Percutaneous brachial catheterization: The hidden hazard of high brachial artery bifurcation

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<ul><li><p>Catheterization and Cardiovascular Diagnosis 14:44-45 (1988) </p><p>Percutaneous Brachial Catheterizati0n:The Hidden Hazard of High Brachial Artery Bifurcation </p><p>Ubeydullah Deligonul, MD, Gregory Gabliani, MD, Morton J. Kern, MD, and Michel Vandorrnael, MD </p><p>We describe a patient in whom a brachial arterial cutdown done at the same site for percutaneous transluminal angioplasty immediately after uncomplicated percutaneous brachial coronary arteriography revealed the percutaneous sheath in a deeper, smaller, and more lateral artery than the brachial artery, complicating placement of the guiding catheter. This case illustrates the potential hidden hazard of normal brachial artery bifurcation variants, which may be responsible for some of the potential complications encountered in percutaneous brachial artery catheterization techniques. </p><p>Key words: catheterization complications, heart catheterization </p><p>INTRODUCTION intra-arterially . Selective coronary arteriography and left </p><p>'The percutaneous brachial approach to cardiac cathe- terization has been reported to be a safe and effective method [ 1-51. The complication rates for brachial per- cutaneous technique were noted to be similar to those of the traditional cutdown technique [6]. The method has been reported to be especially useful in routine outpatient catheterization, as well as in cases without appropriate fernoral access [2,4]. We describe a patient in whom a brachial cutdown was done for percutaneous transluminal coironary angioplasty (PTCA) after uncomplicated per- cutaneous brachial coronary arteriography revealed the pel-cutaneous sheath in an artery that was deeper, smaller tham, and more lateral to the brachial artery, complicating placement of the brachial guiding catheter. </p><p>CASE REPORT </p><p>A 75-year-old male with hypertension, diabetes, and severe peripheral vascular disease was referred for coro- nary angiography because of unstable angina, despite medical treatment in the intensive care unit. </p><p>The percutaneous brachial approach was chosen be- cause of poor distal extremity circulation. It was planned to perform a cutdown on the brachial artery if the angiog- raphy revealed suitable coronary anatomy for PTCA. Tbe percutaneous technique was performed by a modifi- cation of one previously described [l]. In brief, the brachial artery pulsations were localized 3 4 cm above the elbow crease. An 18-gauge medicut short catheter </p><p>ventriculography were performed using a 6 French left Amplatz 11 and a 6 French pigtail catheter, demonstrating total occlusion of the proximal right coronary artery, anomalous origin of a small circumflex branch (with a 60% proximal stenosis) from the right coronary artery, and 90% stenosis of a large, first diagonal artery. Left ventriculography showed severe posterobasal hypokine- sis, with an ejection fraction of 55 % . </p><p>Because of unstable angina, PTCA on the large diago- nal artery was elected. A 1-1.5-cm skin incision was performed slightly above the percutaneous entry site. Subcutaneous tissue was dissected carefully along the indwelling sheath. After isolation of the large brachial artery, it was noted that the sheath was not in this artery, but a few mm lateral to it without contacting the wall and going more deeply into the muscular level. Dissection deeper along the sheath showed it was placed into a smaller artery, large enough to accommodate the 6 French sheath but not an 8 French PTCA guiding catheter. This smaller artery was isolated (Fig. l), the sheath removed, and the entry hole closed with a purse string suture. After repair, good pulsations were visible and palpable distal to the entry site. The radial and ulnar pulses remained intact. Subsequently, an arteriotomy was performed on the larger brachial vessel, and PTCA of the diagonal artery was performed successfully, using an 8 French brachial guiding (Stertzer) catheter. Afterwards, the ar- teriotomy and the skin were closed in the usual fashion. The patient had an uneventful recovery. </p><p>was introduced percutaneously at an observation of pulsatile blood return, a 0.035-in straight </p><p>skin incision was made at the entry Address reprint requests to Dr. Ubeydullah Deligonul, Cardiac Cath- catheter was replaced with a 6 French side-arm