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May 2010
Brachial and Axillary Arterial Access
An overview of when and how these approaches are used.
Due to the wide variety of lesion types, locations, and access-route challenges in patients with peripheral vascular disease, today's interventionists must know and understand a corresponding variety of access techniques. Each access location has benefits and drawbacks, many of which have been demonstrated in previous clinical studies, and these must be carefully weighed before selecting the appropriate access for each individual patient's presentation. Although not routinely used by many, there is an important role for vascular intervention via brachial and sometimes even axillary access techniques.
The indications for brachial and axillary access are quite similar to those of the radial approach. These include the presence of an occluded or severely diseased aortoiliac segment, operator preference in visceral artery interventions or when working with stent grafts requiring multiple accesses, infected/excoriated inguinal regions, and severely obese patients. The major drawback to using the upper extremity access sites is the length of the instruments required to reach even the visceral branches; generally, lesions below the popliteal artery are difficult to reach and treat. The primary advantage is the more direct line of entry into the usually caudally oriented proximal visceral arteries.
AXILLARY ACCESS
The axillary artery was the first upper extremity access
site used by angiographers. Three decades ago, Hessel et al
conducted a large survey regarding the complications of
angiography.1 This study showed that the incidence of
complications using the transaxillary approach was much
greater than those seen with the translumbar or transfemoral
approaches. When the cases were analyzed in
greater detail, the most frequent and severe complication
of the transaxillary approach was shown to be hemorrhage,
which could potentially produce brachial plexus
compression syndrome injuring the median or ulnar
nerves. Thereafter, investigators began to search for alternative upper extremity approaches as
well as methods to reduce the complications
of using this access site when it is necessary.
UNIQUE ANATOMIC
CONSIDERATIONS:
THE MEDIAL BRACHIAL
FASCIAL COMPARTMENT (MBFC)
The anatomy of the structures surrounding
the axillary and brachial arteries and the
nerves are considerably different than those
of the radial artery and influence the complications
due to accessing them. The MBFC,
a tough fibrous sheath was first described by
Smith et al, as extending along the axillary
and brachial arteries starting “outside a thin
axillary sheath to the elbow. The median and
ulnar nerves are within the MBFC at an arterial
puncture site just lateral to the anterior
axillary fold. The radial and musculocutaneous nerves
exit the MBFC more proximally. The different levels at
which the major nerves of the brachial plexus exit the
MBFC explain the anatomic distribution of the nerve
injuries associated with compression by a hematoma
after transaxillary arteriography.”2
This anatomy is also the foundation for the compressive complications and the nerves affected that can occur as a result of puncturing the brachial artery; blood escaping from puncture at any part of these arteries can spread within the MBFC to compress the nerves.
THE BRACHIAL APPROACH
It was originally hoped that the high brachial puncture,
initially described by Lipchik et al, would eliminate
the relatively high risk of nerve compression when puncturing
the axillary artery.3 Lipchik stated that the
brachial artery is a better access choice because it is
more easy to puncture than the axillary, which rolls considerably
more. Therefore, brachial puncture and postprocedure
compression are easier, and should one occur,
a hematoma will be recognized earlier and therefore be
less likely to compress the nerves. As described previously,
there are also fewer nerves surrounding the brachial
artery than the axillary artery. These nerves spare the
ventral surface of the brachial artery, so there is less
chance of a direct needle injury during puncture.
However, it is now recognized that the risks of the axillary, high brachial, and even the low brachial approaches are somewhat “equalized” because hematomas can spread very easily within the medial brachial fascial compartment, thus the median and ulnar nerves within the same fascia at both the axillary and brachial locations are potentially vulnerable to nerve injury.2 This realization was disappointing because the most compelling reason to use the high brachial technique was the hope that nerve compression would be less frequent.
Investigators then began to look at the low brachial approach as an option. Chatziioannou et al reported that in 2,250 patients, a relatively low incidence of major complications occurred with this technique.4 In this study, the right-sided approach was used, presumably for reasons similar to why the right radial approach is favored (eg, ease of operator access).
