Brachial Artery Thrombosis Research Articles

Kawasaki Disease - A Rare Presentation in a Bangladeshi Infant - A Case Report

A three month old exclusively breast fed, immunized, male baby having presented with high continued fever for 5 days. There was no clue to any infection. It was treated as viral fever. As soon as Kawasaki Disease was suspected, on about 12th day of fever, appropriate treatment was started. The baby developed multiple coronary artery aneurysms, large pericardial effusion and a rare complication, right brachial artery thrombosis resulting in pulselessness and subsequently dry gangrene of right hand and forearm. Effusion was tapped. The baby died following amputation of the limb - probably of a major adverse cardiac event. Early diagnosis and appropriate treatment according to guidelines on time are essential for saving life of children with Kawasaki disease. Lack of awareness about the disease is a problem in our country. DOI: http://dx.doi.org/10.3329/birdem.v1i1.12392 Birdem Med J 2011; 1(1): 43-45

Hand ischemia associated with elbow trauma in children

Previous observational studies suggest that children with hand ischemia following elbow trauma can be safely observed if Doppler signals are present in the wrist arteries (pink pulseless hand, PPH). Nonoperative management of PPH is predicated on the assumption that PPH results from local arterial spasm, but the mechanism of arterial compromise has not been investigated. We hypothesized that PPH signifies a brachial artery injury that requires surgical repair. Retrospective review of operations performed on children with hand ischemia following elbow trauma at a level I trauma center pediatric hospital. Between 2003 and 2010, 12 children (seven males, mean age 7.4 years) underwent brachial artery exploration for hand ischemia following elbow trauma (11 supracondylar fractures, one elbow dislocation) due to falls (n = 10) or motor vehicle crashes (n = 2). At presentation, three subjects had normal radial pulses, eight subjects had Doppler signals but no palpable pulses, and one had weak Doppler flow with advanced hand ischemia. Six of the nine subjects without palpable pulses also had neurosensory changes. All 12 subjects underwent brachial artery exploration either initially (n = 2) or following orthopedic fixation (n = 10) due to persistent pulselessness. At operation, eight of 12 patients (67%) had focal brachial artery thrombosis due to intimal flaps, and four had brachial artery and median nerve entrapment within the pinned fracture site. At discharge, all 12 subjects had palpable radial pulses, but three with entrapment had dense median nerve deficits. One of the three subjects with dense neurologic deficit had complete recovery of neurologic function at ten months. The other two subjects had residual median nerve deficits with partial recovery at 5 and 6 months follow-up, respectively. No patient developed Volkman's contracture. Brachial artery injuries should be anticipated in children with hand ischemia associated with elbow trauma. Neurovascular entrapment at the fracture site is a possible complication of orthopedic fixation. Absence of palpable wrist pulses after orthopedic fixation should prompt immediate brachial artery exploration. PPH should not be considered a consequence of arterial spasm in these patients.

Endovascular Reconstruction of the Occluded Aortoiliac Segment Using “Double-Barrel” Self-Expanding Stents and Selective Use of the Outback LTD Catheter

To present the early and midterm results of endovascular stent reconstruction of the occluded aortoiliac segment with selective use of the Outback LTD re-entry catheter. Between April 2004 and February 2010, 8 patients (5 women; mean age 58.4 years, range 47-68) with occlusion of the infrarenal aorta extending to the common or external iliac arteries underwent endovascular reconstruction with double-barrel self-expanding stents. Indications for treatment were severe claudication in 6 and ulceration in 2 patients. The technical success rate was 100%, facilitated by the use of the Outback LTD catheter for accurate wire re-entry in 3 cases. There was no in-hospital mortality. One patient had a major complication (femoral artery dissection, brachial artery thrombosis, and retroperitoneal hematoma) unrelated to the re-entry device. Mean operating time was 137 minutes (range 70-253) and length of stay was 1.5 days (range 1-2). During a mean follow-up of 12.5 months (range 6-29), primary patency was 100% with no secondary interventions. Total endovascular reconstruction of the occluded infrarenal aorta that extends into the iliac arteries is durable at midterm follow-up. Adjunctive use of the Outback LTD re-entry catheter can facilitate technical success.

