the complications of high brachial artery puncture
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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. CUMBERLAND
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 attempted 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 AND METHODS
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.iCrrespondence to: Dr C. J. Baudouin, NMR Unit, Hammersmith 0spital, Du Cane Road, London W12 0HS.
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.
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 t