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Ann Thorac Surg 2004;78:149-153
© 2004 The Society of Thoracic Surgeons

Original article: cardiovascular

Endoscopic radial artery harvesting is better than the open technique

Amit N. Patel, MD, MSa*, A. Carl Henry, MDa, Carol Hunnicutt, PA-Ca, Carol Ann Cockerham, BSNa, Brittany Willey, BSNa, Harold C. Urschel, Jr, MDa

a Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA

Accepted for publication December 12, 2003.

* Address reprint requests to Dr Patel, Baylor University Medical Center, 3600 Gaston Ave, Suite #1201, Dallas, TX 75246, USA
e-mail: anpatel72{at}hotmail.com

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: Radial arteries are being used more often for coronary artery bypass grafting. A minimally invasive technique was devised for harvesting vessels and compared with the traditional harvesting technique.

METHODS: In a prospective study of 200 consecutive patients undergoing coronary artery bypass grafting, 100 patients had traditional open radial artery harvesting and 100 underwent endoscopic radial artery harvesting. All patients had a preoperative modified Allen's test with Doppler imaging. The traditional technique involved a longitudinal incision over the radial aspect of the arm from the wrist to the antecubital fossa. The radial artery was dissected subfascially and removed. The endoscopic technique involved a 3-cm incision over the radial aspect of the arm. A vessel loop was placed around the artery and carbon dioxide was insufflated into the wound. The radial artery was dissected to the brachial artery and ligated with an Endo-loop ligature. The branches were divided with bipolar electrocautery and ligated with clips. Patients were evaluated for postoperative pain, bleeding, neuralgias, infection, and any adverse events. A p value of less than 0.05 was considered significant.

RESULTS: All 200 radial arteries were successfully harvested and used as grafts. Patients who had undergone endoscopic radial artery harvesting had significantly fewer major complications than patients who underwent the open technique: hematomas (five versus no complications) or wound infections requiring antibiotics (seven versus one complication). The occurrence of major neuralgias that restricted function were also significantly lower postoperatively and 1, 3, and 6 months later (ten versus one, eight versus one, five versus zero, and one versus zero, respectively).

CONCLUSIONS: Endoscopic radial artery harvesting results in good cosmetic results, useable grafts, and minimal neuralgias. Endoscopic radial artery harvesting is better than traditional open radial artery harvesting.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 Discussion
 References
 
The use of the radial artery for coronary artery bypass grafting (CABG) was first described by Carpentier and colleagues in the early 1970s [1]. They harvested the radial artery graft using an open technique (skeletonized) and did not use any vasodilators. The patency of these initial radial artery grafts was very poor, and therefore the radial artery was abandoned for CABG. Many years later, a number of the original radial artery grafts that had been thought to have been occluded were found to be patent. This finding along with the use of vasodilators [2] and a different harvesting technique (pedicle) [3] resulted in the resurgence of the use of the radial artery for CABG. Since that time numerous studies have been published on the use of radial arteries for CABG [4–11]. However, they all have had similar morbidities of neuralgias and few but significant wound complications using the open harvesting technique [12–14]. It has already been shown that endoscopic vessel harvesting (EVH) for saphenous veins is safe and results in minimal morbidity [15]. We modified our EVH technique to perform radial artery harvesting. The purpose of our study was to evaluate a minimally invasive technique for radial artery harvesting and compare this procedure with the traditional open technique.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 Discussion
 References
 
Patients
After institutional review board approval, 200 consecutive patients, undergoing only primary CABG, were prospectively enrolled into the study during a 6-month period. The first 100 patients underwent traditional open harvesting of the radial artery (pedicle) as previously described by Reyes and colleagues [3]. The second 100 patients underwent endoscopic radial artery harvesting with the VasoView System (Guidant Corporation, Santa Clara, CA), as described below. All patients had a preoperative modified Allen's test of the nondominant arm that involved a Doppler study of the forearm and hand [16–19]. Patients with an incomplete palmar arch, no compensatory flow, or renal failure were excluded from enrollment into the study. No bilateral radial artery harvesting was performed. Prior vessel harvesting experience at our institution included 1,800 EVH cases and 300 open radial artery harvests. Before this study no endoscopic radial arteries had been harvested at our institution.

