The benefit of a graft or stent is dependent on persistent patency. After a false start in the 1970s, the radial artery (RA) enjoyed rapid and widespread adaptation following its reintroduction in 1992 [1]. The Parisian experience, where it began on both occasions and spans 20 years from the second start, is herein reported [2, in this issue]. The authors report angiographic follow-up in 351/819 patients having 548 conventional and 205 computed tomography (CT) angiograms. Patency has disappointed by not equaling that of the left internal thoracic artery (ITA) to the left anterior descending (LAD) (95.5% but is a respectable 82.8% at 7 years and similar to that from Rome and Melbourne) [3, 4]. It is well known that target vessel influences patency and usually the RA is grafted to a vessel other than the LAD which is associated with best patency. When the diagonal was the target, RA patency was 93.1% (95/102) [2]. Our unpublished data of the RA as a T-graft to the LAD, diagonal or ramus artery revealed patency of 94% (15/16) at a mean of 10.2 years. Free ITA patency, 80% (49/55), was not different from the RA [2]. Patency for the RA was improved by sequential anastomosis to 91.2% (52/57) from 82.0% (469/572) (p = 0.08) for single anastomosis [2]. Asymptomatic patients had significantly better patency – 88.1%, (347/394) than did those with symptomatic ischemia 74.0% (174/235) (p < 0.001) as the indication for angiography [2]. Most graft failures occurred in the first year beyond which the linear attrition rate was about 0.37% per year. Importantly, there was no evidence for graft atherosclerosis [2] nor in the other two reports [3, 4] or in our unpublished observations to 15.7 years. Although RA patency is no better than for vein grafts, it is likely that this will change in the second decade of observation as graft atherosclerosis develops. How or should we utilize the RA in the future? It has several advantages over the ITA including length, concomitant harvest, less fragility, and reduced sternal infection if combined with one ITA, but the liabilities of spasm and vulnerability to competitive flow. In many instances, the RA falls in line behind the right ITA but there are instances (obese diabetic, morbid obesity, chest wall concerns, and reoperation) where the RA may be preferable. Harvesting is easier and leg-wound complications are avoided if RA is substituted for vein in obese patients where either conduit is otherwise an option including the older patient. Fractional flow reserve is routinely obtained by our cardiologists to assess lesions which are not high grade and only those lesions having a gradient are considered for RA grafting [5]. I continue to selectively use the RA as a T-graft for circumflex and right coronaries but do not graft the posterior descending artery for a right coronary lesion of <90%.