Brachial Route Research Articles

A Misdiagnosed Case of Endoleak Type-III Caused by Inadvertent Bilateral Limb Insertion in the Same Limb Gate of the Ovation Endograft.

We describe an infrequent case of endoleak Type-III due to an unrecognized, inadvertent bilateral limb deployment into the same limb gate of the Ovation aortic endograft, accompanied by thrombosis and acute ischemia. The following computed tomography angiography revealed the open limb gate with the characteristic of radio-opaque polymer in the sealing rings. Intraoperative angiographies via the brachial route identified the open limb gate and facilitated the successful use of an occluding plug to manage the Type-III endoleak.

Endovascular Treatment of Iliac Atheromatous Stenoses: Local and General Complications of the Brachial Approach

Femoral access is the approach of reference for iliac angioplasties. In the current context of early ambulation and reduction in the durations of hospitalization, the brachial route seems an adapted approach, more especially since long 135 cm catheters with a low profile (4F) are available. This approach is useful in presence of a previous femoral approach with the risk of graft weakening or prosthetic infection.

Morphological Assessment of Cadaveric Radial, Brachial and Subclavian Arteries: A Neurointerventional Approach

ObjectiveThe transradial catheterization (TRC) is becoming widespread, primarily for neurointerventions. Therefore, the evaluation of radial artery puncture in clinical practice and a better understanding of the anatomy are important to improve the safety of neuroendovascular surgery.MethodsTen formalin-fixed adult Korean cadavers were dissected to expose radial artery (RA), brachial artery (BrA) and subclvian artery (ScA), bilaterally. Vessel lengths and diameters were meaured using a caliper and distance between the specific point of vessels and the anatomical landmarks including the radial styloid process, the medial epicondyle of the humerus, the sternoclavicular joint, and the vertebral artery orifice were also measured.ResultsThe average length between the radial (RAPS) and the BrA puncture sites (BrAPS) and between the vertebral artery orifice (VAO) and the BrA bifurcation (BrAB) did not differ between sides (p>0.05). The average length between the radial styloid process (RSP) and the RAPS was 13.41±2.19 mm, and the RSP was 26.85±2.47 mm from the median nerve (MN). The mean length between the medial epicondyle (ME) and the BrAPS as 44.23±5.47 mm, whereas the distance between the ME and the MN was 42.23±4.77 mm. The average VAO-ScA angle was 70.94±6.12°, and the length between the ScA junction (SCJ) and the VAO was 60.30±8.48 mm.ConclusionThis study provides basic anatomical information about the radial artery and the brachial route and can help improving new techniques, selection of size and shape of catheters for TRC. This can help neurointerventionists who adopt a transradial neuroendovascular approach and offers comprehensive and safe care to their patients.

A Case of Difficult Catheterization of the Contralateral Limb of the Ovation Abdominal Stent Graft System in Challenging Aortoiliac Anatomy, Facilitated through the Brachial Access: A Word of Caution

The Ovation Stent Graft System is a new trimodular endoprosthesis for the treatment of abdominal aortic aneurysms. A long nitinol stent with anchors serves the suprarenal fixation, whereas inflatable rings in the main body achieve sealing. This dissociation precludes the presence of a nitinol skeleton in the endograft, thus, avoiding competing for the same space within the delivery system, enabling the latter to achieve ultra-low profiles. However, the lack of nitinol support may render the endograft's docking limb prone to collapse in cases of narrow aortoiliac anatomy. We present a case of challenging contralateral limb catheterization, facilitated effectively through the brachial access. Preparing for the brachial route remains a useful and time-sparing adjunctive measure that guarantees the device's safety and effectiveness in challenging anatomies.

