[[300 Technical Outline of Coronary Artery Bypass Grafting]] - Set up chair ergonomically - Set up Mayo stand with equipment for radial harvest, and additional bovie if necessary. - Plan incision on a line from radial pulse to brachial pulse. - Make a superficial incision at the radial, just through dermis - Cut down through overlying fascia on to adventitia of the radial with metzenbaum scissors - Determine if radial is suitable for harvest - Travelling within the fascial plane, along the adventitia, extend incision towards brachial pulse, at the arterial, and the skin level. - The artery will typically dive under the brachioradialis muscle, which may be quite tendinous at this point. While the muscle can be cut to assist in exposure, it is usually possible to just dissect the muscle free, and retract it to one side with a Weitlaner self-retaining retractor. The limits of exposure will be the recurrent radial artery, three or so centimeters from the antecubital fossa, and the superficial palmar branch at the level of the rascettes at the wrist. Even with the gentlest handling, you may see ripples of spasm develop in the vessel. - Stop when the recurrent radial artery is exposed - Start in the middle, work in either direction. - Develop and clip the branches on either side of the artery and the accompanying veins on either side of the vessel. Clip both sides and cut between with tonotomy scissors. - There is an admitted hypocrisy to clipping on either side of the radial branches, when one does not do so at the mammary. With the size branches one deals with from either vessel, cautery is very secure, but there is an atavistic fear of applying electricity to the well-innervated upper extremity. The mammary is much less prone to spasm than the radial, so it is only right to avoid cautery in its harvest. An automatic clip applier is used to double clip the artery side, and singly clip the arm side of the branches. The tip motion of the automatic action does not make this instrument helpful for the mammary, but it is useful in radial harvest. One should plan for three clip appliers typically. - Get into the areolar plane below the artery - Clip the penetrating branches below the radial artery - When the radial has been mobilised completely, occlude it once more with a soft bulldog clamp, and confirm for the last time that the arch is complete. - Clamp at the wrist and the proximal extent with mosquito clamps - Cut with tonotomy scissors. - Immediately cannulate proximal end and flush with heparin-papaverine solution - Mark one side of radial along its length with marking pen to help avoid twisting of graft later - Immerse graft in heparin-papaverine solution. - Tie off both ends of the vessel at the clamps - Hemostasis of radial bed - Close dermis - Close subcuticular - Apply sterile gauze dressing - Secure dressing with fairly tight Ace wrap. - Remove armboard - Tuck arm back in alongside chest under drapes - Obviously, this will have to wait for the mammary retractor to be removed for an ipsilateral radial harvest. - Consider additional side drape.