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Long-term Patency of Endoscopically Harvested
Radial Arteries
From a Randomized Controlled Trial
Daniel J.P. Burns, MD,* Stuart A. Swinamer, MD,* Stephanie A. Fox, RRT,* Jonathan Romsa, MD,Þ
William Vezina, MD,ÞCigdem Akincioglu, MD,ÞJames Warrington, MD,ÞLin-Rui Guo, MD,*
Michael W.A. Chu, MD,* Mackenzie A. Quantz, MD,* Richard J. Novick, MD,* and Bob Kiaii, MD*
Objective: From 2005 to 2007, 119 patients were enrolled in a pro-
spective randomized controlled trial comparing openand endoscopically
harvested radial arteries for coronary artery bypass grafting. The ob-
jective of the current study was to compare graft patency between
intervention groups at more than 5 years from the initial trial. We hy-
pothesized that endoscopically harvested radial arteries would show
equivalent patency to those conventionally harvested.
Methods: At 5 years or greater from their operation, all consenting
patients underwent a single-day anatomic and functional cardiac as-
sessment with coronary computed tomography angiography and
sestamibi myocardial perfusion scanning. Medical Outcomes Study
36-Item Short-Form Health Surveys and Seattle Angina Question-
naires were completed to assess the overall quality of life. All patients
had received calcium channel blocker therapy for at least 6 months
postoperatively.
Results: The mean (SD) duration of follow-up was 79.2 (8.6) months
for all patients. One death occurred within 30 days of coronary artery
bypass grafting in each treatment group, and eight additional noncardiac
deaths occurred during the study time frame. Of 119 patients, 66
consented to follow-up. Thirty-two had open radial artery harvest, and
34 had endoscopic radial artery harvest. At more than 5 years, there
were 28 patent conventionally harvested radial arteries (87.5%) and 31
patent endoscopically harvested radial arteries (91.2%) (P=0.705).
Measured quality of life was comparable between groups.
Conclusions: Endoscopic radial artery harvest is safe and effective
when compared with open radial artery harvest, with excellent graft
patency demonstrated at more than 5 years. Patency results are
noninferior in endoscopic radial artery harvest.
Key Words: Radial artery, Endoscopic harvest, Coronary artery
bypass grafting, Minimally invasive.
(Innovations 2015;10:77Y84)
Currently the second most frequently used arterial conduit
in coronary artery bypass grafting, radial artery (RA) grafts
have been shown to be superior to saphenous vein provided that
the RA is grafted to coronary arteries of appropriate target size
and stenosis severity.
1Y4
Regarding harvest technique, endo-
scopic harvest of the saphenous vein (ESVH) has been widely
adopted at many centers, whereas endoscopic RA harvest
(ERAH) is not commonly performed.
5
Concerns for ESVH
primarily focus on the potential for increased surgical manipu-
lation, pressure, and traction on the vessel itself, ultimately af-
fecting endothelial integrity and long-term patency.
6
There is
currently little evidence to suggest whether the RA is affected in
this manner during endoscopic harvest. Often cited are the risk of
arterial vasospasm, conduit damage, and the necessary learning
curve to become proficient in endoscopic harvest.
5
Cited benefits of ERAH are much the same as those with
ESVH, although again there is less overall evidence assessing
ERAH.
3,5
Open RA harvest is associated with a wound com-
plication rate of approximately 4% and a major neurologic
complication rate of approximately 10%, although rates of any
neurologic injury have been reported as high as 70%, mostly
due to postoperative numbness.
5,7,8
In addition, the larger in-
cision required for open harvest leads to a large postoperative
scar. Wound, neurologic, and cosmetic results are all reportedly
improved with ERAH.
8
This study encompasses 5-year follow-up of patients en-
rolled in a previous randomized controlled trial (RCT) comparing
open RA harvest with ERAH. The previous study demonstrated
significantly improved postoperative arm pain, cosmetics, and
patient satisfaction, with a trend toward a significant decrease in
ORIGINAL ARTICLE
Innovations &Volume 10, Number 2, March/April 2015 77
Accepted for publication November 4, 2014.
