percutaneous brachial artery catheterization

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  • 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 patients arm is abducted and

    elevated, with the patients hand rest-ing under the turned head or on the ta-

    ble above the head.3. The physicians 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

    operators 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 withfishing 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-



    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.


    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 cu