In previous studies, the incidence of neurologic complications after endoscopic harvesting has ranged from 1% to 27.8%.16–20 Although our results are comparable to those of other series, paresthesia related to the superficial radial nerve has unfortunately not been eliminated. This nerve may be encountered during distal forearm dissection. On the other hand, no patient experienced paresthesia or numbness in the distribution of the lateral antebrachial cutaneous nerve. Because the lateral antebrachial cutaneous nerve transverses the brachial muscle fascia sheath, contusion or damage to this nerve is unlikely during the endoscopic technique. In the open longitudinal harvest method, the lateral antebrachial cutaneous nerve can be injured by excessive traction, transection, or suturing during wound closure. Damage to the superficial radial nerve continues to be a problem for both the open method and this less-invasive endoscopic method. We hope that the development of smaller endoscopic equipment may further decrease the incidence of neurologic complications.
The greatest advantage of endoscopic harvesting is the cosmetic outcome. A conventional long incision on a visible part of the body is undesirable for patients. In our series, all patients were satisfied with the procedure because the distal small incision is almost concealed by a wristwatch, and the proximal stab incision healed completely and become invisible. Patients who underwent both techniques expressed significantly greater satisfaction with endoscopic than with open harvesting.
This procedure certainly has a leaning curve. In our series, the harvesting time decreased from 85 min for the first case to 48 min for the last case. Adequate experience with endoscopic vein harvesting is strongly recommend before attempting endoscopic harvesting. We did not have enough experience with endoscopic vein harvesting because we had been aggressively performing total arterial revascularization. Several companies have recently introduced a training model, which should help reduce the required harvesting time.
Although the short-term patency of endoscopically harvested radial arteries was excellent in our series, nothing is known about the mid and long-term patency. Furthermore, the cost of the endoscopic harvesting device remains high. However, this technique results in excellent patient satisfaction, particularly in regard to the cosmetic outcome. We hope that neurologic complication will be further reduced as experience with endoscopic harvesting increases, and this technique will be widely accepted. We believe that the only contraindication to endoscopic harvesting is an emergency procedure where grafts are required as soon as possible. In conclusion, endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly in regard to the cosmetic outcome. Damage to the superficial radial nerve continous to be a problem for both the open method and this less-invasive endoscopic method.
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REFERENCES
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ABSTRACT
INTRODUCTION