The patients were evaluated for postoperative neuralgias, hematomas, and wound or vascular complications. Neuralgias were defined as major (restriction of normal motor function of the hand or arm) or minor (temporary numbness or tingling in the hand or arm). Hematomas were defined as major (collection of blood at the incision or throughout the arm) or minor (any ecchymosis in the hand or arm). Wound complications were defined as major (infection requiring antibiotics) or minor (any erythema in the hand or arm).

Statistical analysis
Statistical analyses were performed using the paired t test and {chi}2 (Statistica-Stat Soft, Tulsa, OK). A p value of less than 0.05 was considered significant.

Technique for endoscopic radial artery harvesting
Preparation of harvesting arm
The donor arm was shaved and prepared from the shoulder to the hand, inclusive of the fingers, per operating room policy. A Stockinet was placed as high as possible on the donor arm proximal to the humeral epicondyles. A tourniquet was applied over the Stockinet, but not pressurized, and connected to the insufflation device.

Skin incision
A longitudinal 2- to 3-cm skin incision was made over the radial artery, just proximal to the wrist crease. The radial artery and both accompanying venae comitantes (radial pedicle) were exposed and controlled with a small vessel loop. Sodium heparin (3,000 U) was administered through a central intravenous catheter. The dissection at the incision relieved the anterior aspect of the radial pedicle from superficial fascia and connective tissue. A blunt dissector was used to create a hood for insertion of the blunt tip trocar (BTT) port. After 2 minutes of heparin administration, 2 soft vascular clamps were placed on the most distal end of the radial artery. A small arteriotomy was created and 30 mg intraarterial papaverine was administered. The distal soft vascular clamp was removed to verify adequate ulnar artery flow through the palmar arch. However, if no flow was observed, then the distal artery was flushed with heparin and papaverine. If there was still no flow, then the radial artery harvest was abandoned. The entire hand and forearm was then wrapped from distal to proximal with an Esmark bandage and the tourniquet was inflated to 200 mm Hg. If blood still flowed through the arteriotomy after removal of the soft vascular clamp, the pressure was gradually increased until no flow was present. Maximum tourniquet time was limited to 1 hour, at which time the tourniquet was removed and the case was converted to an open harvest procedure. The tourniquet was not used during cardiopulmonary bypass. The Esmark bandage was removed and the distal radial artery was ligated. The VasoView conical dissection cannula with preloaded BTT port was inserted in the wound.

Radial artery dissection
The BTT balloon was inflated to the minimum amount necessary to establish an appropriate seal; no more than 5 mL of air was required. The blunt dissection cannula with endoscope was positioned to allow for continuous visualization of the radial pedicle. As the cannula was carefully advanced, CO2 was infused to pressurize the tunnel to approximately 15 mm Hg, as performed in the EVH technique. Continuous expired pCO2 was monitored as with established EVH monitoring of CO2 absorption. Unacceptable pCO2 levels resulted in termination of procedure as with EVH. The full length of the brachioradialis muscle fascia was divided using the bipolar scissors. Anterior and posterior exposure around the pedicle was obtained by careful dissection directly anterior and lateral to the adjacent veins and the radial artery. The exposure was carried out to no further than the origin of the radial artery at the bifurcation of the brachial artery. Additional arterial branch exposure was performed to clear tissue and allow efficient branch cauterization and division with minimal tension.

Radial artery harvesting
The VasoView Uniport Plus dissection cannula without the conical tip but with the bipolar scissors or bisector was inserted into the pre-dissected tunnel. Branch division was carried out in the same manner as with established saphenous vein harvesting technique. All electrocautery was performed at a safe distance from the artery as with the standard open technique. The bipolar electrocautery was set to 30 watts. Spatial distance was maintained between the artery and the bipolar scissors by using the cradle to stabilize the pedicle before coagulation of the branches to minimize thermal injury. Confirmation of complete branch division by lengthwise passage of the vessel cradle as with the EVH technique was performed. Under endoscopic vision, proximal ligation of the radial artery was performed using a slipknot (Endo-loop) of 2-0 Prolene (Ethicon, Somerville, NJ) at the origin from the brachial artery. The radial artery was divided using the endoscopic scissors with no coagulation.