From the *Division of Cardiac Surgery, Department of Surgery, and †Division
of Nuclear Medicine, Department of Medical Imaging, Western University,
London Health Sciences Centre, London, Ontario, Canada.
Presented at the Annual Scientific Meeting of the International Society for
Minimally Invasive Cardiothoracic Surgery, May 28Y31, 2014, Boston,
MA USA.
Disclosures: Michael W.A. Chu, MD, is on the Scientific Advisory Board,
with no remuneration, for Neochord, Inc., Eden Prairie, MN USA; a con-
sultant for Medtronic Canada, Brampton, Ontario, Canada; and Edwards
Lifesciences, Inc., Mississauga, Ontario, Canada. Bob Kiaii, MD, is a con-
sultant for Medtronic, Inc., Minneapolis, MN USA. Daniel J.P. Burns, MD,
Stuart A. Swinamer, MD, Stephanie A. Fox, RRT, Jonathan Romsa, MD,
William Vezina, MD, Cigdem Akincioglu, MD, James Warrington, MD,
Lin-Rui Guo, MD, Mackenzie A. Quantz, MD, and Richard J. Novick, MD,
declare no conflicts of interest.
Addresscorrespondenceand reprint requests to DanielJ.P.Burns, MD,Divisionof
Cardiac Surgery, Western University, London Health Sciences Centre, 6th
Floor, B-Wing, University Hospital, 339 Windermere Rd, London, Ontario,
Canada N6A 5A5. E-mail: Daniel.Burns@londonhospitals.ca.
Copyright *2015 by the International Society for Minimally Invasive
Cardiothoracic Surgery
ISSN: 1556-9845/15/1002-0077
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
postoperative wound infection compared with open harvest.
9
A
small, although statistically significant, length difference was
noted between the groups, with a 0.8 cm longer mean length in
the open group (PG0.001).
9
Equivalent postoperative arm
disability was also demonstrated. In a subgroup followed up at
6 months, angiographic patency was equivalent between the two
groups. The objective of this study was to determine the long-
term angiographic patency of RA grafts procured via ERAH,
as opposed to an open technique.
METHODS
Background Randomized Controlled Trial
Between April 2005 and January 2007, a total of 119
patients undergoing coronary artery bypass grafting with the
use of the RA as an arterial conduit were prospectively ran-
domized to have their RA harvested by either the conventional
open method (n = 59) or an endoscopic minimally invasive
technique (n = 60). This trial had 80% power to detect a 50%
difference in postoperative morbidity caused by pain, wound
infection, and neurological complications as well as improve-
ment in cosmetics, with a two-sided >error of 0.05. Group
allocation took place in the operating room by the sequential
drawing of a sealed opaque envelope. Inclusion criteria in-
cluded eligible patients who were older than 18 years and had
coronary artery disease necessitating elective or urgent coro-
nary artery revascularization using RA as one of the conduits.
The intention for all the patients, based on the patient’s cardiac
catheterization and Allen test result, was to use the RA for the
revascularization. All radial arteries were grafted to nonVleft
anterior descending target vessels exhibiting a stenosis of 90%
or greater. Exclusion criteria included the patient’s refusal to
have surgery or be involved in the study, inability to give in-
formed consent, and documented positive Allen test result
of both hands. The results of this initial trial are currently
awaiting publication.
Surgical Technique
To mitigate variability in surgical skill or technique, all
radial arteries were harvested bya single physician withextensive
experience in both harvest techniques. Patients randomized to the
open technique had their RA harvested essentially as previously
described by Reyes et al.
10
Specifically, access is obtained by
a longitudinal incision over the length of the forearm. The RA
is harvestedusing a combination of self-retaining retractors, low-
voltage electrocautery, and sharp dissection using hemaclips
for significant side branches. A ‘‘no touch’’ technique was em-
ployed using only the vena commitantes or remaining fascia
to retract the RA pedicle. All radial arteries were cannulated
proximally and injected with a solution of verapamil, nitro-
glycerin, and heparin. All radial arteries were immersed in the
same solution before grafting. Standard layered closure involved
a running deep fascial layer and a running subcuticular skin
closure. A small silastic drain was used and removed within
24 hours. Arms were not routinely wrapped.
