Catheterization and Cardiovascular Diagnosis 1055-61 (1984)

Brachial Artery Catheterization Employing a Side Arm Sheath

Edward D. Folland, MD, Andrew Kemper, MD, Peter Bloomfield, MRCP, and Alfred F. Parisi, MD

A major complication of left heart catheterization via the brachial artery is occlusion at the cutdown site. This is particularly a problem when patients with severe athero- sclerosis are catheterized in laboratories where the brachial approach is not routinely used. A method of brachial artery catheterization is described which employs a continuously flushed side arm sheath in order to minimize local trauma to the artery from catheter exchange and manipulation. In 15 consecutive atherosclerotic patients catheterized by this method there were no complications, and all arteriotomies were closed easily with immediate restoration of a good radial pulse. This contrasts with the preceding 33 consecutive brachial catherizations employing standard technique in similar patients in whom four patients required surgical repair, and an additional six patients required more than one closure attempt andlor catheter thrombectomy to restore a good pulse. In our laboratory the brachial sheath technique has facilitated arterial repair and reduced local complications.

Key words: arterial sheath, left heart catheterization, arterial catheterization, catheterization complications, brachial artery sheath

INTRODUCTION

When performed in laboratories where the femoral approach is routine, the brachial approach for arterial catheterization has been associated with an increased incidence of complications [ 11. Often in such laboratories, the only patients studied from the arm are those with advance aorto-iliac and femoral disease that precludes femoral catheterization. These patients frequently have coexistant disease of the brachial, axillary, and subclavian arteries. Consequently, patients at highest risk for arterial complications must be catheterized using a method with which the operators are least

From West Roxbury VA Medical Center and Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts.

Address reprint requests to Edward D. Folland, MD, Director, Cardiac Catheterization Laboratory, Veterans Administration Medical Center, 1400 V.F.W. Parkway, West Roxbury, MA 02 132.

Received July 8, 1983; revision accepted September 20, 1983.

0 1984 Alan R. Liss, Inc.

56 Folland et al

experienced. These problems may be further compounded in training laboratories where increased arterial time is frequently needed for catheter manipulation and exchange.

Use of an in-dwelling sheath with continuous side arm flush has been previously described in percutaneous femoral applications [2,3]. We introduced this method to the brachial approach in the hope of reducing local arterial trauma and subsequent related complications. In this report we describe the sheath technique and compare our year of experience using the new technique to our preceding 2 years of experience using the standard brachial arterial technique.

MATERIALS AND METHODS Patients

All patients undergoing brachial artery catheterizations in our laboratory during calendar years 1980, 198 1, and 1982 are included in this report. All studies performed during 1980 and 198 I employed a standard (described below) brachial catheterization technique without a side arm sheath. All studies during calendar year 1982 employed the new side arm sheath technique. The reasons for choice of brachial route included prior failure of femoral catheterization or primary choice of the brachial route due to diminished or absent femoral pulses, absence of distal leg pulses, or known aneurys- mal disease of the aorta. The procedures were performed by rotating cardiology fellows supervised by staff attendings. There were no major changes in staff personnel during the study. Complications, total heparin dose, reason for brachial approach, number of catheters used, arterial time, use of Fogarty catheter, and number of closures required to restore satisfactory radial pulse by palpation were prospectively tabulated during the later period and retrospectively extracted from records for the initial period.

Sheath Technique

The brachial artery is exposed by a transverse cutdown centered on the artery just proximal to the flexion crease of the antecubital fossa. A section of artery approxi- mately 2 cm long is isolated by blunt dissection and anchored by two soft rubber ligatures. Prior to arteriotomy the patient is given 3000 units of intravenous heparin. The artery is incised anteriorly by a No.ll scalpel blade (sharp side oriented up) while pinching the retracted vessel with angled forceps (Fig. 1). This technique creates a clean, transverse incision (Fig. 2). Care is exercised to make this incision as small as possible. Heparin (1000 units) is then instilled distally via a soft, flexible polyethylene catheter. (We have recently abandoned this step: see Discussion.) The assembled guidewire, dilator, and sheath (7 Fr Cordis or USCI) (Fig. 3) are gently introduced as a unit into the artery. After advancing the sheath to its hub, the guidewire and dilator are withdrawn and the side arm cleared and connected to continuous drip of heparinized flush (2000 units of heparin in 1 liter of normal saline or 5% dextrose infused at 2-5 cc/min). Because the sheath is not restrained by surrounding tissue as it is in percutaneous application, the side arm must be anchored to the corner of the cutdown with a suture (Fig. 4). If not anchored, it is frequently expelled by intru-arterial pressure. Hemostasis can be maintained without occluding flow by arterial retraction if a small arteriotomy is performed. Catheters are intro- duced and employed in the usual fashion. The sheath need not be further manipulated

LS

58 Folland et al

Fig. 3. An example of the assembled guidewire, dilator, and sheath unit used in our cases (Cordis Corp, Miami, FL).

Fig. 4. The sheath is held in position in the artery by a temporary suture around the side arm anchored at the corner of the cutdown (arrow). Once in the artery, the dilator and guidewire are removed, and the sidearm is connected to a continuous drip.

after insertion of the arterial catheter. Catheters are inserted into the arteriotomy under direct vision and with the aid of fine-tipped spreading forceps when necessary. Because the Sones technique is not routinely employed, catheter exchanges are usually required.

