JOURNAL OF SURGICAL RESEARCH 20, 601-606 (1976)

The Pathology of Post-Catheterization Brachial Artery Occlusion

ALLASTAIR M. KARMODY, Ch.M., F.R.C.S., F.A.C.S., NEIL LEMPERT, M.D., F.A.C.S., AND

JOHN JARMOLYCH, M.D. Departments of Surgery & Pathology, Veterans & Medical Center Hospitals,

Albany, New York 12208 Submitted for publication January 3, 1976

Between 1971 and October 1975, of 1084 diagnostic cardiac catheterizations via the brachial artery, 61 patients suffered from im- mediate loss of pulses at the wrist with signs of ischemia of the hand. In the majority of instances, the ischemic signs were not of a limb threatening nature and in only one of these patients were there immediate indica- tions of impending tissue loss. However, for reasons which have been well described by Machelder et al. [5] and because of the probability of future catheterizations in some of these patients it has been the established policy of the Cardiology Unit to request vascular consultation with a view to rein- statement of pulsatile flow in all of these patients. Three patients declined this type of surgery and 58 patients were explored in an attempt to restore brachial artery patency. In each of these patients, the operation was so conducted that an attempt was made to define precisely the cause of loss of pulsatile flow in the brachial arteries (Karmody and Lempert [4]).

In no patient was spasm of the brachial artery found to be a causative factor in the loss of wrist pulses. In each instance an oc- clusive thrombus was found within the lumen of the artery. In 33 of the patients the ap- parent cause of this thrombosis was related either to an unsatisfactory closure of the original arteriotomy and/or to the “wipe- Off” of platelet and fibrin aggregrates (Jacobsson and Schlossman [3]) when the catheter was withdrawn (Fig. la). In these patients adequate balloon thrombectomy, minimal surgical toilet of the edges of the ar- teriotomy and accurate closure was found to be sufficient to restore brachial artery pa-

tency and pulsatile flow to the wrist. This group of patients will not be discussed in any detail in this paper. The remaining 25 patients however fall into a materially different group and these patients form the main thrust of this report. Reference to Fig. lb shows that the catheters used bear a very close size relationship to the lumen of the brachial artery. Autopsy measurements us- ing 7 and 8 Fr. catheters such as are used for cardiac catheterization have shown that their size closely approximates the majority of brachial arteries. Manipulation of such catheters will therefore result in constant friction on the brachial artery particularly at the point of entry through the arteriotomy. It is evident that the longer the catheter time and the more vigorous the manipulation (e.g. for entry into the coronary artery orifices) the greater will be the frictional effect on the posterior wall of the brachial artery. This type of trauma may also be exacerbated by misdirection of the point of the catheter either during the original insertion or sub- sequent changes. The effect of this is to lift a partial thickness tissue flap of the posterior wall of the artery (Fig. lc) before proceeding centrally. In the group of 25 patients under discussion, excised segments of artery ex- hibiting this type of trauma were submitted for special pathological step sections and the resulting histological information has been of considerable practical value in the manage- ment of this type of problem.

MACROSCOPIC PATHOLOGY With two exceptions, the lesions were

situated within 15 mm proximal to the catheter arteriotomy. However, in 80% of

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602 JOURNAL OF SURGICAL RESEARCH: VOL. 20, NO. 6, JUNE 1976

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FIG. 1. Mechanisms of brachial artery occlusion. (a) Inadequate closure and/or adherence of “wipe-off” platelet-fibrin clumps. (b) Frictional denudation of in- tima and media from posterior wall. Note that catheter size corresponds closely to the vessel lumen thus increasing the frictional effect. (c) Dissection of partial thickness wall flap. In the majority of instances, the damaged segment is within 1.5 cm of the arteriotomy.

these patients the damaged sections were present within 10 mm of the arteriotomy and could therefore be easily visualized when this area was cleared of thrombus and cross clamped. The naked eye appearance of these lesions consisted of a ragged area occupying the posterior quarter of the artery wall on which fresh thrombus was invariably adher- ent. In two instances, the catheter had actually perforated this area and in five patients, the wall was so attenuated at this point that when the layer of clot was removed the remaining wall was almost transparent. In 10 of these patients, a dissected tissue flap

could be easily identified (Fig. 2). This seemed to be more prevalent in patients with atheromatous changes in the artery although it was not exclusive to these patients. Prox- imal to this point of injury, the artery usually appeared to be normal.

MICROSCOPIC PATHOLOGY Histological examination of these arterial

segments revealed a series of changes. These ranged from frictionally denuded endothe- lium, fracture and retraction of the internal eleastic lamina, partial necrosis of the media of the arterial wall (Fig. 3), elevation of partial thickness wall flaps, and in some instances pressure necrosis of the entire pos- terior wall of the artery (Fig. 4). In each specimen some or all of these changes were easily identified. In 10 of the specimens it was possible by using longitudinal and transverse sections to see where the catheter tip had im- pinged on the back wall of the artery leaving a well established track with extensive sur- rounding damage.

COMMENTARY It has therefore been possible by micro-

scopic examination of these arterial seg- ments to determine that in a significantly large group of patients in whom post- catheterization brachial artery thrombosis

FIG. 2. Resected specimen with partial thickness wall flap showing through the arteriotomy (arrow).

