British HeartJournal, I973, 35, I080o-084.

Iatrogenic brachial artery injuries

A. P. Barabas, J. Bouhoutsos, and Peter MartinFrom the Department of Surgery, Royal Postgraduate Medical School,Hammersmith Hospital, Du Cane Road, London

During a 7-year period approximately 700 left heart cardiac catheterizations were carried out via openbrachial arteriotomy. Of these, 25 patients with a missing or weak radial pulse after catheterization were

referred for operation. Despite minimal early ischaemic symptoms and signs, all 25 patients had a completeocclusion of the brachial artery at the site of the arteriotomy. Commonest causes for occlusion were circum-ferential intimal tears or excessive suturing.

Technical details of the repair of the damaged artery - debridement, venous patch graft, and no anti-coagulation after operation - werefound to be important and led to long-term patency in i6 of the I7 'early'cases.

Eight 'late' patients, who escaped early detection, were operated on I week to 6 years after brachial arteryocclusion. Of the 8, 7 were successfully relieved of their symptoms.

Brachial artery catheterization not infrequentlyleads to a narrowed or occluded artery. In tworecent prospective studies 24 per cent of 204, andi2'2 per cent of 328 patients, respectively, had thiscomplication (Machleder, Sweeney, and Barker,1972; Campion et al., 197I). On long-term follow-up of those with an untreated brachial artery occlu-sion considerable functional impairment was foundin 68 per cent (Campion et al., I97I). In addition ina few cases, reported by Hall (I97I), severe acuteischaemia and acute amputation of the arm resulted.We report here 25 cases with brachial artery

injury following left heart cardiac catheterization. InI7, reconstructive surgery was carried out within 24hours of catheterization ('early' cases) and in 8 aftermore than 24 hours ('late' cases).

Patients and incidence of complicationThe age and sex distribution of the 25 patients aresummarized in Tables i and 2. They were allreferred for operation between the years i965 andI972. Approximately 700 left heart cardiac catheteri-zations were carried out by means of open brachialarteriotomy in Hammersmith Hospital during these7 years, giving an incidence of this complication ofjust over 3.5 per cent.

'Early' casesSymptoms Seventeen of the 25 cases were

Received 24 April I973.

treated within 24 hours of catheterization (Table i).Only 5 of the I7 had severe symptoms such as painand numbness of the hand. A further 9 experiencedcoldness and minor paraesthesiae only, and theremainder were completely free from symptoms.

Clinical signs Fourteen of the 17 had absent and3 had weak pulses at the wrist; all 17 had objectivecoldness of the affected hand compared to the oppo-site side.

Findings at operation The time of surgicalexploration varied from 3 to 20 hours after cardiaccatheterization. In all cases there was a completeocclusion of the artery at the site of the previousarteriotomy (this includes those 3 cases where aweak pulse had been felt at the wrist).

In all an organic narrowing of the lumen of theartery was present, which led, in turn, to secondarythrombosis and complete occlusion. In IO cases thenarrowing was due to a circumferential tear andcurling up of the intima (Fig. ia); in 4 the suturesclosing the arteriotomy were mainly at fault, and inthe remaining 3 pressure from a periarterial haema-toma accounted for the narrowing.

Surgical procedure In all patients the arterywas opened at least o 5 cm above and below thearteriotomy site. Local thrombectomy was carriedout and an embolectomy catheter was passed up thebrachial and down the radial and ulnar arteries, to

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Iatrogenic brachial artery injuries Io8I

TABLE I 'Early' repairs (first 24 hours) of brachial artery injury after cardiac catheterization

Case Sex Age Symptoms Findings (apart from Procedure Follow-upNo. (yr) thrombosis)

Dura- Symp- Radialtion toms pulse

I M I9 Mild i) Intimal tear+ Thrombectomy alonethrombus

2) Rethrombosis Rethrombectomy, debridement, patchgraft 6 mth o +

2 F 45 Severe Intimal tear+ thrombus Thrombectomy, debridement, patch graft 8 mth o +3 F 40 Mild ,, ,, ,, , , ,5 ,, 4 yr 0 +4 F 49 Severe ,, ,, 3, ,, ,, ,, ,, 6 yr 0 +S M 4o Mild ,, ,, ,, ,, ,, 2 yr 0 +6 M 26 Severe ,, ,, ,, ,, ,, , ,, 4yr 0 +7 F 45 Mild ,, ,, ,, ,, ,, ,, ,,i8 mth o +8 F 6 Nil ,, ,, ,, ,, ,, , ,, 3yr o o (failed)9 F 40 Mild ,, ,, ,, Venous patch graft 4 mth o +10 F 25 Nil ,, ,, ,, ,, ,, ,, 3 mth o +II F 55 Severe Haematoma Evacuation thrombectomy 6 mth o +12 M 60 Mild ,, ,, ,, I8 mth o +13 F I8 Mild ,, ,, ,, 2 yr 0 +14 M 56 Mild Faulty sutures Resuture only I yr 0 +15 M 32 Nil ,, ,, Resuture and vein patch graft Nil 0 +I6 M 40 Severe ,, ,, ,, ,, ,, ,, ,, 5 yr 0 +I7 M I6 Mild ,, ,, ,, ,, ,, ,, ,, 6 mth o +

