Brachial Artery Thrombosis Research Articles

Outcomes of brachial artery transposition in hemodialysis patients

ObjectiveIn hemodialysis patients with a difficult access extremity who are not suitable for an arteriovenous fistula or arteriovenous graft creation, the concept of cannulating a superficialized artery for arterial outflow in dialysis sessions has been adopted as a tertiary alternative. However, its long-term patency and complications have not been recognized widely. We report our 16-year experience with hemodialysis access creation using the brachial artery transposition (BAT) technique. MethodsThis single-center retrospective study included consecutive patients who underwent BAT for hemodialysis vascular access between June 1, 2006, and December 31, 2022. The patency of the whole access circuit and the transposed brachial artery itself was evaluated independently. ResultsIn total, 193 surgical procedures were included. The success rate was 93.2%. The mean operative time was 128 minutes. The median interval from access placement to first cannulation was 21 days. The primary patency rates for BAT were 92.3%, 91.3%, 90.3%, 86.1%, and 71.9% at 1, 2, 3, 5, and 10 years, respectively. The secondary patency rates for BAT were 96.3%, 96.3%, 95.0%, 90.1%, and 74.9% at 1, 2, 3, 5, and 10 years, respectively. The primary patency rates for the whole access circuit were 61.4%, 49.2%, 45.8%, and 26.9% at 1, 2, 3, and 5 years, respectively. The secondary patency rates for the whole access circuit were 85.1%, 83.3%, 82.0%, and 68.6% at 1, 2, 3, and 5 years, respectively. The overall patient survival rates were 79.6%, 69.6%, 54.6%, 36.5%, and 13.4% at 1, 2, 3, 5 and 10 years, respectively. The abandonments of BAT were brachial artery thrombosis (n = 6), pseudoaneurysm (n = 2), aneurysmal change (n = 1), and other reasons (n = 1). The abandonments of the whole access circuit were exhaustion of venous return (n = 26), abandonment of BAT (n = 7), and other reasons (n = 2). Complications were exhaustion of venous return (n = 26), aneurysmal change (n = 12), pseudoaneurysm (n = 6), brachial artery thrombosis (n = 7), impaired wound healing (n = 19), lymphorrhea (n = 9), skin infection (n = 5), hematoma on cannulation (n = 3), and reduced peripheral blood flow (n = 2). ConclusionsThe patency of BAT was excellent, and that of the whole access circuit was adequate, with a few complications. BAT is an effective alternative from a long-term perspective for patients who are unsuitable for conventional hemodialysis access creation.

An Unusual Case of Brachial Artery Thrombosis in a Neonate Following Humerus fracture at Birth

A female infant of a diabetic mother born through LSCS at 39 weeks of gestation with a birth weight of 2908 grams was noted to have a paucity of movement of the left upper limb soon after birth. The extremity was pale, had markedly deranged perfusion, and was cold to touch with absent brachial, radial, and ulnar arterial pulsations. There was a swelling noted over the middle of the left arm, which was tender and associated with crepitus suspicious of a fracture. The right upper limb and lower limbs were normal. An urgent X-ray of the left upper limb showed a displaced fracture of the left humerus fracture and the Doppler study revealed absent flow in the brachial artery distal to the fracture site without thrombus. Urgent close reduction of the fracture following which the doppler showed a thrombus in the brachial artery extending up to its bifurcation. The thrombosis was managed medically with low molecular weight heparin and aspirin. There was a gradual improvement of limb perfusion with normalcy achieved on day 3 of life with no residual complications even on follow-up. The workup of neonatal thrombosis, its immediate management and current evidence for the same have been discussed in detail.

