AHA radial artery in CABG 2004

The use of arterial conduits has ex-panded beyond the LITA to include the right internal thoracic artery RITA, the right gastroepiploic artery RGEA, the inferior epigastric artery IEA, a

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Yves LeClerc and Stephen E Fremes Subodh Verma, Paul E Szmitko, Richard D Weisel, Daniel Bonneau, David Latter, Lee Errett,

Should Radial Arteries Be Used Routinely for Coronary Artery Bypass Grafting?

is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231

Circulation

doi: 10.1161/01.CIR.0000136998.39371.FF

2004;110:e40-e46

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Should Radial Arteries Be Used Routinely for Coronary

Artery Bypass Grafting?

Subodh Verma, MD, PhD; Paul E Szmitko, BSc; Richard D Weisel, MD; Daniel Bonneau, MD; David Latter, MD; Lee Errett, MD; Yves LeClerc, MD; Stephen E Fremes, MD

Case Presentation: Mr P is a

57-year-old construction

worker who has had Canadian

Cardiovascular Society class III angina

for the past 3 months He has multiple

cardiovascular risk factors including

smoking, hypertension, dyslipidemia,

and diabetes He is obese and has had

a previous laparotomy for a perforated

bowel Coronary angiography revealed

triple vessel disease involving the left

anterior descending artery (LAD), the

first obtuse marginal branch, and the

right coronary artery (RCA), and an

akinetic inferior wall with an estimated

ejection fraction of 40% The patient

was referred for consideration of

cor-onary artery bypass graft (CABG)

sur-gery Is Mr P a candidate for CABG

and, if so, which vascular conduits

should be used?

CABG is the standard surgical

pro-cedure for the treatment of advanced

coronary artery disease Since the first

successful results reported by

Favaloro,1 CABG surgery has been

demonstrated to improve symptoms

and, in specific subgroups of patients,

to prolong life.2 Despite its success,

the long-term outcome of coronary

bypass surgery is strongly influenced

by the fate of the vascular conduits used Five to 7 years after surgery, patients are at increased risk of suffer-ing from ischemic complications coin-cident with graft failure.2Furthermore,

as patients undergoing CABG surgery become older with more preoperative risk factors, and treated patients are living longer and therefore requiring reoperation, the optimal selection of vascular grafts for bypass is essential

Conduits Used in Bypass Surgery

Conventional CABG surgery utilizes a combination of arterial and venous grafts Saphenous vein (SV) grafts, the first vascular conduits used in CABG, are still widely utilized, primarily to bypass vessels other than the LAD

Despite being readily accessible, of adequate length to access every vessel

on the heart, and the correct diameter

to facilitate coronary and aortic anas-tomoses, SV grafts are limited by poor long-term patency Because of a com-bination of intimal hyperplasia and accelerated atherosclerosis, up to 15%

of SV grafts are occluded within 1 year,3and by 10 years postoperatively,

at least 50% demonstrate significant

disease.4,5 To bypass the LAD, most centers use the left internal thoracic (mammary) artery (LITA or LIMA) In contrast to SV grafts, the LITA dis-plays excellent long-term patency, up

to 90% after 10 years, which is asso-ciated with improved survival.5–9The excellent results obtained with the LITA anastomosed to the LAD have added strength to the concept of com-plete arterial revascularization to im-prove clinical outcomes Recently, a prospective randomized trial demon-strated that total arterial revasculariza-tion with composite grafts improved patient outcome in terms of freedom from cardiac events, angina recur-rence, and the need for percutaneous transluminal coronary angioplasty re-intervention when compared with con-ventional arterial and venous graft-ing.10 Additional arterial grafts are being increasingly used in place of the

SV to avoid the late complications of vein graft atherosclerosis and restenosis The use of arterial conduits has ex-panded beyond the LITA to include the right internal thoracic artery (RITA), the right gastroepiploic artery (RGEA), the inferior epigastric artery (IEA), and the radial artery (RA)

Bi-From the Division of Cardiac Surgery, Toronto General Hospital (S.V., P.E.S., R.D.W.), St Michael’s Hospital (D.B., D.L., L.E., Y.L.), and Sunnybrook and Women’s College Health Sciences Centre (S.E.F.), University of Toronto, Toronto, Canada.

