On the day of your surgery, you should arrive promptly at the time desginated to you by the surgery scheduler and pre-surgical services.  You will be escorted to the pre-operative area where you will meet with the anesthesiologist and see your surgeon.  Intravenous lines will be started while in the pre-operative area.  Your family can be with you with during this time. 

When it is time for your surgery, your family will be escorted to a waiting area and you will be wheeled, on a stretcher, into the operating room.  There, you will be placed under general anesthesia (completely asleep, unconscious and with a total loss of sensation).  An endotracheal tube is placed and you are connected to a ventilator.

Then, your chest is prepared for surgery and the incision is made.  The incision is usually down the center of your chest and is the length of your sternum (breast bone).  Sometimes, cardiac surgery can be performed without cutting the sternum.  In such cases, the incision(s) is in other areas of your chest.  The kind of incision you receive will be determined by your surgeon during your consultation.

For several kinds of heart surgery, your heart and lungs are stopped and you are placed on a heart-lung machine.  This machine does the work of your heart and your lungs while the surgeons perform the operation.  When the operation is finished, your heart and lungs are restarted. 

When the work on your heart is complete, your sternum will be wired shut with stainless steal wires.  These wires are left in place. They will not set off alarms and it is usually safe to have an MRI.  The remianing stitches are performed using dissolvable sutures - generally, there are no sutures or staples that need to be removed after your surgery. 

When your surgery is complete, you will be transferred from the operating room to the cardiovascular intensive care unit to begin your recovery.

While you are being transferred, your surgeon will talk with your family about the aspects of your operation.  Family members should expect to see their loved one 30 to 60 minutes after meeting with the surgeon.  During that time, the nurses are settling the patient into the room and making sure he or she is stable.

Family members should note:  when you see your loved one for the first time, he or she will be asleep and under anesthesia.  He or she will also have a breathing tube in their mouth and will likely be swollen and pale.  There will be many IV lines, tubes and monitors.  This is normal after cardiac surgery.  During your first visit, the nurses will allow you to stay for a couple of minutes and then will likely ask you to step our.  Their goal is to remove the breathing tube as soon as they sefely can after the surgery.

After your initial visit, you will be able to stay for longer periods of time.

The best conduit in coronary artery bypass surgery is the left internal mammary artery (found in your chest). Many studies have shown that the left internal mammary artery graft has the best longevity compared to saphenous vein (found in the leg), and using the internal mammary artery improves the survival of patients undergoing coronary artery bypass surgery. However, most patients undergoing bypass surgery require multiple grafts and therefore cannot be treated only with internal mammary artery grafts. For many patients, the radial artery (found in your arm) presents a useful alternative to saphenous vein and may improve the long term results of bypass surgery.

How do I Know if my Radial Artery Will be Used?

The radial and ulnar arteries are is located in the forearm and together are the primary blood supply to the hand. Before surgery, patients are examined by ultrasound to see if they are candidates for a radial artery graft.

After the radial artery is removed, the circulation to the hand becomes entirely dependent on the ulnar artery. Therefore, if ulnar artery flow is not as good as it should be, the radial artery is not used. Patients with Raynaud’s disease or other vasospastic disorders are not candidates for radial artery use. Additionally, the radial artery is not typically used in patients with renal failure who require the radial artery for arteriovenous access for hemodialysis.

How is the Radial Artery Removed?

During surgery, all of the arteries that we be used as bypass grafts are removed at the same time.

Following sterile preparation, a long incision is made between the elbow and wrist. A special surgical instrument safely removes the artery. After the artery is removed, the incision is stitched closed and a special dressing is applied to minimize swelling. Dressings are removed on the second postoperative day.

The radial artery is a muscular artery; that is, compared to other arteries, the wall of the radial artery is thick and contains muscular cells. Up to ten percent of radial artery grafts may be prone to spasm. To reduce the risk of radial artery spasm, during surgery the radial artery graft is flushed with a solution containing vasodilators such as nitroglycerin and verapamil. After surgery, patients may be prescribed cardizem, an oral calcium channel blocker and vasodilator.

How Long Does a Radial Artery Graft Last?

Medical studies indicate that the length of time radial artery grafts lasts does vary. Cardiac surgeons have hypothesized that arterial grafts will not develop atherosclerosis and blockage that affects many saphenous vein grafts for five to ten years. A retrospective study from the Cleveland Clinic showed that, in patients with recurrent symptoms, radial artery patency rate was only fifty-one percent; however, most other studies demonstrate that approximately eighty-five percent of radial artery grafts were still functioning five years follow-up. The five year success rate of the radial artery graft is equal to the saphenous vein graft and not as good as the left internal mammary artery graft. Longer follow-up awaits the results of several ongoing prospective randomized trials.

What are the Risks?

There are some risks associated with removing the radial artery. Many patients experience some numbness in their thumbs and wrists after the surgery. Up to four percent may experience hematoma, seroma, or wound infection. Numbness persists greater than one year in about ten percent; significant discomfort may be present in two percent. Weakness or impaired circulation to the hand is rare but has been reported.

Conclusion

Radial artery grafts play an important role in coronary artery bypass surgery. While careful patient selection and meticulous surgical techniques are critical for success, we believe that use of the radial artery and total arterial revascularization may improve the long term surgical results for many patients.

Most patients do not require blood transfusions, but it is occasionally necessary. The blood at Inova Fairfax Hospital is extremely safe and has been thoroughly tested for communicable diseases before being released for transfusion. It may be possible for you to donate your own blood prior to surgery (autologous donation) or others may donate for you (direct donation).

The length of stay following heart surgery is usually three to five days.

You will be encouraged to walk for a few minutes several times a day. You will be given a schedule to follow. Unless otherwise instructed, you can climb stairs. It is NOT necessary to move your bed downstairs from an upstairs bedroom or rent a hospital bed. If your incision is through your breast bone, you must follow “sternal precautions” for six to eight weeks following surgery. Do not lift over five to ten pounds because your bone is wired together with stainless steel wires.

Pain perception varies with each individual. You will be given a prescription for pain medication when you are discharged from the hospital. Some patients never take a pain pill while others use pain medication during the day or only when they go to bed at night. You may experience discomfort in the incisions or you may have muscle pain or tightness in your shoulders and upper back between your shoulder blades. This will get better with time.

It is normal to not have much of an appetite following surgery. It takes several weeks for your appetite to return. Many patients notice that their sense of taste is diminished or almost absent. It will return. Some patients even complain of nausea at the smell of food for a week or two after surgery. We recommend that you eat foods that appeal to you until your appetite returns. At that time resume a heart healthy diet as directed by your cardiologist.

Some patients qualify for home nurses after surgery and this is set up at the hospital prior to your discharge. The nurse will check your vital signs, check your incisions, listen to your lungs, and review your medications. They do not assist with bathing. Generally they visit three times a week for a few weeks. Most patients do fine without a visit from a home nurse. We do recommend that you have a family member or friend stay with you for the first week.

After discharge from the hospital, wash your incisions daily with an antibacterial soap and warm water. Generally no dressings are needed but if there is some minor oozing, gauze may be applied. Dissolvable sutures are used for skin closure so therefore there are no sutures that need be removed.

Check with your practitioner before returning to work, but most patients will begin to feel like returning to light work four to six weeks after surgery.

It’s normal to have difficulty sleeping at night. This will improve with time.