Reaching a crossroads in the management of pink pulseless hand in pediatric supracondylar humerus fracture: exploration Versus conservation

Introduction Supracondylar fracture of the humerus (SFH) is the most common fracture of the elbow in the pediatric population (60%) (1, 2). Displaced SFH in children is commonly associated with vascular insult in the form of absent distal pulses. In such cases, the limb can be cold and cyanotic or warm and pink despite the loss of pulse. Immediate exploration of the cold cyanotic limb is the current recommendation (3). The treatment of pink, warm pulseless limbs is still under debate (4). Aim The aim of this study is to evaluate the role of intraoperative in situ conventional angiography in the same setting of fracture fixation in cases of SFH with pink pulseless hands. Patients and methods This is a comparative study between two groups of pediatric patients admitted to Tanta University Hospitals, who suffered from SFH associated with a pink pulseless hand, and who underwent reduction and closed fixation of the fracture. Group (A) includes prospective data from 30 pediatric patients recruited from January 2021 to January 2023, who were managed by same-session conventional in situ brachial artery angiography. Group (B) includes retrospective data records from December 2016 to December 2019, composed of 50 similar age-group patients who were managed conservatively for 6–12 h after fracture fixation. Then after failure to regain distal pulse, CTA was performed to disclose the underlying arterial condition. Results The mean age of patients was 6.4 years ±2.73. The main mode of trauma was falling to the ground on outstretched hand (47% in group A, and 54% in group B). The types of arterial injury were as follows: brachial artery entrapment (27% in group A, 18% in group B), complete transection (7% in group A, 6% in group B), intimal contusion and thrombosis (43% in group A, 56% in group B), arterial spasm (23% in group A, 20% in group B). The mortality rate was 0% and the limb salvage rate was 100% in both groups, however, the number of anesthesia sessions, the mean total operative time, and the duration of hospital stay were significantly lower and in favor of group (A). Conclusion We believe that in situ conventional angiography is the most appropriate, accurate, and rapid diagnostic tool to define the lesion and plan the procedure in pediatrics with a pink, warm, well-perfused pulseless hand associated with SFH.

Comparative effectiveness and safety of laser, needle, and "quick fenestrater" in in situ fenestration during thoracic endovascular aortic repair.

Special instruments are needed for the revascularization of aortic branches in in situ fenestration during thoracic endovascular aortic repair (TEVAR). This prospective study compared the effectiveness and safety of three currently used fenestraters: laser, needle, and Quick Fenestrater (QF). In all, 101 patients who underwent TEVAR for aortic disease (dissection, n = 62; aneurysm, n = 16, or ulcer, n = 23) were enrolled. All patients were randomly assigned to three groups: 34 were assigned to laser fenestration, 36 to needle fenestration, and 31 to QF fenestration. The epidemiological data, treatment, imaging findings, and follow-up outcomes were analyzed using data from the medical records. The technical success rates of the laser, needle, and QF fenestration groups were 94.1%, 94.4%, and 100% (p > 0.05). After correction of mixed factors such as age and gender, it was showed the average operative time (Laser group: 130.01 ± 9.36 min/ Needle group: 149.80 ± 10.18 min vs. QF group: 101.10 ± 6.75 min, p < 0.001), fluoroscopy time (Laser group: 30.16 ± 9.81 min/ Needle group: 40.20 ± 9.91 min vs. QF group: 19.91 ± 5.42 min, p < 0.001), fenestration time (Laser group 5.50 ± 3.10 min / Needle group 3.50 ± 1.50 min vs. QF group 0.67 ± 0.06 min, p < 0.001), and guide wire passage time after fenestration (Laser group 5.10 ± 1.70 min / Needle group 4.28 ± 1.60 min vs. QF group 0.07 ± 0.01 min, p < 0.001) were all shorter with QF fenestration than with the other two tools. The overall perioperative complication rates of the laser, needle, and QF fenestration groups were 5.9%, 5.6%, and 0% (p > 0.05): One case of sheath thermal injury and one case of vertebral artery ischemia occurred in the laser fenestration group; one case each of access site hematoma and brachial artery thrombosis were reported in the needle fenestration group. 89 (88.1%, 89/101) patients were followed for a median of 12.6 ± 1.6 months. The overall postoperative complication rates of the laser, needle, and QF fenestration groups were 3.3%, 6.5%, and 0% (p > 0.05): In the laser fenestration group, there was one death due to postoperative ST-segment elevation myocardial infarction; in the needle fenestration group, one patient developed occlusion of the bridge stent; no complications occurred in the QF group. All three fenestration methods were effective in reconstructing supra-arch artery during TEVAR. QF fenestration required less contrast agent, with a shorter surgery duration and fewer complications than laser and needle fenestration.

