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Ann Thorac Surg 2001;72:298-299
© 2001 The Society of Thoracic Surgeons

How to do it

Skeletonization of the radial artery: advantages over the pedicled technique

David P. Taggart, MD, FRCSa, Manu N. Mathur, FRACSa, Imran Ahmad, MBBSa a Oxford Heart Centre, John Radcliffe Hospital, Oxford, United Kingdom

Accepted for publication October 23, 2000.

Address reprint requests to Mr Taggart, Oxford Heart Centre, John Radcliffe Hospital, Oxford OX3 9DU, UK
e-mail: david.taggart{at}orh.anglox.nhs.uk


   Abstract
Top
 Abstract
Introduction
 Technique
 Comment
 References
 
The radial artery is usually harvested as a pedicle with surrounding veins, perivascular fat, and areolar tissue. We describe an alternative technique of skeletonization of the radial artery and its potential advantages over the pedicled technique.


   Introduction
Top
 Abstract
 Introduction
Technique
 Comment
 References
 
During the past 5 years the radial artery has become increasingly popular as a conduit for coronary artery bypass grafting. This is mainly because of its favorable handling characteristics, probable superior graft patency in comparison to venous conduits [1] and better wound healing.

The successful revival of the radial artery as a conduit for coronary revascularization in the 1990s was dependent on minimally traumatic harvesting techniques and the use of calcium channel blockers to reduce its proclivity to spasm. The standard, widely adopted, harvesting technique removes the radial artery as a pedicle with accompanying venae comitantes, perivascular fat, and areolar tissue [2–7]. We describe an alternative skeletonization technique of harvesting the radial artery and its potential advantages over the conventional technique.


   Technique
Top
 Abstract
 Introduction
 Technique
Comment
 References
 
A curvilinear skin incision, following the rounded belly of the brachioradialis muscle, commences 2 cm proximal to the wrist crease and extends to 2 cm distal to the elbow crease lateral to the biceps tendon. Subcutaneous tissues are divided with diathermy to expose the fascia overlying the brachioradialis muscle and the superficial flexor muscles of the forearm. The fascia is incised allowing the lateral retraction of the brachioradialis to expose the entire length of the radial artery.

The thin layer of fascia overlying the radial artery is divided over its entire length using scissors to reveal the "shiny" exterior of the radial artery and its accompanying venae comitantes, one vein on each side. With a combination of gentle outward retraction and sharp and blunt dissection of fine areolar attachments the veins are carefully dissected off the artery along its entire length (Fig 1).



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  		Fig 1. The venae comitantes are dissected off the artery.

 
Light upward traction on the radial artery, beginning in the center of the arm, elevates it from its muscular bed and dissected venae comitantes to expose its perforating dorsolateral and dorsomedial branches (Fig 2), which are divided using scissors between two small ligaclips. This process is continued proximally to the radial recurrent artery and distally to the superficial palmar artery (Fig 3) and the intervening radial artery excised.



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  		Fig 2. Upward traction on the radial artery lifts it away from its muscular bed and dissected venae comitantes and exposes the perforating branches.

 


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  		Fig 3. The skeletonized artery.

 
A ligaclip is applied to one end of the harvested radial artery and a fine plastic cannula inserted through the other. The artery is inspected for areas of spasm and unclipped side branches with gentle internal hydrostatic dilatation using a solution of 100 mg of phenoxybenzamine in 50 mL of warm heparinized blood. The cannula is withdrawn and a ligaclip applied to the end. The conduit, containing the solution of phenoxybenzamine and blood, is then placed back into the same solution until use.

Proximal and distal artery stumps are suture ligated. A small suction drain is placed in the muscular bed and the fascia covering the muscles is left open to prevent compartment syndrome. The subcutaneous tissue is closed with continuous absorbable suture and the skin, with a running subcuticular stitch.


   Comment
Top
 Abstract
 Introduction
 Technique
 Comment
References
 
Since the revival of the radial artery as a conduit for coronary artery bypass grafting there has been a universal recommendation to harvest it as a pedicle [2–7], along with its venae comitantes and perivascular fat and areolar tissue. The rationale for pedicle harvesting is to minimize the risk of injury to the vessel and reduce its tendency to spasm [8]. The risk of spasm is currently less of a consideration because of the efficacy of pharmacologic agents, including phenoxybenzamine [9], to prevent or abolish it.

