842 #{149}Radiology September 1986

Percutaneous Brachial Artery Catheterization’

Elliot 0. Lipchik, MDHideharu Sugimoto, MD

We describe modifications and sugges-tions for safer percutaneous catheteriza-tion of the brachial artery based in parton the anatomy of the axillary-brachialartery and surrounding nerves of thebrachial plexus. The brachial artery ap-proach should be nearly as safe as thefemoral artery approach for percutane-ous catheterization and should not beavoided if the femoral arteries cannot beused.

Index terms: Angiography, technology #{149}Am-

tenies, extremities, 91.123 #{149}Catheters and

catheterization, technology

Radiology 1986; 160:842-843

LTHOUGH the axillary artery hasbeen used for percutaneous cath-

etenization for more than 20 years (1,

2), it is still shunned by many angiog-raphers because of their fear of in-

creased complications (3). We present acatheterization technique that is safe

with a relatively low complication mate.

Materials and Methods

1 . Catheter sizes that we used rangedfrom 5 to 7 F and were of various con-figurations. The actual site of puncture

is the proximal brachia! artery, well

distal to the lateral edge of the pectoral

muscles. A higher, more proximal

puncture into the axilla should be

avoided since hemostasis is difficult to

achieve there, hematoma formation caneasily be hidden, and the artery is diffi-

cult to fix in position. The puncture istherefore made distal to the origin of

the subscapulan and circumflex humer-a! arteries.

2. The patient’s arm is abducted and

elevated, with the patient’s hand rest-ing under the turned head or on the ta-

ble above the head.3. The physician’s index and middle

fingers (used for palpating) should beplaced lengthwise along either side of

the artery to fixate it and to avoid mad-

vertent compression of the artery.

I From the Department of Radiology, Medi-cal College of Wisconsin, Milwaukee CountyMedical Complex, 8700 West Wisconsin Aye-flue, Milwaukee, WI 53226. Received March 11,1986; revision requested April 28; revision me-ceived May 12; accepted May 15. Address me-print requests to F..O.L.

� RSNA, 1986

4. Contrary to other authors’ mecom-

mendations (4, 5), the needle approach

should be almost perpendicular to theplane of the artery. This ensures fixa-

tion of the vessel and puncture at thepoint of maximum pulsation on theventral surface of the artery exactly cor-responding to the direction of the anes-

thesia needle track. This should help

the physician avoid touching the

nerves of the bmachial plexus and avoid

more proximal intmaaxillary artery

punctures. Not more than 3 ml of lido-

caine 1% is needed. Brachial nerveblock should be avoided, also contrary

to prior recommendations (3-5).

5. The patient is instructed to tell usimmediately if he perceives an “electric

shock” down the arm into the handduring placement of the anesthesianeedle or arteniogmaphic needle. If the

shock occurs, the needle must be

slightly moved either proximal or dis-tal along the artery.

6. An assistant (technologist, nurse,

trainee) continually palpates the radial

artery pulse during the needle ap-

proach. The axillary-bmachial arterycompresses more easily than the femo-

nal artery and often does not transmitpulsations through the needle to the

operator’s hand. However, the radialartery pulse frequently disappears asthe needle approaches and compresses

the brachial artery. When this is notedby the assistant, a short jab of the nee-

die should cause the needle to enter

the artery despite the lack of transmit-ted pulse.

7. After the punctume has been con-

rectly achieved, with blood spurtingfrom the needle, the needle is lowered

for guide wire insertion. One-wallpuncture, using an open needle, may

decrease potential bleeding.

8. Removal of the catheter with“fishing” is identical to previously de-scnibed catheter removal technique (6);

manual pressure on the artery puncturesite should be maintained for at least iOminutes after removal of the catheter.

Distal pulses should be presentthroughout the anteniographic pmoce-

dune.

Results

During the past 5 years, 1,700 consec-

utive aortofemora! angiograms havebeen obtained at our institutions. Ofthese, 1 10 (6.5%) were obtained via the

axillary artery approach becauseblocked aortas, blocked femomal arter-

ies, on recent surgery militated againstthe femoral artery approach.