RESULTS

As Table I indicates, the baseline characteristics of the two study groups are comparable and not attributable to differences in patient selection, arterial time, number of catheter exchanges or prophylactic Fogarty catheterization. Heparin was given in all cases in similar doses. During the initial period (1980, 1981) brachial procedures constituted 6% of all arterial catheterizations (33 of 526). During the later period brachial catheterization constituted 5 % of all arterial catheterizations (15 of 294).

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The most dramatic result of the sheath technique is subjective: the appearance of the arteriotomy upon conclusion of the study. In all 15 cases the arteriotomy margins were as clean and free from distortion as they were after the initial incision. These include two unusually difficult cases with highly atypical aortic root anatomy requir- ing prolonged manipulation and multiple exchanges of catheters (arterial time = 121 min with 6 catheters, and 142 min with 5 catheters, respectively) and one case where the same brachial artery had been catheterized on two previous occasions. Without exception these arteriotomies were easy to close. As Table I1 indicates, all 15 were successfully closed on the first attempt with immediate restoration of a good radial pulse. In no case was thrombus present requiring Fogarty thrombectomy. The only complication of any kind was a superficial cutdown infection which was probably unrelated to the sheath technique. In contrast, only 23 of 33 standard technique arteriotomies were successfully closed at the first attempt without thrombectomy. In 6 cases either revision, thrombectomy, or both were required in 4 cases repair was required by a vascular surgeon.

DISCUSSION

In our laboratory the most common complication of brachial arterial catheterization is inability to restore adequate radial pulse after closure of the arteriotomy. When this occurs, the patient usually has severe atherosclerosis, and the cause is local trauma such as raised plaques, local dissection, frayed arteriotomy margins, thrombosis, and technical errors in suture placement. All but perhaps the last of these are related to

TABLE 1. Characteristics of Study Groups

Percentage Reason for Mean of all brachial approach arterial Mean

arterial Primary Failed time number of Prophylactic Technique N caths choice femoral (min) catheters fogarty

Standard 33 6 28 5 70 2.8 9

Sheath 15 5 12 3 71 3.1 4 1980-1981 (N=30)a (N=31)a

1982

“Data are derived from less than total study group because of incomplete records.

TABLE 11. Outcome

Pulse Pulse restored with difficulty lost > 1 Closure

Technique repair) required attempt thrombectomy complications

Standard 4a 1 2 3 0

Sheath 0 0 0 0 I’

(surgical Thrombectomy > 1 Closure and Other

N=33

N=15

“Pulse ultimately restored. ’Superficial cutdown infection.

60 Folland et al

the trauma of catheter insertion, withdrawal, and manipulation. The use of an indwelling side arm sheath eliminates this local trauma as well as the additional stress of arterial retraction. The relative benefit may be minimal in laboratories where the brachial approach is routinely employed; however, it provides an important advantage in laboratories where the brachial approach is employed only out of necessity in patients with severe atherosclerosis.

If a small arteriotomy is performed hemostasis can be maintained without arterial traction. We prefer sharp horizontal incision of the artery rather than needle puncture or direct Seldinger technique, because it allows more precise horizontal closure with interrupted sutures. In our experience this is less likely to result in stenosis than purse string or longitudinal closure. It is not necessary to instill heparin distally after performing arteriotomy, because perfusion probably continues past the sheath pro- vided that the artery is not retracted. In addition, the continuous heparin drip via the side arm provides additional local anticoagulation. The elimination of distal heparin injection not only saves time, but also avoids potential arterial damage from antegrade insertion of the injection catheter. Additional systemic heparin is given prior to closure to be certain of full anticoagulation during the period of arterial occlusion required for repair.

An additonal advantage of this method is that arterial pressure can be monitored via the side arm, provided that a catheter is used which is one size smaller than the sheath (Fig. 5) . This is particularly useful in cases of aortic stenosis where simulta- neous brachial artery and left ventricular pressure can be measured without the need for an additional arterial puncture.

Use of the sheath in brachial artery catheterizations has facilitated catheter ex- change, minimized trauma to the arteriotomy site, simplified arteriotomy repair, and reduced the incidence of postcatheterization occlusion. We now use this technique routinely for brachial procedures.

Fig. 5. Simultaneous recording of right brachial artery (BA) pressure via the side arm of an No. 8 French sheath and ascending aortic (no) pressure via a No. 7 French pigtail catheter. In order to monitor pressure accurately via the sheath the indwelling catheter must be one French size number smaller than the sheath.

Brachial Artery Sheath 61

ACKNOWLEDGMENTS

This work was supported in part by the Medical Research Service, U.S. Veterans Administration.

REFERENCES

1. Davis K, Kennedy JW, Kemp HG, Judkins MP, Gosselin AJ, Killip T: Complications of coronary arteriography from the collaborative study of coronary artery surgery (CASS). Circulation 59: 1105- 1112, 1979.

2. Barry WH, Levin DC, Green LH, Bettman MA, Mudge GM Jr, Phillips D: Left heart catheteriza- tion and angiography via the percutaneous femoral approach using an arterial sheath. Cathet Cardiovasc Diagn 5:401-409, 1979.

3. Hillis LD: Percutaneous left heart catheterization and coronary arteriography using a femoral artery sheath. Cathet Cardiovasc Diagn 5:393-399, 1979.