Brachial Artery Pseudoaneurysm: a Rare Complication after Haemodialysis Therapy

Haemodialysis patients carry a high risk of pseudoaneurysm due to inadvertent puncture of the brachial artery during venous cannulation for haemodialysis.

Signs and symptoms are pulsatile mass and a systolic murmur. Complications are rupture, infection, haemorrhage, distal arterial insufficiency, venous thrombosis and neuropathy. Early diagnosis is essential to plan adequate treatment. Doppler US and angiography usually confirm the lesion accurately. Ultrasound guided compression, percutaneous injection of thrombin, endovascular covered stent exclusion, aneurysmectomy and surgical repair are different treatment options.

We report clinical and radiological findings and treatment strategies in four dialysed patients who developed brachial artery pseudoaneurysms.     

Brachial plexus compression due to subclavian pseudoaneurysm from cannulation of jugular vein hemodialysis catheter

Jugular venous cannulation is generally safer than subclavian cannulation. The traumatic complications associated with jugular vein hemodialysis catheters are rare. A jugular vein, therefore, has become the preferred site for hemodialysis catheter insertion. We describe the first case of brachial plexus compression attributable to delayed recognition of a right subclavian pseudoaneurysm as a complication of jugular venous cannulation of hemodialysis catheter. We advocate that any neck swelling, new bruit, and the symptoms of brachial plexopathy after jugular venous cannulation warrant an intensive investigation to exclude arterial injury. Because delayed diagnosis may lead to a worsened prognosis in patients with brachial plexus palsy, physicians should exercise vigilance to detect and manage early the potentially serious and fatal complications of subclavian artery pseudoaneurysm and brachial nerve injury.     

A technique for the placement of a long-term hyperalimentation catheter in the head and neck oncology patient

The relative safety of silicone rubber catheters allows use of the deep brachial vein for long-term central venous access when other vascular access sites are unavailable or undesirable. After local infiltration, a small incision is made across the medial edge of the brachial biceps and the vein is isolated from the artery and median nerve. An introducer is used to aid in insertion of the catheter. Catheter position is checked with a postoperative radiograph of the chest. Sixty of our patients have had catheters in place from 14 to 200 days, with few complications. There was one catheter-related death from acute bacterial endocarditis and one case of clinical thrombosis. The surgical approach to the deep brachial vein provides a simple and safe method of long-term central venous access in the head and neck oncology patient, whereas regional therapy and treatment planning often preclude use of other more conventional access sites.     

Duplex scanning in suspected vasculogenic impotence: a worthwhile exercise?

The value of duplex scanning in the assessment of impotence was evaluated in 146 impotent men. Scanning was by means of a Diasonics DRF 400 and penile artery measurements were taken before and after the intracorporeal injection of papaverine hydrochloride. The penile/brachial index was measured in 82 patients and its predictive value compared with the results of duplex scanning and papaverine-induced erection. On scanning evidence of good arterial inflow but poor erections, indirect evidence of venous leakage was assumed. The results showed that the deep artery responses best characterised the erectile response, with the dorsal artery being less helpful. All 37 patients with full erections following papaverine exhibited bilateral deep artery peak velocities of greater than or equal to 25 cm/s. Of the remaining 109 sub-optimal responders, 17 also has this finding; all had undergone dynamic cavernosography, with 16 exhibiting venous leakage. The penile/brachial index was found to classify 13 patients incorrectly. A critical value of deep artery response to attain erection is postulated, enabling more logical use of cavernosography. The penile/brachial index was shown to be suspect and it was concluded that duplex scanning is a useful, non-invasive method in the assessment of impotence.     

Thoracic and vascular aspects of thoracic outlet syndrome. 1986 update

Upper extremity symptoms of arterial or venous origin are a rarer manifestation of the thoracic outlet syndrome than those caused by brachial plexus compression. Since the authors' original report in 1967, a better understanding of the necessity for detailed history and physical examination preoperatively and advances in angiography and computed tomography have made the selection of patients for thoracic outlet decompression and vascular reconstruction more reliable. Refinement in vascular surgical techniques and the advent of effective thrombolytic therapy have made the results of therapy more consistent. First rib resection and scalenectomy are curative for the majority of patients whose symptoms are caused by compression of the brachial plexus. Removal of the embologenic focus with vascular reconstruction and thoracodorsal sympathectomy are generally required in the presence of subclavian artery compression or aneurysm producing peripheral emboli. In patients who have venous compromise, thrombectomy or thrombolytic therapy and relief of subclavian venous compression may minimize future disability.     

