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Ann Thorac Surg 2002;73:346
© 2002 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Wayne State University, School of Medicine, Detroit, MI 48201, USA
To the Editor
I enjoyed the recent article by Jarvis and colleagues in the October 2000 issue of The Annals [1]. In my practice the radial artery is a conduit of choice in patients less than 65 years old who are not dialysis candidates. The patient is screened using the Allen’s test as described. If the patient has a capillary filling time of 6 seconds or less, the arm is prepared for the surgical field.
A 2.0 cm incision is made over the radial artery at the wrist, and the radial artery is dissected out. A 27-gauge needle attached to a pressure monitoring line is inserted into the radial artery with the tip directed toward the hand. A good waveform is noted. The mean pressure is recorded. A Kitner is then used to occlude the radial artery proximally or toward the anticubital fossa. If the mean blood pressure decreases by less than 15 mm Hg with occlusion, the radial artery is almost always an excellent conduit. Occluding an intact radial artery usually causes a decrease in measured pressure. Should the blood pressure decrease by more than 20 mm Hg, I do not use the radial artery. The 20 mm Hg gradient is my arbitrary cutoff.
If there is no change in blood pressure, the palmar arch is patent but the radial artery may be occluded. This possibility can be differentiated by moving the Kitner distal to the needle at the wrist. If the mean pressure disappears, the radial artery is occluded. If the pressure is unchanged, the radial artery will likely be an excellent conduit.
The radial artery is dissected from the anticubital fossa to the wrist. Before harvesting the radial artery, small clamps are placed proximally at the anticubital fossa and the wrist. The capillary refill in the fingers is then noted. If it is 6 seconds or less, the artery is harvested.
Using this technique in more than 100 patients, no ischemic hand complications have occurred. The determination does not require preoperative Doppler of the hand or a pulse oximeter. It is inexpensive as the standard operating room equipment is required. It can be difficult to keep the 27-gauge needle within the lumen of a small radial artery. It is important that a representative arterial wave trace be present throughout the entire test. With this algorithm for harvesting the radial artery, there are only a few patients with blood pressure drop less than 20 mm Hg in whom I have not used the radial artery (calcified). With a blood pressure drop of greater than 20 mm Hg, I have not harvested the radial artery.
Using a 6-second cutoff on the Allen’s test may exclude several patients, when a Doppler might show an intact palmar arch. I have not been comfortable using the radial artery in patients with a greater than 6-second capillary refill.
The advantage of this strategy is that it does not require preoperative testing, which is expensive, time-consuming, and often cannot be obtained in an urgent or emergency setting. In addition, few patients are excluded from having the radial artery used in coronary operation.
References
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