Endoscopic harvest of the RA used a technique very
similar to that initially described by Connolly et al.
11
We
adapted our standard ESVH retractor (Karl Storz, Tuttlingen,
Germany), with the addition of harmonic shears (Ethicon Endo-
Surgery, Cincinnati, OH USA) for the dissection of the RA
pedicle (Fig. 1). After prepping and draping, the nondominant
armisplacedin90-degreeabductiononanarmboard,andthe
wrist is secured in slight hyperextension over a rolled towel. A
small 2-cm incision is made just proximal to the wrist crease,
just over the radial pulse. A small self-retaining retractor is
inserted, and the neurovascular fascia overlying the RA pedicle
is divided to definitively expose it. The ESVH retractor,
containing an endoscope, is then inserted into the incision.
Further division of this anterior fascial plane is continued
proximally with the harmonic shears after insertion beneath the
FIGURE 1. Equipment used for ERAH.
FIGURE 2. Harvesting the radial artery using harmonic shears.
Burns et al Innovations &Volume 10, Number 2, March/April 2015
78 Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
ESVH retractor, thus creating a working tunnel above the RA
pedicle (Fig. 2). Next, the side branchesand other attachments of
the pedicle are sealed and divided with the harmonic shears just
lateral tovena commitantes. The few inferior branches of the RA
are divided by sweeping the harmonic underneath the pedicle
from a medial and lateral aspect. This dissection is continued
proximally up the arm until a safe distance away from the axial
artery bifurcation into the ulnar and radial arteries is achieved.
Once heparin is systemically administered, the proximal aspect
of the RA is clipped with four medium-large hemaclips using a
10-mm endoscopic applicator. The proximal pedicle is divided
between the clips using endoscopic scissors and/or the harmonic
shears to remove the freed-up pedicle without bleeding. This
pedicle is then retrieved using the endoscopic hook dissector
from the Storz kit, and the clip at the terminal end of the RA is
excised to confirm adequate retrograde back bleeding from the
ulnar artery. As in the open group, this end of the RA is can-
nulated and gently infused with a solution of verapamil, nitro-
glycerin, and heparin. The distal end of the pedicle is clamped
and secured with a 2-0 tie, and the pedicle is placed in the so-
lution. The tunnel is irrigated, and a 4-mm silastic drain is
inserted. The incision is closed with a single 4-0 monofilament
for deep and skin layers (Fig. 3). Importantly, our technique does
not involve the use of CO
2
insufflation to help with tunnel cre-
ation or exposure as in a sealed system, thereby avoiding the
potential pitfalls of CO
2
insufflation.
12,13
No tourniquet is nec-
essary with our technique.
Graft Patency Assessment at 5 Years
All 119 patients were considered eligible for follow-up.
Patient demographics as enrolled in the initial trial are sum-
marized in Table 1. Of the initial 119 patients enrolled in the
original trial, 66 consented to follow-up (55.5%). Thirty-two
had open RA harvest, and 34 had ERAH. The mean (SD)
duration of follow-up for all patients was 79.2 (8.6) months.
Patient follow-up is detailed in Figure 4.
The study protocol for 5-year follow-up was reviewed
and approved by the ethics review board of Western University
and registered with ClinicalTrials.gov (NCT01559376). After
approval was obtained and at a minimum of 5 years, all pre-
viously enrolled patients were contacted for participation in the
follow-up study. Consenting patients were booked for a 1-day
comprehensive anatomic and functional cardiac assessment
using coronary computed tomography angiography (CCTA) to
assess graft patency and myocardial perfusion scintigraphy
(MPS) with rest and stress imaging using technetium-99 m
(
99m
Tc) 2-methoxyisobutyl-isonitrile (MIBI) to evaluate myo-
cardial perfusion. This technique to evaluate long-term patency
has been previously described.
14
Briefly, coronary calcium
scoring and subsequent coronary CCTA were performed on a
GE Light Speed VCT 64-slice CT scanner (General Electric
FIGURE 3. Final incision after endoscopic harvest.