Transradial percutaneous iliac intervention, a feasible alternative to the transfemoral route

Percutaneous angioplasty for atherosclerotic iliac disease is commonly performed via the femoral and/or brachial route. In the coronary field a transradial approach has been shown to reduce both major and minor access site bleedings, in experienced hands. However, this route has not yet been well studied for the majority of peripheral interventions, like those involving the iliac arteries. We investigated the feasibility and safety of a transradial approach in a consecutive series of patients undergoing percutaneous iliac intervention at our center, comparing it to a similar series of patients treated with a transfemoral approach in the same period. Endpoints of the study were procedural success, duration of procedure and event free survival at one month. From our database we enrolled 42 patients undergone iliac percutaneous interventions (21 with a transradial and 21 with a transfemoral approach); the 2 populations had similar baseline characteristics. Procedural success was achieved in all of our patient population. Among the secondary study endpoints analyzed we observed similar duration of the procedure and one-month clinical follow up. Technical aspects of the transradial approach are discussed. A transradial approach is feasible for the treatment of atherosclerotic iliac disease and does not increase procedural time in experienced hands. Further studies are needed to confirm if this approach is as safe as the transfemoral one.

Initial Experience of a Novel Sheath Guide for Transbrachial Coil Embolization of Cerebral Aneurysms in the Anterior Cerebral Circulation

The transfemoral approach is a common technique for coil embolization of cerebral aneurysms in the anterior cerebral circulation. However, it is difficult to advance a guiding catheter into the carotid artery via the femoral route in patients with a tortuous aortic arch, an unfavorable supra-aortic takeoff, aortic diseases, or occlusion of the femoral artery. To report our initial experiences of coil embolization of cerebral aneurysms in the anterior cerebral circulation with a novel sheath guide for transbrachial carotid cannulation. A sheath guide designed specifically for transbrachial carotid cannulation was developed; transbrachial coil embolization for cerebral aneurysms began in May 2011. Included for analysis were patients who underwent transbrachial coil embolization for cerebral aneurysms in the anterior cerebral circulation from May 2011 to January 2012. Adjuvant techniques, angiographic results, procedural success, and periprocedural complications were investigated. Ten patients underwent transbrachial coil embolization of cerebral aneurysms in the anterior cerebral circulation. All procedures were successful using the brachial route. No periprocedural complications occurred. Patients were permitted to get seated immediately after coil embolization even during hemostasis. The sheath guide specifically designed for transbrachial carotid cannulation was useful for coil embolization of cerebral aneurysms in the anterior cerebral circulation.

Abstract 2847: The Feasibility, Efficacy And Safety Of Transbrachial Approach For Carotid Artery Stenting

Backgrounds and Purpose Transfemoral approach for carotid artery stenting (CAS) is a common technique, but patients must be bedridden for several hours following CAS. If CAS can be performed through the brachial artery route, it is less invasive for patients. The purpose of our study was to investigate the feasibility, efficacy and safety of transbrachial approach for CAS. Materials and Methods Transbrachial approach for CAS was started at October 2010 and data was collected prospectively. Included for analysis were patients who underwent transbrachial elective CAS from October 2010 to July 2011. Every CAS was started through the right brachial route with a 6Fr (ID) guiding sheath specifically designed for the brachial approach under local anesthesia. Technical success, periprocedural complications, 30-day major cardiovascular events (stroke, myocardial infarction and death) and 3- month stent restenosis were investigated. Results Forty-five patients underwent transbrachial CAS. Procedures were successful through the brachial route in every case. Periprocedural complications occurred in three cases; confusion following CAS in one case, hypotension in one case and gastrointestinal hemorrhage in one case. Three patients returned to the previous state within a few days and had no neurological deficits. No access-site related complications occurred. Patients were free on the bed immediately after CAS even during hemostasis. Neither 30- day major cardiovascular events nor 3-month stent restenosis occurred. Conclusions Transbrachial CAS is feasible and safe, and has the same efficacy as transfemoral CAS.

Stent migration during transcatheter management of coarctation of aorta

A 13-year-old girl underwent endovascular stent placement for coarctation of aorta. The fully expanded stent migrated to ascending aorta which could be stabilized, recrimped, and repositioned with a 20-mm goose neck snare. Postdilatation was performed from the left brachial route resulting in a good outcome.

