Dr. Mario Gaudino is the Stephen and Suzanne Weiss Professor in Cardiothoracic Surgery at New York Presbyterian – Weill Cornell Medical Center's Department of Cardiothoracic Surgery. He graduated from the University of Rome, Faculty of Medicine and Surgery, with a bachelor's degree in biology and a medical degree in 1994. In this video Dr. Gaudino discusses Coronary Artery Bypass Surgery After Transradial Catheterization.
Coronary Artery Bypass Surgery After Transradial Catheterization: Implementing 2021 ACC/AHA/SCAI Revascularization Guidelines Into Clinical Practice
Abstract In patients referred for coronary artery bypass grafting, the 2021 ACC/AHA/SCAI coronary artery disease revascularization guideline advocates radial artery (RA) access for coronary angiography and RA grafting over saphenous vein grafting. We discuss a case of a patient who had coronary angiography via both RAs and was unable to get RA bypass grafts as a result. (Advanced level of difficulty.) Introduction When compared to femoral access, using the transradial access (TRA) for cardiac catheterization minimizes bleeding and vascular problems (1). Furthermore, TRA is linked to a lower mortality rate in patients with acute coronary syndromes (2). TRA is recommended as the primary arterial access for coronary angiography or percutaneous coronary intervention in the 2021 ACC/AHA/SCAI coronary artery disease (CAD) revascularization guideline (3). The 2021 CAD revascularization guideline (3) recommends radial artery (RA) grafting over saphenous vein (SV) grafting (SVG) in patients referred for coronary artery bypass grafting (CABG) based on clinical trials and meta-analyses showing improved patency rates with RA compared to SVG and observational data reporting lower mortality with RA conduits (4,5). TRA, on the other hand, causes RA damage, and the patency rate of RA CABG conduits after TRA is poor (6). Some individuals who have coronary angiography may require CABG in the future, and TRA may limit the use of the RA as a CABG conduit in those patients. Presentation History The patient is a 52-year-old male who has been experiencing exertional chest pain radiating to the jaw for the past two months. The patient was obese, with a BMI of 38 kg/m2, according to physical examination. Total cholesterol of 256 mg/dL and hemoglobin A1c of 9.9% were found to be significant in laboratory tests. Previous Medical Experience Diabetes mellitus (DM), hypertension, hyperlipidemia, obstructive sleep apnea, a distant stroke with residual left-sided facial droop, peripheral neuropathy, depression, and arthritis were all present in the patient's past medical history. Investigation The patient was taken to an outside hospital for coronary angiography, which revealed 80% stenosis of the distal right coronary artery and distal obtuse marginal artery, as well as 80% to 90% stenosis of the second diagonal branch, via the left RA. The proximal and mid left anterior descending artery (LAD) had 60 percent stenosis of unknown hemodynamic relevance; however, fractional flow reserve was not accessible (Figure 1). The end-diastolic pressure in the left ventricle was 10 to 15 mm Hg. The patient was referred for dobutamine stress echocardiography to determine the hemodynamic relevance of the LAD lesion. The stress test was nondiagnostic due to an insufficient heart rate response (77 percent of the maximum anticipated heart rate), but it did not reveal any anomalies in regional wall motion during peak stress. Management The patient's symptoms improved after receiving initial medical treatment. He was taken to a different hospital a month later with resting chest pain. A second coronary angiography via the right RA revealed 70% stenosis of the proximal LAD and 60% stenosis of the midvessel (Figure 2). The LAD's fractional flow reserve was anomalous (0.74). The patient was referred for CABG because of his diabetic history and the existence of triple vessel disease. With a left internal thoracic artery to the LAD, an SVG to the posterior descending artery, an SVG to the distal obtuse marginal artery, and an SVG to the diagonal branch, he underwent quadruple bypass. Both RAs were unavailable for CABG because bilateral TRA was needed for cardiac catheterizations. Because of the significant risk of sternal wound problems associated with diabetes and obesity, the use of bilateral internal thoracic arteries (ITAs) was not recommended (7). His surgical recovery was uncomplicated. Discussion Expert advice DM is a strong predictor of complicated CAD (8) and long-term mortality following CABG (9). Furthermore, the CABG technique for persons with and without DM may differ (7). When compared to the transfemoral technique, TRA has been linked to better outcomes (1,2). The rate of TRA catherization grew from 10% to more than 25% between 2011 and 2014. TRA for coronary angiography is recommended in the 2021 CAD revascularization guideline (3) to prevent access site hemorrhage and vascular consequences (Class 1, Level of Evidence [LOE]: A). The benefits of TRA should be weighed against the potential of necessitating CABG in this patient with stable angina. CABG is recommended in patients with diabetes and multivessel CAD involving the LAD who are surgical candidates, according to the 2021 CAD revascularization guidelines (3). (Class 1, LOE: A). When grafting the LAD, the ITA is the conduit of choice, and the 2021 CAD revascularization recommendations (3) advocate it to minimize mortality and long-term cardiovascular events (Class 1, LOE: B-NR). The RA is emerging as the preferred conduit for the second graft (4,5), and the 2021 CAD guidelines propose it for grafting the second most significant artery (Class 1, LOE: B). However, the patency rate of RA treated with TRA and later used for CABG is low (6), making it a contraindication for usage, which is why the patient in this case was given SVG. The RA has a thin intima and an interior elastic lamina, and it is possible that TRA will cause considerable structural damage. Intimal dissection and reactive intimal hyperplasia with endothelial dysfunction are about twice as common in the RA of TRA patients compared to those who did not (6). Patients who have had TRA are more likely to experience medial bleeding, adventitial inflammation, and fat necrosis. Although the 2021 CAD guidelines (3) recommend bilateral ITA grafting to improve long-term cardiovascular outcomes (Class 2a, LOE: B-nonrandomized), the increased risk of sternal wound complications, which are independently associated with poor long-term survival and whose risk is significantly increased with bilateral ITA grafting, should be balanced (10,11). Because the RA's involvement in percutaneous diagnosis/intervention and CABG is expanding, close collaboration between the cardiac surgeon and the cardiologist is essential. A femoral approach may be required before coronary angiography if the cardiologist has a high index of suspicion that a patient requires surgical revascularization and the surgeon typically employs the RA as a conduit for CABG. Alternatively, ulnar compensation should be evaluated, and the site with the best compensation should be set aside for surgery. If the patient has had previous TRA procedures, the contralateral RA can be used for CABG if the same arm is used. Conclusions When selecting arterial access, it's critical to weigh the potential benefits of TRA against the possibility of needing bypass operations with a RA conduit in the future. It is critical to gain a better understanding of the advantages of using the RA for coronary angiography and CABG in order to customize treatment regimens for the best possible patient results.