Radial artery graft preparation
The radial artery was cannulated at the proximal end and 30-mg papaverine was flushed. The radial artery was examined closely for arterial spasm, bleeding, arterial hematomas, and cauterization was performed when necessary. Arterial branches were ligated before grafting with metal clips. The incision was closed using 3-0 and 4-0 Vicryl/Monocryl suture. The hand and arm were wrapped fairly tightly with an Ace bandage. An abdominal pad was placed under the wrap and the tourniquet was deflated and removed. Total tourniquet time was recorded. After the coronary grafting was performed, and the heparin had been reversed, the tight wrap was taken down and rewrapped loosely over the entire arm.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 Discussion
 References
 
All 200 patients had successful harvesting of their nondominant hand radial arteries. All radial arteries in the study were found by visual inspection to be usable for grafting. The following demographics were found in both groups for open versus endoscopic harvesting: number of men/women 66/34 versus 71/29; median age 68 versus 69 years; number of cases of hypertension 71 versus 76; number of cases of diabetes 31 versus 39; and number of cases of chronic obstructive pulmonary disease 5 versus 8 (Table 1). No conversions were made from endoscopic to the open technique. No counter-incision was required at the antecubital fossa to control bleeding or the proximal radial artery in any of the endoscopically harvested vessels. No patients required exploration of the wound for recurrent bleeding in the endoscopic group.


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  		Table 1. Demographics

 
The operative findings were as follows for open versus endoscopic harvesting: mean length of incision 24.6 ± 2.8 versus 2.8 ± 1.2 cm (p < 0.05); mean length of graft 17.2 ± 2.1 versus 18.1 ± 2.6 cm; median number of repairs, one in each group; median harvest time 22 versus 26 minutes (Table 2).


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  		Table 2. Results

 
The complications were subtyped as major and minor for hematomas, infections, and neuralgias (Tables 3 and 4). Patients with endoscopic harvesting had significantly fewer major and minor complications. In the open versus endoscopic harvesting groups, the following major complications were observed: five versus zero hematomas (p < 0.05) and seven versus one wound infection requiring antibiotics (p < 0.05). For major neuralgias that restricted motor function, we found ten in the open group versus one in the endoscopic harvesting group postoperatively (p < 0.05), eight versus one at 1 month (p < 0.05), five versus zero at 3 months (p < 0.05), and one versus zero at 6 months (Table 4). Open versus endoscopic harvesting groups had the following minor complications: 21 versus 2 patients with wound ecchymosis (p < 0.05) and 4 versus 0 patients with wound erythema (p < 0.05). For mild neuralgias consisting of mild numbness or tingling in the hand or arm, we found 31 versus 18 patients postoperatively (p < 0.05), 26 versus 8 patients at 1 month (p < 0.05), 14 versus 4 patients at 3 months (p < 0.05), and 7 versus 0 patients at 6 months (p < 0.05).


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  		Table 3. Major Complications

 

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  		Table 4. Major Neurologic Complications Restricting Normal Motor Function

 

   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
Discussion
 References
 
Carpentier's first use of the radial artery for CABG was thought to be a failure due to poor early graft patency [1]. However, interest in the technique was renewed after long-term follow-up showed promising patency of the radial artery grafts. Since that time many studies have described the successful use and patency of radial artery conduits for CABG [4–11]. Most of these studies have described the use of an open technique for harvesting the radial artery. The open technique used in this study was similar to one described by Reyes and colleagues [3]. The endoscopic radial artery harvesting technique was adapted from our approach for endoscopic harvesting of saphenous veins [15]. The first reported use of endoscopic radial artery harvesting was described by Terada and coworkers [20]. Similar techniques have been described by others [21]. Our technique was performed by both surgeons and physician assistants.

Our technique differed in a number of ways from those of the others. Some our variations in technique included the use of bipolar electrocautery instead of ultrasonic shears [22–24]. We used only a single distal incision on the arm and performed ligation of the proximal radial artery using an Endo-loop instead of a counter-incision. Most other researchers used two incisions or required reoperation for tunnel bleeding. We have been fortunate in that neither has been needed for our patients. We noted no increase in bleeding or vascular compromise using the endoscopic technique.