Swelling in the upper arm: the presentation and management of an isolated brachial artery aneurysm

True aneurysms of the brachial artery are uncommon. We describe the presentation and surgical management of an isolated, brachial artery aneurysm in a 64-year-old woman. Excision of the aneurysm and long saphenous venous interposition grafting was performed with no postoperative complications and histology demonstrated true aneurysmal degeneration.     

Increased Concentration of Testosterone in Testis Artery Blood as Compared to Peripheral Venous Blood in Man

In 8 patients undergoing orchidectomy for prostatic carcinoma, blood samples were taken from the testis artery and the brachial vein simultaneously. It was found that the concentration of testosterone in the testis artery was significantly higher (P < 0.01) than the concentration in the brachial vein. These results support the idea of a counter-current exchange mechanism for testosterone between venous and arterial blood in the human, spermatic cord.     

Side-to-side arteriovenous fistula at the elbow with perforating vein ligation

OBJECTIVE: We postulated that ligation of a consistent perforating venous branch at the elbow would improve distention and flow in the superficial veins about the elbow. This would also lesson the likelihood of arterial steal enabling a favorable outcome following a brachial artery medial antecubital or cephalic vein arterio-venous fistula (AVF). METHODS: Pressure measurements were made from the radial artery after side-to-side brachial artery antecubital or cephalic vein AVF in 20 patients. Clamping of the perforating vein increased radial artery pressure significantly indicating that a considerable amount of flow from the side-to-side AVF was diverted into the deep system and away from the accessible superficial veins. Encouraged by this finding, we studied the outcome of brachial cephalic or brachial antecubital AVF with ligation of the deep branch in 134 patients who were not candidates for radio-cephalic AVF. The end point of the study was successful hemodialysis using the fistula. RESULTS: Of the 134 patients treated, 24 died, and 11 were lost to follow-up and were censored from analysis of fistula performance at that time point. The primary fistula success rate was 89.7% +/- 2.66% and 83.7% +/- 3.5% at 1 and 2 years by life table analysis. No patient developed significant arterial steal or venous hypertension. CONCLUSION: We recommend this simple one-stage procedure for patients requiring hemodialysis whose cephalic vein at the wrist is unsuitable.     

Forearm arterial venous shunt for hemodialysis

A new technique for creation of an arterial venous shunt for hemodialysis is described. The proximal radial artery is used for the arterial inflow anastomosis site instead of the brachial artery. The technique provides an adequate arterial inflow but avoids all the complications of utilization of the brachial artery in the forearm arterial venous shunt for hemodialysis.     

肱动脉入路在腔内治疗中的应用及穿刺并发症分析

目的探讨经肱动脉入路行动脉造影和动脉成形的适应证、并发症及其预防措施,以提高腔内治疗的成功率,降低肱动脉穿刺并发症发生率。方法回顾分析2007年1月～2011年12月采用Seldinger技术通过肱动脉穿刺行动脉造影及动脉成形86例106例次的临床资料。分析肱动脉入路的适应证、穿刺并发症及其形成原因、预防措施。结果通过肱动脉入路行动脉造影的成功率为100%(56/56),动脉成形的成功率为84.0%(42/50)。并发症发生率2.8%(3/106),为局部血肿(2例)和假性动脉瘤(1例)。结论肱动脉入路的适应证包括:股动脉无法穿刺,股动脉入路影响力量的传导,股动脉入路无法提供靶血管的受力点,锁骨下动脉开口的定位。本组肱动脉穿刺的并发症为血肿和假性动脉瘤。规范的穿刺及压迫止血技术、充分认识肱动脉解剖学特点可以减少肱动脉穿刺的并发症。     

Reconstruction of deep cubital fossa defects with exposure of brachial artery due to high tension electrical burns and treatment algorithm

In this paper, we selected eight patients who had cubital fossa electrical burns with exposure or damage of the brachial artery, during the period 2000 to 2004 and formulated an algorithm to salvage upper limbs. We demonstrated the effectiveness of the algorithm to rescue the extremity from amputation and to restore the functional ability combined with coverage of the defects. After initial management with decompression and debridement of the nonviable tissues surrounding the brachial artery, we used local fasciocutaneous flaps or pedicled latissimus dorsi (LD) muscle/musculocutaneous flaps immediately to cover and also to avoid the perforation of this artery with a mean of 5.5 operations and with an amputation rate of 12.5%. When perforation or necrotic focus was seen on the arterial wall without viable tissue around the brachial artery, circulation was restored with vein grafts. Deep defects in the cubital fossa with exposure of the brachial artery should be covered with well-vascularized tissue as soon as possible after serial debridements. If the necrotic focus is seen on the wall of the artery, it often requires a venous graft with flap coverage. In the presence of viable tissue around the artery, however, fasciocutaneous flaps are useful and they reduce the operation time and duration of hospital stay. We treated deep defects with exposure of the brachial artery in the cubital fossa according to our established algorithm. Adherence to this approach precluded dilemmas in the selection of flap types for the management of bulky tissue defects.     

