The document discusses minimally invasive radial artery harvesting techniques. It notes that while initially abandoned due to spasms and poor results, the radial artery is now commonly used as a graft due to improved harvesting methods. Key points discussed include using small incisions, minimal handling of the artery, and applying warm papaverine to prevent spasms. The modified Allen's test and Doppler ultrasound are recommended to confirm hand circulation before harvesting. With minimal handling and spasm prevention, radial arteries can be harvested with low complication rates and good long-term patency for coronary artery bypass grafting.

1. Minimally Invasive RadialMinimally Invasive Radial
Artery HarvestArtery Harvest
Ashish GaurAshish Gaur
B.S (BITS),M.D (AM), PG. Dip PPHCB.S (BITS),M.D (AM), PG. Dip PPHC
Senior Surgical AssistantSenior Surgical Assistant
Kokilaben Dhirubhai Ambani hospitalKokilaben Dhirubhai Ambani hospital
MumbaiMumbai

2. History Of Radial Artery As ConduitHistory Of Radial Artery As Conduit
 Professor Alain Carpentier is credited with introducing the radial artery (RA)Professor Alain Carpentier is credited with introducing the radial artery (RA)
as an alternative conduit for CABG.as an alternative conduit for CABG.
 Initial results with the RA were unfavorable, leading Carpentier and others toInitial results with the RA were unfavorable, leading Carpentier and others to
abandon its use.abandon its use.
 Subsequently, several RA grafts were empirically observed to be patent atSubsequently, several RA grafts were empirically observed to be patent at
follow-up coronary angiography, leading to the concept’s reintroduction infollow-up coronary angiography, leading to the concept’s reintroduction in
the late 1980s .the late 1980s .
 Radial Artery Versus Saphenous Vein Patency (RSVP) trial compared 5-Radial Artery Versus Saphenous Vein Patency (RSVP) trial compared 5-
year graft patency for RA versus SVG when placed to circumflex coronaryyear graft patency for RA versus SVG when placed to circumflex coronary
artery branches that were at least 70% stenotic .These data demonstrated aartery branches that were at least 70% stenotic .These data demonstrated a
significantly improved patency for RA grafts (98.3%) relative to SVG graftssignificantly improved patency for RA grafts (98.3%) relative to SVG grafts
(86.4%) .(86.4%) .

3. So Why Was Radial ArterySo Why Was Radial Artery
AbandonedAbandoned
 The occlusion was most likely caused by trauma to the vessel associated withThe occlusion was most likely caused by trauma to the vessel associated with
harvesting techniques, such as mechanical dilation with metal dilators, and forcedharvesting techniques, such as mechanical dilation with metal dilators, and forced
hydrostatic dilation.hydrostatic dilation.
 Harvesting Tech---Too Much handling.Harvesting Tech---Too Much handling.
 Spasms.Spasms.

4. Surgical AnatomySurgical Anatomy

5. Criteria To UseCriteria To Use
 >70% Block in coronary artery.>70% Block in coronary artery.
 Arterial conduit.Arterial conduit.
 Negative Allen's TestNegative Allen's Test
 Negative Modified Allen Test.Negative Modified Allen Test.
 No structural deformity.No structural deformity.
 Multiple GraftsMultiple Grafts
 Non Dominant hand.Non Dominant hand.
 No arterial line.No arterial line.

6. Allen”s TestAllen”s Test
Compression over radial.Compression over radial.

7. MAT vs DopplerMAT vs Doppler
 Visualization of saturation trace over monitor over compressed radial artery.Visualization of saturation trace over monitor over compressed radial artery.
 When MAT was compared with Doppler ultrasonography of the thumb artery, MATWhen MAT was compared with Doppler ultrasonography of the thumb artery, MAT
was noted to have a sensitivity of 100% and specificity of 97% for thumb ischemia.was noted to have a sensitivity of 100% and specificity of 97% for thumb ischemia.
 Ruengsakulrach P, Brooks M, Hare D, Gordon I, Buxton B. PreoperativeRuengsakulrach P, Brooks M, Hare D, Gordon I, Buxton B. Preoperative
assessment of hand circulation by means of Doppler ultrasonographyassessment of hand circulation by means of Doppler ultrasonography
and the modified Allen’s test. J Thorac Cardiovascular Surge 2001; 121:and the modified Allen’s test. J Thorac Cardiovascular Surge 2001; 121:
526-31526-31 ..