Of the 1 10 attempts to perform the

technique, two were unsuccessful ow-

ing to an inability to enter the vessel orthe aorta because of extreme amtenio-

sclerotic changes of the subclavian an-tery. These examinations were success-fully completed via the translumbamapproach.

In 65 procedures performed by oneof the authors (E.O.L.), no major corn-

plications were noted. A total of two

complications (1 .8%) occurred, duringprocedures performed by other staffphysicians: one case of persistent might

median nerve injury and one case ofacute thrombosis on the left side. The

thrombosis was removed by surgerywith no sequelae.

Discussion

The axillary artery begins at the lat-

era! border of the first rib and ends atthe inferior margin of the teres major

muscle, where it continues as the bra-chial artery. The bmachial artery is distal

to the origin of the subscapular artery

and the circumflex humera! arteries.

The axillary artery is surrounded on a!!

sides by three bundles of the bmachialplexus (nerves of C-S through T-i).These dorsal, lateral, and media! cords

then divide and form into their nespec-

tive large nerves. The median nerve(the one most often injured in axillary

catheterizations) is formed from boththe lateral and medial cords joining on

the ventral aspect of the axillary artery(Fig. 1). It then runs on the superolat-era! side of the brachial artery. Thus,

the first portion of the bmachial artery isrelatively clear of nerves on its ventralaspect, whereas higher, the axillamy am-

teny is completely surrounded. Itshould also be emphasized that the am-

Figure 1. Axillary bnachial artery and bra-

chial plexus anatomy. The ventral wall ofthe brachial artery is free of surroundingnerves, and the axillary artery may be

clothed by the cords of the brachial plexus.

The line delineating the brachial artery

points to the site of needle puncture.

Radiology #{149}843

temy and nerves run in a surrounding

common fibrous sheath.

The prevalence of brachial plexus in-jury and overall complications variesmarkedly in the literature from 0.5% to33% (3, 4, 7-9). In one nationwide sum-vey of the complications of angiogra-

phy, Hessell et a!. (10) reported that the

overall prevalence of complication ofthe axillamy approach is 3.29%, signifi-

cantly higher than that of the femoma!

approach (1.73%). Most of the differ-ences reportedly resulted from localcomplication, such as hemorrhage,

thrombosis, and pseudoaneurysm. U

Acknowledgment: Our thanks to PennyWallus, Maxine Omenstein, and Mildred Davisof the Department of Radiology, Mt. Sinai

Medical Center, Milwaukee for their technical

assistance for most of the angiogmams, and Ma-ria Skira of Milwaukee County Medical Corn-plex for her secretarial assistance.

References1. Hanafee W. Axillany artery approach to

carotid, vertebral, abdominal aorta and

coronary artemiography. Radiology 1963;81:559-566.

2. Newton TH. Axillary artery approach toantemiognaphy of aorta and its branches.

AJR 1963; 89:275-283.3. Antonovic R, R#{246}schJ, Dotter CT. Corn-

plications of percutaneous trans-axillarycatheterization for artemiography and se-lective chemotherapy. AJR 1976; 126:386-393.

4. Molnar W, Paul DJ. Complications of ax-illary artemiotomies. Radiology 1972;104:269-276.

5. Roy P. Percutaneous catheterization viathe axillary artery. AJR 1965; 94:1-18.

6. Lipchik EO, Rogoff SM. Abdominal aom-togmaphy: translumbam, femomal, and axil-

lary artery catheterization techniques. In:Abrams H, ed. Angiogmaphy. Vol. 2. 3d ed.

Boston: Little Brown, 1983; 1029-1040.7. Dudmick 5, Masland W, Mishkin M. Bra-

chial plexus injury following axillamy am-tery puncture. Radiology 1967; 88:271-273.

8. Emiksson I, Jorulf H. Surgical complica-tions associated with arterial cathetemiza-tion. Scand J Thorac Cardiovasc Sung1970; 4:69-75.

9. Staal A, Van Voorthuisen AE, vanDijk LM.Neurological complications following am-

temial catheterizations by the axillary ap-proach. Br J Radiol 1966; 39:115-116.

10. Hessel SJ, Adams DF, Abmams HL. Corn-plications of angiogmaphy. Radiology

1981; 138:273-281.

