Basic Techniques and Perioperative Care of Radial Artery Graft: Lessons Learned from 130 Cases

Objective: Radial artery graft (RAG) for complex vascular lesions has been a well-established treatment option. In the last 20 years, our center has performed more than 120 RAGs, during which we have come across various experiences including complications. In this report, we present the surgical technique, and intraoperative monitoring for 10 of our recent cases, based on our experiences of the complications. The results of diffusion-weighted image (DWI) ischemic findings within 2 days after surgery are also reported.Materials & Methods: Recent RAGs performed for unruptured internal carotid aneurysm, and spontaneous carotid-cavernous fistula (CCF) are included in this study. The basic procedure was external carotid artery-radial artery-M2 (ECA-RA-M2) graft bypass combined with superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis. The highlights of this surgical technique are as follows.1) Subcutaneous tunnel insertion using temporary clip to prevent kinking of the graft.2) STA-MCA anastomosis is important for continuous cerebral perfusion pressure monitoring.3) Selection of the recipient MCA for RA and STA anastomosis is confirmed by indocyanine green video angiography (ICGVAG), combined with temporary proximal MCA occlusion clip. The authors used monitoring bypass for select cases.4) Antithrombotic agents are used before surgery for unruptured lesions as well, to prevent ischemic complications due to thrombosis and graft spasm. Additionally, DWI, 3DCTA perfusion CT, SPECT etc. are performed in the early postoperative period for the same reason.Results: In this series with modified RAG technique, no symptomatic ischemic complications were experienced. Although the number of cases is small, the incidence of symptomatic ischemic complications with this surgical technique was lower than that reported in the past.Conclusion: Since three surgical sites are involved, various parameters and possible complications need to be monitored during surgery, and in the postoperative period.