The radial artery: An important component of multiarterial coronary surgery and considerations for its optimal harvest
James Tatoulis
Abstract
Central MessageThe radial artery is emerging as an important component of multiarterial grafting. Its optimal harvest with effective spasm prophylaxis is fundamental for its successful use in coronary surgery.See Commentaries on pages 56, 58, and 60. 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.1Gaudino M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery grafter versus saphenous vein graft with long term cardiovascular outcomes among patients undergoing coronary artery bypass grafting. A systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (65) Google Scholar, 2Taggart D.P. Gaudino M.F. Gerry S. Gray A. Lees B. Dimagli A. et al.Effect of total arterial grafting in the arterial revascularization trial.J Thorac Cardiovasc Surg. March 19, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (17) Google Scholar, 3Buxton B.F. Shi W.Y. Tatoulis J. Fuller J.A. Rosalion A. Hayward P.A. Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.J Thorac Cardiovasc Surg. 2014; 148: 1238-1243Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar 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.4Tatoulis J. Buxton B.F. Fuller J.A. Meswani M. Theodore S. Powar N. et al.Long term patency of 1,108 radial arterial coronary angiograms over 10 years.Ann Thorac Surg. 2009; 88: 23-29Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar 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.4Tatoulis J. Buxton B.F. Fuller J.A. Meswani M. Theodore S. Powar N. et al.Long term patency of 1,108 radial arterial coronary angiograms over 10 years.Ann Thorac Surg. 2009; 88: 23-29Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar 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. The 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 volar (superficial) aspect of the RA are rare. As many as possible of the branches around the wrist should be preserved, especially if the whole length of the RA is not required. Many RA anomalies have been described but are rare.5Ruengsakulrach P. Eizenberg N. Fahrer C. Fahrer M. Buxton B.F. Surgical implications of variations in hand collateral circulation: anatomy revisited.J Thorac Cardiovasc Surg. 2001; 122: 682-686Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar The most important is that of a major lateral branch several centimeters above the wrist, effectively the functional continuation of the RA. A vestigial RA remains in the true anatomic continuation. This may lead to a false negative Allen test. Suspicion should be heightened if the hand fails to blanch at all when compressing the RA when performing the modified Allen test (MAT). Unless the main RA branch, coursing laterally, is compressed, one will not obtain a true assessment of UA dominance and capability of sustaining hand circulation. RA dominance in the Allen test, significant trauma, collagen diseases, Raynaud's phenomenon, dialysis fistula, severe calcification, small size (<2 mm), and although unusual, sustained severe RA spasm with an effective internal diameter of <2 mm despite topical and intraluminal vasodilators and fasciotomy. Cold climate, renal failure with a potential need for an atrioventricular fistula, carpel tunnel syndrome, prior RA arterial monitoring, left breast/axilla surgery, arm lymphedema, RA used for angiography or percutaneous coronary intervention (PCI), and skilled workers (eg, musicians). Five percent to 10% of RAs may not be appropriate or suitable to use.5Ruengsakulrach P. Eizenberg N. Fahrer C. Fahrer M. Buxton B.F. Surgical implications of variations in hand collateral circulation: anatomy revisited.J Thorac Cardiovasc Surg. 2001; 122: 682-686Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 6Kohonen M. Teerenhovi O. Terho T. Laurikka J. Tarkka M. Is the Allen test reliable enough?.Eur J Cardiothorac Surg. 2007; 32: 902-905Crossref PubMed Scopus (59) Google Scholar, 7Gaudino M.F. Fremes S. Schwann T.A. Tatoulis J. Wingo M. Tranbaugh R.F. Technical aspects of the use of the radial artery in coronary artery bypass surgery.Ann Thorac Surg. 2019; 108: 613-623Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar The MAT is the standard screening test for ensuring satisfactory hand circulation. We compress both RA and UA, have the patient clench his or her fist and relax it slowly 5 times, and then release the UA and observe reperfusion and blushing of the previously blanched thenar eminence, thumb, and the 2 adjacent fingers (Figure 2). Reperfusion within 10 seconds is satisfactory. Others have noted that the specificity of this test is maximal (>97%), when a 5-second cutoff is used.6Kohonen M. Teerenhovi O. Terho T. Laurikka J. Tarkka M. Is the Allen test reliable enough?.Eur J Cardiothorac Surg. 2007; 32: 902-905Crossref PubMed Scopus (59) Google Scholar Index with MAT a of M.F. Fremes S. Schwann T.A. Tatoulis J. Wingo M. Tranbaugh R.F. Technical aspects of the use of the radial artery in coronary artery bypass surgery.Ann Thorac Surg. 2019; 108: 613-623Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar is in the P. M. 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Powar N. et al.Long term patency of 1,108 radial arterial coronary angiograms over 10 years.Ann Thorac Surg. 2009; 88: 23-29Abstract Full Text Full Text PDF PubMed Scopus (101) Google M. P. Benedetto U. et artery as a coronary artery bypass PubMed Scopus Google Scholar observational and have RA patency to be superior to saphenous vein graft M. Benedetto U. Fremes S. Ballman K. Biondi-Zoccai G. Sedrakyan A. et al.Association of radial artery grafter versus saphenous vein graft with long term cardiovascular outcomes among patients undergoing coronary artery bypass grafting. A systematic review and meta-analysis.JAMA. 2020; 324: 179-187Crossref PubMed Scopus (65) Google J. Buxton B.F. Fuller J.A. Meswani M. Theodore S. Powar N. et al.Long term patency of 1,108 radial arterial coronary angiograms over 10 years.Ann Thorac Surg. 2009; 88: 23-29Abstract Full Text Full Text PDF PubMed Scopus (101) Google M.F. Benedetto U. Fremes S. Biondi-Zoccai G. Sedrakyan A. et artery or saphenous vein graft in coronary artery bypass J PubMed Scopus Google Scholar The RA remains of in the long-term and morphologic over Its and more in with the with RA use with left as of a is approximately at 10 on the original patient and to 10% better patients with left saphenous vein grafting at 10 B.F. Shi W.Y. Tatoulis J. Fuller J.A. Rosalion A. Hayward P.A. Total arterial revascularization with internal thoracic and radial artery grafts in triple-vessel coronary artery disease is associated with improved survival.J Thorac Cardiovasc Surg. 2014; 148: 1238-1243Abstract Full Text Full Text PDF PubMed Scopus (101) Google Scholar The RA has many and is in of It be with the left using to for saphenous vein grafting. It is to and for sequential It and not are are and is for prophylaxis is and of is It allows including in patients with and and is associated with excellent and superior long-term The RA is the to the of in a and