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Ann Thorac Surg 1995;59:118-126
© 1995 The Society of Thoracic Surgeons

Technique for Harvesting the Radial Artery as a Coronary Artery Bypass Graft

Department of Cardiothoracic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

Accepted for publication June 29, 1994.

	Abstract

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
The radial artery was proposed and then abandoned as a coronary artery bypass graft in the 1970s. Development of new pharmacologic antispasmodic agents and minimally traumatic harvesting techniques has led to a revival of the use of the radial artery in coronary artery bypass procedures. Unlike the saphenous vein in the lower extremities, the radial artery in the volar forearm is not a subcutaneous structure. Safe harvest of the artery requires an understanding of volar forearm anatomy. Based on review of anatomy, cadaver dissection, and clinical experience with 40 patients, we have developed a technique for radial artery harvest. The volar forearm is divided into three zones: the proximal zone, the middle zone, and the distal zone. In each zone, important anatomic landmarks are identified. Our harvesting technique has resulted in minimal postoperative morbidity and no postoperative ischemic complications. Although the pedicled internal thoracic artery graft remains the primary arterial conduit for myocardial revascularization, the radial artery is an excellent additional bypass conduit.

	Introduction

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
See also page 126.

In the 1970s, the radial artery (RA) was introduced as an alternative conduit for coronary artery bypass grafting (CABG) [1]. Graft occlusion secondary to spasm from traumatic harvesting and preparation in addition to complications of crippling hand ischemia led to abandonment of this artery as a coronary artery graft by the mid-1970s [2–5]. The introduction of calcium-channel blockers, minimally traumatic dissection, and gentle hydrostatic graft dilation, and the unexpected observation that some RA grafts originally thought to be occluded are fully patent 15 years after operation, encouraged Acar and associates [6, 7] to revive the use of the RA in CABG. Unlike the saphenous vein in the lower extremities, the RA in the volar forearm is not a subcutaneous structure. Knowledge of volar forearm anatomy ensures safe harvest with minimal postoperative complications.

After review of anatomy and cadaver dissection, we have developed a technique of RA harvest that divides the volar forearm into three distinct zones: the proximal zone, the middle zone, and the distal zone. In each zone, important landmarks are clearly emphasized. Since November 1993, this technique has been applied in 40 patients. All patients underwent preoperative hemodynamic assessment that confirmed collateral circulation to the radial aspect of the hand with interruption of the RA supply. There have been no ischemic complications. This report reviews the pertinent anatomy and our technique for harvesting the RA for use as a coronary artery bypass graft.

	Forearm Anatomy Relevant to Radial Artery Harvest

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
Knowledge of volar forearm anatomy prevents inadvertent dissection in the wrong tissue planes and ensures safe RA harvest and wound closure. Postoperative complications such as ischemia, dysesthesia, or compartmental syndrome can be eliminated if proper attention is directed to three factors: (1) adherence to anatomical landmarks that define the boundaries of forearm dissection, (2) protection of the sensory innervation to the volar forearm, and (3) meticulous control of the branching points of the RA as it courses through the three zones.

Superficial Anatomy of the Volar Forearm
The volar forearm extends from a line drawn between the two humeral epicondyles to the wrist crease and, for the purpose of RA harvest, is divided into proximal, middle, and distal zones (Figs 1, 2). Superficial inspection of the proximal zone reveals the ridge of the biceps tendon medially and a lateral muscular prominence that is freely movable when pinched between the thumb and index finger (see Fig 1) [8]. This palpable outpouching of muscle on the radial aspect of the proximal forearm is composed of the brachioradialis, the extensor carpi radialis longus, and the extensor carpi radialis brevis muscles. It is known as the ``mobile wad of 3'' (MW3) and separates the flexor muscle group on the volar aspect of the forearm from the extensor muscle group on the dorsal aspect of the forearm [9]. In the middle zone of the volar forearm, the curving lateral edge of the brachioradialis muscle gently flattens to take the contour of the radius bone. A palpable pulse may be felt in this zone of the forearm at the point where the RA exits from underneath the cover of the brachioradialis muscle. On inspection of the distal zone, a bony prominence can be palpated at the distal lateral extent of the radius bone. This is the radial styloid. Medial to the radial styloid, two prominent tendons can be seen superficially as they move into the palmar aspect of the hand-the tendon of the flexor carpi radialis muscle is lateral, and the tendon of the palmaris longus muscle is medial [10].