Skeletonization of the radial artery offers several advantages including:

  1. provision of extra length. This is an important consideration if the radial artery is to be used for more than a single graft, as a sequential graft, or "recycled" to extend other grafts;
  2. allows thorough visual inspection to identify spastic or damaged areas that can, otherwise, be obscured by perivascular fat;
  3. facilitates sequential anastomoses and composite arterial grafting as the venae comitantes, perivascular fat, and areolar tissue do not obscure the anastomosis;
  4. aids judgment of graft length; and
  5. minimizes the risks of kinks or twists in the conduit.

There are, however, several points of caution to be emphasized with the skeletonization technique. It is technically more demanding than pedicle harvest and careful and meticulous dissection is required. Skeletonization takes approximately an additional 15 minutes compared to the pedicle technique. Small arterial branches, especially in the region of the wrist, can be inadvertently avulsed by excessive upward retraction. Finally, skeletonization probably induces a greater degree of spasm in the radial artery, although this can be very effectively treated with phenoxybenzamine [9].

Skeletonization of the radial artery has become our standard technique and we have used it consecutively in approximately 100 cases (having performed more than 400 pedicled harvests) and in the majority of cases of sequential anastomoses. Only one artery was discarded because of harvest injury. Although we do not have angiographic follow-up data, there have been no clinically apparent perioperative problems suggestive of graft spasm. Skeletonization is an alternative safe and effective technique for harvesting the radial artery, that consistently improves visualization and facilitates composite grafting.


   References
Top
 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Taggart D.P. The radial artery as a conduit for coronary artery bypass grafting. Heart 1999;82:409-410.[Free Full Text]
  2. Acar C., Jebara V.A., Portughese M., et al. Revival of the radial artery for coronary artery bypass grafting. Ann Thorac Surg 1992;54:652-660.[Abstract]
  3. Dietl C., Benoit C. Radial artery grafts for coronary artery bypass grafting. Ann Thorac Surg 1995;60:102-110.[Abstract/Free Full Text]
  4. Buxton B., Fuller J., Gaer J., et al. The radial artery as a bypass graft. Curr Opin Cardiol 1996;11:591-598.[Medline]
  5. Dumanian G.A., Segalman K., Mispireta L.A., Walsh J.A., Hendrickson M.F., Wilgis E.F. Radial artery use in bypass grafting does not change digital blood flow or hand function. Ann Thorac Surg 1998;65:1284-1287.[Abstract/Free Full Text]
  6. Royse A.G., Royse C.F., Shah P.H., Williams A., Kaushik S., Tatoulis J. Radial artery harvest technique, use and functional outcome. Eur J Cardiothorac Surg 1999;15:186-193.[Abstract/Free Full Text]
  7. Ronan J.W., Perry L.A., Barner H.B., Sundt T.M. Radial artery harvest: comparison of ultrasonic dissection with standard technique. Ann Thorac Surg 2000;69:113-114.[Abstract/Free Full Text]
  8. Chester A.H., Marchbank A.F., Borland J.A., Yacoub M.H., Taggart D.P. Comparison of the morphologic and vascular reactivity of the proximal and distal radial artery. Ann Thorac Surg 1998;66:1972-1977.[Abstract/Free Full Text]
  9. Taggart D.P., Dipp M., Mussa S., Nye P. Phenoxybenzamine prevents spasm in radial artery conduits for coronary artery bypass grafting. J Thorac Cardiovasc Surg 2000;120:815-817.[Free Full Text]



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This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
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Right arrow Citation Map
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Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
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Right arrow Author home page(s):
David P. Taggart
Right arrow Permission Requests
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Right arrow Citing Articles via HighWire
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Right arrow Articles by Taggart, D. P.
Right arrow Articles by Ahmad, I.
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PubMed
Right arrow PubMed Citation
Right arrow Articles by Taggart, D. P.
Right arrow Articles by Ahmad, I.
Related Collections
Right arrow Coronary disease

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