Abstract
Background
Percutaneous vascular access for coronary intervention is currently achieved predominately via the radial route, the femoral route acting as a backup. Percutaneous trans-brachial access is no longer commonly used due to concerns about vascular complications. This study aimed to investigate the safety and feasibility of percutaneous brachial access when femoral and radial access was not possible.
Methods
This is a retrospective data analysis of patients who attended a single tertiary cardiology centre in the UK between 2005 and 2014 and had a coronary intervention (coronary angiogram or PCI) via the brachial route. The primary endpoints were procedural success and the occurrence of vascular complications.
Results
During the study period 26602 patients had a procedure (15655 underwent PCI and 10947 diagnostic angiography). Of these, 117 (0.44% of total) had their procedure performed via the brachial route. The procedure was successful in 96% (112/117) of cases. 13 (11%) patients experienced post procedural complications, of which 2 (1.7%) were serious. There were no deaths.
Conclusion
Percutaneous trans-brachial arterial access is feasible with a high success rate and without evidence of high complication rate in a rare group of patients in whom femoral or sometimes radial attempts have failed.
1
Introduction
Coronary angiography and percutaneous coronary intervention (PCI) are routinely performed via the femoral or radial route. Occasionally these two routes cannot be used safely e.g. when the radial arteries are impalpable or there is severe peripheral vascular disease, making femoral approach unfavourable and alternative access route is required. A percutaneous brachial approach is often used in these cases.
Trans-brachial access has the same advantages of large calibre as trans-femoral access, with the reduced risk of life threatening haemorrhage however, there is concern over compartment syndrome and the use of an end artery. This risk may be reduced with percutaneous access as compared to brachial cut down . There are historic data concerning the rate of complications from brachial cut down, in an era of predominantly diagnostic procedures , with relatively few data concerning percutaneous brachial access in the modern era . In BRAFE (Brachial, Radial, or Femoral approach for Elective Palmaz–Schatz stent) Benit et al demonstrated that in a population of 150 patients, femoral puncture (n = 56), radial (puncture) (n = 56), or brachial (cut down) (n = 38) local complications and length of hospital stay were similar with the three possible approaches, and brachial approach was associated with a shorter procedural time .
This goal of this study was to evaluate the safety and feasibility of using a percutaneous brachial approach for diagnostic and therapeutic coronary interventions, when radial and femoral routes were not possible, in a ‘real world’, single-centre setting. We have attempted to address a relatively dormant but important issue in the vascular access: the modern utilisation of the brachial route.
2
Methods
2.1
Study population
This was a retrospective analysis of patients undergoing coronary angiography or PCI via the percutaneous brachial route at the South Yorkshire Cardiothoracic centre from January 2005 to August 2014. The reason for choice of brachial route was determined from hospital records. Complications were categorised as major and minor, defined as follows:
3.1
Major complications
Major complications are as follows: bleeding complications that were categorised according to BARC (Bleeding Academic Research Consortium) definition of bleeding; vascular complications that required surgery; and permanent neurological deficit in the arm or lower limb.
3.2
Minor complications
Minor complications are all vascular complications not requiring blood transfusion or surgery; and transient neurological deficit in the arm or lower limb. These assessments were made during the inpatient stay, up to the time of discharge. A successful procedure was defined as completion of diagnostic or therapeutic procedure without complications.
2.4
Data collection
Patients who had undergone coronary angiography or PCI using the brachial route were identified from the Sheffield database. Demographic, clinical and procedural data were collected from hospital records. Outcome data were collected using the UK national mortality database.
2.5
Data analysis
Data are presented as mean ± SD or as percentages (proportions) unless otherwise stated. Analysis was carried out using a Student’s t-test or one-way ANOVA for continuous variables and chi squared for categorical variables. Analysis was carried out using SPSS version 21. (IBM, SPSS Inc. NY, USA)
2
Methods
2.1
Study population
This was a retrospective analysis of patients undergoing coronary angiography or PCI via the percutaneous brachial route at the South Yorkshire Cardiothoracic centre from January 2005 to August 2014. The reason for choice of brachial route was determined from hospital records. Complications were categorised as major and minor, defined as follows:
3.1
Major complications
Major complications are as follows: bleeding complications that were categorised according to BARC (Bleeding Academic Research Consortium) definition of bleeding; vascular complications that required surgery; and permanent neurological deficit in the arm or lower limb.