TABLE 2 Late repairs of brachial artery occlusion after cardiac catheterization

No. Age Time of operation Procedure Follow-up(yr), after catheterizationsex Duration Symptoms Radial pulse

I 29 M i wk Vein bypass I yr 0 +2 32 M 2 wk ,, ,, i8 mth 0 +3 48 F 4 wk ,, ", (failed) 3 yr + 04 25 M 4 wk ,, ,, 2 yr 0 +5 66 F 6 wk Thrombectomy and 8 yr 0 +

on-lay vein graft6 42 M I yr Vein bypass 3 yr 0 +7 25 F 2 yr 3, ,, I yr 0 +8 36 M i6 yr ,, ,, 2 yr 0 +

remove propagating thrombi. After dealing with thecause of the narrowing, the arteriotomy was closedwith a venous patch graft in all but 4 cases. In the IOpatients with circumferential tear of the intima avenous patch graft was used in every case, though inone case (Case i) only after the failure of the firstoperation. Local arm veins (brachial or cephalic)were used in ii and the saphenous vein in 4 cases.

Anticoagulation Intravenous heparin (io,ooounits 6 hours) was started as soon as possible afterdetecting a weak or absent wrist pulse. This was

continued all through the operation and was stoppedafter.

Results Sixteen of the I7 patients had return ofwrist pulses and are free of any symptoms on follow-up from 3 months to 6 years. One patient's brachialartery (a child of 6) was technically difficult to repairand was left occluded, but she has no symptoms 2

years later.

'Late' casesEight of the 25 patients had operation for brachialartery occlusion more than 24 hours after cardiaccatheterization (Table 2). They first noticed ischae-mic symptoms on return to normal activities afterdischarge from hospital. No patient had rest pain,but pain in the arm developed on such simple every-

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io82 Barabas, Bouhoutsos, and Martin

A thrombus

FIG. I (A) Schematic drawing of typicalfindings atthe site of arterial injury. (B) Recommended repair:trimming of intima and venous patch graft.

day tasks as combing the hair, shaving, washing up,or even writing. Two patients (Table 2, Cases 7 and8) complained of this only after successful heartsurgery had abolished other symptoms (i.e. severebreathlessness) and had restored full activity.

Signs The radial pulse was absent in 6 of the 8and could be felt only on occasions and with diffi-culty (when warm and at rest) in 2. Blanching of theaffected hand on lifting was more pronounced com-pared to the normal side; pain in the forearm stoppedclenching and unclenching of the hand within 5minutes.

Radiology All patients had an arteriogram eitherbefore operation (selective aortic arch aortogram) or,preferably, an open operative brachial arteriogramjust before the arterial operation. Complete occlu-sion of the segment of the brachial artery was shownin every case. Rich collateral channels were presentin those (Cases 6, 7, and 8) who had a long-standingocclusion (Fig. 2). The radial and ulnar arterieswere patent in all 8 cases.

Surgical procedure Seven of the 8 had end-to-end vein bypass, using the cephalic vein in 2 andthe saphenous in 5. One case had a thrombectomyand long (6-7 cm) on-lay vein patch graft. Heparinwas only used locally by injection into distal arteriesduring operations.No anticoagulants were given before or after

operation.

Results Seven of the 8 patients had a return ofpulses and became symptom free and remained sofor periods between i and 8 years. In one patientthe graft failed and she continues with ischaemicsymptoms.

FIG . 2 Brachial arteriogram I6 years after cardiaccatheterization via the brachial artery. Despite richcollaterals this patient had ischaemic symptoms of thehand. A vein graft was inserted. He remains free fromsymptoms 2 years later.

DiscussionThe incidence of brachial artery occlusion in thisseries (3 5%) is lower than reported by others(Machleder et al., 1972; Campion et al., 197I). Ourstudy was retrospective and this may partly accountfor the low apparent incidence. The fact that openbrachial arteriotomy was used in preference topercutaneous puncture, in our view, also contributedto this low complication rate. In any case, as sur-geons, we were not involved in the catheterizations,and are unable to comment on how this low inci-dence was achieved. The discussion will be con-

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Iatrogenic brachial artery injuries 1083

fined, therefore, to the management of brachialartery occlusion after cardiac catheterization, onceit has occurred.