Correspondence to Subodh Verma, MD, PhD, Division of Cardiac Surgery, Toronto General Hospital, 14 EN-215, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada E-mail subodh.verma@sympatico.ca

(Circulation 2004;110:e40-e46.)

Circulation is available at http://www.circulationaha.org DOI: 10.1161/01.CIR.0000136998.39371.FF

e40 by guest on February 26, 2013 http://circ.ahajournals.org/

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lateral ITAs, using the RITA as a

pedicled or free graft, have been

dem-onstrated to have long-term patency

exceeding SV grafts and result in

im-proved patient survival.11–14However,

no randomized trials have been done

The use of bilateral ITAs is commonly

avoided in elderly, obese, or diabetic

patients, characteristics common to

CABG patients, because of higher

rates of sternal infection, dehiscence,

and mediastinitis.15 The RGEA,

pri-marily used as an in situ graft to

bypass the RCA and its branches, has

shown reasonable long-term patency

that exceeds 90% up to 5 years

post-operatively.16,17 Its use, however, has

been limited because of the fragile

quality of the artery, the small

diame-ter of the vessel at the site of distal

anastomosis, concerns regarding

ves-sel twisting, increased operative time,

and incisional discomfort with

associ-ated ileus The IEAs, used in

compos-ite arterial conduits or as free

grafts,18 –20 are limited primarily by

their short usable length, only making

them suitable as grafts to diagonal or

intermediate branches The principle

adverse events associated with IEA

harvesting are related to wound

com-plications such as abdominal wall

he-matoma or infection, and relative

con-traindications to their use include

obesity, lower abdominal surgery, or

coexisting illness potentially requiring

abdominal surgery Thus, despite

im-proved graft patency, multiple arterial

conduits have not gained wider

accep-tance for myocardial revascularization

because of increased operative time,

limited access to distal coronary sites

because of graft length, and patient

factors that preclude their use The

final arterial conduit used, the radial

artery, which is the focus of this

re-view, overcomes many of these

disadvantages

Radial Arteries for CABG:

Historical Perspective

The RA was first used for coronary

revascularization by Carpentier and

colleagues in 1971.21However, 2 years

later, its use was abandoned because of

an occlusion rate that was greater than that observed in SV grafts A combi-nation of graft spasm and severe inti-mal hyperplasia,22,23likely the result of endothelial denudation from mechani-cal dilation and trauma on skeletonized harvesting, was thought to contribute

to the initial poor results obtained with

RA grafting The discovery of a patent

RA graft 15 years postoperatively, which was initially thought to be oc-cluded, prompted the revitalization of the RA as a bypass conduit.24

In 1992, Acar and colleagues24 re-ported the results from 104 patients who received a RA graft as a bypass conduit since 1989 The study showed that the RA is a reasonable alternative

to other types of conduits to comple-ment the LITA Notably, in contrast to initial attempts, early RA patency was 100% in this modern experience, likely because of modifications that reduced endothelial damage and graft spasm

Three major modifications are now used to minimize RA spasm, the primary cause of early graft failure First, the RA is harvested as a pedi-cle, including 2 satellite veins and the surrounding fatty tissue, using an atraumatic “no-touch” technique similar to that used in the harvest of other arterial conduits for coronary surgery (see the Figure).25,26During harvesting, direct handling of the RA

is avoided Second, mechanical dila-tion of the graft has been replaced by pharmacological dilation with papav-erine, a phosphodiesterase III inhib-itor that enhances the nitric oxide pathway, minimizing endothelial damage and dysfunction Third, in hopes of minimizing postoperative

RA spasm, vasodilator therapy, most commonly with calcium channel blockers or nitrates, has been adopted, despite limited clinical out-come data to support this practice