We have recently started training other surgeons and physician assistants in our technique. We suggest that they should perform 50 to 75 endoscopic vein harvests and 10 to 20 open radial artery harvests before attempting endoscopic radial artery harvesting. This recommended minimum number of surgeries is to ensure familiarity with the endoscopic equipment and adequate knowledge of the surgical anatomy for radial artery harvesting. The use of papaverine may be substituted with calcium-channel blocker or nitroglycerin solution, as per the surgeon's preference [2]. The solution used has been shown to have little difference on patency or spasm of the graft. The tourniquet may be used or not, based on surgeon's preference. Both techniques have been described, but neither one has increased morbidity. However, when a tourniquet is used [25, 26], the operating field is increased because the radial artery and the associated veins are collapsed. A tourniquet also decreases the risk of bleeding due to the branches being divided under no back-pressure. The use of an Endo-loop increases the length of the radial artery graft harvested. If a small proximal incision is used as in the "stab & grab" technique to retrieve and ligate the proximal radial artery, the length of graft harvested decreases by 0.5 to 1.5 cm. Using our technique we have had no failures of the Endo-loop. All these strategies help facilitate the procedure and, it is hoped, decrease complications.

The decrease in neurologic complications observed in the endoscopic harvesting group could have been attributed to the smaller skin incision, which would have resulted in fewer cutaneous nerves being transected. Also, the use of bipolar electrocautery may have decreased neurologic complications by decreasing thermal spread of energy. In our early experience, we found that minimal inflation of the BTT port balloon decreased compression of the superficial radial nerve, resulting in fewer thenar neuralgias. Because a "no touch" technique of the radial artery pedicle was used, this strategy would reduce possible shear-and-traction injury to median or radial nerves. Other complications reduced by the endoscopic harvesting technique included infection and hematomas, which may be related to the small incision and adequate hemostasis of the smaller dissection planes compared with the open technique.

The effective cost for endoscopic radial artery harvesting is not significantly higher than that of the open technique, because we used the same equipment for the open and the endoscopic vein harvesting procedures. Therefore, only one set of disposable equipment is required per patient to perform all vessel harvesting. Currently, all of our endoscopic radial artery harvesting is performed by the physician assistants.

Radial artery grafts are being increasingly used for conduit in patients undergoing CABG. The use of an endoscopic approach is safe and effective for reducing the morbidity commonly associated with open harvesting. Long-term patency along with event-free intervals will need to be followed.


   Discussion
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
References
 
DR ALAA Y. AFIFI (Albany, NY): I enjoyed your paper very much, as I did also Dr Moon's paper earlier. A couple of comments. We, like many surgeons throughout the country, are always in the pursuit of complete arterial revascularization during coronary artery bypass surgery, and obviously the radial artery has played a huge role over the past several years. There are some limitations, as you have pointed out, such as neurological complications related to paresthesia, concerns for cosmesis, as well as a desire to minimize postoperative hematomas.

The reason for the significant resurgence of the radial artery as a bypass conduit in coronary artery revascularization is that many have identified that the midterm patency is much better than what was once thought. Since the initiation and subsequent success of endoscopic vein harvesting, many groups have been developing techniques for endoscopic harvesting of the radial artery. My concern is when we have been harvesting the endoscopic radials, at least in the early learning curve, subintimal or subadventitial dissections and subsequent hematomas have resulted, which occasionally have led to a suboptimal conduit.

Instead of getting an absolutely beautiful conduit like we do with the openly harvested radial artery obtained with the use of the Harmonic scalpel, we come up with less than ideal conduits. I have been less thrilled with embracing this endoscopic approach simply because I want a perfect conduit when I am using it for coronary bypass. What have you seen in your learning curve as far as going from the open procedure to this endoscopic approach?

DR PATEL: Our recommended learning curve for endoscopic radial artery harvesting is 50 endoscopic vein and 20 open radial artery harvests. This results in a sound knowledge of the endoscopic equipment along with the anatomy and techniques required for safe radial artery harvesting.

The key to our dissection is dividing the brachioradialis fascia. This strategy creates a large enough tunnel, using the carbon dioxide, that it decreases the risk of subintimal dissections. It also enables ligation and decreased tearing of branches close to the radial artery. It took about five cases before we realized how important it was to completely divide that brachioradialis fascia in order to obtain a similar tunnel as you obtain in the leg with endoscopic veins. You must divide your branches at least 2 to 3 mm away from the main pedicle.

We have performed more than 400 endoscopic radial artery harvests and found no arteries that have had complications as a result of this endoscopic dissection.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 Discussion
 References
 

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