sheath eterization Laboratory, st. Louis University Hospital, 1325 S . Grand, over the guide wire. Heparin, 5,000 units, was given st. Louis, ~063104 . </p><p>Of 450. A*er From the St. Louis University Hospital, St. Louis, Missouri. </p><p>guide wire was inserted smoothly into the artery. A small Received February 25, 1987; revision accepted May 30, 1987. and the </p><p>0 11988 Alan R. Liss, Inc. </p></li><li><p>High Brachial Artery Bifurcation 45 </p><p>occurred in 112 (31%). The brachial artery variations have been noted to complicate arm surgery or vein punc- ture [7]. An angiographic documentation of the anatomy of our patient would have been desirable but inappro- priate in this clinical setting. </p><p>The diagnostic study was accomplished in our case without any difficulty despite the unusual percutaneous entry site. Without the cutdown for PTCA, this situation would probably have gone unrecognized. However, be- cause of the smaller size of the variant artery, a signifi- cant arterial complication would have been likely if a large-sized sheath was used. Another possible complica- tion may be a difficulty in controlling the bleeding after sheath removal if manual pressure is applied on the more superficial artery instead of the deeper, punctured artery. </p><p>This case illustrates that a successful percutaneous puncture may not always be in the brachial artery. In cases in which difficulty in inserting larger catheters or in which complications following the use of this tech- nique occur, a variance of the normal brachial artery anatomy must be considered. </p><p>Fig. I. Placement of a 6 French percutaneous sheath (black and white arrow) into a deeper and smaller artery (single arrow) that is lateral to the large caliber brachial artery (double arrows). </p><p>DISCUSSION </p><p>In general, the brachial artery can accommodate 7 French (2.33-mm) catheters in females and 8 French (2.6;-mm) catheters in males [3,5]. However, in using the percutaneous technique for PTCA, the residual arte- rial puncture may present difficulty in control of bleeding after removal of the percutaneous sheath and catheter [5]. Thus, in this patient, we switched the arterial entry technique from percutaneous to direct cutdown to permit better hemostasis after PTCA. In our review, there are no reports of complications using cutdown technique for PTC A or for cutdown technique after percutaneous bra- chial artery entry. </p><p>The percutaneously entered artery in our case was lateral to and deeper than the actual brachial artery. Nornnal anatomic variants involving various bifurcation types, and different levels of the radial, ulnar, and bra- chial arteries have been reported. In a study of 750 anatcimically dissected upper extremities, McCormack et a1 [7] found high origin of radial artery and of ulnar artery in 14 % and 2 % , respectively, and high bifurcation of brachial artery into superficial and profunda branches in 1%. These authors noted that in 364 cadavers with both upper extremities studied, major arterial variations </p><p>REFERENCES </p><p>1. </p><p>2. </p><p>3. </p><p>4. </p><p>5 . </p><p>6. </p><p>7 </p><p>Fergusson DJG, Kamada RO: Percutaneous entry of the brachial artery for left heart catheterization using a sheath. Cathet Cardio- vasc Diagn 7:111-114, 1981. Pepine CJ, Gunten CV, Hill JA, Culp JR, Feldman RL, Rubin M, OBrien JT: Percutaneous brachial catheterization using a modi- fied sheath and new catheter system. Cathet Cardiovasc Diagn </p><p>Maouad 1, Hebert JL, Fernandez F, Gay J: Percutaneous brachial approach using the femoral artery sheath for left heart catheteriza- tion and selective coronary angiography . Cathet Cardiovasc Diagn 11:539-546, 1985. Engster GS, Reisig AH, Ugaldea CT: Percutaneous left brachial catheterization using 5 French performed (Judkins) catheters. Cathet Cardiovasc Diagn 12:274-276, 1986. Fergusson DJG, Kamada RO: Percutaneous entry of the brachial artery for left heart catheterization using a sheath: Further experi- ence. Cathet Cardiovasc Diagn 12:209-211, 1986. Cohen M, Rentrop KP, Cohen BM, Holt J: Safety and efficacy of percutaneous entry of the brachial artery versus cutdown and arteriotomy for left sided cardiac catheterization. Am J Cardiol </p><p>McCormack LJ, Cauldwell EW, Anson BJ: Brachial and antebra- chial arterial patterns. A study of 750 extremities. Surg Gynecol Obstet 96:43-54, 1953. </p><p>10:637-642, 1984. </p><p>571682-684, 1986. </p></li></ul>