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only moderate stenosis aect long- term mortality? J orac
Cardiovasc Surg. 2016;151(3):806– 11.
50. Samano N, Geijer H, Liden M, Fremes S, Bodin L, Souza D. e notouch saphenous vein for coronary artery bypass graing maintains a
patency, aer 16years, comparable to the le internal thoracic artery:a
randomized trial. J orac Cardiovasc Surg. 2015;150(4):880– 8.
51. Tranbaugh RF, Dimitrova KR, Lucido DJ, Homan DM,
Dincheva GR, Geller CM, etal. e second best arterial gra:a
propensity analysis of the radial artery versus the free right
internal thoracic artery to bypass the circumex coronary artery.
J orac Cardiovasc Surg. 2014;147(1):133– 40.
52. Aldea GS, Bakaeen FG, Pal J, Fremes S, Head SJ, Sabik J, etal.
e Society of oracic Surgeons clinical practice guidelines on
arterial conduits for coronary artery bypass graing. Ann orac
Surg. 2016;101(2):801– 9.
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34
Bilateral internal thoracicarteries
Implications of the 10- year outcomes of the
Arterial Revascularisation Trial (ART)
David P. Taggart
Introduction
Although promoted by individual advocates before 1986, the use
of an internal thoracic artery (ITA) rather than a saphenous vein
to bypass the le anterior descending coronary artery became the
standard of care following the seminal study from the Cleveland
Clinic that year reporting that this strategy reduced mortality,
myocardial infarction, recurrent angina and the need for repeat
revascularization over a 10- year period.
Even earlier, in 1973, the use of bilateral internal thoracic artery
(BITA) graing was reported in ten patients out of a cohort of 43
who also had electromagnetic gra ow studies in the operating
room and early postoperative angiography that conrmed a gra
patency rate of 97%. Subsequently, the clinical outcomes of BITA
graing from several individual institutions, the largest series being
from the Cleveland Clinic, were combined into meta- analyses to
estimate the potential benets of BITA graing. e rst metaanalyses, reported in 2001, suggested a strong survival benet of
BITA graing and several subsequent meta- analyses provided conrmatory evidence.– e meta- analyses with the longest follow- up
of almost 15,000 patients to a mean of 9years also reported a survival benet with BITA graing.
Despite these consistent reports of the benets of BITA gras,
their actual use in contemporary clinical practice remains low,
being used in fewer than 5% of patients in the United States and
around 10% of patients in Europe but with a higher use in the Far
East. For almost two decades, uncertainties about BITA graing
have centred on three issues:(1) the increased complexity of the
operation, (2)a potential for increased mortality and morbidity
(especially the risk of sternal wound complications) and (3)the
lack of ‘hard evidence’ as the use of BITA gras had never been
subjected to randomized trials. It should, however, also be remembered that the seminal study from the Cleveland Clinic in 1986
describing the benets of a single ITA gra, which changed clinical
practice, was based on observational data rather than any evidence
from a randomized trial.
Furthermore, Gaudino etal. in an analysis of 38 observational
studies (with >174,000 patients) including 12 propensity scorematched studies (including 34,000 patients) reported a similar mortality reduction for BITA versus single internal thoracic artery (SITA)
both at 1year (when no additional survival benet would be expected)
and longer- term follow- up (when a survival benet might be expected
with progressive failure of vein gras), implying that unmeasured
confounders rather than biological superiority may explain, at least in
part, the survival advantage of BITA in observational series.
Consequently, in an attempt to obtain more robust scientic evidence as to whether BITA graing oers a survival benet over SITA
graing, the Arterial Revascularisation Trial (ART) enrolled 3102
patients between June 2014 and December 2017 in 28 centres in
seven countries. e primary outcome was all- cause mortality at
10years and the secondary outcome a composite of death, myocardial infarction, and stroke.
Analyses ofART byintention- to- treat and
as- treatedanalyses
Interim analyses of ART were published at 1year and 5years and
–
the nal analysis at 10years. e results were analysed both on
an intention- to- treat (ITT) basis to preserve randomization but also
on an as- treated basis because 40% of patients actually received a
dierent treatment from that initially proposed. is included 14%
of patients initially allocated to BITA graing who actually received
SITA graing, 4% of patients allocated to SITA graing who received BITA graing, and 22% of patients in the SITA group who
also received a second arterial gra in the form of a radial artery.
