Intraoperative radial nerve injury during coronary artery surgery – report of two cases (original) (raw)
Neurological Damage After Radial Artery Harvesting In Coronary Surgery: a Direct Measure
Interactive …, 2006
Background: The incidence of neurological complications in the forearm after radial artery harvesting varies in the literature, ranging from 2% to more than 50%. Also, the areas affected and the type of neurological complications differ a lot. Peripheral nerve injuries may be divided into three types: neuroapraxia (conduction block that recovers within 3 months), axonotmesis (recovers 1 ml/day) and neurotmesis (needs surgery for recovering). We decided to perform a neuroelectrophysiological study, before and after surgery, in peripheral nerves of the forearm to find out the real incidence and the type of lesion after radial artery harvesting. Methods: Fifteen consecutive patients whose RA was going to be harvested were selected. Emergency patients, patients with severe liver or renal dysfunction were excluded. A complete neuroelectrophysiological study was performed in the median, ulnar and radial nerve. The amplitude was measured to check mielina status, whereas with the latency and nerve velocity conduction (NVC) we checked the axonal integrity. An electromyogram was also performed in the forearm muscles. A neurological clinical exploration was also performed. All these tests were performed before surgery and two weeks and two months after surgery. Results: Median nerve: A significant decrease in the amplitude that improved over time was registered. This decrease was observed in the motor and sensitive part of the nerve. No changes were observed regarding latency or NVC. Ulnar nerve: A decrease in the amplitude of the sensitive part of the nerve was observed (11.7-9.2-10.4 mV; Ps0.006). No changes were observed regarding latency or NVC. Radial nerve: A statistical trend decrease observed regarding NVC of the sensitive part of the nerve branch was found (50.9 mys vs. 47.1 mys vs. 47.2 mys; Ps0.10). The electromyogram found no alterations. Clinically, three patients presented sensitive disorders in the median nerve territory and one of these also complained of sensitive disorders in the radial territory. Another patient referred dysesthesias in the ulnar nerve territory. All patients with the exception of one were asymptomatic two months after surgery. Conclusions: Although only a few patients refer symptoms, most patients suffer changes in the peripheral nerves of the forearm (especially in the sensitive part) after RA harvesting. In our study the median nerve and the sensitive part of the ulnar and radial nerve were affected. These changes were temporary, affecting mainly the axon. All these data suggest neuroapraxia as the main peripheral nerve type lesion. We think that physicians and patients must be aware of this.
Nerve injury in lower limb vascular surgery
The Surgeon, 2008
Objective: Nerve injury is one of the most common complications of varicose vein surgery and is a frequent cause for litigation but its incidence following lower limb arterial surgery has not been well documented. This study was undertaken to determine the incidence of nerve injury following lower limb arterial surgery. This was addressed in relation to long saphenous or femoral vein harvesting, or re-operative surgery. Materials and Methods: A total of one hundred patients who had undergone lower limb arterial reconstruction in the previous Ý ve years were invited to participate in this study. Seventy-eight patients responded, of which 44 patients (66 operated legs) agreed to participate. They underwent neurological assessment of the lower limbs. Results: 66.7% of limbs had objective evidence of sensory deÝ cit following lower limb arterial surgery but none had motor deÝ cit. Redo surgery or superÝ cial femoral vein harvest had no inÞ uence on the incidence of nerve injury. Below knee incisions had a higher incidence of nerve injury than other approaches. Long saphenous vein harvest signiÝ cantly increased the rate of nerve injury. Conclusions: There is a high incidence of sensory nerve damage following lower limb arterial surgery. In the present climate of increasing litigation it is important to know the likely incidence of post-operative nerve damage so that patients can be counselled appropriately during the process of obtaining informed consent.