Axillary and Brachial Artery Thrombosis after Left Radial Access for Coronary Angiography

One case of brachial artery occlusion and no cases of axillary artery occlusions have been reported in the literature. Here we describe a case of a 50 years old female who presented for diagnostic coronary angiogram after having a positive stress test who developed a brachial, axillary and radial artery thrombosis after left transradial access.

Upper Limb Ischemia Following COVID-19 Infection: A Case Report

Introduction: COVID-19 infection can cause a wide range of complications, from respiratory infection to skin rashes. Case Presentation: Here, we report a case of a 73-year-old woman with left brachial artery thrombosis 2 weeks after the onset of COVID-19 infection, leading to left upper limb ischemia. Conclusions: Given the life-changing nature of limb ischemia that can lead to amputation, it is crucial to consider it from the beginning of COVID-19 infection and think of preventive measures in this pandemic.

Thrombosis praecox: Thromboembolic complication preceding the onset of overt Nephrotic syndrome in a patient with Membranous Nephropathy

Thromboembolism is a well-recognized complication of Nephrotic syndrome. In adults, most thromboembolic events occur following the diagnosis of Nephrotic syndrome or during relapses. There is a paucity of literature describing thromboembolic events preceding the appearance of overt nephrotic state. Unless a high index of suspicion is maintained, the diagnosis of Nephrotic syndrome could be missed. We describe a patient of Primary Membranous Nephropathy whose clinical course was marked by thrombotic events - Pulmonary embolism and brachial artery thrombosis, occurring six months prior to the presentation with Nephrotic syndrome.

A CLINICAL CASE OF ARTERIAL THROMBOSIS IN A PREMATURE BOY WITH NEONATAL SEPSIS AND HIGH RECTAL ATRESIA

Occlusion of the venous or arterial vessels in childhood is rather rare but dangerous complication. Occurrence of neonatal thrombosis is 0.5 per 10 000 of live newborns. Promoting factors include congenital defects of coagulation, maternal diabetes, neonatal sepsis, necrotic enterocolitis, asphyxia, and metabolic diseases. More than 90 % cases of neonatal thrombosis are associated with catheterization (umbilical arterial or venous, other central venous lines). Acute arterial thrombosis caused by a peripheral venous catheter is very rare complication, but it can result in severe consequences. The article contains a clinical case of right brachial artery thrombosis in a premature boy with extremely low body weight complicated by development of dry gangrene and amputation of the limb. Complex risk factors promoting development of neonatal arterial thrombosis were found: preterm birth, neonatal sepsis, possible incorrect insertion of a peripheral venous catheter. Associative factors were congenital developmental defects of the intestine (high rectal atresia) and heart (bicuspid aortal valve, open oval foramen), and maternal factors. The authors emphasize their attention on the necessity to continuous education of the medical staff concerning the technique of catheter insertion and care of them, absolute implementation of safety policy concerning nosocomial infection, adequate provision of ultrasound examination devices with high rarefaction sensors, involvement of a multi-disciplinary team of specialists to manage complicated clinical cases.

P02 Doctor, I just don't feel alright

P02 Doctor, I just don't feel alright

Complication rates of percutaneous brachial artery puncture: effect of live ultrasound guidance

