Clinicians share their long-term experiences and strategies for ERAH

How do you approach patient selection for Endoscopic Radial Artery Harvesting (ERAH), and what criteria do you consider most crucial to ensure optimal outcomes?

Kelly Lynn: “The way we evaluate patients for radial artery harvesting is with the Allen's test. We do it upstairs before they come to surgery and then in surgery I do a more complete test with a pulse oximeter.

If the Allen's test is good then I feel comfortable going ahead and taking the radial artery. We usually try and take the non-dominant hand and I also do an ultrasound of the artery to make sure it's at least 2mm in size and there aren't any plaques. I feel like the Allen's test and the ultrasound both are required to make sure that you have an artery that's going to be usable for the graft.”

Erin Miller:”Our current selection criteria for patients for radial artery harvesting includes the following. Age less than 75, a positive Allen's test, a non-instrumental arterial artery. That would be either through a cardiac Cath or an arterial line. Patients who are not currently on dialysis. Anybody on dialysis will automatically get disqualified. But also those patients who are going towards dialysis or may need a dialysis in the future, they will also be disqualified. The next most important thing is to look at the cardiac Cath.

Will the patient benefit from a radial?

We don't like to put radials to left sided graphs that are less than about or 70% - 80% and the right sided target really needs to be very tight, so about 85% - 90%. Some programs will not use the dominant arm, but we have found that in patients who will benefit from it, we will use the dominant arm as long as the patient is in agreement. And then finally, the most important criteria that I found is once a patient gets into the operating room, you will ultrasound the radial to make sure that there is no calcification or minimal calcification and also make sure it's an adequate size for the target vessel.”

What key insights or techniques from your extensive experience with ERAH would you share to help other clinicians improve their proficiency and patient outcomes?

Kelly Lynn: ”Insights I have on radial harvesting is doing as much of the dissection as you can open that you can see. My first incision is right at the watch band area and I take care of all side branches with small HEMA clips and using an army Navy to get as much done as I can. Also making sure that you get that anterior fascia down so you have plenty of area to work in and really doing a good dissection on the side branches.

I make sure not to pass that crossing vein up by the elbow because I know I don't want to get above that area and compromise the ulnar artery.”

The first one is the cut down. The cut down tends to be a little difficult for people in the beginning. I. myself had the same issue in the beginning. There're a couple ways that you can kind of help yourself and set yourself up for a good harvest. I will use a, you know, make a small incision.

I will use a Wheat lander and then a sends retractor are the two most important things that I think are well set you up for a good harvest. The sends retractor is just kind of an angled retractor and it's very small and thin and it'll help get around that vessel. You can lift up on it on the radio without causing any issues because really what you want to do is get an about an inch or two around the radial so that your scope can go in pretty easily. I found the most important thing is to get on the fascia layer above the radial and below the radial and kind of leave yourself a little bit of a landing zone. So that when you put your scope in, in the next portion, you can, you can see exactly where the fascia layer is. And you can just glide right in and start your, your dissection without any damage to the radial.

The second part would be the dissection As long as you left yourself that nice landing zone, you should be able to just put your dissector right into the arm and start your harvest. Now the most important thing is a little bit different from the vein. You really need to go slow. You need to give yourself, you know, about a centimetre, two centimetre at a time. You'll go forward a little bit and then just let the CO2 do the work for you. It really opens up a lot of the tunnel and it'll almost dissect a lot of the branches out without you having to put the dissector really anywhere near them. So you'll just kind of go forward a little and let it blow up, go forward a little, let it blow up. I do the same technique as I do in the leg where I go posterior first. I'll go to the top of the tunnel, come back, go anterior again. If I left myself that little bit of the landing zone on the top and the bottom, I'll be able to go right into the anterior path, going slow again so that I make sure you know I'm going a centimetre or two. I'm letting it blow up. If there's any big branches on the top or the bottom, I will very gently put a little window in them at that time and then I'll get to the top of my tunnel.

I found for the dissection as well. When I'm at the top of the tunnel now, I will, I will try to give myself, you know, all right around where I'm going to do the stab and grab and where I'm going to hook onto the v-keeper near the elbow. I'll make sure that that is all clear.

You really don't have to do this in the rest of the of the procedure, but if you give yourself a good area to put the beekeeper around at the top of the tunnel, the whole thing is going to go smoother. I'll make sure that I have a good spot to put the V-keeper on now and then I'll just come back. And again, same thing in the leg where you just make small windows. But in the radial, you really don't have to do that much. You just make a couple small windows on the right and the left side come back and now you'll move into the dissection part.

The third part of the harvest is the dissection. Again, if you've left yourself a good, that good landing zone with the fascia, you're going to put the cutter in and you could right away start cutting the fascia because cutting the fascia, unlike in the leg where you can do it sometimes or you don't have to, it'll just help your harvest a little bit in the radial, it's mandatory. You have to cut the fascia at least 3/4 of the way up on the anterior fascia. I will hook onto that anterior fascia right away because I've left myself that little bit of fascia to see and then just cut it all the way up. Now there are times where the muscle on the anterior pass, the muscle will kind of flop into your tunnel. If you start to see that you just move on to the to continue your harvest and you could always come back, but you have to make sure you cut that fascia by the end of the harvest. Now with the dissection, you're going to get up to the top. You left yourself that nice, dissected area around the elbow so you can hook right on right away. And now you're just going to come back the same as in the vein. And but you just have to be really gentle, slowly rocking back and forth to cut all of those branches on the way back down.”

How do you see the role of ERAH evolving in Coronary Artery Bypass Grafting surgery?

Kelly Lynn:”How do I see endoscopic radial evolving through cardiac surgery? I've been doing this for 30 years, and I have seen the radial artery come and go probably three times in my career. In the beginning, people weren't putting it to the right spaces, and the graphs would go down. We've learned that we need to have a calcium channel blocker as to keep the radial artery muscle smooth and without spasm. And I think that if we use the artery in the right way for the grafts going to a high occluded graft and not doing sequential, it can be used especially in young people.”

Erin Miller: “I see the role of endoscopic radial artery harvest. You know, even this year, I see it evolving very quickly. A lot of our surgeons, a lot of our newer surgeons are very interested in giving the patients more than one arterial graft. and a lot of patients do not qualify for bheemas due to being diabetic or, you know, being a larger patient. And for whatever reason, it's also a little easier if they're working on the mammary while we're working on the radio and it moves the case along a little quicker. I've seen a lot of more interest this year for sure in radial artery harvesting.

I do see the role evolving a little bit in the fact that there are a lot of patients like I mentioned earlier that we exclude from radial artery harvesting due to, you know, the big thing would be an arterial line being placed there or the Cath being done through there. There are some studies coming out showing that this could be safe to use those instrumented radials. We'll really see as the time goes on if, if my practice or if a lot of practices are going to move towards that as well to include more patients and allow them to get radio artery harvesting.”