View larger version (66K): [in this window] [in a new window]   Fig 1. . Superficial landmarks and skin incision for radial artery harvest. A groove between the ``mobile wad of 3'' and the biceps tendon can be palpated as an aid in defining the proximal extent of the wound. The skin incision follows a curvilinear course that mimics the curving edge of the belly of the brachioradialis muscle.

View larger version (69K): [in this window] [in a new window]   Fig 2. . Note the course of the lateral antebrachial cutaneous nerve in the volar forearm. In addition, the superficial branch of the radial nerve travels in close proximity to the radial artery but then turns underneath the tendon of the brachioradialis muscle toward the dorsum of the forearm and hand in the distal zone.

View larger version (38K): [in this window] [in a new window]   Fig 3. . Sensory innervation to the radial aspect of the volar forearm and portions of the dorsum of the forearm and hand is provided by the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve.

Branches of the Radial Artery in the Volar Forearm
The biceps tendon and the bicipital aponeurosis create a vertical partition that divides the proximal zone with an inverted antecubital V (see Fig 2). The antecubital V identifies the takeoff of the radial recurrent artery, the first major arterial branch of the RA in the volar forearm (Fig 4) [9]. The radial recurrent artery originates from the main trunk of the RA approximately 1 cm distal to the radial edge of the bicipital aponeurosis. Immediately after the takeoff, the radial recurrent artery turns proximally and then divides into a fanlike leash of vessels that travel dorsally to supply the extensor muscle compartment of the forearm [9]. The takeoff of the radial recurrent artery is the landmark that defines the proximal boundary for dissection in RA harvest.

View larger version (74K): [in this window] [in a new window]   Fig 4. . The main branches of the radial artery in the volar forearm include the radial recurrent artery proximally and the superficial palmar artery distally. In addition, there are numerous fasciocutaneous and muscular perforating branches that exit the main trunk of the vessel at varying points. Note the venae comitantes that travel with the radial artery along its entire course in the volar forearm.

In addition to the radial recurrent artery and the superficial palmar artery, the RA gives off many small perforating branches that form a rich vascular network that supplies the forearm and hand. These small branches exit the main trunk of the RA at irregular points throughout its entire course in the volar forearm. Most of these branches come off the dorsal aspect of the RA [16]. In the proximal half of the RA course in the forearm, the segment covered by the brachioradialis muscle, there are an average of 4.2 branches (range, 0 to 10) [16]. In the distal half of the RA course, the portion that lies directly under skin and fascia, the great majority of these small branches (9.6 branches on average with a range of 4 to 14) exit the main trunk of the vessel [16]. The perforating branches in the proximal half of the RA course in the volar forearm tend to be longer, sturdier, and more prominent than those in the distal zone. Those in the distal portions of the RA are short, fine, and delicate; they require more care to isolate and clip.

	Surgical Anatomy of Volar Forearm

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
The Proximal Zone
DEFINITIONS AND ANATOMIC LANDMARKS.
The proximal zone contains the antecubital fossa and extends from a line drawn between the two humeral epicondyles to the brachioradialis muscle laterally and the superficially palpable biceps tendon and the curving belly of the flexor carpi ulnaris muscle medially. The brachialis, supinator, and pronator teres muscles constitute the floor, and the deep fascia strengthened by the bicipital aponeurosis with overlying subcutaneous fat and skin forms the roof. The supinator and brachialis muscles generally lie above the level of dissection necessary for RA harvest; these muscles should not be seen during the operation.

