564363
research-article2014
JETXXX10.1177/1526602814564363Journal of Endovascular TherapyTreitl et al
Clinical Investigation
Complications of Transbrachial Arterial Access for Peripheral Endovascular Interventions
Journal of Endovascular Therapy 2015, Vol. 22(1) 63–70 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602814564363 www.jevt.org
Karla Maria Treitl, MD1, Cosima König1, Maximilian F. Reiser, MD, FACR, FRCR1, and Marcus Treitl, MD, EBIR, EDIR1
Abstract Purpose: To prospectively assess current limitations and complication rates of the transbrachial access technique for endovascular treatment of peripheral vascular pathologies. Methods: In total, 150 patients (112 men; mean age 66.3±10.0 years) with arterial occlusive disease underwent endovascular therapy via a transbrachial access. Periprocedure data (sheath size, dose area product, fluoroscopy time, and procedure duration) were analyzed. Postprocedure complications of the puncture sites were categorized as minor (local hematoma, pseudoaneurysm, embolization, dissection, minor bleeding) and major (thrombotic occlusion, hematoma requiring surgery, major bleeding, nerve injury). Results: The minor and major complication rates were 14.0% (n=21) and 2.7% (n=4). The most frequent major complication was thrombotic occlusion of the brachial artery requiring surgical treatment (3/150, 2%). There was only one temporary palsy of the median nerve and no stroke. Local hematoma (15, 10%), pseudoaneurysm (3, 2%), or a combination of both (3, 2%) dominated the minor complications. The average dose area product and fluoroscopy time were 12,752.1±9524.5 cGy*cm2 and 24.3±18.4 minutes, respectively, though procedure duration was acceptable (121.8±48.9 minutes). Conclusion: Complication rates of the transbrachial access for endovascular treatment of peripheral or visceral artery occlusive disease are tolerably low, making it a safe and an important alternative to the transfemoral access in selected cases, though the radiation exposure is rather high. Keywords transbrachial access, vascular access, endovascular treatment, radiation exposure, stenosis, occlusion, peripheral artery disease, visceral artery
Introduction Over the years, the indications and potentials for endovascular treatment of peripheral artery disease (PAD) have evolved dramatically. Access to the arterial system is typically established in the groin, with puncture of the common femoral artery (CFA). In some cases, such as severe bilateral iliac artery disease, recent surgery to the CFA, groin infection, obesity, or sharply angled origins of the visceral arteries, an alternative access from the upper extremities might be favorable or even necessary. The most often used access sites of the upper extremity are the brachial and radial arteries. The brachial artery is flanked by nerves in the antecubital fossa and is an end artery. For that reason, its use as an access vessel for endovascular treatment is still discussed controversially because of the potential risk of severe nerve injury or loss of the entire blood supply to the hand. The alternative use of the radial artery is established for coronary intervention,1,2 and recent
reports describe successful interventions to the renal and iliofemoral vessels via radial access.3–5 Limitations of the radial access are difficulties in catheter manipulation if there is tortuosity,6 the even longer distance to the target vessel in comparison with the brachial access, and the risk of total occlusion of the radial artery, which might have no clinical sequelae but is typically left untreated, which implies accepted iatrogenic damage. Reports on indications, limitations, and complication rates of transbrachial access for peripheral endovascular 1
Hospitals of the Ludwig-Maximilians University of Munich, Germany
Corresponding Author: Karla Maria Treitl, Institute for Clinical Radiology, Hospitals of the Ludwig-Maximilians-University of Munich, Pettenkoferstraße, 8a, Munich 80336, Germany. Email: [email protected]
64 interventions are rare,7–11 typically retrospective, and mostly encompassing only a few patients; they all lack a standardized follow-up of the access site with duplex ultrasound. The last clinical reports on the limitations and complications of the transbrachial access for peripheral endovascular treatment were published 10 years ago.7,8 Meanwhile, catheter materials and indications have evolved, building an ideal setting for a more recent evaluation of the applicability and performance of a transbrachial access. The aim of this prospective study was to assess the current indications, limitations, and complication rates of the transbrachial access for endovascular treatment of peripheral artery lesions.