The RA, harvested as a pedicle, is dissected through a skin incision starting 3 cm distal

to the elbow crease lateral to the biceps tendon, stopping 1 cm before the proximal crease at the wrist level, centered over the radial pulsation, between the flexor carpi radialis and the radial tubercle Care is taken to avoid damaging the lateral antebrachial cutaneous nerve (sensory), which crosses obliquely from medial to lateral After incision

of the skin and fatty tissue, the RA can be seen in the distal third of the forearm beneath the fascial layer and is completely exposed by lateral mobilization of the bra-chioradialis All side branches are ligated and the artery is irrigated topically with dilute papaverine solution during the dissection Compared with the LITA, the RA has a much thicker muscular media that likely contributes to its increased propensity to go into spasm The RA may be proximally anastomosed to the LITA, forming a composite graft,

or to the ascending aorta to bypass all coronary territories Illustrated is the use of a free RA graft anastomosed proximally to the ascending aorta to bypass a lesion in the right coronary artery, the LITA anastomosed to the LAD, and a SV graft to the first obtuse marginal branch This operation is representative of those included in the RAPS.

OM indicates first obtuse marginal branch.

Verma et al Radial Arteries for CABG Surgery e41

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Potential Advantages of

Radial Artery Use

The RA possesses several anatomical

features that make it an excellent

can-didate for use in coronary

revascular-ization.27 The average length of the

RA, ⬎20 cm, makes it suitable to

bypass all coronary artery territories,

and its inner diameter, which is

be-tween 2 to 3 mm, closely matches that

of the coronary arteries Both coronary

and aortic anastomoses are technically

less demanding to construct with the

RA when compared with other arterial

conduits because of its thick muscular

wall On a practical basis, harvesting

of the RA may occur concurrently with

harvesting of all other conduits,

reduc-ing the duration of the surgical

procedure.26

When compared with other vascular

conduits, the RA provides additional

benefits According to observational

studies, relative to SV grafts, RAs can

be harvested without interfering with

ambulation and their use has been

shown to be protective against both

early and late mortality and

morbidi-ty,28resulting in enhanced late

surviv-al.29Also, unlike SV grafts, RA grafts

are adapted to higher arterial pressures

and have a homogeneous caliber free

from internal valves, characteristics

possibly contributing to the RA’s

su-perior results Compared with other

arterial grafts, contraindications such

as obesity, diabetes mellitus, or

previ-ous laparotomy do not apply to RA

harvesting, allowing this conduit to be

harvested in a majority of patients

When comparing the RITA to the RA

as a second arterial graft, patients re-ceiving a RA have a lower incidence

of sternal wound infection and de-creased transfusion requirement, though there is no difference in peri-operative or intermediate-term cardiac morbidity or mortality rates.30 Further-more, RA use is safe in patients with moderate to severe left ventricular dys-function31and in patients over the age

of 6532(see Table 1)

Potential Disadvantages of Radial Artery Use

Before harvesting the RA, it is manda-tory to assess the adequacy of the ulnar collateral circulation to the hand to avoid ischemia Methods to detect ad-equate forearm collateral flow include the Allen test, static and dynamic Doppler testing, direct digit pressure measurement during RA compression, and oxymetric plethysmography, to-gether with the computation of a per-fusion index.33 If concerns with the adequacy of the forearm collateral cir-culation are raised by the preoperative testing method, RA harvesting is con-traindicated Other contraindications to

RA harvesting include a radial artery plaque on ultrasound, damage to the

RA due to trauma or previous cannu-lation, the presence of an arterio-venous fistula for hemodialysis, vascu-litis, or Raynaud’s disease.26,34If there are no contraindications before har-vesting, removal of the RA does not result in any symptoms of hand

ische-mia or motor dysfunction.35Although rare, complications after RA harvest-ing may occur The most common complications noted, occurring in 2.6% to 15.2% of patients, are sensory abnormalities, especially cutaneous paresthesias in the radial distribution

of the lateral antebrachial cutaneous nerve or superficial branch of the ra-dial nerve, likely secondary to nerve injury from direct trauma, edema, or carpal tunnel hematoma.35,36Other dis-advantages of the RA include a slightly higher degree of atherosclero-sis as compared with the LITA and its increased chance of being subject to previous iatrogenic vascular

trau-ma.33,37 However, the inability to use the RA because of severe calcification

or chronic dissection from prior can-nulation is relatively rare, occurring in less than 2% of candidates for RA harvest34(see Table 1)