SURGICAL ANATOMY IN PROXIMAL ZONE.
The RA enters the proximal zone medial to the biceps tendon and lateral to the bicipital aponeurosis (Figs 5, 6). The two legs of the inverted antecubital V of the proximal zone straddle the RA as it exits the crotch between the biceps tendon and the bicipital aponeurosis. Dissection must be kept along the radial side of the bicipital aponeurosis to avoid damage to major structures located medially: (1) the brachial artery, (2) the ulnar artery, and (3) the median nerve. The RA lies at its deepest point in the proximal zone. In this zone of the forearm, the RA is completely covered by the brachioradialis muscle and is surrounded by perivascular fat and areolar tissue.

View larger version (80K): [in this window] [in a new window]   Fig 5. . Surgical anatomy in the volar forearm. The proximal, middle, and distal zones are shown. Cross-sectional anatomic relationships are emphasized.

View larger version (78K): [in this window] [in a new window]   Fig 6. . Surgical anatomy in the volar forearm with the brachioradialis muscle retracted to reveal full course of the radial artery. Note the close proximity of the superficial branch of the radial nerve to the radial artery in the proximal and middle zones.

The Middle Zone
DEFINITIONS AND ANATOMIC LANDMARKS.
The middle zone begins at the distal extent of the antecubital fossa and ends as the bellies of the brachioradialis, flexor carpi radialis, and flexor carpi ulnaris muscles converge into their respective tendons (see Figs 5, 6). This distal point generally lies four fingerbreadths proximal to the wrist crease. In the middle zone, the RA is bounded laterally by the brachioradialis muscle as it gently flattens to take the contour of the radius bone and medially by the superficial flexor muscle compartment of the forearm (the flexor carpi radialis, palmaris longus, and flexor carpi ulnaris muscles). The floor beneath the RA in the middle zone comprises primarily the pronator teres muscle. In the distal portions of the middle zone, as the ulnar and humeral heads of the pronator teres muscle insert into the lateral aspect of the midshaft of the radius bone, the flexor digitorum superficialis and flexor pollicis longus muscles take over from the pronator teres muscle to continue the bed over which the RA travels. This bed is further cushioned in the middle zone by the thick belly of the flexor digitorum profundus muscle.

SURGICAL ANATOMY IN MIDDLE ZONE.
The LABCN and sRN are at greatest risk in the middle zone of the volar forearm. The RA and the sRN enter the middle zone of the forearm encased in a muscular sleeve created by the brachioradialis muscle laterally, the flexor carpi radialis muscle medially, and the pronator teres muscle dorsally. As the middle zone ends, the sRN separates from the RA and turns underneath the tendon of the brachioradialis muscle to enter the dorsal aspect of the forearm. Because of the intimate relationship between the RA and the sRN in the middle zone, careless dissection or unnecessary lateral retraction of the brachioradialis muscle results in damage to the sRN with subsequent dysesthesia of the thumb and dorsum of the hand.

Trauma to the LABCN, if it occurs, will happen as the forearm dissection is carried down past subcutaneous tissues to the level of the MW3 and flexor carpi radialis muscle. The LABCN overlies the fascial sheath that covers the brachioradialis and flexor carpi radialis muscles in the middle zone. This sheath is divided between the bellies of these two muscles to allow lateral retraction of the MW3 for complete exposure of the RA in this portion of the forearm. The LABCN must be kept in the lateral compartment of the fascial division. This maneuver automatically retracts the LABCN out of the operative field, and sensory innervation to the distal forearm and dorsum of the hand is not jeopardized.

The Distal Zone
DEFINITIONS AND ANATOMIC LANDMARKS.
In the distal zone, the RA, like beauty, is only skin deep (see Figs 5, 6). Abandoned by the sRN and covered simply by skin, superficial fascia, and connective tissue, the RA lies in a groove created by the tendon of the brachioradialis muscle and the distal radius bone laterally, the tendon of the flexor carpi radialis muscle medially, and the belly of the flexor pollicis longus muscle dorsally. The flexor digitorum profundus and pronator quadratus muscles provide deep medial support to the flexor pollicis longus muscle; these three muscles form the floor of the pulse groove in the distal zone.

