Clinical Radiology (1990) 42, 277-280

Technical Report The Complications of High Brachial Artery Puncture C. J. BAUDOUIN, A.-M. BELLI, R. J. PECK and D. C. C U M B E R L A N D

Departments of Radiology, Royal Hallamshire and Northern General Hospitals, Sheffield

Fifty-two angiograms via a high brachial puncture were performed in Sheffield from 1986 to 1988 in patients in whom femoral artery catheterization was not possible or was contra- indicated. Follow-up was obtained in 49 procedures. The procedure was initially successful in 43 cases. Twelve patients developed haematomas, graded large in 5, but no intervention for haematoma was required. The radial pulse was diminished or absent at the end of examination in four patients; three of these patients had no associated ischaemia, the pulse returning spontaneously within 24 hours, although remaining chronically reduced in one patient. One patient developed ischaemia due to acute occlusion of the brachial artery - this was successfully treated with immediate angioplasty. Paraesthesiae in the median nerve distribution were noted in two patients. These resolved spontaneously and no permanent neurological problem was seen. We conclude that high brachial artery puncture is a useful alternative when femoral artery puncture is not possible. Baudouin, C.J., Be!li, A.-M., Peck, R.J. & Cumberland, D.C. (1990). Clinical Radiology 42, 277-280. Technical Report. The Complications of High Brachial Artery Puncture

It is generally accepted that the femoral artery is the route 0fchoice for percutaneous access to the arterial system. A number of alternative routes have been employed when femoral artery puncture is not possible, most frequently using direct puncture of the abdominal aorta or the axillary artery. The brachial artery at the elbow has been used for many years, initially by cut-down and arterio- t0my for cardiological examinations (Sones and Shirley, 1962), later by percutaneous puncture (Fergusson and Kamada, 1981) and, more recently, high brachial punc- ture has been described for access to the peripheral vascular tree (Gaines and Reidy, 1986).

We have reviewed all angiograms performed via a high brachial puncture in Sheffield to assess the complications of this technique.

Table 1-Indications for high braehial artery puncture

Indication No. of studies

No palpable femoral artery pulses 30 Failed attempt at femoral artery catheterization 14 Recent femoral artery surgery 1 Arterial grafts 2 Aneurysmal dilatation of femoral arteries 1 Weak femoral pulse puncture not a t tempted 1

in all cases using low-osmolar contrast. The procedures were performed by radiologists of all grades on the Sheffield rotation but with a consultant or senior registrar experienced in the technique present on all occasions.

PATIENTS A N D M E T H O D S

From September 1986 to October 1988 52 examin- ations were performed via the brachial artery in 51 patients in whom femoral artery catheterization was not possible or was contraindicated. During this period digital subtraction angiography (DSA) was not available in Sheffield. Follow-up was obtained in 48 patients (49 procedures) by review of the medical records. Studies Were performed in 16 females and 32 males of mean age 66 Years (range 40 to 82 years). The indications for high brachial puncture in this series are listed in Table 1.

The brachial artery was punctured midway between the axi[la and elbow (Gaines and Reidy, 1986) using a single Piece needle. A 5 French pigtail catheter was introduced Over a 0.035 inch guidewire in all but three cases (6 French 0r 7 French catheters). The left arm was used initially in 45 Patients. The catheter was intermittently flushed with heParinized saline. Non-selective studies were performed

i.iC°rrespondence to: Dr C. J. Baudouin, N M R Unit, Hammersmith 0spital, Du Cane Road, London W12 0HS.

Results

The initial procedure was successful in 43 cases. In three cases the brachial artery could not be catheterized. In two of these three cases the artery could not be punctured and in one case a wire could not be introduced. In one patient a stenosis of the subclavian artery could not be negotiated, a small intimal flap was raised and the procedure was abandoned, but there were no adverse sequelae. In two cases the catheter could not be passed into the descending aorta preferentially entering the ascending aorta. In one patient, in whom the right brachial artery could not be catheterized, a left brachial artery puncture was successfully performed during the same session.

It is interesting to note that in three patients in whom brachial artery catheterization was attempted (two unsuc- cessfully and one successfully), a subsequent femoral catheterization was possible. Angiograms showed that 25 patients had aortic or bilateral iliac occlusions, with 19 patients having combinations of occlusions and stenoses.

The following complications were observed:

278 CLINICAL RADIOLOGY

1 A haematoma was reported in 12 patients, graded large in five. In only one of these patients was the radial pulse affected (see below) and no intervention for haema- toma was required. 2 The radial pulse was absent or reduced at the end of the procedure in four cases. There were no related ischaemic changes in three patients and in these three patients the pulse returned spontaneously within 24 hours, although in one patient who had also developed a large haematoma the brachial and radial pulses remained chronically reduced in volume. The patient experienced no symptoms related to this.

The major complication of the series occurred in a 50- year-old female with no palpable femoral pulses undergo- ing investigation for peripheral vascular disease (rest pain in right leg). A single pass puncture of the left brachial artery was performed and a 5 French catheter advanced to the abdominal aorta without difficulty. An angiogram demonstrated left common iliac occlusion and a severe stenosis of the right common iliac artery. On withdrawal of the catheter the patient complained of numbness of the left hand with paraesthesiae of the lateral aspect of the forearm. The hand was cool with no radial or brachial pulse palpable. Using the information obtained from the diagnostic angiogram, the right femoral artery was immediately catheterized. The right common iliac steno- sis was crossed and dilated by balloon angioplasty. A catheter was advanced to the left subclavian artery. Injection of contrast showed a 5 cm occlusion of the mid brachial artery with normal vessels distal to this (Fig. 1). 500 #g of glyceryl trinitrate injected selectively produced no change in the appearances. The occlusion was easily Fig. 2 Angioplasty balloon in brachial artery.