2010
The incidence of neurological complications in the forearm after radial artery harvesting varies in the literature, ranging from 2% to more than 50%. Also, the areas affected and the type of neurological complications differ a lot. Peripheral nerve injuries may be divided into three types: neuroapraxia (conduction block that recovers within 3 months), axonotmesis (recovers 1 ml/day) and neurotmesis (needs surgery for recovering). We decided to perform a neuroelectrophysiological study, before and after surgery, in peripheral nerves of the forearm to find out the real incidence and the type of lesion after radial artery harvesting. Methods: Fifteen consecutive patients whose RA was going to be harvested were selected. Emergency patients, patients with severe liver or renal dysfunction were excluded. A complete neuroelectrophysiological study was performed in the median, ulnar and radial nerve. The amplitude was measured to check mielina status, whereas with the latency and nerve velocity conduction (NVC) we checked the axonal integrity. An electromyogram was also performed in the forearm muscles. A neurological clinical exploration was also performed. All these tests were performed before surgery and two weeks and two months after surgery. Results: Median nerve: A significant decrease in the amplitude that improved over time was registered. This decrease was observed in the motor and sensitive part of the nerve. No changes were observed regarding latency or NVC. Ulnar nerve: A decrease in the amplitude of the sensitive part of the nerve was observed (11.7-9.2-10.4 mV; Ps0.006). No changes were observed regarding latency or NVC. Radial nerve: A statistical trend decrease observed regarding NVC of the sensitive part of the nerve branch was found (50.9 mys vs. 47.1 mys vs. 47.2 mys; Ps0.10). The electromyogram found no alterations. Clinically, three patients presented sensitive disorders in the median nerve territory and one of these also complained of sensitive disorders in the radial territory. Another patient referred dysesthesias in the ulnar nerve territory. All patients with the exception of one were asymptomatic two months after surgery. Conclusions: Although only a few patients refer symptoms, most patients suffer changes in the peripheral nerves of the forearm (especially in the sensitive part) after RA harvesting. In our study the median nerve and the sensitive part of the ulnar and radial nerve were affected. These changes were temporary, affecting mainly the axon. All these data suggest neuroapraxia as the main peripheral nerve type lesion. We think that physicians and patients must be aware of this.
Avoiding peripheral nerve injury in arterial interventions
Diagnostic and Interventional Radiology, 2019
A lthough peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually are not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The paired nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or manual pressure. Nerve injuries have been reported most frequently with axillary and brachial arterial access due to the anatomic proximity of the vessels and nerves at this location in combination with anatomic challenges for hemostasis. Given the higher rate of complications, axillary and brachial arterial access is typically reserved for situations where the interventionalist needs upper extremity arterial access, but the radial or ulnar arteries are not options due to anatomic or other factors. Subclavian arterial access is rarely used owing to high complication rates due to hemostasis challenges as it traverses the thoracic inlet (1). Femoral nerve injury, associated with common femoral artery access, is the second most frequently encountered. This is likely due to the high frequency of use of this access site in combination with the proximity of the femoral nerve just lateral to the common femoral artery in the femoral triangle. It has been suggested that nerve injuries related to angiography may be under-reported due to delayed onset of symptoms, their impermanent nature, lack of recognition, or reluctance of operators to report complications (2-5). Given the increasing frequency of endovascular arterial procedures and the increasing use of non-traditional access points, it is important that interventionalists have a working knowledge of peripheral nerve anatomy and function as it relates to arterial access sites. Upper limb Radial artery Radial artery access has gained popularity as a safe and technically useful technique, particularly for coronary, upper limb, mesenteric, renal, and neurovascular interventions since it has been associated with a lower incidence of major access site related complications compared to the traditional transfemoral approach (6-9). Although transient sensory impair-ABSTRACT Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury. Diagnostic and Interventional Radiology Kuo et al. MCP, metacarpophalangeal; IP, interphalangeal; PIP, proximal IP; DIP, distal IP. *Branches of the anterior interosseous nerve. **Brachialis shares innervation from the radial and musculocutaneous nerves. Figure 3. Color doppler ultrasound image of the brachial artery (A), paired brachial veins (V), and median nerve (MN) above the elbow.