SURGICAL ANATOMY IN DISTAL ZONE.
The perforating branches that exit the main trunk of the RA at irregular points along the dorsolateral and dorsomedial aspect of the vessel are at greatest risk for avulsion in the distal zone. Not only does the RA give off the great majority of fasciocutaneous and muscular branches in the distal zone, but, with a mean diameter of 0.5 mm (range, 0.1 to 1.1 mm), the perforating branches found in this portion of the RA are shorter, finer, and more delicate than those present in the two other zones [16]. These qualities make the distal-zone perforating branches more difficult to isolate and clip. In addition, dissection in the distal-zone can be tedious, as the RA can be encased in scar tissue and inflammatory adhesions as a result of prior cannulation for arterial blood gas measurements or continuous blood-pressure monitoring.

	Harvest of Radial Artery

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
Preparation for Harvest
The nondominant arm is usually selected for RA harvest. The circumferentially prepared upper extremity is extended and supinated on a standard operative arm board positioned at approximately 90 degrees to the operating table. Harvest of the RA is performed in conjunction with preparation of the internal thoracic artery for CABG. A pulse oximeter probe can be placed on the thumb of the chosen hand for intraoperative monitoring of oxygen saturation. The extremity is secured in position with two towel clips affixed to hand towels and the arm-board wrap. The arm is left in this position for the duration of CABG.

Incision and Harvest
The MW3, the biceps tendon, the radial styloid, and the tendon of the flexor carpi radialis muscle are the superficial landmarks that define the proximal and distal extent of the skin incision. In the proximal forearm, a palpable groove can be identified between the biceps tendon and the medial border of the MW3. A gentle curvilinear incision that mimics the rounded belly of the brachioradialis muscle is made extending from a point about one fingerbreadth lateral to the palpable biceps tendon and down the length of the forearm to a point midway between the tendon of the flexor carpi radialis muscle and the radial styloid at the wrist crease (see Fig 1). Prominent subcutaneous veins are clipped and divided only if they obstruct the operative field.

After sharp subcutaneous dissection and acquisition of hemostasis, the fascia overlying the MW3 and the superficial flexor muscles of the forearm is divided between the bellies of the brachioradialis and the flexor carpi radialis muscles (Fig 7). If care is taken to keep the LABCN on the lateral side of the fascial division, release of tension after complete division automatically pulls both the fascial layer and the LABCN out of the operative field. With the muscular fascia divided, careful retraction of the brachioradialis and flexor carpi radialis muscles reveals the entire course of the RA in the forearm. At this point, a loading dose (0.15 to 0.25 mg/kg) of diltiazem hydrochloride is delivered, and a continuous intravenous infusion (0.5 to 1.0 µg • kg^-1 • min^-1) is begun [6].

View larger version (73K): [in this window] [in a new window]   Fig 7. . After creation of the skin incision, the fascial sheath that covers the superficial muscles of the volar forearm is divided between the brachioradialis and flexor carpi radialis muscles. Care is taken to keep the lateral antebrachial cutaneous nerve in the lateral compartment of the fascial division.

View larger version (72K): [in this window] [in a new window]   Fig 8. . Gentle upward traction with a vessel loop placed around the radial artery in the middle zone brings perforating branches into view in preparation for division.

Proximal division is now performed. The RA is gently raised up almost perpendicular to the forearm, and a 2-0 silk tie is placed around the vessel at the selected point of division. With this tie secured, the proximal RA is divided. The RA graft is then wrapped in papaverine hydrochloride–soaked gauze (60 mg of papaverine per 60 mL of saline solution) and removed from the operative field. Another 5-0 polypropylene suture ligature is placed around both the distal and proximal stumps for added security. Harvest of the RA is now complete. Saline solution–soaked gauzes, a sterile towel, a plastic sheet that acts as a vapor barrier, and sterile covering drapes are applied to cover and to protect the forearm wound for the duration of myocardial revascularization.