TABLE 1. Patient Demographics
Open (n = 59) Endoscopic (n = 60)
Age, mean (SD) 57.9 (7.9) 57.8 (6.8)
Preoperative LOS,
mean (SD)
3.5 (4.4) 3.0 (3.8)
Preoperative LOS Q1 d 33 (55.9) 32 (53.3)
Female 4 (6.8) 6 (10.0)
Ventricular grade
1 34 (57.6) 33 (55.0)
2 9 (32.2) 23 (38.3)
3 6 (10.2) 4 (6.7)
Urgency
Elective 27 (45.8) 29 (48.3)
Emergent 0 (0) 2 (3.3)
Urgent 32 (54.2) 29 (48.3)
BMI, mean (SD) 29.8 (4.4) 30.7 (4.5)
BMI 930 24 (40.7) 34 (56.7)
COPD 5 (8.5) 6 (10.0)
Recent MI 18 (30.5) 4 (6.7)
PVD 2 (3.4) 0 (0)
CCS angina class
1 1 (1.7) 1 (1.7)
2 5 (8.5) 2 (3.3)
3 20 (33.9) 29 (48.3)
4 33 (55.9) 28 (46.7)
Diabetes
None 47 (79.7) 45 (75.0)
Diet control 1 (1.7) 4 (6.7)
Oral agents 8 (13.6) 10 (16.7)
Insulin 3 (5.1) 1 (1.7)
Cerebrovascular disease
None 59 (100) 57 (95.0)
CVA 0 (0) 2 (3.3)
TIA 0 (0) 1 (1.7)
Preoperative serum
creatinine
e120 55 (93.2) 57 (95.0)
9120Y180 4 (6.8) 3 (5.0)
CHF 1 (1.7) 1 (1.7)
Aortic atherosclerosis 3 (5.1) 7 (11.7)
Planned off pump 1 (1.7) 2 (3.3)
Values reported as n (%) unless otherwise specified.
BMI indicates body mass index; CCS, Canadian Cardiovascular Society; CHF,
congestive heart failure; COPD, chronic obstructive pulmonary disease; CVA, cerebro-
vascular accident; LOS, length of stay; MI, myocardial infarction; PVD, peripheral vas-
cular disease; TIA, transient ischemic attack.
Innovations &Volume 10, Number 2, March/April 2015 Open Versus Endoscopic Radial Artery Harvest
Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery 79
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
Healthcare, Milwaukee WI USA). On the same day, MPS was
performed using
99m
Tc-MIBI in accordance with a 1-day rest per
stress protocol (350Y450 MBq and 1000Y1500 MBq, respec-
tively). Studies were acquired and attenuation was corrected
using GE Infinia Hawkeye cameras (General Electric Healthcare).
All CCTA and MPS-MIBI studies were performed and interpreted
by a nuclear medicine physician with resulting reports reviewed
by members of the cardiac surgery investigators (Fig. 5).
This dual-modality evaluation provided both an anatomic
and functional assessment of graft function. Adding MPS to the
CCTA evaluation contributed functional information to the an-
atomic assessment, providing a more thorough understanding
of graft function in the face of equivocal anatomic infor mation.
Results of the CCTA were correlated with their hemodynamic
significance on MPS, and the results were graded accordingly.
14
Grade 1 was a widely patent graft. Grade 2A was an image
artifact or stenosis on CCTA that was found to not be hemo-
dynamically significant by MPS. Grade 2B was an image ar-
tifact or stenosis that was hemodynamically significant on MPS.
Grade 3 was a graft occlusion. If the patient had developed
symptoms prompting selective coronary artery and bypass graft
angiography, invasive angiographic results were used in lieu of
CCTA and MPS-MIBI.
Quality-of-Life Assessment
Quality of life was assessed using the Medical Outcomes
Study 36-Item Short-Form Health Survey (SF-36) as well as the
Seattle Angina Questionnaire (SAQ). These two validated health
surveys address symptom-related quality of life. The SAQ as-
sesses the following five dimensions of health in patients with
cardiovascular disease and is sensitive to their clinical change:
physical limitation, angina stability, angina frequency, treatment
satisfaction, and disease perception.
