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JACC Cardiovasc Interv. Author manuscript; available in PMC 2017 March 17.
Published in final edited form as:
PMCID: PMC5357052

Radial Artery Graft String Sign Due to Lumen Obliteration by Neointima: Insight From Optical Coherence Tomography

David Adlam, BM, DPhil and Keith M. Channon, MD

The radial artery is a commonly used conduit for coronary artery bypass grafting. Long-term patency rates are at least as good and in some series are better than for saphenous vein grafts (1,2). However, radial artery graft failure remains a significant problem (3), in particular in cases where radial conduits are used on smaller target vessels or where there is significant competitive fl from a native coronary with a relatively low grade stenosis (4). The string sign, where the radial graft conduit is patent but with only a thread of antegrade fl is a well-recognized angiographic presentation of radial graft failure (3). We describe for the first time optical coherence tomography (OCT) images of a radial conduit presenting with the string sign.

A 62-year-old man presented electively for angiographic follow-up as part of the ART (Arterial Revascularization Trial) 3 years after 4-vessel coronary artery bypass grafting, including a radial artery graft to the principle obtuse marginal branch of the circumfl coronary artery. He was clinically well and without angina at the time of the study. Angiography demonstrated the radial graft string sign with minimal contrast penetration (Figs. 1A and 1B). OCT (M3, LightLab Imaging, Westford, Massachusetts) demonstrated a thick smooth neointima throughout the length of the radial graft almost obliterating the lumen and with no OCT features of atherosclerotic plaque formation or calcification (Figs. 2A, 2B, 2D, 2E, and 2G). The neointima formation in a saphenous vein graft from the same patient is shown for comparison (Figs. 2C and 2F).

Figure 1
Angiographic Appearances of the Radial Artery Graft “String Sign”
Figure 2
OCT Findings of Lumen Obliteration by Neointima

OCT imaging can provide novel insights into the mechanisms underlying coronary and graft conduit pathology. Although other mechanisms may be relevant in different patients, this case suggests the radial artery string sign may result from an exaggerated neointimal reaction in the radial graft leading to a severe reduction of luminal cross-sectional area.


This study is supported by the National Institute for Health Research Biomedical Research Centre, Oxford, United Kingdom


The authors have reported that they have no relationships to disclose.


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