The Use of Protection Device in Landmark-wire Technique of Symptomatic Subclavian Artery Occlusion with Combined Approach via Trans-femoral vs. Trans-brachial Arteries: Technical note

PurposeSince we reported about a landmark technique to reopen an occluded subclavian artery, we have faced difficulty in using protection devices in the vertebral artery to protect against thromboembolism from the reversed steal phenomenon after angioplasty and stenting. Therefore, we are presenting an optimal solution in using a protection device while recanalizing the occluded subclavian artery.Materials and MethodsAmong 21 cases of stenting for subclavian artery steno-occlusion, we applied the landmark technique at the opposite end of an occluded segment in 4 patients and used a protection device in two patients. Because the embolic protection device was placed in the vertebral artery via the brachial artery, optimal angioplasty and stenting via the brachial route were limited. Therefore, angioplasty via the trans-brachial approach was needed to be followed by stenting through a trans-femoral approach. We estimated the safe and optimal steps for placement and retrieval of the protection devices in addition to stenting.ResultsThe procedure was safely performed when a stent was introduced via the femoral artery and a protection device was used via the brachial artery. However, in cases when a guidewire wasn't passed via the transfemoral route, simultaneous use of two systems via the brachial route could cause friction of devices or trapping of protection devices in a stent. When a protection device was trapped in a deployed stent, we retrieved the protection device with a 4F angiocatheter by selectively rotating the catheter tip. To avoid such procedural difficulty, we recommend using a transbrachial angioplasty followed by trans-femoral stenting while placing the protection device in the vertebral artery via the trans-brachial route.ConclusionIf a guidewire is not passed through using a trans-femoral approach while performing the landmark technique, changing the stenting route from brachial to the femoral artery can be useful after securing the lumen in the occluded subclavian artery after angioplasty via the brachial artery.

Cannulation of a LIMA graft via the right brachial arterial route using a MANI catheter: an alternative approach

Some different revascularization methods including coronary artery bypass surgery can be performed in the treatment of coronary artery disease. Saphenous vein grafts and/or arterial grafts including left internal mammary artery (LIMA) can be implanted during coronary bypass surgery. It is necessary to perform cannulation of the LIMA, in order to diagnose and treat these patients. In addition to conventional internal mammary artery catheters, several types of catheters can be used for this purpose.In general, LIMA catheterization via the femoral artery has been preferred over other methods. However, the right brachial arterial approach can be mandatory in some rare conditions.In this report, we describe an alternative method to the conventional techniques of the LIMA graft angiography via the right brachial arterial approach using a MANI catheter. According to our knowledge, no data are available using the MANI catheter for this purpose in the current literature.

Left brachial approach for transcatheter arterial embolization therapy in patients with hepatocellular carcinoma.

We evaluated the efficacy of the lipiodol-transcatheter arterial embolization (L-TAE) technique for hepatocellular carcinoma (HCC) performed using a left brachial approach. A total of 64 procedures were performed using the brachial route in 53 patients with HCC between 1989 and 1996 using a 4-French catheter and these patients were retrospectively studied. The technical success rate was 95.3%. The overall complication rate was 31.3%: fever of over 38.0 degrees C lasting longer than three days (18.8%), transient neurologic complications (4.7%), and pancreatitis (1.6%). Complications such as lumbago, back pain, and dissection of the celiac artery or its branches, which frequently complicated femoral approaches, were avoided. These data indicate that L-TAE using the left brachial approach may be a safe and effective alternative to the transfemoral approach in patients with HCC.

Intracoronary stent implantation: New approach using a monorail system and new large‐lumen 7 f catheters from the brachial route

In this brief report we describe a case of successful multivessel PTCA with intracoronary stent implantation using a new large-lumen 7F catheter from the left brachial approach. The application of this technique should be considered for intravascular stent implantation when anticoagulation ideally should not be interrupted or in anatomical situations limiting femoral vascular access.