PurposeThe current literature on the use of brachial artery access is controversial. Some studies found increased puncture site complications. Others found no higher complication rates than in patients with femoral or radial access. The purpose of this study was to determine the impact of ultrasound (US)-guidance on access site complications.Materials and methodsThis is a single-center retrospective study of all consecutive patients with brachial arterial access for interventional procedures. Complications were classified into minor complications (conservative treatment only) and major complications (requiring surgical intervention). The brachial artery was cannulated in the antecubital fossa under US-guidance. After the intervention, manual compression or closure devices, both followed by a compression bandage for 3 h, either achieved hemostasis.ResultsSeventy-five procedures in seventy-one patients were performed in the study period using brachial access. Access was successful in all cases (100%). Procedures in different vascular territories were performed: neurovascular (10/13.5%), upper extremity (32/43.2%), visceral (20/27.0%), and lower extremity (12/16.3%). Sheath size ranged from 3.2F to 8F (mean: 5F). Closure devices were used in 17 cases (22.7%). In total, six complications were observed (8.0%), four minor complications (5.3%, mostly puncture site hematomas), and two major complications, that needed surgical treatment (2.7%). No brachial artery thrombosis or upper extremity ischemia occurred.ConclusionExclusive use of US-guidance resulted in a low risk of brachial artery access site complications in our study compared to the literature. US-guidance has been proven to reduce the risk of access site complications in several studies in femoral access. In addition, brachial artery access yields a high technical success rate and requires no additional injection of spasmolytic medication. Sheath size was the single significant predictor for complications.

A Case of Brachial Artery Thrombosis Caused by Massage of an Occluded Arteriovenous Graft

Background: Acute upper limb ischemia (AULI) is a potential complication associated with massages of occluded vascular accesses in patients undergoing hemodialysis. Pharmacological thrombolysis, endovascular intervention and surgical intervention are possible treatment options. Deciding the appropriate treatment strategy is still a controversial issue. Case Presentation: The patient was a 43-year-old woman with renal failure who underwent hemodialysis and peritoneal dialysis. She was found to have an arteriovenous graft (AVG) thrombosis at the start of a hemodialysis session. She underwent massage of the vascular access, and immediately after the massage, she reported pain and cyanosis in her right-hand fingers and was referred to our hospital. Duplex ultrasonography revealed a large number of thrombi in the brachial, radial and ulnar arteries. AULI due to brachial artery thrombosis was diagnosed and surgical intervention was performed on the same day. The vascular wall of the forearm artery was incised vertically against the running vessel and thrombi around the bifurcation of the radial and ulnar arteries were removed. Angiography guided-surgical intervention was performed and improvement in blood flow was achieved. The patient was discharged on the second day after the operation. Conclusion: Surgical intervention has been reported as an effective treatment of AULI due to brachial artery thrombosis after massage of an occluded vascular access.

Shoulder Pain- Trampoline

HISTORY: A 10 year old female presented with left shoulder pain 1 week after she fell while attempting a handstand on a trampoline. She was seen in the ED on the day of injury where x-rays of her c-spine and entire left upper extremity were normal. She was diagnosed with a shoulder contusion and placed into a sling. Despite Motrin and Tylenol, she continued to complain of ongoing pain and was unable to raise her arm out of the sling. She denied numbness or weakness in the extremity but mom mentioned that her hand occasionally appeared mottled. PHYSICAL EXAM: Ecchymosis to the posterior aspect of her upper arm. Tender to palpate over the glenohumeral joint line. ROM diminished in all planes due to pain. Strength 5/5 IR, 4/5 ER. Absent radial pulse. Sensation intact. AIN/PIN intact. Normal exam of her c-spine, elbow and wrist. Her hand was pink and well perfused. DIFFERENTIAL DIAGNOSIS: 1) Arterial compromise 2) Fracture 3) MDI of shoulder4) Rotator cuff injury TESTS & RESULTS: MRI Left Shoulder: 1. High grade tear of the latissimus dorsi and teres major with avulsion of the teres major/latissimus dorsi tendon 2. Brachial artery cut off at the level of the humeral neck 3. Tear of IGHL 4. Myotendinous junction tear of the infraspinatous tendon with intrasubstance tear of the distal tendon 5. Humeral head contusion CTA: Abrupt cutoff of the brachial artery at the level of the proximal humerus. Appearance consistent with arterial injury with resultant thrombosis. FINAL/WORKING DIAGNOSIS: 1) Brachial artery thrombosis 2) Latissimus dorsi/teres major tendon tear. Tear of IGHL. TREATMENT & OUTCOMES: 1) Admitted to Hematology service for initiation of anticoagulation therapy- Enoxaparin 1 mg/kg BID for 3 months followed by ASA 81 mg for 9 months. 2) Serial US with Doppler of her LUE monitored monthly until resolution of her thrombus3) Managed non-operatively with close follow up with orthopedics, IR, hematology and plastic surgery services. 4) MRI shoulder with arthrogram completed 3 months following injury revealed healing of her IGHL tear without extravasation of contrast. Interval healing of previously seen teres major/latissimus dorsi tears. 5) Continues to progress in PT working to improve strength and motion.

