Is the Allen's test adequate to safely confirm that a radial artery may be harvested for coronary arterial bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the Allen's test, plethysmography, Doppler ultrasound or MRI imaging was the best method of assessing the presence of adequate collateral blood flow in the arm preoperatively prior to radial artery harvest for conduits during CABG surgery. Altogether 176 papers were identified using the reported search of which 15 represented the best evidence on the topic. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that whilst there are theoretical limitations with the Allen's test, for most patients it is an adequate method of assessing collateral arm flow prior to radial artery harvest and several large studies have confirmed the absence of neurological and vascular adverse outcome with a modified Allen's test cut-off point of up to 12 s. However, if there are concerns about collateral flow then a second confirmatory test such as dynamic Doppler ultrasound or measurement of digital pressure changes with radial artery occlusion can also be used prior to harvest. Newer techniques such as Gadolinium-enhanced magnetic resonance angiography have also been described to confirm adequate collateral circulation prior to radial artery harvest for CABG conduit and whilst in time they might come to represent an ultimate 'gold standard' they are clearly too expensive and impracticable for everyday use.