Radial Artery Harvesting

If the results of the Allen's test are normal in both upper extremities, the nondominant extremity is generally selected as the harvest site. The nondominant forearm is surgically prepped circumferentially and draped from the mid-arm to the hand. The forearm is extended and supinated directly perpendicular to the patient's torso. The upper extremity is draped in such a manner that, after harvesting, the radial artery can be easily placed parallel to the torso in preparation for coronary artery bypass grafting.

Exposure of the radial artery requires a thorough understanding of its course along the forearm. A curvilinear incision is made, extending from approximately 2 cm below the antecubital crease, along the length of the forearm, to the wrist crease point (Fig. 1). The incision parallels the medial edge of the brachioradialis muscle. The skin and subcutaneous tissue are incised down to the fascia overlying the flexor carpi radialis muscle. The fascial sheath that overlies the superficial muscles of the volar forearm is divided between the brachioradialis muscle and the flexor carpi radialis. The lateral cutaneous nerve of the forearm usually overlies the brachioradialis in the same plane as the fascial sheath. Care is taken to prevent injury to this nerve: this is accomplished by displacing it laterally (Fig. 2).

Fig. 1 The Initial skin incision for radial artery harvesting.Fig. 2 The musculature and nerves of forearm exposed during radial artery harvesting.

After the superficial volar muscular sheath is incised, careful retraction of the brachioradialis and flexor carpi radialis muscles, 1st laterally and then medially, is performed with a self-retaining retractor. This maneuver reveals the entire course of the radial artery from the biceps tendon to the radial styloid. The easiest site to begin dissection of the radial artery pedicle is the middle portion of the forearm as the artery emerges from beneath the brachioradialis muscle. 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. Careful, gentle, and progressively upward traction of the pedicle is performed. The side branches are then isolated and either clipped or ligated with the harmonic scalpel.

When the entire radial artery pedicle is completely mobilized, the proximal and distal ends of the pedicle are prepared for division. A 2-0 silk suture is placed around the radial pedicle along the length where the radial styloid meets the radial pedicle, and the distal end of the radial artery is ligated. The stump of the remnant radial artery is then palpated in order to document its pulsation and verify ulnar artery collateral circulation. Next, the proximal end of the radial artery pedicle is prepared. The pedicle is lifted perpendicular to the forearm, ligated with a 2-0 silk suture, and divided (Fig. 3). We place a small cannula in the proximal end of the graft and gently flush the entire graft with papaverine, being careful not to over-distend the vessel. The harvested radial artery graft is inspected to ensure that all side branches are ligated securely. The entire radial artery pedicle graft is then wrapped in papaverine-soaked gauze (1 mg papaverine per 1 mL saline).

Fig. 3 Dissection and harvesting of the pedicle.

Hemostasis of the radial artery harvest site is achieved with electrocautery. The forearm wound is closed before the administration of systemic heparin. The deep fascia of the forearm is closed with a running 2-0 polyglycolic suture. The skin is closed with a running 4-0 polyglycolic suture. No drains are placed unless moderate drainage persists despite hemostasis.