Simultaneous arterial and venous thromboembolic events associated with COVID-19. A case report

Infections with COVID-19 can induce thrombophilia and increase the risk of thrombotic events. We describe a case of a 64- years-old male who presents with intermediate-risk pulmonary embolism and brachial artery thrombosis secondary to an undiagnosed patent foramen ovale and COVID-19 infection. The patient was successfully treated with thrombolysis and heparin infusions and was discharged home with long-term anticoagulation. Managing patients with multiple pathologies occurring concurrently requires effective inter-speciality working in order to take a holistic approach to managing the patient opposed to managing the conditions in isolation. This case report highlights how clinical guidelines can support decision making of the individual pathologies but working as a team will enable the best care.

613 Microsurgical Salvage of Neonatal Upper Limb Ischaemia Subsequent to Intrauterine Brachial Vessel Constriction

Abstract Introduction We report a case of limb salvage due to intra uterine brachial artery thrombosis. Treatment modalities include medical, endovascular, and surgical. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity. Description A male baby at (36 + 6week) gestation was born to a nulliparous mother with gestational diabetes via uncomplicated elective caesarean section. The child was noted to have a ‘flail’ ischeamic limb post-delivery. There were no palpable pulses in the limb and ultrasonography confirmed thrombosis of the proximal brachial artery. Aetiology was due to dense fibrotic circumferential constriction of the brachial vessels and plexus. Successful revascularisation was achieved with a contralateral interposition reversed great saphenous vein graft. Discussion Neonatal limb ischaemia is a rare disease entity with devastating morbidity- including compartment syndrome, tissue loss, limb loss, reduced limb growth, irreparable neuropathies and Volkmann’s syndrome. The initial diagnosis is based on the characteristic sequelae of ischaemia. Therapy should be individualised based on the clinical presentation. Early recognition, prompt institution of appropriate treatment and monitoring is vital to achieve successful revascularisation and prevention of lifelong morbidity.

Brachial Artery Thrombosis as a Presentation of Non-Small Cell Pulmonary Carcinoma Growing Into the Left Atrium

We present a case of a thrombus in the left brachial artery as a cardioembolic presentation of pulmonary carcinoma. There have been few reports describing this clinical presentation, but if present, prognosis is very poor. Therefore, a cardioembolic event should be borne in mind as an atypical presentation of pulmonary carcinoma. (Level of Difficulty: Beginner.)

Brachial artery thrombosis following multiple wasp stings

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Abstract 16206: An Atypical Presentation of Spontaneous Coronary Artery Dissection in a Young Male Patient

Background: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in women but rare in young healthy males. We report a case of a young male who presented with left hand tingling/numbness and was ultimately diagnosed with SCAD. Case Presentation: A 24-year-old male with history of asthma developed left hand tingling/numbness while playing basketball. This progressed to cold left upper extremity, prompting him to go to emergency room. Doppler ultrasound showed acute left brachial thrombus and emergent embolectomy of left brachial artery was done. Transesophageal echocardiogram, performed to investigate possible cardiac source of thrombus, showed normal ejection fraction, dyskinetic apex and biventricular thrombus (Figure 1A). Cardiac MRI revealed a large transmural MI in distribution of a wraparound left anterior descending artery (LAD) with associated regional akinesis of the left ventricular apex and an infarct in the right ventricular apex. Subsequent angiography revealed normal coronary arteries (Figure 1B) except a heterogenous linear filling defect in the apical LAD consistent with Type 1 SCAD (Figure 1C). No intervention was performed and the patient was treated conservatively. It was postulated that patient sustained an apical MI after SCAD of LAD, leading to formation of ventricular thrombi which then embolized to cause acute brachial artery thrombosis. Discussion: SCAD in young males is rare and can be a diagnostic challenge. Type 1 “pathognomic” angiographic finding in SCAD, is the classic appearance of multiple radiolucent lumens or arterial wall contrast staining. In case of inconclusive angiography, intravascular ultrasound or optical computed tomography can confirm diagnosis. Interventionalists should be familiar with angiographic appearance of SCAD as advanced imaging might not be available and in many cases, conservative management is preferred to percutaneous coronary intervention.