15
The SF-36 is a multi-item
scale used to assess eight general health concepts as follows:
limitations in physical activities because of health problems,
limitations in social activities because of physical or emotional
problems, limitations in usual role activities because of physical
health problems, bodily pain, general mental health (psycho-
logical distress and well-being), limitations in usual role activities
because of emotional problems, vitality (energy and fatigue), and
general health perceptions.
16
All patients were eligible for the
FIGURE 4. Patient flow diagram from trial to 5-year follow-up.
FIGURE 5. An example of a patent endoscopic radial to right
coronary artery.
Burns et al Innovations &Volume 10, Number 2, March/April 2015
80 Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
quality of life assessment, regardless of coronary reinter-
vention, in an intention-to-treat manner.
Statistical Analysis
Binary patency outcomes between groups were com-
pared using Fisher exact test, testing a null hypothesis of no
correlation between harvest technique and patency outcome. In
quality-of-life assessment comparisons, questionnaire scores were
compared between groups using nonparametric methods, spe-
cifically the two-sample Wilcoxon rank sum test, a distribution-
free method given nonnormally distributed data. This tested
a null hypothesis of no difference in median between the two
intervention groups. A PG0.05 was considered statistically
significant. All statistical analysis was performed using Stata
13.1 (StataCorp LP, College Station, TX USA).
RESULTS
Patients
Six deaths were recorded in the open harvest group, one
within 30 days of initial surgery, and five late deaths. Of these,
two were cancer related, one occurred secondary to a stroke
experienced approximately 4 years from the initial procedure,
one died of pneumonia and respiratory failure secondary to
interstitial lung disease on an unrelated admission, one died of
complications after an elective abdominal aortic aneurysm
repair, and one died of a pulmonary embolism at home within 3
to 4 weeks of the initial procedure. There were four deaths
recorded for the endoscopic harvest group, one within 30 days
of initial surgery and three late deaths. Of these, three were
cancer-related deaths, and 1 patient experienced a cardiac arrest
at home within 30 days of the initial procedure (postoperative
day 17). No patients in either group refused consent or were
excluded because of renal dysfunction.
Graft Assessment
Target vessel distribution of RA grafts by harvest group
is summarized in Table 2. In the open group, 32 RA grafts were
assessed. Coronary computed tomography angiography found
24 widely patent grafts with no evidence of associated ischemia
on MPS-MIBI. Two grafts exhibited an imaging artifact or stenosis
on CCTA that was nonhemodynamically significant on MPS-
MIBI, with no evidence of associated myocardial ischemia. Two
patients underwent conventional angiography, revealing widely
patent RA grafts. There were four graft occlusions. Overall,
patency in the open group at 78.7 (7.9) months was 87.5%.
In the endoscopic group, 34 radial grafts were assessed.
Coronary computed tomography angiography found 24 widely
patent grafts with no evidence of associated ischemia on MPS-
MIBI. Three grafts exhibited an imaging artifact or stenosis on
CCTA that was nonhemodynamically significant on MPS-
MIBI, with no evidence of associated ischemic myocardium.
There were two graft occlusions on CCTA. Five patients
underwent conventional angiography. Of these, four radial
arteries were found to be widely patent, with one complete
occlusion. Overall, patency in the endoscopic group at 79.7
(9.3) months was 91.2%.
Graft patency was not statistically significant between
intervention groups (P= 0.705). Duration of follow-up was
also found to be nonsignificant between groups (P= 0.812).
Statistical results for patency are summarized in Table 3.
Quality-of-Life Assessment
At the time of follow-up, 56 patients completed the SF-
36, and 57 patients completed the SAQ. In the open group, 28
patients completed both the SF-36 and SAQ; four patients
failed to complete either questionnaire. In the endoscopic
group, 28 of 34 patients completed the SF-36, whereas 29
endoscopic patients completed the SAQ. Scores from the SF-36
responses show that patients had a consistently high level of
functioning at the time of follow-up. Patients scored highly in
areas of physical, emotional, and social well-being. Mean (SD)
scores in all domains were greater than the baseline values of
50 (10) for the SF-36.