Perioperative Peripheral Nerve Injuries
Anesthesiology, 2009
This article has been selected for the ANESTHESIOLOGY CME Program. Learning objectives and disclosure and ordering information can be found in the CME section at the front of this issue. Background: Peripheral nerve injuries represent a notable source of anesthetic complications and can be debilitating. The objective of this study was to identify associations with peripheral nerve injury in a broad surgical population cared for in the last decade. Methods: At a tertiary care university hospital, the quality assurance, closed claims, and institution-wide billing code databases were searched for peripheral nerve injuries over a 10-yr period. Each reported case was individually reviewed to determine whether a perioperative injury occurred, defined as a new sensory and/or motor deficit. The location and type of the injury were also identified. Nerve complications as a result of the surgical procedure itself were excluded, and an expert review panel assisted in the adjudication of unclear cases. Patient preoperative characteristics, anesthetic modality, and surgical specialty were evaluated for associations. Results: Of all patients undergoing 380,680 anesthetics during a 10-yr period, 185 patients were initially identified as having nerve injuries, and after review, 112 met our definition of a perioperative nerve injury (frequency ؍ 0.03%). Hypertension, tobacco use, and diabetes mellitus were significantly associated with perioperative peripheral nerve injuries. General and epidural anesthesia were associated with nerve injuries. Significant associations were also found with the following surgical specialties: Neurosurgery, cardiac surgery, general surgery, and orthopedic surgery. Conclusions: To our knowledge, this is the largest number of consecutive patients ever reviewed for all types of perioperative peripheral nerve injuries. More importantly, this is the first study to identify associations of nerve injuries with hypertension, anesthetic modality, and surgical specialty.
European Journal of Cardio-Thoracic Surgery, 2005
Objective: Radial artery (RA) is now used widely as a conduit of choice in coronary artery bypass grafting. Although RA removal is considered safe in the presence of adequate collateral arterial supply, there is still a considerable suspicion on the functional status of the forearm and hand. However, a neurological dysfunction may occur owing to either surgical trauma or ischemic neuropathy. This study was aimed to investigate the functional outcome of the donor forearm nerves of the patients who underwent coronary artery bypass grafting surgery with RA conduits. Methods: A consecutive series of 50 patients who underwent coronary artery bypass graft surgery with one or two RA grafts were investigated in the study. Motor and sensory functions of donor forearm nerves were measured by ENMG studies, pre-and postoperatively at the third week and sixth month of the operation. The conduction velocities, distal latencies and amplitudes of action potentials for motor and sensorial conductions of radial, ulnar and median nerves were measured in each ENMG examination. Neurologic status of the donor forearm and hand was assessed by the same neurologist who performed a detailed neurologic physical examination and ENMG studies. Results were statistically compared using one-way ANOVA test. Results: The incidence of any neurologic symptoms was 32% in early postoperative period. All reported neurologic complaints were associated with sensory conduction deceleration in ENMG investigations of related nerves. In postoperative assessment, median nerve sensory-motor, and ulnar nerve motor conduction records were slightly lower than the preoperative values, but no statistical difference was observed. Pre-and postoperative radial nerve motor and sensory conduction records were statistically similar (PO0.05). Conclusions: We advocate that removal of RA does not lead to any major neurologic hand complications in the presence of adequate collateral arterial blood supply. ENMG studies confirmed minimal conduction alterations with no statistical significance, even if neurologic symptoms were stated.
Early postoperative ulnar neuropathies following coronary artery bypass surgery
Muscle & Nerve, 1992
Ulnar neuropathies following surgery are common. However, they often go undetected during the early postoperative period, because the patient may be unaware of symptoms related to the neuropathy. Nerve conduction studies are useful in localizing the lesion, but are usually employed only in cases developing signs and symptoms. We undertook this study to determine the incidence, time of onset, and outcome of clinical and subclinical ulnar neuropathies. Electrophysiological studies were carried out preoperativety, immediately following surgery, and 4 to 6 weeks postoperatively in 20 coronary artery bypass patients. Conduction velocity across the elbow was reduced in 3 limbs (8%) postoperatively, all of which were detected irnmediately following surgery. One patient developed conduction block and weakness in ulnar supplied intrinsic hand muscles. Denervation was seen in 2 cases and, in 1 case (5%), a right brachial plexus injury was clinically evident 5 days following surgery. All newly developing ulnar neuropathies were asymptomatic, with most recovering to their preoperative electrophysiological status at follow-up.
