Yihan Lin, MD, MPH and Jessica Yu Rove, MD
University of Colorado, Aurora, CO, USA
Essential Operative Steps
1. Preoperative assessment: Perform preoperative Allen’s test (<10s refill)
2. Positioning: Keep the patient’s head straight, and do not hyperextend or over-abduct the arm
3. Circumferentially prep and drape the arm from mid bicep to the hand
4. Make a 3cm incision at the wrist over the radial artery. Identify the radial artery. Place a vessel loop around the radial artery with venae comitantes
5. Curvilinear incision along the medial edge of the brachioradialis muscle, from 1cm distal to the wrist to 1cm proximal to the elbow
6. Bovie subcutaneous tissue, expose brachioradialis muscle, and incise brachioradialis fascia
7. Minimize injury to superficial veins and nerves
8. Retract the brachioradialis with a self-retaining retractor to expose the radial artery
9. Starting at the wrist and moving proximally up the arm, divide the radial artery branches with a harmonic scalpel. Minimize traction on the radial artery
10. Continue dissection up to the level of the recurrent branch of the radial artery
11. Place a bulldog on the radial artery pedicle and a crile hemostat on the proximal end. Sharply divide the proximal radial artery to confirm collateral flow through the palmar arch. Suture ligate the proximal radial artery stump
12. Suture ligate and divide the distal radial artery at the wrist
13. Place the radial artery in a solution with papaverine and heparin
14. Obtain meticulous hemostasis
15. Keep the deep fascia open and close the deep dermal and skin in 2 layers
Potential Complications and Pitfalls
- Radial artery injury or dissection. Do not use the radial if patient has had recent radial catheterization
- Brachial plexus injury. Positioning is critical to avoid brachial plexus injury: keep the patient’s head straight and avoid
turning the head away from the arm. Do not hyperextend the arm or over-abduct the arm. The arm should look comfortable - Injury to radial artery (technical)
- Injury to superficial radial and lateral antebrachial cutaneous nerves (technical)
- Postoperative hematoma (technical)
- Compartment syndrome. Avoid this by not closing compartment
- Hand ischemia. Never with adequate preoperative testing and checking collateral flow through palmar arch prior to distal
ligation - Vasospasm of the conduit. Rare, but if suspected can use calcium channel blockers in the postoperative period
Template Dictation
Preoperative Diagnosis: [INDICATION: Exertional or unstable angina, dyspnea]
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Radial artery harvest
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of [COMPLAINT: Exertional chest pain,
syncope]. Preoperative cardiac catheterization revealed [FINDINGS]. Preoperative TEE demonstrated [FINDINGS]. It was
determined that a [PROCEDURE: CABG] would be performed with the radial artery as a conduit. A preoperative Allen’s test
was performed and was determined to be adequate for radial artery harvest. It was also confirmed that the patient did not have
a radial artery catheterization in the chosen radial artery.
Description of the Procedure: The patient was taken to the operating room on [DATE] and was placed upon the operating
room table in the supine position. An arm board was placed on the [RIGHT/LEFT] side for the radial artery harvest.
The arm was circumferentially prepped and draped from the mid-bicep to the hand and placed on the arm board. The radial
artery was palpated at the level of the wrist crease. A 3cm incision was made and the radial artery was identified. The radial
artery was confirmed to be of good quality and not overly calcified. A vessel loop was placed around the radial artery and
venae comitantes. A curvilinear skin incision was started 1cm distal to the elbow crease, following the medial border of the
brachioradialis muscle, down to 1cm proximal to the wrist crease. The subcutaneous tissues were dissected with a bovie. The
cephalic vein was identified and preserved.
Once through the skin, the fascia of the radial artery distally was incised, and the radial artery was followed proximally, up to
the level of the brachioradialis muscle. The brachioradialis muscle was exposed and its fascia incised. The brachioradialis
muscle was then retracted laterally with a self-retaining retractor, exposing the radial artery lying immediately below. The
superficial radial nerve and the lateral antebrachial cutaneous nerve were identified and preserved.
The radial artery was then harvested as a pedicle, with preservation of the venae comitantes. A harmonic scalpel was used to
divide the branches of the radial artery. A vessel loop was used to help expose the radial artery pedicle and branches with care
taken to minimize traction on the artery. Dissection was continued proximally up to the level of the recurrent branch of the
radial artery, about 1cm proximal to the elbow crease. The ulnar branch was identified and protected.
Once the entire radial artery was circumferentially dissected, a bulldog was placed on the radial artery pedicle and a crile
hemostat on the proximal side. The radial artery was sharply divided, the bulldog released, and we ensured adequate backflow
through the palmar arch circulation. The bulldog was replaced. The proximal radial artery stump was suture ligated. The distal
end was then divided and suture ligated at the wrist. The bulldog was then placed on the distal end of the artery and was clearly
marked.
The radial artery was then placed in a solution of papaverine, heparin, and lactated ringers.
The entire wound was inspected for hemostasis and was felt to be adequate. Next, closure of the arm was performed. The deep
fascial layers were left open. The deep dermal layer and skin were closed using absorbable suture. The arm was wrapped
loosely with dressings.
All sponge, instrument, and needle counts were correct at the completion of the case.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of the procedure.
Multiple Choice Question(s)
The following are possible to be injured during the radial artery harvest except:
A. Cephalic vein
B. Lateral antebrachial cutaneous nerve
C. Superficial radial nerve
D. Ulnar artery
E. Brachioradialis nerve
Answer: E. The cephalic vein, lateral antebrachial cutaneous nerve, superficial radial nerve, and ulnar artery could all
potentially be injured during this procedure. The brachioradialis muscle must be dissected and retracted in order to expose the
radial artery.
Sources
Zisquit J, Velasquez J, Nedeff N. Allen Test. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507816/
Arie Blitz A, Osterday R, Brodman R. Harvesting the radial artery. Ann Cardiothorac Surg. 2013 Jul; 2(4): 533–542.
Gaudino M, Lau C. Open Radial Artery Harvesting and Preparation. March 2018. DOI: 10.1510/mmcts.2018.021
https://mmcts.org/tutorial/947
Chathoth V, Gopal K, Jose R, Padmanabhan M, Varma P. Endoscopic Radial Artery Harvesting. January
- doi:10.25373/ctsnet.11569743. https://www.ctsnet.org/article/endoscopic-radial-artery-harvestin