At the time of conception and inception of the trial there was no
conclusive evidence that the use of a radial artery would result in
superior angiographic and clinical outcomes compared to a saphenous vein.
On the primary ITT analysis (Fig. 34.1) there was no dierence
in all- cause mortality at 10years between BITA and SITA (hazard
SECTION 6 Conduits forcoronary artery bypass graft surgery270
Death from Any Cause at 10 Yr(a)
(b) Composite of Death from Any Cause, Myocardial Infarction, or Stroke at 10 Yr
Bilateral graft
1548
1435
1362
1299
1214
830
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100
25
90
20
80
15
70
60
10
50
5
40
0
30
Patients Who Died (%)
20
10
No. at Risk
Single graft
Bilateral graft
100
90
80
70
60
50
40
30
20
Patients Who Event (%)
No. at Risk
Single graft
10
0 246810
0
02
Years since Randomization
1554
1548
0
02
1554
1484
1481
25
20
15
10
5
0
0 246810
Years since Randomization
1427
Single graft
Bilateral graft
Hazard ratio, 0.96 (95% CI, 0.82–1.12)
P = 0.62
46810
1432
1417
Hazard ratio, 0.90 (95% CI, 0.79–1.03)
46810
1366
1370
1359
Single graft
Bilateral graft
1296
1283
1283
1195
894
882
820
Fig.34.1 Primary outcome of death from any cause and composite outcome of death from any cause, myocardial infarction, or stroke at 10years.
Hazard ratios use the single- graft group as the reference. Insets show the same data on an enlarged y- axis.
Reproduced from Taggart DP, Benedetto U, Gerry S, etal. Bilateral versus Single Internal- Thoracic- Artery Grafts at 10 Years. N Engl J Med. 2019;380(5):437– 46.doi:10.1056/
NEJMoa1808783 with permission fromMassachusetts Medical Society.
ration (HR) 0.96, 95% condence interval (CI) 0.82– 1.12; P=0.62).
ere was a trend towards a reduction in the HR in favour of BITA
graing on the composite outcome of death, myocardial infarction,
and stroke but this did not reach statistical signicance (HR 0.9, 95%
CI 0.79– 1.03). In contrast, in the as- treated analysis, patients who
actually received two or more arterial gras had a clear reduction in
both mortality and the composite end point at 10years (Fig. 34.2).
While the as- treated analysis cannot rely on the minimization of
confounders assured by randomization, it is nevertheless reassuring
that 20 baseline characteristics of patients in the single and multiple
arterial gra groups, which are strong predictors of both short and
long- term outcomes, were very similar.
Effects ofthe radial artery inART
During the design of ART in 2001, it was assumed that a radial
artery gra was simply an alternative conduit to saphenous vein
without superior angiographic patency or additional clinical benet.
However, in 2018 in an analysis of six randomized trials with 1036
patients, comparing angiographic and clinical outcomes in coronary
artery bypass gra (CABG) patients receiving a supplemental radial
artery or saphenous vein gra at 5years, there was a signicant reduction in the composite end point of death, myocardial infarction,
and repeat revascularization in favour of the radial artery almost
certainly explicatable by an angiographic failure rate of 8% for the
radial artery versus 20% for the saphenous vein. Around 20% of all
patients in ART received a radial artery. In ART, comparison of the
primary composite end point of death, myocardial infarction, and
repeat revascularization in propensity- matched patients who did or
did not receive a radial artery showed that addition of a radial artery resulted in a signicantly lower incidence of the composite end
point (8.8% vs 13.9%; P=0.005). It should also be appreciated that
in ART a radial artery was typically used as a second arterial gra
and may have had a greater benecial eect on clinical outcomes
than when used as a third arterial gra.
Death from Any Cause at 10 Yr(a)
(b)
25
No. at Risk
Multiple arterial grafts
Single arterial graft
998
750
81
No. at Risk
Multiple arterial grafts
Single arterial graft
1330
1212
1162
1101
1006
934
691
81
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100
90
20
80
15
70
10
60
5
50
40
30
Patients Who died (%)
20
10
0
0246810
02
Single arterial graft
Multiple arterial grafts
46
Time from enrolment (years)
34 Bilateral internal thoracicarteries 271
0
1690
1330
100
90
80
70
60
50
40
30
20
Patients With event (%)
10
0
0246
1690
1632
1270
30
25
20
15
10
5
0
0246810
1591
1567
1222
Single arterial graft
Time from enrolment (years)
1510
1510
1163
Multiple arterial grafts
1442
1430
1081
1353
0
Fig.34.2 (a) As- treated analysis of multiple (two or more) arterial grafts versus single arterial graft (mortality). Adjusted HR 0.81; 95%, CI 0.68– 0.95.