Brachial Approach for Coronary Angiography and Intervention: Totally Obsolete, or a Feasible Alternative When Radial Access is Not Possible?

This study aims to assess the safety and feasibility of brachial arterial puncture for coronary procedures when radial access is not possible. Radial arterial approach is the usual option for coronary procedures in our hospital. Whenever radial access is not possible, the brachial approach is preferred instead of the femoral approach. As many clinicians considered percutaneous brachial coronary angiography as an obsolete and hazardous procedure, we carried out this study to compare the outcomes of the brachial approach to the femoral approach in our centre. We retrospectively evaluated all cases of brachial artery puncture and femoral artery puncture in our centre from 1 January 2007 to 31 March 2009 through a prospectively collected database and looked for all complications which occurred in both groups. The femoral group had a slightly higher incidence of major complications--3 out of 121 cases (2.5%) in the femoral group and 1 out of 180 cases (0.6%) in the brachial group, even though this was not statistically significant (P = 0.15). There was also no difference between these 2 groups for minor complications: 8 patients (4.4%) in the brachial group and 6 patients (5%) in the femoral group developed haematoma that did not require any blood transfusion or surgery. There was no incidence of brachial artery thrombosis and no puncture-related neurological deficit documented in the brachial group. Brachial artery puncture and catheterisation may be a viable, safe and efficient alternative to the transfemoral approach in a centre that is experienced with the arm approach, when radial access is not possible.

The brachial artery: A critical access for endovascular procedures

The brachial artery is often used for coronary angiography. However, data on brachial access for aortic and peripheral interventions are limited. This study evaluated our experience with brachial artery catheterization for diagnostic arteriography and endovascular interventions. Between August 2004 and August 2005, 2026 endovascular procedures were performed. Of these, 323 cases (16%) in 289 patients required brachial artery access, forming the basis for this study. Patients who underwent multiple interventions, but with a single access (ie, thrombolysis), were considered a single case. Demographic and clinical data were recorded in a database and analyzed using logistic regression analyses with generalized estimating equations and the Fisher exact test for nominal variables. The mean age of all patients was 66.4 years, with 57% men. Brachial access was used for diagnostic purposes in 27% and for interventions including angioplasty, stenting, and thrombolysis in 73%. The use of brachial access was considered obligatory in 40%, adjunctive in 19% (ie, endovascular repair of abdominal aortic and thoracic aortic aneurysms) and preferential to femoral access in 41%. In 91% of patients, the brachial arteries were accessed percutaneously, and 9% underwent surgical cutdown for access. In patients whose brachial artery was approached percutaneously, access was achieved in all but one (99.6% technical success rate). Hemostasis after catheterization was achieved by manual compression in 89%. Operative mortality rate was 6.2% and not related to brachial artery access. Brachial access site-related complications occurred in 21 patients (6.5%). Thirteen of these 21 patients (62%) required a surgical correction, mostly for brachial artery thrombosis or pseudoaneurysm. Patients with complications were more commonly women (odds ratio [OR], 4.7; 95% confidence interval [CI], 1.68-13.26; P = .003) and had a long interventional sheath (OR, 6.7; 95% CI, 1.53-29.07; P = .012). The risk of a brachial artery complication was not associated with thrombolysis, procedure type, vascular territory treated, or the use of heparin. No upper extremity limb or finger loss occurred. Brachial artery access is necessary for complex endovascular procedures and can be achieved in most patients safely. Postprocedural vigilance is warranted because most patients with complications will require operative correction.

Necrotic Skin Lesions and Cerebral Infarction in the Newborn: Two Case Reports

Localized skin necrosis with deeper soft tissue injury at birth is unusual and has been rarely reported in association with cerebral infarction. Two cases with forearm necrotic skin associated with injured deeper soft tissue are described in which brachial artery thrombosis was documented. Considering the possibility of disseminated thrombosis, cerebral ultrasound showed brain infarction due to unilateral middle cerebral artery thrombosis on Doppler. The origin of the embolism was identified in the inferior vena cava and umbilical and portal vein. No thrombophilia or other risk factors were identified. The various causes of the cutaneous lesions pointed to an antenatal process whose etiology and mechanisms are discussed. Localized necrotic skin lesions must be considered as part of a systemic embolic process and can lead to extensive especially cerebral ultrasound exploration.