The major disadvantage, which may affect long-term performance, is the propensity of the RA to go into spasm

RA graft spasm is more intense and more difficult to reverse compared with spasm of the internal thoracic artery.38 Basic science investigations have elucidated the mechanism by which RA spasm is mediated Al-though nonreceptor-mediated spasm in response to surgical trauma and local tissue acidity is important, it is the receptor-mediated response to cate-cholamines and platelet-derived fac-tors, induced by endothelial damage and platelet aggregation, which should

be abrogated in the setting of a coro-nary bypass graft Endothelial function

of the RA, in terms of the release of endothelium-derived relaxing factors such as nitric oxide, is similar to that of other arteries, as is its sensitivity to vasoconstricting agents.38 Thus, the propensity for the RA to go into spasm

is likely due to the higher density of muscle cells in the media of this vessel that are organized into multiple tight layers, whereas the internal thoracic, gastroepiploic, and epigastric arteries have fewer muscle cells that are less organized.27Because of the more mus-cular nature of the RA, a significantly

TABLE 1 The Advantages and Disadvantages of Using the RA as a Bypass Conduit

Anatomical

Length ( ⵑ20 cm)

Luminal diameter (2 to 3 mm)

Thick muscular wall/easy to work with

Clinical

Excellent short-, mid-, and long-term patency

Obesity, diabetes, and previous laparotomy

are not contraindications

Decreased transfusion requirement

Lower rate of sternal wound infection

Practical

Decreased operating time since harvested

concurrently with other grafts

Increased propensity to spasm Contraindications include poor forearm collateral circulation, plaque on ultrasound, damage due to trauma or previous cannulation, presence of an arterio-venous fistula for hemodialysis, vasculitis,

or Raynaud’s disease Risk of hand sensory or motor dysfunction

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higher maximal contractile force can

result in response to vasoconstricting

agents, such as norepinephrine,

seroto-nin, endothelin I, and angiotensin II,

generated in response to endothelial

damage and dysfunction.33,38Thus, use

of the RA as a bypass conduit in

patients at high risk of needing

post-operative vasopressor support should

be avoided Currently, the propensity

of the RA to spasm has been greatly

reduced by minimal touch harvesting,

pharmacological dilation, and the use

of both topical and systemic

vasodila-tors, including calcium channel

block-ers,24,30 papaverine,24 the

phosphodies-terase inhibitor milrinone,34intravenous

nitroglycerin,39and␣-adrenergic

recep-tor blockers.40 Finally, studies suggest

that the RA should be limited to grafting

native vessels with a high degree of

stenosis (⬎70%) because of graft

sensi-tivity to competitive flow and its

in-creased propensity to spasm.41

Patency Rates of Radial Artery Conduits

The long-term success of CABG de-pends largely on graft patency Based

on the perceived advantages from ar-terial revascularization, the RA was increasingly used in the 1990s, either

as a separate graft or in composite grafts.20,24,34,42–56Several angiographic observational studies have shown that the RA achieves excellent short-, mid-, and long-term patency when used as a conduit for revascularization (see Ta-ble 2) Patency rates exceed that of SV grafts at all time points and are com-parable to those observed for other arterial conduits Similarly, the use of the RA in composite grafts, as T or Y grafts to the LITA, displays favorable short- and long-term patency.42– 44 Re-cently, Possati and colleagues56 de-scribed the long-term (105⫾9 months)

angiographic patency of RA grafts in a series of 90 consecutive CABG

pa-tients They found that the long-term patency rate of the RA, which was grafted to either an obtuse marginal or posterior descending branch, was 88% This was less than that of the LITA (96.3%), but was significantly better than the patency rate for saphenous vein grafts (53.4%) Thus, the long-term pa-tency of the RA appears to be superior to that of the SV, supporting its proposed role as a complementary arterial conduit for myocardial revascularization Al-though these results are encouraging, there are few long-term studies assessing the patency rates of RA grafts in symptom-free patients in a randomized, controlled setting To address this con-cern, there are 3 ongoing randomized trials to compare angiographic patency

of RA grafts versus other vascular con-duits These are the Radial Artery Pa-tency and Clinical Outcome (RAPCO) study,45 the Radial Artery Patency Study (RAPS),46and the VA