Femoral Torsion: CT Measurement’

Soroosh Mahboubi, MDHelen Horstmann, MD

We report a new method using comput-ed tomography (CT) to measure femoraltorsion more accurately in patients withcerebral palsy. The method involves CTscanning through the femoral head, thefemoral neck at the region of the greatertrochanter, and the femoral condyle.

Index terms: Femur, abnormalities, 443.1489

#{149}Femur, CT diagnosis, 443.1211 #{149}Femur,

torsion, 443.1489

Radiology 1986; 160:843-844

C OMPUTED tomography (CT) is the

most accurate and convenient

technique for the measurement of fern-

oral torsion (1-3), which is the inclina-

tion of the axis of the femomal neckwith reference to the transcondylam

plane of the distal femur. We present

our modification of the current method

of measurement of femoral torsion us-

ing CT in patients with cerebral palsy.

Our method requires superimposition

of the capital femoral epiphysis on the

1 From the Departments of Radiology, Chil-dren’s Hospital of Philadelphia, 34th Street and

Civic Center Boulevard, Philadelphia, PA19104 and the University of PennsylvaniaSchool of Medicine, Philadelphia (SM.); andthe Division of Orthopaedic Surgery, MedicalCollege of Pennsylvania, Philadelphia (H.H.).Received December 23, 1985; revision request-ed February 14, 1986; revision received May 1;accepted May 9. Address reprint requests to

SM.C RSNA, 1986

femoral neck at the region of the great-en trochantem to obtain the proximal

axis and another section through the

femonal condyle.

Materials and Methods

Thirty children with cerebral palsy,aged 3-15 years, were evaluated by CT

scanning prior to surgical interventionfor subluxing or dislocated hips. All pa-

tients had coxa valga, so that the anglebetween the neck and the shaft of thefemur was greater than 140#{176}.

Sedation was necessary in all pa-

tients. Chlomal hydrate medication was

not effective in most children with ce-nebral palsy, so we used 3-6 mg/kg

Nembutal (pentobanbital sodium; Ab-bott, North Chicago, Ill.) intramuscu-

lamly (maximum, 120 mg) with 0.1-0.2

mg/kg morphine intramuscularly.

CT scans were obtained with a Gen-

era! Electric (Milwaukee) 8800 CT scan-nem. An initial measurement of femonal

torsion was followed by measurement

of the axis of the femoral neck and the

axis of the transcondylar plane of the

distal femur by previously describedtechniques (1). With modification ofthe usual technique as described below,

our measurements became more accu-

rate.We first obtained a CT scan through

the capital femora! epiphysis. Another

CT scan was obtained through the fem-oral neck at the region of the greater

trochanter, and a third scan was ob-

tamed through the transcondylar area

of the distal femur. As in previous

studies, the transcondylar axis is deter-mined by first drawing tangents to theanterior and posterior aspects of thefemonal condyle. A line is then drawn

that bisects the angle between the two

lines (Figs. 1, 2). In our modification to

determine the femona! neck axis, theimages of the ossified femoral head andfemoral neck at the region of the great-

en trochanter are superimposed by dou-

ble exposure on the same study. A line

is then drawn from the center of the

femora! neck in its most lateral aspectthrough the center of the femona! head(Figs. 1, 2). To define the image of the

femoral head over the femonal neck, we

use different window widths for thefemonal head and the femoral neck. Ifthe femoral head is not dense enough

to be seen when superimposed on the

femonal neck on double-exposed film,

the head can be identified by outlining

it prior to superimposition.

Results

Measurements of femoral torsion bythe modified technique as opposed to

the old technique in 18 patients withcerebral palsy are presented in Figure

3. The modified method is more reli-

able, since prior methods inaccurately

estimate the angle of anteversion witha difference of more than 10#{176}in hips ofsome patients with cerebral palsy.

Discussion

The angle of femonal torsion de-creases from 40#{176}in healthy infants to18#{176}in healthy adults (4). In patients

with cerebral palsy, the femoral torsionremains closer to that of the healthy in-

fant (4, 5). Our results show that there

is a wide range of anteversion and ret-rovension in patients with cerebral pal-

sy with subluxing on dislocated hips.

Current CT techniques for measuring

Volume 160 Number 3