The Midterm Results of Stent Graft Treatment of Thoracic Aortic Injuries

Several publications document the technical feasibility of stent graft repair of aortic transection. We report our mid-term results of endovascular repair of thoracic aortic transections using covered stent grafts and compare this to a cohort undergoing open repair during the same time period to demonstrate the shift in practice pattern at our institution. A retrospective review of patients who sustained blunt thoracic transection was undertaken. Medical records were examined to identify the clinical outcome of the procedure, and follow-up CT scans were reviewed to document adequate treatment of the transection. Outcome measures include procedure-related mortality, neurological morbidity, and successful immediate and mid-term coverage of the thoracic false aneurysm and absence of graft migration or endoleak. From July, 2000 to October, 2004, 27 patients were identified with descending thoracic aortic transection at our level I trauma center. Fourteen patients were managed nonoperatively, five patients underwent thoracotomy and direct aortic repair, and eight patients underwent endoluminal stent graft repair. Of the endovascular group (n=8), repairs were performed with stacked AneuRx aortic cuffs (Medtronic, Inc., Minneapolis, MN) (n = 6), a Gore thoracic aortic stent graft (Thoracic EXCLUDER; W.L. Gore, Flagstaff, AZ) (n=1), or a Medtronic Talent thoracic endograft (Medtronic, Inc.) (n=1). Access for stent graft deployment was the common femoral artery (n=2), iliac artery (n=4), or distal abdominal aorta (n=2). Completion arch aortography and postoperative CT scanning confirmed successful management of the aortic transection in each patient. There were no procedure-related deaths, paraplegia, or stroke. Postoperative complications included a brachial artery thrombosis in one patient as well as an external iliac artery dissection and acute renal failure in a second patient for a complication rate of 37.5%. Two patients died as a result of their injuries unrelated to the stent graft repair. Mean follow-up of 16.6 mo has shown no evidence of endoleak or stent graft migration. Of the open repair group (n=5), one patient died in the operating room during attempted aortic repair, and one patient had a postoperative stroke. Due to technical success and absence of delayed complications including endoleak and graft migration, stent graft repair of traumatic aortic transection has replaced open aortic repair as the primary treatment modality in the multiply injured trauma patient at our institution. The postoperative complication rate observed in this small series tempers the success to some degree, but the severity of the complications compares favorably with those observed in the open repair group.

Brachial Artery Thrombosis in Infants: An Algorithm for Limb Salvage

Arterial occlusion in infants, although uncommon, is usually an iatrogenic event associated with arterial vascular access. Most common in the upper limb, the consequences of iatrogenic arterial occlusion may be gangrene and limb loss. Even if there is adequate collateral flow and limb loss is avoided, long-term growth disturbances may be seen. There are few published data to guide the management of arterial occlusion in premature or sick infants. In general, there is agreement regarding the importance of early diagnosis and the reestablishment of limb perfusion with the fewest risks, but the optimal choice and timing of treatment modalities remain unknown. This article examines the authors' experiences at the Royal Children's Hospital, Melbourne, and provides their algorithm for the management of this complex iatrogenic disease. The management algorithm has successfully treated 11 limbs in 11 patients with arterial vascular access-associated thrombosis over the period 1995 to 2003, with no instances of limb loss. Five of these patients required surgical intervention. The authors recommend a multidisciplinary approach involving plastic surgeons and hematologists for all cases of suspected or confirmed arterial thrombosis. A consensus algorithm that determines the role of heparin, thrombolysis, and acute surgical interventions, and the sequence of such interventions, is useful in providing the framework of therapy. The early recognition of the limb at risk is a key factor in obtaining a successful outcome.