(b)As- treated analysis of multiple (two or more) arterial grafts versus single arterial graft (all- cause mortality, myocardial infarction, or stroke). Adjusted
HR 0.80, 95% CI 0.69– 0.93.
Reproduced from Taggart DP, Benedetto U, Gerry S, etal. Bilateral versus Single Internal- Thoracic- Artery Grafts at 10 Years. N Engl J Med. 2019;380(5):437– 46.doi:10.1056/
NEJMoa1808783 with permission fromMassachusetts Medical Society.
Surgeonexperience
e importance of surgeon experience to achieve optimal surgical
outcomes is increasingly recognized whether for o- pump CABG or
multiple arterial gras. In a pooled analysis of 34 studies including
almost 28,000 patients undergoing BITA graing, the incidence of
long- term mortality and deep sternal wound infection was inversely
correlated with surgeon experience. BITA series from surgeons/
centres with a higher percentage of BITA graing typically report
signicantly lower long- term mortality and deep sternal wound infection, suggesting a very specic volume/ outcomes relationship
for BITA graing. Asimilar eect was seen in the ART study at
10years, where even in the ITT analysis a signicant survival benet
as well as a signicant reduction in the composite end point in favour of BITA was observed when BITA was performed by surgeons
who had enrolled at least 50 patients in the trial. It is of particular
note that the highest volume performing surgeon in ART who personally enrolled 416 cases had a signicant reduction in mortality
in an ITT analysis at 10years with survival curves continuing to diverge. An interim analysis of the ART study at 5years among the 131
participating surgeons reported that while the overall conversion
rate from BITA to SITA graing was 14%, per individual surgeon it
varied from 0% to 100%. Patients who underwent conversion received a signicantly lower number of gras (2.95 vs 3.21; P <0.001).
Hospital mortality was lower in those patients who did not require
conversion (0% vs 1.6%; P=0.1), but this comparison did not reach
statistical signicance. At 5years there was a non- signicant excess
of deaths (11.9% vs 8.4%) and major adverse events (17.1% vs 13.2%;
mainly driven by repeat revascularization) in those who underwent
conversion.
On- pump versus off- pump inthe ARTstudy
In ART, 1260 of 3102 patients underwent o- pump CABG (40%). In
an interim analysis of the 5- year results, 1260 patients were selected
for propensity matching. e conversion rate from o- pump to
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on- pump surgery was 2.3% which was much lower than in other
contemporary trials of on- pump versus o- pump surgery where
conversion rates have been reported to vary from 7% to 12%. e
overall hospital mortality outcomes were equivalent between onpump and o- pump CABG (1% vs 1.2%; P=not signicant), but
there was a striking increase in in- hospital mortality in patients
undergoing conversion from o- pump to on- pump (10.3% vs
0.7%:P <0.001). At 5years, the overall mortality rates were similar
advantage at 10years in patients actually receiving two or more
arterial gras. Two other important messages from ART are that
surgeon experience is critical to achieving improved survival
with BITA graing and that o- pump CABG leads to equivalent
long- term outcomes as on- pump CABG when performed by experienced surgeons. Finally, use of a skeletonization rather than
pedicled harvest technique reduces the risk of sternal wound
complications in BITA graing.
between on- pump and o- pump CABG (8.9% and 8.3%) as was the
overall incidence of major adverse cardiac and cerebral vascular
events (14.3% vs 13.8%). e 5- year interim analysis suggested that
both o- pump and on- pump surgery are equally safe and eective.
e 10- year analysis also conrms again no signicant dierence in
outcomes between on- pump and o- pump CABG. is is a particularly important nding because there are no other such 10- year
follow- up data from other randomized trials and especially as several analyses of trials performed by less experienced o- pump surgeons suggested inferior outcomes with o- pump surgery at 5years.
e 10- year outcomes of ART are consistent with the ndings of
Kirmani etal., who showed in a series of almost 13,000 patients no
dierence in survival between on- and o- pump CABG at 15years.
Sternal wound complications:pedicled
and skeletonized BITAharvesting
e overall incidence of sternal wound reconstruction was 0.6% in
the SITA group and 1.9% in the BITA group, that is, an absolute difference of 1.3% or a number needed to harm of 78. In a subsequent
analysis of four methods of harvesting comparing pedicled SITA
(N=607), pedicled BITA (N=459), skeletonized SITA (N=512),
and skeletonized BITA (N= 478), propensity scores were used to
estimate the risk of any wound complication in these four groups.