Fig. 1 Occlusion of mid brachial artery. Fig. 3 Appearance of brachial artery after angioplasty.

COMPLICATIONS OF HIGH BRACHIAL ARTERY PUNCTURE 279

traversed with a wire and dilated with a 4 mm angioplasty balloon (Fig. 2). A good radiographic result was obtained (Fig. 3) and at the end of the procedure left brachial, left radial and right femoral pulses were present. There were tlo long term complications.

Paraesthesiae in the distribution of the median nerve were noted in two other patients. Neither of these patients had large haematomas and the symptoms resolved spon- taneously within a few hours.

DISCUSSION

Femoral artery puncture is widely accepted as the access route of choice to the arterial system. Hessel et al. (1981) in a multi-centre survey found the rate of signifi- cant complications (those requiring treatment or compli- cating patient care) to be 1.7% for femoral artery puncture compared to 2.9% for trans-lumbar aortogra- phy and 3.3% for axillary artery puncture. Intravenous digital subtraction angiography (DSA) can give diagnos- tic images of the peripheral vasculature. However, it is still not available in all hospitals and may itself be contraindicated in some patients, e.g. those with poor cardiac output. Moreover, it cannot be used for selective studies or if interventional procedures are to be per- formed. An arterial access route is therefore necessary when femoral puncture is impossible or contraindicated.

Translumbar aortography cannot be used for selective studies or interventional procedures, while the position of the axillary artery within a sheath containing the brachial plexus predisposes to vascular and neurological compli- cations (Staal et al., 1966; Molnar and Paul, 1972).

Brachial arteriotomy (Sones and Shirley, 1962) and, more recently, percutaneous brachial artery puncture at the elbow (Fergusson and Kamada, 1981; Andersen, 1985; Maouad et al., 1985) have been used extensively for cardiological examination. There is increasing experience in the USA of the technique, often as an out-patient procedure, mainly for examination of the cerebral circu- lation (McCreary et al., 1985; Hicks et al., 1986; Gritter et aL, 1987; Barnett et al., 1989) and less frequently for peripheral or abdominal angiography (Grollman and Marcus, 1988). The technique has not been used as extensively in the United Kingdom. In 1986, Gaines and Reidy proposed that high brachial puncture, with arterial punctures midway between axilla and elbow, was a safe alternative to femoral artery puncture for examination of the peripheral vascular tree. In this position the brachial artery is superficial and therefore easy to palpate.

In Sheffield this route was used in preference to translumbar aortography from September 1986 until DSA became available in 1988. Although the artery should be easy to compress, it may be mobile, and five Patients in our study experienced large haematomas. HOWever, as the artery is not tightly contained within a sheath, haematoma should not compromise the brachial artery as it does the axillary artery, and none of our Patients required intervention for haematoma. Gritter et al. (1987), using percutaneous puncture at the elbow, report one patient requiring evacuation of a haematoma COmpressing the artery, but this has not been reported as a Problem in other series (Hicks et al., 1986; Barnett et al., 1989).

Similarly, it is the compressive effect of a haematoma Which accounts for much of the brachial plexus damage

seen with axillary artery puncture. In the mid-arm the brachial artery is related to the median nerve. Neither of the patients with median nerve paraesthesiae had large haematomas and it may be that these symptoms are explained by a temporary effect of the local anaesthetic. Gritter et al. (1987) report a 7.3 % incidence of paraesthe- siae resolving spontaneously (although symptoms could last for over a week) but, as in our series, found no significant relationship between haematoma and paraes- thesiae. Lipchik and Sugimoto (1986), using a high puncture site, report one case of permanent median nerve injury.

Vascular damage at the site of puncture, e.g. acute thrombosis, stricture or false aneurysm formation is a complication in any artery. Cohen et al. (1986) comparing brachial arteriotomy and percutaneous puncture at the elbow found pulse loss in 1.1% ofarteriotomies and 1.6% of percutaneous punctures. Barnett et al. (1989) and Hicks et al. (1986) report a similar incidence with temporary pulse deficits in 1.6% and 0.8% respectively, with permanent loss in 0.2% and 0.55%. Grollman and Marcus (1988), however, found a 4% incidence of brachial thrombosis requiring surgical intervention.

In our series reduction in pulse volume in the absence of ischaemic changes was treated conservatively and no long term clinical problems were seen. Ifischaemic changes are present urgent intervention is required. Percutaneous transfemoral angioplasty of brachial artery occlusions subsequent to Sones catheterization has been described (Dorros and Lewin, 1987; Maouad and Guermonprez, 1988) but in all three of these cases the lesion was chronic, with angioplasty 1-18 months after the initial angiogra- phy. We describe the use of angioplasty in the acute situation with a successful outcome. This was the only major complication requiring intervention. Gaines and Reidy (1986) also describe one serious complication of high brachial artery puncture in 45 procedures, a case of late bleeding and false aneurysm formation.

The complication rate of high brachial artery puncture compares reasonably with that of other alternatives to femoral artery puncture. When DSA is available intra- venous contrast injections wilt often be sufficient for diagnostic examinations. However, if DSA is not avail- able, or if selective or interventional procedures are required, a site of arterial access is still needed when the femoral artery is not suitable for catheterization. High brachial artery puncture is a useful technique in these situations.

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