16
A score of 100 on the SF-36 denotes
symptom free, with a full level of functioning. When com-
paring SF-36 scores between intervention groups, no signifi-
cant score differences were found (Table 4).
Results of the SAQ show similarly that in all domains of
interest, patients scored consistently high. High scores on the
SAQ show greater freedom from symptoms and higher levels
of functioning.
15,17
Patients experienced a relative freedom
TABLE 3. Radial Artery Patency: CCTA, MPS-MIBI, and
Angiography
Open (32) Endoscopic (34) P*
Follow-up, mean
(SD), mo
78.7 (7.9) 79.7 (9.3) 0.812
Graft grade
G1: Patent 24 (75) 24 (70.6)
G2A:
Nonhemodynamically
significant stenosis or
image artifact
2 (6.3) 3 (8.8)
G2B: Hemodynamically
significant stenosis or
image artifact
0 (0) 0 (0)
G3: Total graft occlusion 4 (12.5) 2 (5.9)
Angiographic patency 2 (6.3) 4 (11.8)
Angiographic stenosis/
occlusion
0 (0) 1 (2.9)
Total patency 28 (87.5) 31 (91.2) 0.705
Values reported as n (%) unless otherwise specified.
*Wilcoxon rank sum test (follow-up); Fisher exact test (patency).
CCTA indicates coronary computed tomography angiography; MIBI, technetium-
99m 2-methoxyisobutyl-isonitrile; MPS, myocardial perfusion scintigraphy.
TABLE 2. Graft Frequency by Target Site
Target Open Endoscopic
Circumflex 0 (0) 1 (2.9)
Obtuse marginal 11 (34.4) 7 (20.6)
Diagonal 0 (0) 1 (2.9)
Ramus intermedius 0 (0) 1 (2.9)
Right coronary 3 (9.4) 7 (20.6)
Posterior descending 15 (46.9) 14 (41.2)
Posterolateral 3 (9.4) 3 (8.8)
Total 32 34
Values reported as n (%).
Innovations &Volume 10, Number 2, March/April 2015 Open Versus Endoscopic Radial Artery Harvest
Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery 81
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
from angina, without significant progression of symptoms
during the past year. Scores of higher than 50 in the angina
stability category indicate a lack of progression of angina
symptoms relative to the previous year. On the basis of the
SAQ, patients experienced a high level of physical functioning
and a low level of limitation with a positive disease perception.
When comparing SAQ scores between intervention groups, no
significant score differences were found (Table 5).
DISCUSSION
It has been shown previously that the RA provides pa-
tency superior to the saphenous vein, provided that it is grafted
to a vessel of adequate proximal stenosis, generally more than
90%.
1,2,4,18,19
Our patency results of 87.5% and 91.2% for open
and endoscopically harvested radial arteries, respectively, are
consistent with major RCTs examining RA use. In the 5-year
follow-up of the Radial Artery Patency Study (RAPS) multi-
center RCT, Deb et al
4
describe patency outcomes of 88% and
91.1% when considering functional and total graft occlusions,
respectively. Similarly, 5-year results from the Radial Artery
Versus Saphenous Vein Patency Randomized Trial (RSVP) re-
port RA patency of 88.1% and 98.3% when considering func-
tional and total graftocclusions.
20
The Radial Artery Patency and
Clinical Outcomes (RAPCO) trial reported RA patency ranges
from 89.3% to 92.3%.
18,19
Finally, a recent RCT demonstrated
RA patency of 89.5% at 1 year.
21
All of these cited trials have
examined patency in conventionally harvested radial arteries.
Our results demonstrate no statistical difference in patency be-
tween harvesting technique, with patency rates consistent to
those found in the literature, lending further support to the en-
doscopic technique.
Currently, little evidence exists comparing patency in
open RA harvest and ERAH. Few observational studies cur-
rently compare patency rates between these two harvesting
techniques. All fail to show significant differences in patency
between techniques over a follow-up range of 1 week to more
than 6 years.