Successful angioplasty of a chronically occluded saphenous vein graft using a prolonged urokinase infusion from the brachial route

A 68-year-old man who presented with unstable angina had had cardiac bypass surgery 12 years earlier and successful angioplasty of a native circumflex lesion 18 months previously. Repeat catheterization showed a widely patent angioplasty site but interval closure of a saphenous vein graft to a large marginal branch that was totally occluded proximally. A stress test revealed significant myocardial ischemia. Severe peripheral peripheral vascular disease with known bilateral iliac artery occlusions mandated a brachial approach. Because of his high risk for repeat cardiac surgery, it was elected to attempt saphenous graft angioplasty following a prolonged urokinase infusion. After an infusion of urokinase for 36 hr, antegrade flow was restored and angioplasty was carried out successfully on a discrete mid-graft legion. Subsequent stress testing showed resolution of the ischemia. There were no vascular complications.

Neurologic Complications of Axillary and Brachial Catheter Arteriography in Atherosclerotic Patients: Predictive Factors

Catheter arteriography by the axillary or brachial route can be responsible for central neurologic complications. The objectives of this prospective study were to define the predictive factors of these complications and determine their incidence. This report is based on 288 consecutive arteriography sessions performed between January 1985 and June 1987. All patients had arterial atheromatous pathology. Ten central neurologic complications (3.5%) occurred, two of which (0.7%) were permanent. Four factors were significantly associated with increased incidence of central neurologic complications: antecedent transient ischemic attack (p less than 0.001); tight (greater than 80%) stenosis of at least one internal carotid artery (p less than 0.02); angina pectoris (p less than 0.05); age over 80 years old (p less than 0.001). Seldinger's or Dos Santos' techniques are preferable to axillary or brachial catheter techniques for investigation of the lower limbs and the abdominal aorta. The former obviates the need to catheterize the aortic arch and reduces the risk of embolism to the supraaortic arteries. Digital venous arteriography is an alternative to aortic arch catheterization when investigating the supraaortic arteries in the presence of risk factors.

A CASE REPORT OF ASD ASSOCIATED SITUS INVERSUS, MIRROR IMAGE-DEXTROCARDIA, AZYGOS CONTINUATION OF IVC AND SITE-ANOMALY OF RIGHT ATRIUM

A 6-year-old girl was admitted with the chief complaint of heart murmur. Chest X-ray film, ECG and abdominal examination disclosed mirror image-dextrocardia with situs inversus. Heart catheterization was performed via femoral route. The catheter passed behind the heart, turned round, and then entered the right ventricle through the azygos vein and SVC, but could not entered the pulmonary artery. Then it was repeatedly performed to the pulmonary artery via the brachial route. There was oxygen saturation step up at the level of the right atrium with a 56% of left to right shunt. Final diagnosis was ASD associated with situs inversus, mirror image-dextrocadia and azygos continuation of IVC. The patient underwent radical operation using extra-corporeal circulation. It was found that the right atrium showed site-anomaly and IVC connected only to the hepatic vein. Fixation of IVC cannula was unstable. ASD was closed with direct suture. She was discharged without any complaints.

Incidence and results of arterial complications among 16,350 patients undergoing cardiac catheterization

A total of 16,350 patients underwent cardiac catheterization from January 1981 to December 1987. The brachial artery was used in 10,500 patients (group I), and the femoral artery was used in 5850 patients (group II). Surgical intervention for complications was necessary in 60 (0.57%) of the group I patients and in 14 (0.23%) of the group II patients. Hand ischemia in group I and bleeding in group II were the most frequent indications for operation. Procedures performed were segmental resection, vein interposition, and long bypass in group I, and simple suture and angioplasty were performed in group II. Fifty-six patients of the total of 74 underwent early repair (within 48 hours), and 18 patients underwent delayed intervention. Only one (1.7%) of the 56 patients who had early repair had a complication. Five of the 18 patients (28%) with delayed intervention suffered significant complications. Cardiac catheterization by the brachial or femoral route has a low incidence of complications. Delayed intervention is associated with high morbidity despite adequate restoration of circulation. Although there were fewer complications in the femoral group, they were far more serious with respect to life- or limb-threatening events.