Wound Closure
The forearm wound is closed at the completion of CABG after infusion of protamine sulfate. Prior to wound closure, the harvest site is examined for hemostasis to minimize the risk of postoperative compartmental syndrome in the upper extremity. The closure is performed in two layers. The deep fascia of the volar forearm is closed in an interrupted fashion with 3-0 polyglycolic acid sutures. A running subcuticular stitch (4-0 polyglycolic acid) is then used to close the skin. No drains are used. No pressure dressings are applied; a small sterile dressing suffices. Tape used to secure the dressing is placed in a longitudinal fashion to the volar surface of the forearm to avoid circumferential compression of the extremity. Elevation of the extremity is not required postoperatively.

Dilation, Preparation, and Orientation
After removal of the harvested RA graft from the operative field, the vessel is wrapped in papaverine-soaked gauze until it is ready for anastomosis. Inspection of the graft is performed with gentle hydrostatic dilation of the RA using a solution of blood and papaverine (60 mg of papaverine per 60 mL of blood). Any bleeding areas are identified and clipped. Methylene blue is applied to the volar aspect of the graft as a mark to ensure against twist during storage and subsequent use. The methylene blue–marked side of the graft is placed toward the heart surface during anastomosis. This leaves the dorsal side of the graft exposed. As previously described, the dorsal aspect of the RA contains most of the muscular perforating branches. Therefore, if bleeding points are observed after completion of revascularization and weaning from bypass, these sites are easily visualized and even more easily controlled.

	Comment

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
The high incidence of late obstruction of venous bypass grafts combined with the proven advantage of total arterial revascularization has stimulated a search for alternative arterial conduits for CABG. Use of the RA, condemned as a bypass graft 20 years ago, has been revived with encouraging early results. We have developed a technique for RA harvest that stresses meticulous attention to structural and anatomic details in the volar forearm and minimally traumatic dissection. All of our patients who underwent RA harvest had full use of the upper extremity on the first postoperative day. No upper-extremity ischemic complications have been observed in any of the patients. No motor deficit in the forearm and hand has been noted. Transient dysesthesia in the area of the skin incision and dorsum of the hand secondary to surgical trauma to the sRN and LABCN was experienced in the immediate postoperative period in 2 of the 40 patients seen early in this experience; the dysesthesia resolved within 48 hours. Our method of RA harvest has proved to be efficient and safe and is associated with almost no morbidity or postoperative pain. The pedicled internal thoracic artery graft continues to be the arterial conduit of choice for coronary artery revascularization. However, when preoperative assessment confirms adequate collateral supply to the radial aspect of the hand, use of the RA is an excellent and attractive adjunct.

	Addendum

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
Since submission of this article we have harvested an additional 67 radial arteries in 53 patients. The diltiazem protocol has been modified as follows: the loading dose is now 0.05 mg/kg followed by a continuous infusion of 0.15 to 0.2 µg • kg^-1 • min^-1. This lower dose is effective with fewer side effects.

In addition, closure of the deep and superficial fascia is performed with a running 3-0 polyglycolic acid suture immediately after harvest of the radial arteries. This may occur before the patient has been heparinized for cannulation. Harvest of the radial arteries now takes about 20 to 25 minutes. Skin closure is performed after administration of protamine. There have been no wound hematomas, compartment syndromes, or wound infections. Transient paresthesia (2 weeks) occurred in the lateral thenar eminence in 1 patient.

	Acknowledgments

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
We thank Hugh Thomas for the outstanding graphics.

	Footnotes

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 
Address reprint requests to Dr Brodman, Department of Cardiothoracic Surgery, Montefiore Medical Center, 3316 Rochambeau Ave, Bronx, NY 10467.

	References

Top Footnotes Abstract Introduction Forearm Anatomy Relevant to... Surgical Anatomy of Volar... Harvest of Radial Artery Comment Addendum Acknowledgments References

 

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				A. Rukosujew, R. Reichelt, A. M. Fabricius, G. Drees, T. D. T. Tjan, M. Rothenburger, A. Hoffmeier, H. H. Scheld, and C. Schmid Skeletonization versus pedicle preparation of the radial artery with and without the ultrasonic scalpel Ann. Thorac. Surg., January 1, 2004; 77(1): 120 - 125. [Abstract] [Full Text] [PDF]

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