The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest

Abstract

There is mounting evidence from large observational studies and randomized trials (RCTs) that coronary artery bypass grafting using multiple arterial grafts (MAG) results in superior graft patency and better long-term clinical outcomes without compromising perioperative mortality and morbidity. [1][2][3] The radial artery (RA) has emerged as the second arterial graft of choice. It has the same patency as the right internal thoracic artery (ITA) when placed to the same vessels under the same conditions, but is much more versatile and easier to use. 4 Introduced in 1971 by Carpentier, lack of knowledge about arterial graft spasm and management of this with mechanical dilatation was problematic. Observation of excellent, patent, atheroma-free RA grafts from the original series 2 decades later has prompted its reappearance as a coronary graft. Advantages include ease of procurement, length (18-22 cm), robustness, versatility, excellent diameter appropriate to the coronaries, ease of constructing sequential anastomoses, potential for total arterial revascularization when used with the left ITA, especially as a T or Y graft, few infections and wound problems, suitable for use in patients with diabetes, and suitable for use in all ages, including the elderly, facilitating early ambulation. Proximally, its size generally allows direct anastomosis to the aorta or to an ITA. 4 Crucial to successful RA use is optimal harvesting, preparation to maximize its perioperative and long-term efficacy, and minimizing harvest-related complications or impediments. These include wounds, cosmesis, neurologic (particularly sensory) abnormalities, finger/hand ischemia, graft damage (especially intimal), and spasm. Therefore, knowledge of RA anatomy, assessment of hand circulation, its morphologic and pharmacologic characteristics, relationships to relevant nerves, harvest strategies, and a reproducible technique to avoid these potential complications is mandatory. AnatomyThe brachial artery bifurcates into the ulnar artery (UA) and RA at the elbow. The RA is usually smaller and fortuitously is not accompanied by any major nerves-unlike the UA (median nerve). The RA runs deep to the brachioradialis muscle and emerges between it and the flexor muscles approximately two-thirds of the way down the forearm, becoming superficial and easily accessible just above the wrist before its termination in the superficial and deep palmar arches (Figure 1).Proximally, the recurrent RA arises 1 cm distal to the RA origin and runs laterally and proximally. The interosseous artery originates from the deeper aspect. In its proximal two-thirds, the RA lies in loose areolar tissue with few branches. The branches become more numerous in the distal third, particularly around the wrist. Branches on the

Commentary: The radial won't bite, if you treat it right

“… 3 Our center performs multiarterial bypass grafting in 40% of appropriate patients undergoing isolated coronary artery bypass grafting (CABG) with the radial artery as the preferred second conduit. The reasons are similar to those mentioned by Tatoulis, 4 including ease of procurement, simultaneous procurement with left internal thoracic artery, versatility in constructing sequential anastomoses or Y or T grafts, and ease of anastomosis to the ascending aorta.…”

“…Tatoulis, 4 a leader in the field of multiarterial grafting, presents an invited technical expert review focused on optimal radial artery harvesting technique. He expertly distills the key elements of anatomy and radial artery dissection and provides practical tips to help improve graft patency.…”

Upcoming expert opinions on adult coronary surgery

“…Most of the data that led to the reintroduction of the RA in coronary surgery can be attributed to James Tatoulis and colleagues from Melbourne. In an upcoming review of RA harvesting and preservation strategies, Tatoulis and colleagues 16 offer a pragmatic approach to make even the most unfamiliar surgeon comfortable with using the RA in CABG. Additionally, as the use of intraoperative graft flow verification becomes more common, Akhrass and Bakaeen 17 will encourage routine use with judicious interpretation to avoid unnecessary graft revision.…”

Commentary: Radial artery—Try it; you might like it, and your patients will love it

“…Commentary: Radial artery-Try it; you might like it, and your patients will love it Thomas A. Schwann, MD, MBA This report 1 represents the multidecade experience with radial artery (RA) in coronary artery bypass grafting (CABG) by a pioneer and expert in this field. It is an excellent summary of the technical and practical aspects of RA use as a coronary conduit.…”