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Page 4 of 10 Naik et al. Vessel Plus 2018;2:38 I http://dx.doi.org/10.20517/2574-1209.2018.62

Figure 1. Endoscopic vs. open radial artery (RA) harvesting incision

[29]
diameter when harvested in skeletonized fashion (P < 0.01) , others point out the disadvantage of longer
[30]
harvesting time and the risk for endothelial damage especially when the Harmonic scalpel is used . The
Harmonic scalpel uses ultrasonic energy for tissue dissection which is well known to cause increased release
[31]
of nitric oxide leading to vasodilation and endothelial damage . Considering the lack of clear evidence
pointing towards a significant improvement in patency rate using the skeletonizing technique, this approach
[16]
should be discouraged .

The open technique requires the forearm to be incised in its entirety. The artery is accessed via a curvilinear
incision along the edge of the brachioradialis muscle. The incision is initiated 1 cm distal to the elbow and
extends up to 1 cm proximal to the wrist. After retraction of the superficial veins, the fascia is incised to
expose the radial artery in the mid arm under the belly of brachioradialis muscle [Figure 1] .
[32]
Endoscopic approach of RA harvesting involves a longitudinal incision about 2-3 cm long proximal to the
wrist crease. Dissection is done using bipolar scissors or bisector under direct endoscopic vision. Dissection
is done as a pedicle with accompanying venae comitantes included. Carbon dioxide (CO ) is insufflated
2
at 10-12 mmHg to provide a working tunnel. Addition of CO insufflation prevents spasms in the artery.
2
This is followed by anterior dissection along the radial artery bilaterally up to the level of the antecubital
fossa. Posterior dissection is then done up to the level of the radial plexus. Dissection is carried out laterally
to achieve adequate branch length for sealing later. Fasciotomy enhances visualization and prevents the
development of compartment syndrome. This is followed by branch division using a C-ring to stabilize the
pedicle. The graft is then finally retrieved .
[33]
[34]
Navia et al. found that ERAH requires more equipment in comparison with ORAH, hence it is more
[35]
expensive than ORAH. Shapira et al. showed that the cost of an endoscopic kit, including the disposable
Harmonic shears, is $550. ERAH was also found to take a longer duration as compared to ORAH with
[36]
an associated steep learning curve in inexperienced hands . The reported learning curve for endoscopic
harvest ranges from 5 to 30 cases . Although, Kiaii et al. found that the endoscopic approach requires
[38]
[37]
a significantly lower harvest time (36.5 ± 9.4 min) compared to the open approach (57.7 ± 9.4 min) when
performed by a surgeon adequately experienced in endoscopic harvest.

POSTOPERATIVE OUTCOMES
Patency rates
[7]
Radial artery as a graft for CABG was first introduced by Carpentier et al. , in 1973, however, its use was
abandoned because of concerns of spasm and intimal hyperplasia. In 1975, Curtis et al. found that in the
[8]