Atotal of 219 of 2056 patients (10.6%) experienced a sternal wound
complication within 1year from the index operation. Of those, only
25 patients (1.2%) required sternal wound reconstruction. Pedicled
BITA (odds ratio (OR) 1.80, 95% CI 1.23– 2.63) but not skeletonized
BITA (OR 1.00, 95% CI 0.65– 1.53) or skeletonized SITA (OR 0.89,
95% CI 0.57– 1.38) was associated with a signicantly increased risk
of any sternal wound complications compared with pedicled SITA.
In conclusion, pedicled BITA, but not skeletonized SITA or skeletonized BITA was associated with a signicantly increased risk of any
sternal wound complications. is substudy suggested that the risk
of sternal wound complications with a BITA skeletonization technique is similar to that of standard pedicled SITA harvesting and
that skeletonized SITA harvesting did not add any further benet
compared to pedicled SITA harvesting.
Summary andconclusions
ART was the rst randomized trial of BITA versus SITA graing
and at 10years on an ITT analysis showed no dierence in outcomes for the primary end point of all- cause mortality or the
composite end point. However, the interpretation of ART was
confounded by 40% of the population actually receiving a different treatment from that initially proposed. Consequently, an
as- treated analysis was performed that showed a strong survival
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gra on 10- year survival and other cardiac events. N Engl J Med.
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Akhrass R, etal. Two internal thoracic artery gras are better
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revascularisation on survival:a systematic review of studies
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Cardiothorac Surg. 2013;2(4):390– 400.
7. Yi G, Shine B, Rehman SM, Altman DG, Taggart DP. Eect of
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Deb S, etal. Unmeasured confounders in observational studies
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11. Taggart DP, Altman DG, Gray AM, Lees B, Nugara F, Yu LM,
etal. Randomized trial to compare bilateral vs. single internal
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of the Arterial Revascularisation Trial (ART). Eur Heart J.
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12. Taggart DP, Altman DG, Gray AM, Lees B, Gerry S, Benedetto U,
etal. Randomized trial of bilateral versus single internal- thoracicartery gras. N Engl J Med. 2016;375(26):2540– 9.
13. Taggart DP, Benedetto U, Gerry S, Altman DG, Gray AM, Lees
B, etal. Bilateral versus single internal- thoracic- artery gras at
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14. Gaudino M, Benedetto U, Fremes S, Biondi- Zoccai G,
Sedrakyan A, Puskas JD, etal. Radial- artery or saphenousvein gras in coronary- artery bypass surgery. N Engl J Med.
2018;378(22):2069– 77.
15. Taggart DP, Altman DG, Flather M, Gerry S, Gray A, Lees B, etal.
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35
The radialartery
Robert F. Tranbaugh, Mario Gaudino, Brian F. Buxton, and James Tatoulis
Introduction
and greater than 80% at 20years are reported., Hence, the RA can
be used as the second or third gra of choice aer the LITA and/
Introduced and then abandoned by Carpentier and revived by Acar,
the radial artery (RA) is a versatile, long, robust, facile coronary bypass gra with excellent long- term patency, providing spasm and
competitive ow are avoided. Although intuitively the right internal
thoracic artery (RITA) is the natural second arterial gra during
coronary artery bypass graing (CABG), it is rarely used, or may
or RITA., Of note, the RA carries a classIB indication in the 2018
European Society of Cardiology/ European Association for Cardiooracic Surgery Guidelines for myocardial revascularization. RAs
are especially useful in reoperations (prior SVG), severe pulmonary
disease, and in obese, insulin- dependent diabetics where BITA
graing has relative contraindications.
not reach the desired target unless used as a free gra. Concerns
over sternal infection, adequacy of single inow in T gras, and unfamiliarity with bilateral internal thoracic artery (BITA) graing
Anatomy, histology, andpharmacology
results in 95% of all CABG operations using only the le internal
thoracic artery (LITA). e majority of conduits are saphenous vein
gras (SVGs) which develop neointimal hyperplasia and atheroma
and occlude in the long term with resulting recurrent symptoms,
reinterventions, and poorer prognosis. Arterial gras always have
Fig. 35.1 shows the RA in relation to the brachioradialis muscle and
the supercial radial and lateral cutaneous nerves. e RA has a thin
intima, a fenestrated internal elastic lamina, a thick muscular media,
and an adventitia rich in vasa vasorum. e RA wall is up to 450
higher patencies than SVGs. RA patency rates of 90% at 10years
(a)
Lateral
cutaneous
nerve
Superficial
radial
nerve
Fig.35.1 (a) Diagrammatic representation of the left radial artery and its relationship to the brachioradialis, laterally, pronator teres medially, and to
the superficial radial nerve and the lateral cutaneous nerve of the forearm. (b)The harvested radial artery, mean length 22cm.