22Y24
An additional observational study reported
separate patency results for those followed up by CCTA and
those undergoing symptom-driven angiography.
25
Combining
the patency results from this study gives patency outcomes of
90.2% versus 97.6% (P= 0.09) for open RA harvest and
ERAH, respectively.
25
Our results are consistent with current
observational studies and support the lack of patency differ-
ences between harvesting techniques.
Damage caused by working within a confined tunnel,
with instruments causing excess traction and pressure on the
vessel, is a concern for endoscopic harvest.
6
Also of concern is
thermal injury caused by the use of bipolar electrocautery in
sealed systems (Vasoview System, MAQUET Cardiovascular,
Wayne, NJ USA) or ultrasonic shears in open systems (Karl
Storz, Tuttlingen, Germany; Ethicon Endo-Surgery), which our
center uses. Ultrasonic shears may provide less thermal spread
relative to bipolar electrocautery.
26
However, space restrictions
in ERAH may still predispose the artery to damage, regardless
of instrument used. In arterial tissue samples from randomly
selected RCT patients, minimal signs of inflammation were
present upon histological examination. On further examination
by electron microscopy, minimal endothelial damage was
noted, with no differences found between open and endoscopic
groups.
27
Two prospective cohort studies show consistent re-
sults, noting no significant differences in major endothelial
damage involving the arterial lumen, no signs of bleeding or
inflammation in either harvest technique, and no difference in
arterial damage on comparative histology.
22,28
Upon functional
assessment, conventional and endoscopically harvested radial
arteries have failed to show significant differences in hormone-
mediated vasoreactivity, vasospasm, or endothelial-dependent
arterial relaxation.
27,28
All radial grafts assessed in this study were harvested by
a single physician, extensively experienced in both open and
endoscopic radial harvest. This physician was also extensively
experienced in ESVH using the same surgical equipment.
Harvester proficiency may be a major reason behind our re-
sults, mitigating conduit damage due to the act of endoscopic
harvest. Less experienced harvesters may potentially introduce
a bias toward conventional harvest as a result.
Our study used a formal protocol to conduct 5-year
follow-up using a combination of CCTA and MPS-MIBI to
evaluate both patency and function in open and endoscopically
harvested radial arteries. Provided that the coronary calcium
score is low, 64-multislice CCTA has been shown to demonstrate
no difference in terms of diagnostic sensitivity or specificity
when compared with conventional angiography.
29
Coronary
computed tomography angiography has also been shown to have
high sensitivity and specificity for detecting lesions of more
than 50%.
30
However, coronary artery visualization becomes
problematic on CCTA when faced with heavy coronary calci-
fication, surgical clips, intracoronary stents, small caliber ves-
sels, motion ar tifact, and increased body mass index. We feel we
have addressed these limitations by using MPS-MIBI as an
TABLE 4. MOS SF-36 Scores
Domain Open Endoscopic P*
Physical functioning 80.5 (21.9) 80.8 (19.6) 0.9473
Role limitations caused by physical health 79.5 (36.7) 80.4 (34.9) 0.9672
Role limitations caused by emotional
problems
94.0 (22.3) 91.7 (25.1) 0.6546
Energy/fatigue 65.4 (18.7) 65.6 (20.1) 0.9722
Emotional well-being 83.2 (14.2) 82.9 (12.2) 0.8719
Social functioning 92.0 (18.1) 90.6 (18.8) 0.8369
Pain 82.1 (19.8) 75.8 (26.0) 0.4989
General health 68.3 (20.0) 71.4 (18.3) 0.4124
Values reported as mean (SD).
*Wilcoxon rank sum test.
MOS SF-36 indicates Medical Outcomes Study Short-Form Health Survey.
TABLE 5. SAQ Results
Domain Open Endoscopic P*
Physical limitation 86.5 (14.3) 85.0 (18.4) 0.7758
Angina stability 56.3 (16.1) 56.0 (19.7) 0.7895
Angina frequency 96.4 (7.3) 94.1 (16.8) 0.7985
Treatment satisfaction 95.0 (9.7) 97.3 (10.0) 0.138
Disease perception 88.6 (13.1) 84.8 (17.9) 0.3657
Values reported as mean (SD).