8. TechniqueTechnique
 Incision parallels the medial edge of the brachioradialis muscle .Incision parallels the medial edge of the brachioradialis muscle .
 Skin and subcutaneous tissue are incised down to the fascia overlying theSkin and subcutaneous tissue are incised down to the fascia overlying the
flexor Carpi radialis muscle .flexor Carpi radialis muscle .
 Fascial sheath that overlies the superficial muscles of the volar forearm isFascial sheath that overlies the superficial muscles of the volar forearm is
divided between the brachioradialis muscle and the flexor Carpi radialis.divided between the brachioradialis muscle and the flexor Carpi radialis.
 The lateral cutaneous nerve of the forearm usually overlies theThe lateral cutaneous nerve of the forearm usually overlies the
brachioradialis in the same plane as the fascial sheath. Care is taken tobrachioradialis in the same plane as the fascial sheath. Care is taken to
prevent injury to this nerve: this is accomplished by displacing it laterally .prevent injury to this nerve: this is accomplished by displacing it laterally .
 Careful retraction of the brachioradialis and flexor Carpi radialis muscles,Careful retraction of the brachioradialis and flexor Carpi radialis muscles,
1st laterally and then medially, is performed with a self-retaining retractor1st laterally and then medially, is performed with a self-retaining retractor
 This maneuver reveals the entire course of the radial artery from the bicepsThis maneuver reveals the entire course of the radial artery from the biceps
tendon to the radial styloid .tendon to the radial styloid .
 The radial artery pedicle is gently mobilized to lift it from its muscular bed.The radial artery pedicle is gently mobilized to lift it from its muscular bed.
As the pedicle is lifted, the side branches of the radial artery are exposed.As the pedicle is lifted, the side branches of the radial artery are exposed.
Careful, gentle, and progressively upward traction of the pedicle isCareful, gentle, and progressively upward traction of the pedicle is
performed. The side branches are then isolated and either clipped or ligatedperformed. The side branches are then isolated and either clipped or ligated
with the harmonic scalpelwith the harmonic scalpel..

9. Minimally InvasiveMinimally Invasive
 Small CutsSmall Cuts
 2 cms each2 cms each
 Bridge in middle.Bridge in middle.
 Minimal Diathermy (setting 15 Coag)Minimal Diathermy (setting 15 Coag)
 Use Scissors. (For dissection).Use Scissors. (For dissection).
 Warm Papaverine Spray and warm papaverine dipped gauze.Warm Papaverine Spray and warm papaverine dipped gauze.
 Minimal handelling.Minimal handelling.

10. DissectionDissection

11. ClosureClosure
 Good Homeostasis.Good Homeostasis.
 Washing with normal saline.Washing with normal saline.
 Undyed number 1 vicrylUndyed number 1 vicryl
 Drain –Romovac.Drain –Romovac.
 MonocrylMonocryl
 Crape Bandage for 4 daysCrape Bandage for 4 days

12. InstrumentationInstrumentation
 Long tip Diathermy,Long tip Diathermy,
 Roller under mid arm.Roller under mid arm.
 Light.Light.
 Retractor -- Cats Paw and Mastoid.Retractor -- Cats Paw and Mastoid.
 Surgical Loupes.Surgical Loupes.