Radial artery
(b)
22 cm
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(a)
Distals
ITA 2 mm
(b)
ITA RA
Fig.35.2 (a) Comparing the distal ends of the internal thoracic artery (ITA) and radial artery (RA). (b)Histological cross- section comparing the ITA and
RA noting a thicker (×2) media layer. (c)The distal radial artery prepared for coronary anastomoses; 3mm internal diameter, 6mm when opened for
anastomosis.
composed predominantly of the muscular media. It has more intimal
thickening, lipid deposits, and calcication, particularly distally, and
is slightly larger than the ITA. In organ bath models, vasoconstriction can be intense, prolonged, and twice that for the ITA due to the
substantive muscular media (Fig. 35.2). Spasm prophylaxis is then
considered essential— by atraumatic harvest and smooth muscle
relaxants, including topical or intraluminal papaverine, nitroglycerine, nitroprusside, diltiazem, milrinone, or phenoxybenzamine.
e RA is an autoregulatory ‘living gra’. In competitive ow situations, vasoconstriction and a ‘string sign’ may occur., Conversely,
in high- ow scenarios, it can dilate to diameters of 5– 8mm. e
RA functions optimally when used to bypass tightly stenosed or occluded coronaries.
Although the evidence is anecdotal, RA gra spasm has been
reported days or weeks postoperatively. Oral calcium channel antagonists are oen given empirically for 6months. However, aer
implantation in the coronary circulation, the RA undergoes a
morphofunctional remodelling characterized by a progressive thinning of the muscular component of the media and switches from
a muscular to an elastomuscular wall architecture. is change in
histology is accompanied by a marked reduction of the initial hyperreactive tendency. is adaptive phenomenon is probably the patho-
2– 3cm longitudinal incision at the wrist and, occasionally, an additional incision at the elbow to secure the RA proximally. It appears
that both endoscopic and open harvestings result in equivalent
quality RA conduits with no dierences in patency or survival.
Both techniques have very low rates (<1%) of infection and neurological complications. A small longitudinal drain and a rm
dressing and bandage are used routinely. e RA is stored in arterial blood at 37°C, with the preferred vasodilator. Some surgeons
skeletonize the RA by removing the venae comitantes to maximize
vasodilatation and length.
Contraindications to RA use include prior major forearm trauma,
severe calcication, collagen vascular diseases, and Raynaud’s syndrome. In addition, patients with renal failure or end- stage renal disease who may require vascular access for dialysis should not have
routine RA graing unless there are exceptional circumstances (e.g.
no other suitable conduits). Traditionally, the RA has been harvested
from the non- dominant arm, but harvesting of the arm of the dominant side is performed by many groups. Previously cannulated RAs
oen have intimal damage and the distal portions are best avoided.
Low patency rates have been reported for RA gras from arteries recently used for transradial procedures but waiting 3months prior to
using an instrumented RA may obviate this risk.
RA 3 mm
(c)
6 mm
physiological background to the lack of benets of chronic therapy
with calcium channel blockers.
Radial arteryharvesting
Surgicalstrategy
If used with the LITA, the RA should be used to bypass the next most
important, tightly stenosed coronary artery. Alternatively, the RA
Adequacy of the hand circulation must be assessed by the Allen’s
test and index nger wave plethysmography (reperfusion within 10
seconds). Pulse oximetry changes with RA occlusion can also be
helpful. Ultrasonography can assess RA size, ow, and calcication.
Open and endoscopic techniques are used with excellent outcomes. e open technique allows securing of branches by diathermy, harmonic scalpel, or small vascular clips. Endoscopic
harvesting can be performed with various technologies through a
can be deployed to the posterior descending coronary artery in the
context of BITAs, as they are usually deployed to the le side. e
RA is best used as an aortocoronary gra and is suited to sequential
graing if required. e proximal inow can be from the ascending
thoracic aorta or as a LITA– radial ‘Y’- gra. ARITA– RA composite
gra can also be used to bypass the posterior descending artery or
passed through the transverse sinus to bypass the obtuse marginal
artery(ies).