Acute Brachial Artery Thrombosis: A Rare Complication of Diabetic Ketoacidosis

Diabetes mellitus is a worldwide disease that leads to several acute complications including diabetic ketoacidosis, hyperosmolar hyperglycemia, and hypoglycemia. In addition, diabetes causes many chronic complications that lead to debilitation and diminished quality of life. Diabetic ketoacidosis is one of the serious acute complications; however, it is usually preceded by infection, acute myocardial infarction, stroke, or other dire events. Rarely does it accompany acute arterial thrombosis. Here, we report on a female patient who suffered from diabetic ketoacidosis combined with acute brachial artery thrombosis. After emergency treatment, including insulin therapy and surgical thrombectomy, the brachial artery was rescued and her prognosis was good.

Acute brachial artery thrombosis as the initial manifestation of human immunodeficiency virus infection

Thrombosis of upper extremity arteries is most commonly due to atherosclerosis of the proximal subclavian artery, trauma, or catheter-related injury. In the absence of an identifiable cause, a search for a hypercoagulable state is indicated. Hematologic manifestations of human immunodeficiency virus (HIV) infection and AIDS are frequent occurrences (Coyle TE. Med Clin N Am 1997;81:449–476). The most important of these are cytopenias (anemia, neutropenia, and thrombocytopenia). The incidence and severity of cytopenia are generally correlated to the stage of the HIV infection. In addition, various coagulation abnormalities have been reported in HIV-infected patients. Apart from thrombocytopenia, these have included a prolonged APTT due to the presence of lupus anticoagulant, an increased prevalence of protein S and heparin cofactor II deficiency, and hypoalbuminemia-related fibrin polymerization defects (Toulon P. Ann Bio Clin (Paris) 1998;56:153–160). HIV infection has also been associated with endothelial dysfunction. Although for the most part asymptomatic, elevated d-dimer levels have been found in HIV-infected patients, suggesting the existence of a prethrombotic state. In fact, clinical thrombosis eventuates in 2% of these patients (Toulon, 1988). Documented thromboses have involved both veins and arteries. We hereby present a patient who developed an acute thrombosis of his brachial artery as the initial manifestation of HIV infection. Am. J. Hematol. 64:137–139, 2000. © 2000 Wiley-Liss, Inc.

Venous graft repair following brachial artery thrombosis in a neonate

A case of venous graft repair to recover blood flow of a newborn's upper extremity, is described. Even though this complication remains uncommon, we emphasize on to avoid brachial artery for vascular monitorization and to perform microsurgical revision as elective procedure if conservative therapy is unsuccessful.

Arterial injury following shoulder trauma: a report of two cases

Anterior dislocation of the shoulder is a common injury with several well recognized complications including bony, neural and soft tissue injuries. Vascular damage is very rare and usually limited to a short segment of the axillary artery adjacent to the humeral head (Zuckerman et al, 1984). This report is of a patient with proximal subclavian artery occlusion following anterior shoulder dislocation and of another patient with extensive axillary and brachial artery thrombosis following a longstanding displaced fracture of the proximal humerus. Digital angiography demonstrated the unusual extent of these lesions accurately and is recommended in the pre-operative assessment of such cases.

Carotid artery: percutaneous transbrachial selective arteriography with a 4-F catheter.

Bilateral selective common carotid artery catheterization was attempted in 72 patients by means of percutaneous placement of a 4-F catheter from a right brachial artery puncture site in the antecubital fossa. The success rate was high (95.8%) and the complication rate low (6.9%), and there were no instances of brachial artery spasm or thrombosis. The experience, while small, suggests that selective common carotid arteriography can be done safely and efficaciously from the right brachial artery approach.

Results of Catheter Ablation of Ventricular Tachycardia Using Direct Current Shocks

Thirty-three patients with recurrent ventricular tachycardia (VT) underwent catheter ablation with direct-current shocks. One to four shocks of 100-300 joules were delivered to the presumed VT exit sites as identified by endocardial mapping and pace mapping. Fifteen patients (45%) had no recurrence of symptomatic VT during a follow-up interval of 15.5 +/- 10 months (mean +/- standard deviation). Five patients experienced six nonfatal complications (new VT or ventricular fibrillation, transient neurological deficit, atrioventricular block, brachial artery thrombosis). In conclusion, catheter ablation in selected patients with recurrent VT has the potential for preventing recurrences of VT over the long-term and is relatively safe.