Compara-TABLE 2 Relative Patency Rates of Radial Artery Grafts

Acar et al 24/p early 56/56 (100%) 48/48 (100%) 11/11 (100%) 16/18 (89.9%) 䡠䡠䡠䡠䡠䡠 8/9 (88%) Calafiore et al47 early 26/26 (100%) 43/43 (100%) 35/35 (100%) 䡠䡠䡠 5/5 (100%) 䡠䡠䡠䡠䡠䡠 Calafiore et al 20 early 75/76 (98.7%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 67/70 (95.7%) 䡠䡠䡠 Chen et al 48 early 90/94 (95.7%) 62/62 (100%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 24/26 (92.3%)

da Costa et al 49 early 59/61 (96.7%) 31/32 (96.8%) 12/13 (92.3%) 䡠䡠䡠 1/1 (100%) 䡠䡠䡠 13/14 (92.8%)

Amano et al 51 early 137/139 (98.6%) 99/100 (99%) 27/27 (100%) 䡠䡠䡠 48/50 (96.0%) 䡠䡠䡠 34/38 (89.5%) Acar et al 24 mid 29/31 (93.5%) 28/28 (100%) 9/9 (100%) 11/13 (84.6%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠 Calafiore et al 47 mid 16/17 (94.1%) 31/31 (100%) 22/23 (95.6%) 䡠䡠䡠 2/2 (100%) 䡠䡠䡠䡠䡠䡠 Calafiore et al 20 mid 33/35 (99.3%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 25/25 (100%) 䡠䡠䡠 Manasse et al 52 mid 43/49 (87.8%) 45/47 (95.8%) 1/2 (50%) 2/4 (50%) 5/5 (100%) 䡠䡠䡠 35/46 (76.1%) Tatoulis et al 34 mid 21/22 (95.7%) 16/16 (100%) 䡠䡠䡠 1/1 (100%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠 Bhan et al 53 mid 60/62 (96.8%) 56/57 (98.2%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 Amano et al 51 mid 213/229 (93.0%) 142/149 (95.3%) 27/27 (100%) 䡠䡠䡠 75/82 (91.4%) 䡠䡠䡠 71/79 (89.8%) Acar et al 24 late 54/64 (84.4%) 44/47 (93.6%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 Possati et al 55 late 57/61 (91.9%) 58/60 (96.7%) 3/4 (75%) 䡠䡠䡠 9/10 (90%) 䡠䡠䡠 43/58 (74.1%) Buxton et al 45 group 1 late 38/39 (95%) 䡠䡠䡠䡠䡠䡠 29/29 (100%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠 Buxton et al 45 group 2 late 21/24 (86%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 21/22 (95%) Possati et al 56 late 74/84 (88%) 79/82 (96.3%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 39/73 (53.4%) Totals: early 529/542 (97.6%) 283/285 (99.3%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠

mid 415/445 (93.3%) 318/328 (97.0%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 late 244/272 (89.7%) 181/189 (95.8%) 䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠䡠 Early inidcates a mean follow-up of ⬍6 months; mid, a mean follow-up of 6 to 36 months; late, a mean follow-up exceeding 36 months; and SVG, saphenous vein graft.

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tive Study (Dr Steven Goldman,

per-sonal communication, 2004)

The RAPCO study was undertaken

to compare elective angiographic

pa-tency and cardiac event-free survival

of the RA graft with that of the free

RITA or SV during a 10-year period

after primary CABG surgery The RA

was compared with the free RITA in a

younger patient group (n⫽285, age

⬍70 years) and with the SV in an older

patient group (n⫽153, age ⱖ75 years)