35 The radialartery 277
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Patencyrates
e results of the largest angiographic series of RA gras are summarized in Table 35.1.– In the protocol- driven series, the RA patency
rate ranged from 89% at 1year in the VA trial, to 88% at 7.7years in the
Radial Artery Patency Study (RAPS) trial, and to 84.8% at 19years in
Gaudino etal.’s series. Results of the symptoms- driven angiographic
studies are much more discordant. However, a major selection bias is
obviously present in all symptoms- driven studies.
e location of the target vessel does not aect RA angiographic outcome, whereas the severity of the target vessel stenosis
is a key determinant of patency. Target vessel stenosis greater than
70% in the le circulation and greater than 90% in the right circulation lead to the best patency rates. It has been shown that when
used to revascularize target vessels with greater than 90% stenosis, the
20- year risk of occlusion of the RA is comparable to that of the LITA.
rather than the SV to bypass non- le anterior descending artery
(LAD) targets. Goldman etal. found no dierence in survival at
1year in the Veterans Administration (VA) study while the RAPS
trial found a tendency to lower incidence of adverse follow- up
events in the RA group. Propensity- matched observational studies
consistently found better survival in RA patients. Arecent metaanalysis of 14 studies and 20,931 patients reported that the use of
the RA to gra the second target vessel was associated with a 26%
relative risk reduction in mortality at 6.6- year follow- up compared
to the use of the SV.
e most scientically robust analysis to date, a patient- level
meta- analysis of six randomized trials of RA versus SVG showed
that the RA was associated with a signicant reduction of the composite of death, myocardial infarction, and repeat revascularization
and better patency rate at 5years’ follow- up with occlusion of almost
20% of vein gras and 8% of radial arteries. ere is also evidence
showing that higher- risk subgroups of patients— the elderly, diabetics, and women— benet from RA graing.
Clinicaloutcomes
Radial artery versus saphenousvein
ere is compelling evidence that RA graing results in improved
long- term survival in patients undergoing CABG using the RA
Radial artery versusRITA
A recent meta- analysis of eight propensity- matched studies concluded that the use of the RITA compared to the RA was associated with better long- term survival and freedom from repeat
revascularization. However, there was signicant heterogeneity in
Table35.1 Overview ofthe main RA angiographic series
Author or trial Journal Yea r Number of
Protocol driven
13
VA
14
RAPCO
15
RAPS
16
RSVP
Achouh etal.
Possati etal.
Gaudino etal.
Symptoms driven
Maniar etal.
Shah etal.
Knot etal.
Tatoulis etal.
Amano etal.
Dimitrova etal.23Innovations 2013 318 Symptoms 4.6 84.2% <80%:54.4%
18
20
21
JAMA 2011 367 Protocol 1 89 NS
Annals of Cardiothoracic
Surgery
Journal of the American
College of Cardiology
Circulation 2016 59 Protocol 5 98.3 NS
17
European Journal of
Cardiothoracic Surgery
Circulation 2003 90 Protocol 9 91.6 <70%:58%
5
Journal of the American
College of Cardiology
19
Journal of Thoracic and
Cardiovascular Surgery
European Journal of
Cardiothoracic Surgery
Circulation 2004 392 Symptoms 2 51.3 NS
4
Annals of Thoracic
Surgery
22
Annals of Thoracic
Surgery
2013 311 Protocol 5.5 80.2 NS
2012 269 Protocol 7.7 88 NS
2012 629 Protocol 7 82.8 NS
2016 33 Protocol 19 84.8 NS
2001 231 Symptoms 2 95 <70%:40%
2005 363 Symptoms 3 91 NS
2009 1108 Symptoms 4 89 >80%:89.4%
2001 229 Both 1.5 93 NS
grafts
Main indication to
catheterization
Mean follow- up
(years)
RA patency
rate (%)
RA patency rate by
% of target vessel
stenosis
70– 90%:85%
>90%:96%
70– 90%:60%
> 90%:75%
<80%:86.6%
>80%:91.0%
NS, not specified; RAPCO, Radial Artery Patency and Clinical Outcomes study; RAPS, Radial Artery Patency Study; RSVP, Radial Artery Versus Saphenous Vein Patency trial; VA, Veteran’s
Administration.
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