UNDERSTANDING POTENTIAL AXILLARY
AND BRACHIAL ACCESS COMPLICATIONS
The axillary access approach began to lose favor
because of its known complications related to the puncture,
and interventionists began to use as an alternative
the high3 and low4 brachial entries. However, for the reasons
discussed previously, regardless of the entry site,
patients must be carefully monitored after these punctures
and made aware of the importance of self-monitoring
for the following signs and symptoms after discharge:
(1) Swelling and discoloration (hematoma) in axilla or arm.
(2) Motor and sensory symptoms in hand with the following important caveats:5
TIPS AND TRICKS
It is my recommendation that high or low brachial,
rather than axillary punctures, should be performed using
micropuncture needles and with ultrasound guidance if
the operator is comfortable with this modality. When
puncturing the brachial artery, it is important to understand
that, ventrally, the artery is relatively easy and less
dangerous to access because there are no nerves located in
the vicinity. Especially when using ultrasound guidance,
the operator should be able to avoid all the major nerves
by visualizing them.
The number of puncture attempts made has some influence on the occurrence of complications. For example, if an intervention including thrombolysis takes place after many unsuccessful attempts to enter the artery, the chances of bleeding and hemorrhage are much greater.
For the same reason, the lowest-profile devices and sheaths should be used with the least-possible amount of manipulation and exchange.
One of the technical tricks I employ involves using the Omni Flush catheter to redirect the wire into the descending thoracic aorta when entering the ascending aorta or transverse aortic arch from the left or right subclavian artery (Figure 1). This is similar to the technique used to cross the aortic bifurcation from a retrograde approach where the Omni Flush can be used to direct the wire into the contralateral iliac artery. These turns can sometimes be difficult in elderly patients, but the wire opens the tip of the Omni Flush predictably, and the wire can be safely and controllably directed into the descending thoracic aorta. This is a fairly simple way to navigate this corner.
CURRENT CLOSURE METHODS
The major cause of developing nerve compression is a
large hematoma. Aftercare is one of the most important
considerations when evaluating and deciding between access sites. With a wide variety of closure devices coming
to market since the initial complications data were
presented, there is the possibility that brachial and axillary
access approaches can be made safer by using a closure
device. In 2008, Lupattelli et al described a lower
incidence of bleeding complications using closure
devices after low brachial access.6 The results showed
that by using the Angio-Seal device (St. Jude Medical,
Inc., St. Paul, MN), hematoma occurred 2.5 times less
often than that observed using manual compression;
unfortunately, the reverse was found to be true in terms
of vessel occlusion or thrombosis. There is no inherent
reason that a high brachial or even an axillary approach
could not be closed in a similar fashion, of course also
with similar potential complications.
I am not certain that closure devices are universally beneficial, but they may be an option, especially in patients with difficult anatomy and in whom continued anticoagulation is required or coagulopathy cannot be controlled. Medicated compression pads may also be useful for achieving faster clotting at the puncture site.
CONCLUSIONS
Meticulous techniques such as those detailed above
must be followed for the brachial and axillary approaches.
Finally and most importantly, the physician and patient
must be aware of and vigilant regarding the early signs
and symptoms of nerve compression. Motor deficits are
more ominous than sensory ones, but both should be
carefully looked for, and early decompression should be
performed. Decompression within 4 hours of the onset of
symptoms carries an 8.3 times greater chance for complete
recovery than delayed treatment does.5
Thomas A. Sos, MD, is Professor and Vice Chair of Radiology at New York Presbyterian Hospital, Weill Medical College of Cornell University, and Director, Peripheral Arterial Disease at Weill Cornell Vascular in New York. He has disclosed that he holds a royalty agreement with AngioDynamics. Dr. Sos may be reached at (212) 746-2601; tas2003@med.cornell.edu.
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