Arteriovenous fistula combined with brachial artery superficialization is effective in patients with a high risk of maturation failure

Objective

In patients with a high risk of fistula immaturity, we created arteriovenous fistulas (AVFs) combined with brachial artery superficialization. With this procedure, the superficialized arteries are used as drawing routes and the AVFs as returning routes. This is a technical report about AVFs combined with brachial artery superficialization.

Metachronous giant brachial artery pseudoaneurysms: a case report and review of the literature

Brachial artery pseudoaneurysms secondary to intravenous drug abuse represent a limb-threatening problem to patients and a technical challenge to the vascular surgeon. Here information is reported about a patient with metachronous bilateral giant brachial artery pseudoaneurysms secondary to intravenous drug use that were successfully treated with excision of the aneurysm and ligation of the brachial artery. Furthermore, a review of the current literature on the treatment of brachial artery aneurysm is presented.     

Revision Using Distal Inflow: A Novel Approach to Dialysis-associated Steal Syndrome

Current access-preserving treatment options for dialysis-associated steal syndrome (DASS) include fistula lengthening or banding and distal revascularization interval ligation (DRIL). We describe a novel technique for the treatment of DASS that we have termed revision using distal inflow (RUDI). Briefly, the technique involves ligation of the fistula at its origin followed by reestablishment of the fistula via bypass from a more distal arterial source to the venous limb. Four patients with brachial artery-based arteriovenous fistula and DASS underwent RUDI as described above using either the proximal radial or ulnar artery as inflow and vein as conduit. Patients were diagnosed with DASS based on the clinical findings of pain, pallor, loss of radial pulse, and sensorimotor dysfunction after creation of an AVF. Noninvasive vascular studies confirmed diminished finger pressures that improved with compression of the fistula. All patients experienced rapid resolution of their symptoms, although one patient complained of mild residual parasthesias. Follow-up ranging from 4 to 14 months has revealed patent functional fistulas. These initial results demonstrate that RUDI can be an effective treatment of DASS. By design, RUDI incorporates many of the advantages of established access-preserving procedures. That is, by using a smaller distal artery as inflow, RUDI lengthens the fistula, decreases the radius, and preserves antegrade flow in the brachial artery. In contrast to DRIL, it is the fistula, not the native arterial supply, that is placed at risk by ligation and revascularization. Consequently, we believe that RUDI may become the procedure of choice for DASS after brachial artery-based fistulas.Presented at the Peripheral Vascular Surgery Society 29th Annual Spring Meeting, Anaheim, CA, June 4-5, 2004.     

The management of subclavian artery injuries following blunt thoracic trauma

The records of 15 patients who sustained blunt rupture of the subclavian artery were reviewed. The findings on physical examination included arterial hypotension, unilateral absence of the radial pulse, brachial plexus palsy, and supraclavicular hematoma. The chest roentgenographic findings included wide mediastinums, apical pleural hematomas, and first rib fractures. Fourteen patients survived to undergo angiography and operation. Arterial continuity was restored by primary anastomosis, synthetic grafts, and venous interposition grafts. Ligation of a pseudoaneurysm was carried out in 1 patient with a complete brachial plexus palsy. Amputation of an upper extremity was required in 1 patient. Two patients died postoperatively. We conclude that blunt subclavian artery injuries may be suspected clinically. Absent upper extremity pulses, a wide mediastinum, unrelenting thoracic hemorrhage, and persistent hypotension dictate the necessity for aortography. Relative indications for angiography include brachial plexus palsy, apical pleural hematoma, and a fractured first rib.     