Cerebrovascular disease: outpatient evaluation with selective carotid DSA performed via a transbrachial approach.

A total of 355 outpatients and 73 inpatients were studied for cerebrovascular disease with intraarterial digital subtraction angiography (DSA). The studies were performed by means of selective carotid and vertebral artery catheterization from a transbrachial approach. Selective catheterization of the carotid artery was possible in 95% of patients, with definitive examinations of both extra- and intracranial circulation obtained in 95%-100% of all patients. Vessel opacification was very good to excellent, and the technique was inherently free from artifact caused by vessel overlap or involuntary motion. There were 25 complications, of which 20 were local in nature. Iodine load per case was extremely low, averaging 4.2-7.0 g. Selective carotid and vertebral catheterizations by the brachial route proved to be as safe as intravenous DSA and aortic arch intraarterial DSA with less contrast material load and superior images.

A multipurpose steerable catheter for left-sided cardiac catheterization

Since Sones and Shirey 1 introduced coronary arteriography various techniques have been developed, involving different shapes and types of catheter and approaches via the femoral or brachial routes, with the goal to make cardiac catheterization easy and complication free. 2–5 Today, developments in the technology of coronary angiography have made this technique a safe diagnostic method with relatively rare complications. 6 The widespread use of invasive therapeutic techniques, such as percutaneous transluminal coronary angioplasty, 7 valvuloplasty 8 and especially electrophysiologic techniques such as His bundle ablation, 9 has led to the creation of new catheterization systems (steerable catheters) that provide safe and precise access to different areas of the heart. We describe a new, multipurpose steerable catheter, which was designed to meet all left-sided heart catheterization requirements and thus minimize catheterization time and complications.

Early postoperative angiographic findings after carotid endarterectomy.

This report reviews the early postoperative evaluation of 70 patients who underwent carotid bifurcation endarterectomy within our department (before patients' releasing). Angiography was performed by femoral catheterization or the retrograde brachial route; three times only digital venous techniques were employed. No complications due to radiological procedures occurred. Postoperative angiographic findings include asymptomatic occlusion of ICA, occlusion of ECA, the presence of mural thrombi, diffuse surface roughness, intimal flaps and kink of ICA. Dilatation of the arteriotomized segment was detected with a high rate of frequency. Postoperative vascular changes are then analyzed in relation to surgical techniques, to early postoperative clinical course and to the occurrence of late re-stenoses.

Percutaneous transluminal balloon valvuloplasty of adult aortic stenosis: Report of 92 cases

Percutaneous transluminal balloon valvuloplasty was attempted in 92 adult patients with severe calcific aortic stenosis. The mean age was 75 +/- 11 years (range 38 to 91) and 35 patients were more than 80 years old. Most of the patients were severely disabled; 66 were in New York Heart Association functional class III or IV, 27 had syncopal attacks and 21 had severe angina pectoris. Because of unacceptably high surgical risk or contraindication to thoracic surgery, 42 patients could not be considered for valve replacement. Other patients either were in a category of high operative risk or refused the surgical intervention. Valvuloplasty was performed by way of the femoral route (82 patients) or the brachial route (10 patients). Catheters of size 15, 18 and 20 mm were successively placed across the aortic valve and three inflations were usually done with each of them, lasting 80 seconds on average, until a decrease in peak to peak systolic pressure gradient to 40 mm Hg or less was attained, a result considered satisfactory. The inflated balloons were not totally occlusive in most cases and clinical tolerance of inflation was good. Valvuloplasty resulted in a reduction of mean systolic gradient from 75 +/- 26 to 30 +/- 13 mm Hg (p less than 0.001); the final gradient was less than 40 mm Hg in 78 patients. Mean calculated aortic valve area increased from 0.49 +/- 0.17 to 0.93 +/- 0.36 cm2 (p less than 0.001). Immediately after the procedure, ejection fraction increased from 48 +/- 16 to 51 +/- 16% (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)