Tips and Tricks for Radial Artery Harvesting with the Harmonic Scalpel

Radial artery use as a second conduit in coronary artery surgery has amassed more than fifty years of experience with waxing and waning levels of enthusiasm. Initial use in the Carpentier case series found a high rate of graft occlusion, but subsequent improvements in technique and understanding of graft failure led to its establishment as a strong contender for use as a second arterial graft (1). Debates as to whether radial artery should be the first option for second arterial conduit rather than a second mammary are outside the scope of this video case presentation.

The Gaudino et al. meta-analysis of radial artery (RA) versus saphenous vein (SV) grafting in CABG demonstrated that the use of the RA led to a significantly lower risk of death, myocardial infarction, repeat revascularization as a composite and MI, and repeat revascularization as individual components at five years of follow-up (2). This was more pronounced in younger, female patients without chronic kidney disease.

Multiple registry studies have highlighted the importance of using the RA on targets that are greater than 70 percent stenotic, and ideally greater than 90 percent subtotally occluded, because of the sensitivity of this graft to competitive flow and propensity to spasm (3).

As such, the use of the RA as a conduit has attained a class I, level B recommendation for use on targets with high degree stenosis in the ESC/EACTS 2018 Myocardial Revascularization Guidelines and a class I, level B recommendation for the use of the RA in preference to SV as the conduit of choice for the second most important non-LAD target in the 2021 ACC/AHA/SCAI guidelines for coronary artery revascularization (4,5).

Utmost attention to technique is paramount in ensuring a healthy conduit is procured. There is a paucity of high-level evidence as to the best technique in RA harvest—whether harmonic scalpel, clips and scissors, or clips and diathermy—and it is unlikely that a definitive study will be conducted. However, in this unit’s experience over the past twenty years, the harmonic scalpel can be used to harvest the RA quickly and effectively. This video presents the authors’ practice for RA harvesting.



The Technique

First, adequacy of collateral ulnar circulation was confirmed with a modified Allen’s test. The nondominant arm was then abducted to 90 degrees, prepped, and draped. A lazy-S-shaped incision was made over the course of the radial artery and dissection with harmonic scalpel at proximal end was initiated in a no-touch manner.

Next, proximal dissection was completed to the level of the muscular arterial branch beneath the level of the recurrent radial artery, making sure to avoid the brachial artery bifurcation. This was continued distally, maintaining a no-touch technique and using the harmonic to ligate collateral arterial and venous branches. In the mid-portion of the incision, surgeons were mindful of the lateral forearm cutaneous nerve and the superficial branch of the radial nerve.

After completing the dissection, the radial artery was placed on a papaverine swab while in situ and the posterior wall was painted with methylene blue to help maintain orientation. To check the patency of the radial artery and for intraoperative confirmation of ulnar collateral blood flow, the “squirt test” was performed (6). Two clips were placed on the radial artery—one on the proximal end and one on the distal end. A small longitudinal arteriotomy was also made distally. When the distal clip was taken off, retrograde blood flow from the ulnar artery was allowed flow through the radial artery and pulsatile flow was seen to come out of the small incision. 

Finally, both the distal and proximal ends were clipped before dividing the radial artery.

References

1. Acar, Christophe, Victor A. Jebara, Michele Portoghese, Bernard Beyssen, Jean Yves Pagny, Philippe Grare, Juan C. Chachques et al. "Revival of the radial artery for coronary artery bypass grafting." The Annals of thoracic surgery 54, no. 4 (1992): 652-660.
2. Gaudino, M., Benedetto, U., Fremes, S., Biondi-Zoccai, G., Sedrakyan, A., Puskas, J.D., Angelini, G.D., Buxton, B., Frati, G., Hare, D.L. and Hayward, P., 2018. Radial-artery or saphenous-vein grafts in coronary-artery bypass surgery. New England Journal of Medicine, 378(22), pp.2069-2077.
3. Maniar, H.S., Sundt, T.M., Barner, H.B., Prasad, S.M., Peterson, L., Absi, T. and Moustakidis, P., 2002. Effect of target stenosis and location on radial artery graft patency. The Journal of thoracic and cardiovascular surgery, 123(1), pp.45-52.
4. Neumann, F.J., Sousa-Uva, M., Ahlsson, A., Alfonso, F., Banning, A.P., Benedetto, U., Byrne, R.A., Collet, J.P., Falk, V., Head, S.J. and Jüni, P., 2019. 2018 ESC/EACTS Guidelines on myocardial revascularization. European heart journal, 40(2), pp.87-165.
5. Writing Committee Members, Lawton, J.S., Tamis-Holland, J.E., Bangalore, S., Bates, E.R., Beckie, T.M., Bischoff, J.M., Bittl, J.A., Cohen, M.G., DiMaio, J.M. and Don, C.W., 2022. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 79(2), pp.e21-e129.
6. Birdi, I. and Ritchie, A.J., 2002. Intraoperative confirmation of ulnar collateral blood flow during radial artery harvesting using the “squirt test”. The Annals of thoracic surgery, 74(1), pp.271-272.

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