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KARMODY. LEMPERT AND JARMOLYCH: ARTERY OCCLUSION PATHOLOGY 605

occurs, the genesis of the thrombosis had been extensive damage to the posterior wall of the artery by the mechanical effects of the catheter. Areas which have been so trau- matized are highly thrombogenic and will, in our experience, rapidly form a source of in- tramural thrombus if not recognized and removed from the flow path. In our exper- ience, previous to this series, this important pathological fact was not identified and this resulted in some failures. This problem was probably also unrecognized in 9 cases reported by Campion et al. [2] in which repeated thrombectomies appeared to be unsuccessful. Discovery of this “catheter le- sion” prompted the organization of this prospective study.

SURGICAL APPROACH Awareness of this data had led to the evo-

lution of a simple surgical approach to this problem. In view of the possibility that in nearly 50% of cases, resection of 1 cm of damaged artery may be required, the first step in exploration has been the mobilization of an adequate length of brachial artery. From the arteriotomy, at least two cm of artery are first dissected proximally and 1 cm distally. This can be readily done under local anesthesia, using small extensions of the transverse wounds which are used by the majority of Cardiologists. The arteriotomy is then reopened, the lacerated edges are trimmed transversely and thrombus is re- moved distally by balloon catheter. The ar- tery is cross clamped distally, the proximal thrombectomy is carried out, and the artery is cross clamped proximally. The empty seg- ment of artery between the clamps is now carefully inspected under good light using gentle traction on the edges of the ar- teriotomy so that the proximal area is well seen. If no arterial damage can be identified, the now transverse arteriotomy is carefully closed with appropriate suture material (e.g. 6-O Prolene). If a “catheter lesion” is present a segment of artery including the area of arteriotomy is resected proximally back to normal tissue. End-to-end anas-

tomosis is then carried out. In the majority of instances this has posed no problem and up to 2 cm of artery have been removed without undue difficulty in reapproximation. Flexion of the elbow will generally assist in reducing tension on the arterial ends during anas- tomosis. Using this technique, we have re- stored patency in all but one of these patients. In this patient, streptococcal infec- tion occurred in the wound causing wide spread arterial and venous thrombosis in the area. Fortunately, he has not suffered serious ischemia of the hand. Whenever doubt exists as to the adequacy of the reconstruction, operative angiography and Doppler ultra- sound have been utilized routinely in the solu- tion of these problems.

DISCUSSION Acute brachial artery occlusion following

catheterization is not as serious as acute oc- clusion of its homologue, the popliteal artery. In the latter, limb survival is almost always threatened but in the vast majority of patients with brachial thrombosis, the col- lateral circulation around the elbow is suffi- cient to at least maintain the viability of the hand and fingers. However, these patients are subjectively uncomfortable with initial coldness, numbness and stiffness of the fin- gers and at least 70% will later suffer from marked claudication of the forearm and hand. These symptoms are very frequent in heavy manual workers but will also occur in individuals doing lighter tasks, e.g. house- work, writing or typing. For these reasons alone, it is therefore whorthwhile to restore arterial normality to these patients. In addi- tion, however, it can be predicted that in at least half of the patients undergoing cardiac catheterization further catheter diagnostic studies may be required at a later date. Since it is very much easier to do the relevant studies from the right side and the majority of people are right-handed, it is therefore of some importance to restore patency of the right brachial artery, to obtain normal re- vascularization of the right forearm and hand. In nearly 60% of our 58 patients, this

606 JOURNAL OF SURGICAL RESEARCH: VOL. 20, NO. 6, JUNE 1976

aim was achieved with relative ease but in the remainder more care was required in order to achieve a satisfactory result. The presence of severely damaged portions of arterial wall (“catheter lesion”) will militate against continued arterial patency since these areas are highly thrombogenic. Barabas et al. [l] advocated the use of onlay patch grafts following thrombectomy but it seems that optimal therapy would necessitate removal of the dead tissue which has been so clearly demonstrated histologically. This approach has been used in all 25 cases with consider- able success. The recognition of the presence of an area of specific catheter trauma ap- pears to be a cardinal factor in the favorable outcome of these cases, since nothing is more frustrating to both patient and surgeon to experience long, tedious and unrewarding at- tempts at reconstruction.

ACKNOWLEDGMENTS The authors thank Lu Battistello and Medical Illus-

tration, VAH, for their great help.

REFERENCES 1. Barabas, A. P., Bouhoutsos, J., and Martin, P. Iatro-

genie brachial artery injuries. Brit. Heart J. 35:1080, 1973.

2. Campion, B. C., Frye, R. L., Pluth, J. R., Fairbairn, J. F., and Davis, G. D. Arterial complications of retrograde brachial artery catheterization. Mayo Clin. Proc. 46:589, 197 1.

3. Jacobsson, B., and Schlossman, D. Thrombogenic properties of heparinised vascular catheters. Acta Radiol. (Diagn.)(Stockh.) 14569, 1973.

4. Karmody, A. M., and Lempert, N. Post catheteriza- tion brachial artery thrombosis. Therapy and prophy- laxis. Circulation 48(Suppl. 4):116, 1973.

5. Machelder, H. I., Sweeney, J. P., and Barker, W. F. Pulseless arm after brachial artery catheterization. Lancer 1:407, 1972.