13. Spasm-Is that a worry?Spasm-Is that a worry?
 Initial Reason for abandoning radial artery was spasm related to handling andInitial Reason for abandoning radial artery was spasm related to handling and
dilatation.dilatation.
 Vasoconstriction related to adventitia over radial artery.Vasoconstriction related to adventitia over radial artery.
 This tendency to spasm, occurring in 5 to 10% of the patients, has been correlated toThis tendency to spasm, occurring in 5 to 10% of the patients, has been correlated to
a significant proportion of early RA graft failures. It is generally accepted that thea significant proportion of early RA graft failures. It is generally accepted that the
adventitia provides structural support to the vessel. Although, in the last decade,adventitia provides structural support to the vessel. Although, in the last decade,
several studies have indicated that the adventitia also has an active role in vasomotorseveral studies have indicated that the adventitia also has an active role in vasomotor
tone.tone.
 Limb arteries such as the RA are known to be more prone to spasm than somaticLimb arteries such as the RA are known to be more prone to spasm than somatic
(IMA) or splanchnic arteries .(IMA) or splanchnic arteries .
 Vasodilatation of the harvested RA should begin intraoperatively by exposing theVasodilatation of the harvested RA should begin intraoperatively by exposing the
conduit to papaverine or verapamil /nitroglycerin.conduit to papaverine or verapamil /nitroglycerin.
 StrictlyStrictly NO DILATATION.NO DILATATION.
 Spasm intraopeartively-Can cause graft failure, slow flow and hemodynamicSpasm intraopeartively-Can cause graft failure, slow flow and hemodynamic
instability.instability.
 Post Op-String sign in angio.Post Op-String sign in angio.

14. Spasm-How to deal?Spasm-How to deal?
 Adventitial Dissection of the Radial Artery Graft:Adventitial Dissection of the Radial Artery Graft:
 The adventitial dissected RA is less susceptible to vasoconstriction and more proneThe adventitial dissected RA is less susceptible to vasoconstriction and more prone
to vasorelaxationto vasorelaxation ex vivoex vivo. Therefore, we recommend to perform adventitial dissection. Therefore, we recommend to perform adventitial dissection
of the RA graft to reduce vasospasm for arterial revascularization in CABGof the RA graft to reduce vasospasm for arterial revascularization in CABG ..
 Minimal Handling.Minimal Handling.
 Warm papaverine spray.Warm papaverine spray.

15. DissectionDissection

16. EndoscopicEndoscopic
 Latest Trend in India.Latest Trend in India.
 Successful,aesthetic,cosmetic.Successful,aesthetic,cosmetic.
 Needs TrainingNeeds Training
 CostCost

Patency rates are similar regardless of method of harvestingPatency rates are similar regardless of method of harvesting
 Bleiziffer S, Hettich I, Eisenhauer B, et al. Patency rates of endoscopicallyBleiziffer S, Hettich I, Eisenhauer B, et al. Patency rates of endoscopically
harvested radial arteries one year after coronary artery bypass grafting. Jharvested radial arteries one year after coronary artery bypass grafting. J
Thorac Cardiovascular Surg 2007; 134: 649-56Thorac Cardiovascular Surg 2007; 134: 649-56..
 Should Graduate-First step is minimally invasive.Should Graduate-First step is minimally invasive.

17. Endoscopic Vs MinimalEndoscopic Vs Minimal
 Cost effective.Cost effective.
 Better quality.Better quality.
 Minimal Handling.Minimal Handling.
 No instrumentation.No instrumentation.
 Small cuts contract 6 months post op.Small cuts contract 6 months post op.
 Practically no visible scar.Practically no visible scar.

18. Learning curveLearning curve
 Initially make 3 cuts.Initially make 3 cuts.
 Dissect between 2 bridges.Dissect between 2 bridges.
 Decrease length of those cuts and use long tip diathermy.Decrease length of those cuts and use long tip diathermy.
 Graduate to 2 cuts with long incision.Graduate to 2 cuts with long incision.
 Graduate to small incision.Graduate to small incision.
 Can try horizontal 2 incisions (Very difficult).Can try horizontal 2 incisions (Very difficult).
 Remember No surgery should be performed at the cost of the safetyRemember No surgery should be performed at the cost of the safety
of conduitof conduit

19. ResultResult
 Harvested =Near about 2000 radialsHarvested =Near about 2000 radials
 90% Arterial Conduits in our setup90% Arterial Conduits in our setup
 OF 90%- 85 % Radial Artery.OF 90%- 85 % Radial Artery.
 Infection=0%Infection=0%
 Ecchymosis =1%.Ecchymosis =1%.
 Resuturing =0%Resuturing =0%
 Vasomotor Deficit=0%Vasomotor Deficit=0%
 Vascular Injury=0%Vascular Injury=0%

20. Can be a Surgical assistant”s forteCan be a Surgical assistant”s forte
ThanksThanks