Long-term brachial artery catheterization: ischemic complications.

The brachial artery is not used for long-term catheterization and routine hemodynamic monitoring because a high incidence of ischemic complications is anticipated. However, in a review of 157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days). One hundred seventy-three catheters (77%) were removed electively and 52 catheters (23%) were removed because of complications. Diminution or loss of the radial pulses occurred on insertion of 88 catheters (39.1%) and 16 of these (8%) were removed after 24 hours because ischemic symptoms developed. Subsequently, 25 other catheters (11.1%) were removed because of complications such as paresthesia, eight (3.5%); brachial artery thrombosis, four (1.7%); microembolization, three (1.3%); claudication, two (0.8%); and pseudoaneurysm, one (0.4%). Seven catheters (3.1%) were removed because of a combination of pallor, diminished pulses, and muscle weakness. Hemorrhage from the arteriotomy site necessitated the removal of 11 other catheters (4.9%). Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.

Long-term brachial artery catheterization: Ischemic complications

The brachial artery is not used for long-term catheterization and routine hemodynamic monitoring because a high incidence of ischemic complications is anticipated. However, in a review of 157 patients who had 225 percutaneous transbrachial hepatic artery catheters placed for infusion of chemotherapeutic agents, catheters remained in situ from 1 day to 14 months (median 68 days). One hundred seventy-three catheters (77%) were removed electively and 52 catheters (23%) were removed because of complications. Diminution or loss of the radial pulses occurred on insertion of 88 catheters (39.1%) and 16 of these (8%) were removed after 24 hours because ischemic symptoms developed. Subsequently, 25 other catheters (11.1%) were removed because of complications such as paresthesia, eight (3.5%); brachial artery thrombosis, four (1.7%); microemoblization, three (1.3%); claudication, two (0.8%); and pseudoaneurysm, one (0.4%). Seven catheters (3.1%) were removed because of a combination of pallor, diminished pulses, and muscle weakness. Hemorrhage from the arteriotomy site necessitated the removal of 11 other catheters (4.9%). Amputation, ischemic ulceration, major neuromuscular sequelae, and peripheral embolization to the head or lower limbs did not occur. This study suggests that long-term brachial artery catheterization is associated with a low incidence of permanent ischemic complications.

Hospital-Incurred Vascular Trauma: Management of Brachial Artery Thrombosis Following Cardiac Catheterization

This study reviews the authors' experience with 13 cases of brachial artery thrombosis following cardiac catheterization. Eleven patients underwent bra chial artery exploration with complete restoration of normal distal pulses and excellent long-term results. There was no morbidity or mortality. The 2 patients who did not undergo surgical repair complained of exercise-induced hand ische mia. The etiology of the thrombosis and alternatives in surgical management are discussed. An aggressive approach toward vascular injury associated with retrograde brachial artery catheterization is warranted.

Catheter ablation of ventricular tachycardia with intracardiac shocks: results in 33 patients.