The most commonly injured nerves at surgery: A comprehensive review
Clinical Anatomy, 2020
Introduction: Iatrogenic nerve injury during surgery is a major source of concern for both patients and surgeons. This study aimed to identify the nerves most commonly injured during surgery, along with the commonly associated operative procedures. Materials and Methods: A literature search was conducted using the PubMed database to identify nerves commonly injured during surgery, along with the surgical procedure associated with the injury. Results: The following eleven nerves, ranked in order with their associated surgical procedures, were found to be the most commonly injured: (1) intercostobrachial nerve in axillary lymph node dissections and transaxillary breast augmentations, (2) vestibulocochlear nerve in cerebellopontine tumor resections and vestibular schwannoma removals, (3) facial nerve in surgeries of the inner ear and cheek region, (4) long thoracic nerve in axillary lymph node dissections, (5) spinal accessory nerve in surgeries of the posterior triangle of the neck and cervical lymph node biopsies, (6) recurrent laryngeal nerve in thyroid surgeries, (7) genitofemoral nerve in inguinal hernia and varicocele surgeries, (8) sciatic nerve in acetabular fracture repairs and osteotomies, (9) median nerve in carpal tunnel release surgeries, (10) common fibular nerve in varicose vein and short saphenous vein surgeries, and (11) ulnar nerve in supracondylar fracture surgeries. Conclusion: Although the root cause of iatrogenic nerve injury differs for each nerve, there are four unifying factors that could potentially decrease this risk for all peripheral nerves. These four
Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital, 2001
After heart surgery, complications affecting the brachial plexus have been reported in 2% to 38% of cases. The long thoracic nerve is vulnerable to damage at various levels, due to its long and superficial course. This nerve supplies the serratus anterior muscle, which has an important role in the abduction and elevation of the superior limb; paralysis of the serratus anterior causes "winged scapula," a condition in which the arm cannot be lifted higher than 90 degrees from the side. Unfortunately the long thoracic nerve can be damaged by a wide variety of traumatic and nontraumatic occurrences, ranging from viral or nonviral disease to improper surgical technique, to the position of the patient during transfer to a hospital bed. Our patient, a 62-year-old man with triple-vessel disease, underwent myocardial revascularization in which right and left internal thoracic arteries and the left radial artery were grafted to the right coronary, descending anterior, and obtuse mar...
Median nerve injury: an underrecognised complication of brachial artery cardiac catheterisation?
Journal of Neurology, Neurosurgery & Psychiatry, 1997
Methods-A follow up study to determine the mechanism of injury and outcome of patients who sustained a high median nerve palsy after this procedure. Five right handed patients were identified in a 24 month period. Each was assessed clinically and electrophysiologically at presentation. All were followed up initally (range six to 22 months) clinically, electrophysiologically, and using components from the Chessington occupational therapy neurological assessment battery (COTNAB) functional hand assessment. Results-The incidence of this complication was between 0.2 and 1.4%. Three mechanisms of injury were identified. These included direct nerve compression due to formation of antecubital fossa haematoma, direct nerve trauma, and ischaemia secondary to brachial artery occlusion. The initial neurological and nerve conduction deficits improved with time. However, all cases had persistent disability in hand function as documented clinically and on the dexterity and stereognosis subcomponent of the COTNAB test. Those performing cardiac catheterisation via the right brachial artery should be aware of the potential risks of damage to the median nerve. They should evaluate hand function after the procedure and take prompt action if median nerve dysfunction is noted. Damage to the median nerve results in appreciable long term disability, which may have medicolegal relevance.