3.2
Minor complications
Minor complications are all vascular complications not requiring blood transfusion or surgery; and transient neurological deficit in the arm or lower limb. These assessments were made during the inpatient stay, up to the time of discharge. A successful procedure was defined as completion of diagnostic or therapeutic procedure without complications.
2.4
Data collection
Patients who had undergone coronary angiography or PCI using the brachial route were identified from the Sheffield database. Demographic, clinical and procedural data were collected from hospital records. Outcome data were collected using the UK national mortality database.
2.5
Data analysis
Data are presented as mean ± SD or as percentages (proportions) unless otherwise stated. Analysis was carried out using a Student’s t-test or one-way ANOVA for continuous variables and chi squared for categorical variables. Analysis was carried out using SPSS version 21. (IBM, SPSS Inc. NY, USA)
3
Results
3.1
Patient characteristics
During the study period 117 patients underwent diagnostic or interventional procedures via the brachial route. This represented 0.44% of all patients undergoing such procedures during the time period studied. The mean age was 67.7 years, 56% were male, 59% underwent angiography only and 41% underwent PCI. Of the PCI procedures, 50% were performed for stable symptoms, 38% for non ST elevation ACS (NSTEACS) and 6% for ST elevation myocardial infarction (STEMI). 94.2% of patients had significant peripheral vascular disease. 8 patients (6.8%) had previously undergone coronary artery bypass grafting. 70 (59.8%) had initial failed attempts at radial access (right radial and left radial) and in 47 (40.2%) cases operator opted for brachial route as first choice due to un favourable femoral access (attempted both right and left femoral arteries) and operator was not comfortable with radial access during the study period.
Patent characteristics and various complications are summarised in Tables 1 and 2 . None of the patient or procedural characteristics were associated with an increased rate of complications.
| Brachial without complications | Brachial with complications | P value | |
|---|---|---|---|
| No. of patients | 104 | 13 | |
| Age | 68.1 ± 12.4 | 64.7 ± 10/6 | 0.34 |
| Male | 60 (58%) | 5 (38.5%) | 0.29 |
| Current smoker | 52 (50%) | 7 (53.8%) | 0.79 |
| Diabetes | 52 (50%) | 6 (46.2%) | 0.45 |
| Dyslipidaemia | 92 (88.5%) | 12 (92.3%) | 0.417 |
| Hypertension | 92 (88.5%) | 11 (84.6%) | 0.16 |
| Previous MI | 42 (40.4%) | 7 (53.8%) | 0.80 |
| PVD | 98 (94.2%) | 11 (84.6%) | 0.13 |
| Previous CABG | 7 (6.7%) | 1 (7.7%) | 0.91 |
| Degree of CAD | 0.83 | ||
| No vessels | 22 (21.1%) | 3 (23.1%) | |
| 1 vessel | 40 (38.5%) | 5 (38.5%) | |
| 2 vessels | 17 (16.3%) | 1 (7.7%) | |
| 3 vessels | 25 (24%) | 4 (30.8%) | |
| Procedure | 0.24 | ||
| LHC only | 63 (60.6%) | 6 (46.2%) | |
| PCI | 41 (39.4%) | 7 (53.8%) | |
| Indication | 0.545 | ||
| STEMI | 6 (5.8%) | 1 (7.7%) | |
| NSTEMI | 38 (36.5%) | 7 (53.8%) | |
| Stable angina | 54 (62.5%) | 5 (38.5%) | |
| Other (pre-op) | 6 (5.8%) | 0 (0%) | |
| Catheter size | 0.14 | ||
| 4F | 2 (19.2%) | 0 (0%) | |
| 5F | 55 (52.9%) | 5 (38.5%) | |
| 6F | 45 (43.3%) | 8 (61.5%) | |
| 7F | 2 (19.2%) | 0 (0%) |
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