Safety and Efficacy of Transbrachial Access for Endovascular Procedures: A Single-Center Retrospective Analysis

BackgroundEndovascular procedures nowadays are generally performed via the femoral and radial artery. Although not routinely used by many, there is still an essential role for vascular interventions via brachial access. The technological advancement of endovascular devices leads to a significant increase of the variety of percutaneously treatable vascular pathology. The brachial artery approach nowadays is becoming crucial for complex procedures either as single access or in the context of mandatory double vascular approach for many complex interventions. ObjectiveTo evaluate the safety and efficacy of brachial artery access for diagnostic arteriography and endovascular interventions in different vascular territories in a single-center setting on the basis of a retrospective analysis of prospectively collected data in a large patient cohort. MethodsBetween 01/2013 and 09/2016, 11,274 endovascular procedures were performed in our hospital, 847 (7.5%) of them via brachial access, presenting the database for this study. All demographic, clinical, and periprocedural data were obtained prospectively and included in the computerized hospital records, and on this basis, a retrospective analysis was performed. ResultsWhile the radial access was the most used and constant for coronary and noncoronary interventions in our center (71%) in this period, the use of brachial access increased (from 4% to 12%) causing the femoral to decrease (from 27% to 16%). We used the brachial approach for diagnostic purposes in 162 patients (19%) and for head to toe endovascular interventions (including angioplasty, stenting, thrombolysis, or as adjunctive access) in 685 patients (81%). For 53 patients (6.2%), this was the only possible access for endovascular intervention. Overall access site-related complications occurred in 25 patients (2.9%), in 19 of them (2.2%) required surgical correction, for brachial artery thrombosis or pseudoaneurysm. The other six were managed conservatively. No permanent neurological deficits of the arm or severe bleeding were observed. Minor complications, mostly hematomas, occurred in 62 patients (7.3%), but they required no further treatment. ConclusionBrachial artery access expands our capability to perform complex procedures by allowing us to reach arterial targets in all territories. Complications of brachial vascular access are gradually decreasing together with the decrease of the crossing profile of the devices used in practice. However, when they occur, they often require surgical treatment. The growing experience of the team not only while obtaining the access but also while achieving adequate hemostasis (“patent hemostasis”) is of great importance for minimizing the complications.

Stellate ganglion block as a complementary therapeutic modality for arterial thrombosis in upper limb of a neonate

Stellate ganglion block or lower cervical sympathetic block is an interventional procedure, in which a local anesthetic is injected to the sympathetic trunk of the neck, for adjustment of autonomic tone in head, neck and the upper extremity. This procedure is frequently used as a complementary therapeutic modality in a variety of complex heterogeneous problems. We report a case of rapid onset radial and brachial artery thrombosis, which developed in a neonate patient after multiple attempts for a peripheral venous access by cannulation. The condition was diagnosed with Doppler ultrasound, and was successfully managed with stellate ganglion block along with intravenous administration of an anticoagulant.&#x0D; Citation: Taheri M, Radfar M, Tabasi S, Alijanpour E, Jabbari A. Stellate ganglion block as a complementary therapeutic modality for arterial thrombosis in upper limb of a neonate. Anaesth pain &amp; intensive care 2019;23(4)__&#x0D; Received: 22 July 2019; Reviewed: 18 August, 15 November 2019; Revised: 2 December 2019; Accepted: 6 December 2019

Delayed extensive right brachial and radial artery thrombosis: A rare complication of transradial cardiac catheterization

Delayed extensive right brachial and radial artery thrombosis: A rare complication of transradial cardiac catheterization