Methods Study Design Patients with symptomatic PAD in the supra-aortic, visceral, or iliofemoral vessels admitted to our center between January 2009 and December 2013 were screened for study inclusion according to the following criteria: (1) indication for endovascular treatment of stenotic lesions of the peripheral or visceral arteries, (2) written informed consent and agreement to study inclusion, and (3) agreement to manual compression of the puncture site and consequent longer immobilization instead of the use of a vascular closure device. The indication for endovascular treatment of all screened patients was determined in an interdisciplinary consensus conference (radiologists, vascular surgeons, angiologists) according to the current national guidelines of the German Society for Angiology and Vascular Medicine.12 Predefined exclusion criteria were allergy to iodine contrast media, renal insufficiency as expressed by a serum creatinine level >1.3 mg/dL and a glomerular filtration rate (GFR)
research-article2014
JETXXX10.1177/1526602814564363Journal of Endovascular TherapyTreitl et al
Clinical Investigation
Complications of Transbrachial Arterial Access for Peripheral Endovascular Interventions
Journal of Endovascular Therapy 2015, Vol. 22(1) 63–70 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1526602814564363 www.jevt.org
Karla Maria Treitl, MD1, Cosima König1, Maximilian F. Reiser, MD, FACR, FRCR1, and Marcus Treitl, MD, EBIR, EDIR1
Abstract Purpose: To prospectively assess current limitations and complication rates of the transbrachial access technique for endovascular treatment of peripheral vascular pathologies. Methods: In total, 150 patients (112 men; mean age 66.3±10.0 years) with arterial occlusive disease underwent endovascular therapy via a transbrachial access. Periprocedure data (sheath size, dose area product, fluoroscopy time, and procedure duration) were analyzed. Postprocedure complications of the puncture sites were categorized as minor (local hematoma, pseudoaneurysm, embolization, dissection, minor bleeding) and major (thrombotic occlusion, hematoma requiring surgery, major bleeding, nerve injury). Results: The minor and major complication rates were 14.0% (n=21) and 2.7% (n=4). The most frequent major complication was thrombotic occlusion of the brachial artery requiring surgical treatment (3/150, 2%). There was only one temporary palsy of the median nerve and no stroke. Local hematoma (15, 10%), pseudoaneurysm (3, 2%), or a combination of both (3, 2%) dominated the minor complications. The average dose area product and fluoroscopy time were 12,752.1±9524.5 cGy*cm2 and 24.3±18.4 minutes, respectively, though procedure duration was acceptable (121.8±48.9 minutes). Conclusion: Complication rates of the transbrachial access for endovascular treatment of peripheral or visceral artery occlusive disease are tolerably low, making it a safe and an important alternative to the transfemoral access in selected cases, though the radiation exposure is rather high. Keywords transbrachial access, vascular access, endovascular treatment, radiation exposure, stenosis, occlusion, peripheral artery disease, visceral artery
Introduction Over the years, the indications and potentials for endovascular treatment of peripheral artery disease (PAD) have evolved dramatically. Access to the arterial system is typically established in the groin, with puncture of the common femoral artery (CFA). In some cases, such as severe bilateral iliac artery disease, recent surgery to the CFA, groin infection, obesity, or sharply angled origins of the visceral arteries, an alternative access from the upper extremities might be favorable or even necessary. The most often used access sites of the upper extremity are the brachial and radial arteries. The brachial artery is flanked by nerves in the antecubital fossa and is an end artery. For that reason, its use as an access vessel for endovascular treatment is still discussed controversially because of the potential risk of severe nerve injury or loss of the entire blood supply to the hand. The alternative use of the radial artery is established for coronary intervention,1,2 and recent
reports describe successful interventions to the renal and iliofemoral vessels via radial access.3–5 Limitations of the radial access are difficulties in catheter manipulation if there is tortuosity,6 the even longer distance to the target vessel in comparison with the brachial access, and the risk of total occlusion of the radial artery, which might have no clinical sequelae but is typically left untreated, which implies accepted iatrogenic damage. Reports on indications, limitations, and complication rates of transbrachial access for peripheral endovascular 1
Hospitals of the Ludwig-Maximilians University of Munich, Germany
Corresponding Author: Karla Maria Treitl, Institute for Clinical Radiology, Hospitals of the Ludwig-Maximilians-University of Munich, Pettenkoferstraße, 8a, Munich 80336, Germany. Email: [email protected]
64 interventions are rare,7–11 typically retrospective, and mostly encompassing only a few patients; they all lack a standardized follow-up of the access site with duplex ultrasound. The last clinical reports on the limitations and complications of the transbrachial access for peripheral endovascular treatment were published 10 years ago.7,8 Meanwhile, catheter materials and indications have evolved, building an ideal setting for a more recent evaluation of the applicability and performance of a transbrachial access. The aim of this prospective study was to assess the current indications, limitations, and complication rates of the transbrachial access for endovascular treatment of peripheral artery lesions.
Methods Study Design Patients with symptomatic PAD in the supra-aortic, visceral, or iliofemoral vessels admitted to our center between January 2009 and December 2013 were screened for study inclusion according to the following criteria: (1) indication for endovascular treatment of stenotic lesions of the peripheral or visceral arteries, (2) written informed consent and agreement to study inclusion, and (3) agreement to manual compression of the puncture site and consequent longer immobilization instead of the use of a vascular closure device. The indication for endovascular treatment of all screened patients was determined in an interdisciplinary consensus conference (radiologists, vascular surgeons, angiologists) according to the current national guidelines of the German Society for Angiology and Vascular Medicine.12 Predefined exclusion criteria were allergy to iodine contrast media, renal insufficiency as expressed by a serum creatinine level >1.3 mg/dL and a glomerular filtration rate (GFR)