Patients were randomly assigned to

receive either the RA, RITA, or SV

grafted to the largest available

coro-nary artery other than the LAD The

5-year interim results of this

prospec-tive, randomized, single-center trial

were recently reported.45 Buxton and

colleagues45 report that in the first 5

years after surgery, there were no

dif-ferences in the angiographic failure

rates and major clinical outcomes,

namely survival and cardiac event-free

survival, of the RA compared with the

RITA or SV However, these results

were based on only a small proportion

of the expected angiographic results

Furthermore, in their study,45SV graft

patency rates were much better than

those previously recorded or the

non-study SVs Also, the 5-year time point

may be too short to assess the true

difference in patency as SV grafts

begin to display accelerated graft

ath-erosclerosis and increasing rates of

graft failure between 5 and 10 years

postoperatively Thus, the final results

obtained after 10 years of follow-up

should help clarify the long-term RA

patency rates and whether the use of

this graft in CABG is superior to the

RITA or SV

The results of the second trial,

RAPS,46 were reported at the 2003

American Heart Association Scientific

Sessions.57 RAPS was a prospective,

multicenter, randomized clinical trial

comparing RA patency with that of the

SV when randomly allocated as the

graft to the right or circumflex

coro-nary arteries The primary objective of

the study was to determine the 8- to

12-month angiographic patency of the

RA relative to the SV, with each

pa-tient serving as his or her own control

The long-term patency (5 to 10 years)

of the RA relative to SV grafts will be assessed in follow-up studies A total

of 561 patients were enrolled, of whom

440 underwent follow-up angiography

Graft patency was greater in RA grafts (91.8%) than in SV grafts (86.4%,

P⫽0.01; graft occlusion odds ratio

⫽0.53, 95% confidence interval 0.31

to 0.85) Perfect graft patency, defined as grafts with Thrombolysis In Myocardial Infarction (TIMI) 3 flow, was similar

(87.7% versus 85.7%, P⫽0.37) Perfect

patency of the radial artery was highly dependent on the severity of the proxi-mal native coronary artery stenosis (70%

to 89% coronary stenosis: 81.7%; ⱖ

90% coronary stenosis: 91.5%) Patency

of the RA graft was similar in the RCA and circumflex territories

The Future of the Radial Artery as a Vascular Conduit

The RA is becoming increasingly pop-ular as a third arterial conduit in asso-ciation with the LITA and RITA, or as the second in patients with contraindi-cations to bilateral ITA harvesting

With the movement toward complete arterial revascularization and more fre-quent off-pump surgery to avoid aortic manipulation, the use of the RA to form composite arterial grafts to the LITA will become more common.58,59

Techniques simplifying the construc-tion of anastomoses between vessels and the aorta, by use of aortic connec-tors, may be extended to RA grafts.60

New pharmacological agents or gene therapy strategies61will be developed

to further decrease the potential for RA spasm, which remains a problem that may be most relevant in patients who require postoperative vasopressor sup-port Furthermore, minimally invasive approaches for the harvesting of the

RA are being developed, providing desirable clinical and cosmetic out-comes.62Finally, as more patients re-quire reoperation, the RA will be one

of the few conduits still available for use

Mr P was deemed eligible for CABG Because of his age, the use of arterial grafts was preferred However, his obesity, diabetes, and previous lap-arotomy prompted the surgeons to avoid harvesting the RITA, IEA, and RGEA His right Allen test was slug-gish; however, it was normal on the left Therefore, Mr P underwent CABG with a LITA to the LAD, a left radial artery graft to the distal RCA, and a SV graft to the first obtuse marginal branch, similar to the proce-dure illustrated in the Figure His peri-operative course was unremarkable and he was discharged from hospital 5 days after surgery

Note Added in Proof

During the review process, an impor-tant article on radial arteries was pub-lished by Zacharias et al.63The authors evaluated 6-year outcomes in propensity-matched CABG-LITA-LAD patients (925 each) divided into those with one radial graft and those with vein-only grafting Perioperative outcomes, including death, were simi-lar, although cumulative survival was better for patients receiving the radial artery graft Angiography data in re-studied symptomatic patients showed a trend for greater radial artery graft patency Furthermore, the extent of vein graft failure was significantly worse than that of radial graft falure These data would support the use of radial arteries as a second arterial con-duit in CABG-LITA-LAD as opposed

to vein grafting

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