Absent or weak distal pulses on return to theward after brachial artery catheterization should beregarded as indicative of arterial injury. Arterialspasm should not be considered as an alternative, asit is rare and we have never seen it on exploring thebrachial artery. Furthermore, it does not last long inan undamaged vessel.While lying in a warm bed, still dazed from the

premedication, the patient will feel no ischaemicpain and complain of no symptoms. Clinical signs,other than a missing pulse, may also be absent.On detecting an absent or weak radial pulse,

intravenous heparin infusion (io,ooo units 6 hours)should be started immediately to prevent thedevelopment or extension of local thrombosis, andarrangements should be made to take the patient tothe operating theatre. These preparations will takeat least an hour, and if there is no return of normalpulsation within this time all thoughts of transientarterial spasm should be discarded.The technical details of the operations are

important. General anaesthesia is not necessary andmay be contraindicated because of the patient'scardiac condition. The brachial artery is widelyexposed, down to the bifurcation into radial andulnar arteries to ensure that the embolectomycatheter will be guided, if this is needed, into botharteries under direct vision and with the leasttrauma. Arteriotomy incision should start at thesite of the puncture and should be at least I to 2 cmlong. After local thrombectomy and the clearance ofpropagating thrombi, arterial clamps are applied.An attempt is now made to identify the cause for thethrombosis. In most cases (IO out of I7 in the presentseries), this will be a torn and curled up intima. Thisshould be trimmed back to the points where itbecomes normal. If the whole thickness of theartery is severely damaged, a portion may have to beexcised and end-to-end anastomosed or grafted, butwe have not found this necessary in 'early' cases.After debridement of the lumen of the artery, avenous patch graft is sutured to the arteriotomy andthe sutures should include the cut ends of theintima to prevent it curling up again and causingrecurrent thrombosis (Fig. ib).

Faulty suturing (4 out of I7) was found to be thesecond commonest cause of obstruction at the site ofarteriotomy. Narrowing of the lumen resulted frommistaken attempts to control all bleeding by immedi-ate further suturing after the initial closure wasfound to leak. Slight pressure at the site and waitingfor 5 to IO minutes for the bleeding to stop spon-taneously would have been advisable.

Once thrombosis follows removal of the faultysutures, thrombectomy and resuturing are rarelysufficient. Trimming away the arterial wall, which isdamaged by previous attempts at suturing, until anundamaged edge is obtained, and closure withvenous patch graft are needed to prevent recurrenceof thrombosis.Once the mechanical cause for local thrombosis is

removed, there is no need for further anticoagula-tion, and heparin infusion is discontinued. Post-operative anticoagulants are not only unnecessarybut probably haful as they may contribute tohaematoma formation and infection. A suctiondrain is used and the wound closed by skin sutures.

Before closing the wound and after the arterialrepair, we carry out routine operative radiography.This can show patency or otherwise at the site ofrepair, and also distinguishes between occlusion ofthe distal arteries by a clot, or narrowing by spasm.Arteriography thus often prevents unnecessary,harmful, and persistent attempts at passing embolec-tomy catheters as, unlike the brachial artery, theulnar and radial are liable to prolonged spasm. Afteroperation the arm is raised in a sling. Movementsare encouraged straightaway to avoid contracture atthe elbow.

All but one of our 'early' arterial repairs in adultswere successful (Table i, Case i). At this operationthe rules outlined above were not followed; thearteriotomy was closed after thrombectomy withoutdebridement of the intima and without a venouspatch graft. Rethrombosis followed despite con-tinued anticoagulation and a second successfuloperation was carried out within 24 hours.The consequences of not operating on brachial

artery occlusion were pointed out by Machleder etal. (I972). Of their 49 patients with absent or weakradial pulse after catheterization, one lost an arm dueto ischaemia and 68 per cent discharged fromhospital had considerable functional impairment onlong-term follow-up. These patients with chronicischaemia of the arm may not complain of anysymptoms because their severe cardiac disabilityovershadows them. Others complain but are notreferred for operation, possibly because of improperunderstanding of the possibility of successfulsurgical relief.

All but i of the 8 patients with long-standingocclusion had successful repairs of their thrombosedbrachial artery. The technique of end-to-end auto-genous vein grafting is well established and in trau-matic cases the long-term prognosis is excellent.

Patients who escape early detection and repair ofbrachial artery injury, therefore, should be given thebenefit of surgical relief of their ischaemic armsymptoms.

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1o84 Barabas, Bouhoutsos, and Martin

We are grateful to Professor J. F. Goodwin and Dr.C. M. Oakley for referring their patients, and for adviceon the preparation of this paper.

ReferencesCampion, B. C., Frye, R. L., Pluth, J. R., Fairbairn, J. F., and

Davis, G. D. (197I). Arterial complications of retrogradebrachial arterial catheterization. Mayo Clinic Proceedings,46, 589.

Hall, R. (I97I). Vascular injuries resulting from arterialpuncture or catheterization. British Journal of Surgery, 58,5I3.

Machleder, H. I., Sweeney, J. P., and Barker, W. F. (I972).Pulseless arm after brachial artery catheterisation. Lancet,I, 407.

Requests for reprints to A. P. Barabas, Esq., F.R.C.S.,Department of Surgery, Royal Postgraduate MedicalSchool, Hammersmith Hospital, Du Cane Road, LondonWI2 OHS.

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Iatrogenic brachial artery injuries.

A P Barabas, J Bouhoutsos and P Martin

doi: 10.1136/hrt.35.10.10801973 35: 1080-1084 Br Heart J

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