Arteriovenous fistula for long-term venous access for boys with hemophilia

OBJECTIVES: Hemophilia is a sex-linked condition affecting about 1 of every 5000 males in the United States. The management of children with hemophilia can be improved with regular intravenous infusion of factor VIII or IX, thus preventing crippling and sometimes fatal hemorrhage. Maintaining this vital intravenous access is often hampered by gradual loss of superficial veins or repeated central catheter sepsis and thrombosis. This study reviewed an experience with arteriovenous fistula in selected hemophilia patients with limited venous access. METHODS: Consecutive patients operated on between October 2000 and July 2006 for venous access with the creation of an arteriovenous fistula were reviewed. They were selected because of repeated problems with other venous access. Patency, ease of use, duplex scan derived brachial artery diameter, and arm length were assessed. RESULTS: During a 69-month period, 10 arteriovenous fistulas (five brachial artery-basilic vein fistulas, 5 brachial artery-cephalic vein fistulas) were created for nine patients. The patients were a median age of 5.5 years (range, 1 to 27 years), and all were <13 except the 27-year-old patient. There were no postoperative hematomas requiring evacuation. One arteriovenous fistula failed to mature and was redone in the opposite arm, which subsequently occluded after 13 months. Of the mature fistulas, patency was 100% at 1 year, 80% (4/5) at 3 years, and 75% (3/4) at 4 years, with mean follow-up of 22 months. Brachial artery diameter increased in the involved arm by a ratio of 1.95 (range, 1.51 to 2.5) compared with the opposite arm. Arm length disparity was increased by 0.5 cm (range, 0.8 to 1.5 cm) in the involved arm. All fistulas allowed good access at home by a care provider. CONCLUSIONS: For hemophilia patients with compromised venous access, arteriovenous fistulas provide good early patency. Brachial artery diameter and arm length require continued follow-up.     

纵向生物力学特性对动脉损伤修复方法选择的影响

目的 研究人体四肢主要动脉不同长度损伤与修复方法选择之间的关系，比较由于因管纵向性物力学特性面产生的修复差异，为临床修复效果及近，远期疗效评价提供依据。方法 回顾分析应用端端吻合法和自体静脉移植法修复的四肢主要动脉伤共１７７例１８５条血管，对相同损伤部位而不同修复方法的血管的真性缺损长度做ｔ检验比较，通过９５％置信区间分析两种修复方法的选取界限。对自体静脉移植修复血管中真性缺损长度做ｔ移植长度做线     

肱动脉穿刺术并发症的预防与处理

目的 总结经皮肱动脉穿刺术的临床经验,探讨相关并发症发生的原因及其预防及处理对策.方法 回顾性分析2001年6月至2009年6月因行血管腔内诊疗而接受超声引导下肱动脉穿刺术87例患者的临床资料,总结发生并发症情况及其发生原因.结果 87例患者在超声引导下行肱动脉穿刺术均成功,成功率为100%,其中超声引导下一次穿刺成功有53例(61%),经多次穿刺成功有34例(39%).16例患者(19例次)发生了并发症,并发症发生率为18.4%.其中导丝进入血管周围间隙4例(4.6%),穿刺局部发生血肿11例(12.6%),其中3例合并局部神经损伤(1例为迟发型神经损伤),假性动脉瘤1例(1.2%).结论 熟悉肱动脉穿刺术部位的解剖特点,掌握相应的操作技巧并对其并发症有足够的认识和处理对策的充分准备可以减少并发症及其不良后果的发生.     

肱骨中上段骨折合并肱动脉损伤的手术治疗(附9例)

目的 探讨肱骨中上段骨折合并肱动脉损伤的特点，提出手术治疗的方法。方法 自2000年来，采用单侧外固定架骨折固定、自体大隐静脉桥接修复肱动脉治疗9例。结果 随访1～2年，吻合段血管均无狭窄。除1例骨折术后骨不连，再次手术外，余骨折均达临床愈合，肢体功能恢复满意。结论 术式对肱骨中上段骨折合并肱动脉损伤治疗较为理想，操作简单，具有推广应用价值。     

Percutaneous catheterization of the deep brachial vein

50 attempts of deep percutaneous antecubital catheterization are reported. A tourniquet was applied to the upper arm and the medial deep brachial vein was punctured in a point immediately medial to the brachial artery, in the antecubital fossa. Venepuncture was successful in 88% of the cases (44 cases), catheterization possible in 72% of the cases (36 cases). The catheter reached the central venous compartment in 60% of the cases (30 cases). The only benign complication was injury to the brachial artery in 6 cases. Mean duration of catheterization was 20 days. This very easy and safe technique can be used when superficial veins are unusable and use of the deep central veins dangerous or impossible.