*Wilcoxon rank sum test.
Burns et al Innovations &Volume 10, Number 2, March/April 2015
82 Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery
Copyright © 2015 by the International Society for Minimally Invasive Cardiothoracic Surgery. Unauthorized reproduction of this article is prohibited.
accompanying examination. Using MPS-MIBI, we were able to
assess any equivocal or abnormal computed tomography an-
giography information as well as its functional significance, by
being able to detect and localize areas ischemic myocardium.
We used a four-item patency scale, which harmonized the
computed tomography angiography and MPS-MIBI results.
We have also demonstrated that patients undergoing
ERAH have a high quality of life and level of functioning. We
used two health questionnaires to evaluate quality of life at
5 years after RA harvest. Patients scored consistently well above
baseline on the SF-36, a validated general health question-
naire. There was also consistently high scoring on the SAQ, a
disease-specific questionnaire more responsive tothe patients’
clinical change.
17
The merits of this study include its being a follow-up of a
previously randomized population at more than 5 years with a
comprehensive anatomic, functional, and quality-of-life as-
sessment. There are some limitations to the interpretation of
our results. The initial trial was not powered for patency dif-
ferences, and our follow-up study may be underpowered as a
result. Only 55.5% of the patients initially enrolled in the trial
were followed up at more than 5 years. A significant proportion
of patients refused consent (25.2%), whereas a smaller pro-
portion of patients were lost to follow-up (10.9%). This not
only decreases the power of our study to detect differences but
also introduces potential systematic error into the results. Most
notably, there is the potential for differential loss to follow-up,
whereby we cannot predict the proportions of patients lost who
have functioning or failed grafts. Similarly, patients who did
not consent to the study may be more likely to be asymp-
tomatic, with a high level of functioning and quality of life, and
elect not to be tested.
Because clinical records from the initial trial were
available and patency was not a primary outcome of the initial
trial, the outcome assessors were not blinded to group alloca-
tion at the time of graft and quality-of-life assessment. Al-
though results were assessed by both the nuclear medicine and
cardiac surgery teams (or also cardiology team if a symp-
tomatic patient underwent angiography), the potential for the
assessors to introduce bias is possible.
We conclude that ERAH is safe, effective, and durable at
more than 5 years when performed by an experienced harvester
using a nonsealed system. Patency results are excellent and
noninferior to those achieved in open RA harvest. Endoscopic
RA harvest is also associated with a high global level of func-
tioning, overall quality of life, and freedom from angina.
ACKNOWLEDGMENTS
The authors thank Ryan MacDonald and Michelle
Hewitt of the Division of Nuclear Medicine, London Health
Sciences Centre, London, Ontario, Canada, for their assis-
tance in patient scheduling and follow-up.
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Innovations &Volume 10, Number 2, March/April 2015 Open Versus Endoscopic Radial Artery Harvest
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CLINICAL PERSPECTIVE
This study reported on the long-term patency of endoscopically harvested radial arteries from a randomized, controlled study.
One-hundred nineteen patients at the London Health Sciences Centre were prospectively enrolled into a randomized trial
comparing open and endoscopically harvested radial arteries for coronary artery bypass grafting. Of these, 66 patients
consented to follow-up with similar numbers in both groups. In a follow-up of more than 5 years, 88% of conventionally
harvested radial arteries and 91% of endoscopically harvested radial arteries were patent with no significant differences
between the groups.
This is an excellent report and provides important mid-term patency data. Although there were a relatively small number of
patients available for late follow-up, their data strongly suggest that in an experienced center, endoscopic radial artery harvest can
achieve patency results similar to open. The authors rightly conclude that endoscopic radial artery harvest is an effective and
durable procedure. Their results are reassuring and an important contribution to the literature.
Burns et al Innovations &Volume 10, Number 2, March/April 2015
84 Copyright *2015 by the International Society for Minimally Invasive Cardiothoracic Surgery
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