Direct Percutaneous Non-Catheter Left and Right Brachial Angiography

Abstract

In 1947, Radner (1) introduced a method of thoracic aortography and vertebral angiography by the insertion of a catheter in the radial artery and its placement in the thoracic aorta. This proved to be a successful procedure but required surgical exposure of the radial artery and later its sacrifice. Other investigators at the time could not duplicate the ease of the performance as described by Radner or the quality of his results. Vertebral angiography was performed by Lindgren (2), by placement of a catheter in the subclavian artery from a brachial artery puncture by the percutaneous method. Excellent films were reported by this means, with few complications. Pygott and Hutton (3) catheterized the brachial artery percutaneously to demonstrate the vertebral artery, using the modified Seldinger technic. This procedure, which was accepted by many, obviates the danger of intramural injection of the contrast medium, a technical complication of direct vertebral arteriography which can cause an occasional death. Percutaneous brachial catheterization was discussed in 1962 by Samuel (4), who used it at the Royal Infirmary, Edinburgh, for investigation of aortic coarctation and for obstructions and aneurysms of the thoracic and descending aorta. There is a satisfactory collateral arterial circulation around the elbow from the profunda brachii and superior ulnar collateral anastomosing with the inferior ulnar collateral, the radial, recurrent ulnar and the dorsal interosseous. The lacertus fibrosus helps to maintain the location of the brachial artery during direct puncture. The relationship of the median nerve and the brachial artery becomes less intimate in the lower part of the antecubital fossa. The venae comitantes of the brachial artery lie on the anterolateral and posterior medial aspect of the artery, but are somewhat separated from it in the antecubital fossa. It is felt that some of the difficulties experienced by other investigators in puncturing the brachial artery are due to the fact that they punctured it too high along its course. A low puncture site is important if the anastomotic circulation is not to be jeopardized. The type of vascular needle is also important in the puncture of the artery. We have found that a specially designed blunt-end 17-gauge needle with a fine pointed obturator is the best. A small piece of stainless steel is attached to the base of the needle to enable one to better guide it into the brachial artery. A Cournand No. 18 needle may also be used. A Seldinger 160 needle, by virtue of its large size, makes puncture of the brachial artery quite difficult. Some workers have reported excellent results with a Riley needle that has a special round point. All of these needles have an especially thin wall. Description of Method The puncture site is infiltrated with 1 per cent Xylocaine. The arm is abducted from the side to an angle of about 35°, with the elbow extended.