Catheter electrical ablation of ventricular tachycardia (VT) was attempted in 33 patients who had recurrent unimorphic VT refractory to 3.7 +/- 1.2 (mean +/- SD) antiarrhythmic drugs. Their mean age was 56 +/- 14 years. Twenty-two patients had coronary artery disease, six had other types of heart disease, and five had no structural heart disease. The mean left ventricular ejection fraction was 0.34 +/- 0.17. Thirty patients had only one documented morphologic type of spontaneous VT, whereas three patients had more than one. One to four shocks of 100 to 300 J each were delivered to the endocardial exit site of VT, as identified by endocardial activation mapping and pace-mapping. In each patient endocardial activation at the exit site of VT preceded the onset of the QRS complex (mean activation time -50 +/- 30 msec). Pace-mapping was possible in 26 patients, and in all but two patients the QRS complexes during VT and during pacing at the exit site of VT were very similar in at least 10 of 12 electrocardiographic leads. In 29 patients, shocks were delivered between an endocardial electrode (cathode) and a patch electrode on the chest wall (anode). Seven patients (including three who first received shocks using an external anode) whose VT originated in the septum received transseptal shocks between two electrodes positioned on either side of the septum. The procedure was successful in 15 patients (45%), who had no recurrence of VT either on no antiarrhythmic therapy or on the same regimen that was ineffective before ablation, over a follow-up period of 15.5 +/- 10 months (range 5 to 35). The ablation attempt was unsuccessful in 18 patients (55%). There were no significant differences in clinical and electrophysiologic variables between patients with and without a successful outcome. Seven nonfatal complications occurred in six patients: sustained nonclinical VT immediately after the shock, ventricular fibrillation on days 5 and 6 after ablation, neurologic deficits (n = 2), atrioventricular block (n = 2), and brachial artery thrombosis. In conclusion, catheter electrical ablation of VT has modest efficacy and is relatively safe in a selected group of patients who have predominantly one configuration of unimorphic VT.

Brachial artery injury after cardiac catheterization

During a 3-year period, 12,158 cardiac catheterizations were performed via the brachial artery. During this same period, 106 patients were operated on for complications of brachial artery injury and/or thrombosis, an incidence of 0.9%. The indication for the cardiac catheterization was coronary artery disease in almost 92% of the patients. Early (less than 4 days) brachial artery repair was done in 90% of the patients. The operative findings were thrombosis (91%), intimal injury (54%), stenosis (13%), laceration and/or perforation (11%), and atherosclerotic plaque (6%). Because of vessel injury, localized resection was done in two thirds of the patients. Vascular continuity was obtained with axial reanastomosis in 45 patients and interposition vein graft in 26 patients. Primary lateral repair was performed in 23 patients (22%). Ninety-five percent (101 patients) had initial excellent results. Of the five patients who required reoperation, flow was restored in four patients. Thus, 99% of patients had restoration of a patent brachial artery. Contributing factors for brachial artery complications are “redo” catheterization, prolonged catheterization time, catheter change, brachial artery atherosclerosis, improper arteriotomy closure, experience of cardiologist, female patient, and failure to use heparin. Because of the unpredictability of ischemic symptoms occurring after brachial artery thrombosis, the need for bypass graft surgery when delayed, and the good results with early surgical intervention, early exploration of brachial artery complications after cardiac catheterization and appropriate repair are recommended.

Minimizing mortality and morbidity from iatrogenic arterial injuries: the need for early recognition and prompt repair.

Seventy-one cases of iatrogenic arterial injury requiring repair at our institution from 1972 through 1984 were retrospectively analyzed. Cardiac catheterization accounted for most of the injuries (62%). Ten injuries (14%) resulted from angiography or percutaneous transluminal angioplasty; four injuries (5.6%) occurred after invasive monitoring devices were inserted. Six injuries (8.45%) stemmed from complications of intra-aortic balloon pump insertion, whereas the remainder occurred during various surgical procedures. Most injuries were in the femoral (42.3%) and brachial (38.1%) locations. Thrombectomy (23.9%) and resection with end-to-end anastomosis (35.2%) were the repairs most commonly performed. Morbidity and mortality were low; only one case resulted in limb loss, and neither of the two deaths resulted from the vascular repair itself. On the basis of our experience, we can make certain recommendations with regard to specific injuries. First, the conservative approach to brachial artery thrombosis occurring after catheterization is early exploration and repair. Second, although most injuries can be managed simply with thrombectomy and primary repair, iliofemoral injuries are more likely to require complex reconstructive techniques. Third, large-bore catheter injuries to the carotid artery require immediate exploration and repair to prevent thrombosis, pseudoaneurysm, and cerebral embolism. Fourth, symptoms of nerve compression after transaxillary arteriography require prompt exploration. Our results indicate that, depending on the site of injury, individualized techniques of varying complexity are required for repair. In general, serious sequelae can be minimized by early recognition, prompt operation, and adherence to sound vascular surgical principles.