Endoscopic RA harvest technique
The RA in all patients of ERAH group was harvested by an expert surgical
assistant who has since 2012 performed a total of 462 cases before
participating in this trial. The same operator has initiated the program
of endoscopic SVG harvesting in our institution in 2010. Currently all
SVG and RA conduits are harvested endoscopically.
Arm preparation . The donor arm was shaved and prepared from the
shoulder to the fingers. A Stockinet was placed over the humerus of the
donor arm and a tourniquet applied over the Stockinet and connected to
the insufflation device. Endoscopic harvesting was performed using the
VASO-VIEW® HemoPro Endoscopic Vessel Harvesting System (Getinge AB,
Maquet Cardiovascular, Santa Clara, CA.).
A longitudinal 2-3cm incision was made in proximity to the wrist crease
over the radial artery. A pressure cuff was applied above the hand and
inflated to 150-200mmHg and both time of inflation and pressure were
monitored and documented. The RA with the venae comitantes were
dissected as one pedicle directly through the lateral fascia. Then, the
endoscope with its conical tip was advanced over the radial artery to
allow for the insertion of the port. The port was inflated with air to
create a seal and carbon dioxide insufflated at a flow rate of 3L/min
and pressure 10-12mmHg to create a tunnel. The anterior aspect of the RA
was dissected first with the aid of the conical tip followed by the
lateral and posterior aspects. The conical tip was then removed, and the
endoscope positioned into the Endoscopic Vessel Harvesting System.
Fasciotomy was done using direct low intensity energy force. Dissection
of the tissues was performed by grasping them between the jaws of the
cannula and gentle traction and rotation of the tool so as to apply
controlled tension. The branches of the RA were caught between the Jaws
by pulling the Toggle into the middle position, all branches were
divided, and the radial artery pedicle was freed from the surrounding
tissues. The proximal part of the RA after it was brought out of the
skin through a 0.5cm long horizontal skin incision it was divided and
ligated. The radial artery was cannulated at the proximal end and 30mg
of papaverine was flushed in it. The radial artery was examined closely
for arterial spasm, bleeding and arterial hematomas. Arterial branches
were ligated before grafting with metal clips. The incision was closed
using 4-0 Vicryl/Monocryl suture.