1Department of Cardiothoracic Surgery, Weill
Cornell Medicine, New York, NY, USA
Conflict of Interest: None
Funding : None
Disclosures : None
Article word count : 533
IRV Information: None required
Address for correspondence :
Mario Gaudino, MD, PhD
Weill Cornell Medicine, Department of Cardiothoracic Surgery,
525 E 68th St, New York, NY 10065
Phone +1 212 746 9440
Fax +1 212 746 8080
Email mfg9004@med.cornell.edu
The use of the Radial Artery (RA) as a conduit in coronary artery bypass
grafting (CABG) has been steadily increasing since the early 1990’s and
based on the most recent data may well become the standard of care for
patients with multi-vessel coronary artery disease (CAD) requiring
multiple arterial grafts.1,2 The use of the RA confers
a morbidity and mortality benefit over the use of the saphenous vein for
CABG.1,2 The most recent Guidelines on myocardial
revascularization recommend the RA as the first choice for grafting the
second most important coronary artery (Class I, LOE
B).3
The TRA approach for cardiac catherization has also increased steadily
in use by interventional cardiologists owing to its reduction in
bleeding and vascular complications when compared with the femoral
approach4 and is now considered the preferred arterial
access according to the 2018 ESC/EACTS Guidelines on myocardial
revascularization (Class 1, LOE A)3.
However, prior use of transradial access (TRA) for cardiac catherization
is a contra-indication for the use of the RA for CABG because of high
rates of structural damage to the vascular wall and potential for graft
failure.5 TRA leads to significantly high rates of
intimal hyperplasia, impaired vasomotor function, intimal tearing,
dissection, and decreased diameter, which all contribute to higher rates
of graft failure.5
Although there are plenty of studies looking into the effects of TRA on
the RA5 , there are only two studies that specifically
examined the effect of TRA on RA CABG graft function and patency when
used in CABG and these studies looked only at short- and medium-term
outcomes.6,7 Kamiya et al.6 found
rates of stenosis free patency were more that 20% lower in those
patients who had prior TRA when compared with control (77% vs 98%) and
that intimal hyperplasia rates were 30% greater in the RA of patients
who underwent TRA compared to those who did not (68% vs 30%). Ruzieh
et al.7 had similar results with patency rates that
were nearly 20% lower in patients who had prior TRA when compared to
patients who did not.
At the moment, there is very limited evidence on the long-term impact of
TRA on the RA. Although the consensus is that the RA should not be used
early following TRA, because of the lack of data questions linger if in
the long term the RA will heal and be able to be used as a CABG conduit.
In this issue of the Journal of Cardiac Surgery Clarke et
al.8 examine the RA of two patients who had TRA for
coronary angiography 8 and 12 years prior and note that both patients
had chronic injury with dissection and obstruction of the lumen
secondary to fibrosis suggesting that TRA causes long-term and
irreversible damage rendering them unsuitable as conduits for CABG.
More data is needed but it appears that at least some of the damage
caused by TRA is permanent, and therefore the RA should not be used for
CABG even late after TRA. Due to the increasing use of the RA for both
percutaneous intervention and CABG this is an issue that will not go
away and close coordination and teamwork is needed between clinical and
interventional cardiologists and the cardiac surgery team.