1. Basic skills for Endovascular Specialists: Vascular Access: Brachial and Axillary Hugo Londero MD, FSCAI Sanatorio Alllende Cordoba-Argentina
2011

2. Basic skills for Endovascular Specialists:
Vascular Access: Brachial and Axillary
Background:
During the 70’s the Cardiologist were trained in Sones Technique: brachial arteriotomy and malleable catheters
The radiologist were experts in Judkins Technique: percutaneous arterial access and pre-shaped catheters
The fast grow of Transcatheter Interventions during the 80’s popularized the Femoral Percutaneous access
Currently numerous vascular access are utilized: radial, brachial, axillary, femoral, popliteal, tibial, etc.
Access selection is related with the pathology and devices
Occasional use of brachial access transform the technique in a difficult procedure. However in especial circumstances we must know how to use it.

3. Anatomic considerations:
Artery
Nerve I
E: Median nerve
F: Radial nerve
I: Brachial artery

4. Brachial Arteriotomy: Modified Sones Technique

5. Brachial cut down: Arteriotomy suture:

6. Brachial: Percutaneous
Radial artery introducer sheath

7. Local Complications: Pseudo-Aneurysm

8. Local Complications: Acute Occlusion-Distal Embolization

9. Local Complications: Median Nerve injury

10. Complications Associated with Cardiac Catheterization and Angiography
(J Ward Kennedy, MD, Chairman and the Registry Committee of the Society for Cardiac Angiography-Cath Cardiovasc Diag 1982;8:5-11)
66 US Cath Labs – patients
Major Complications:
Death 0.14 %
AMI 0.07 %
CVA 0.07 %
Arrhythmia 0.56 %
Vascular 0,57 %
Total 1.82 %
There were no differences between Brachial and Femoral Techniques

11. Prospective comparison of:
Percutaneous Right Brachial Artery Approach with 5F Catheters for Studying Coronary Artery Disease Lupón-Rosés J et al.Cath Cardiovasc Diag 1991;22:47-51
Prospective comparison of:
60 patients with 5F cath. by percutaneous right brachial approach
100 patients with 5F cath. by femoral approach
100 patients with 8F cath. by femoral approach
Results:
No differences between 5f brachial or femoral approach except for:
> X Ray exposure and compression time for Brachial
Mild increase in difficulties and decreases in image quality with 5F
More frequent local hematoma with 8F

12. (11 operators / 55 cases brachial approach)
Ocasional-Operator Percutaneous Brachial Coronary Angiography: First, Do No Arm Hildick-Smith DJR et al.Cathet Cardiovasc Intervent 2002;57:161-5
One Center comparison of habitual femoral approach vs. occasional brachial approach (October 1997/October 2000)
(11 operators / 55 cases brachial approach)
Femoral %
Radial %
Brachial Arteriotomy %
Brachial Puncture %
Brachial Puncture – Complications:
Total 20/55 36 %
Major 3/55 5 %
Minor 17/55 31 %

13. Major Complications: Minor Complications:
Ocasional-Operator Percutaneous Brachial Coronary Angiography: First, Do No Arm Hildick-Smith DJR et al.Cathet Cardiovasc Intervent 2002;57:161-5
Major Complications:
False Aneurysm / Surgery
Brachial Hematoma / Surgery
Hematoma + Median Nerve Injury
Minor Complications:
Need for repeat catheterization Weakness of radial pulse
Brachial artery dissection Artery spasm=finish procedure
Wound oozing Significant Hematoma
Transient ischemic attack Humeral aneurysm

14. One operator-400 consecutive patientes Technique:
Percutaneous Brachial Catheterization
Lucien Campeau. Cathet Cardiovasc Diag. 1985;11:443-4
One operator-400 consecutive patientes
Technique:
Percutaneous arterial puncture
Introducer sheath
Premedication with intra arterial Papaverine/Heparine
Pre shaped catheters
Protamine post procedure
Finger compression
Complications:
Hematoma 4 %
Loss of the radial pulse 2 %
Surgical thrombectomy 1 %

15. Axillary Access:
Anatomic Considerations
Complications

16. Final Comments:
Brachial approach could be considerer as an alternative access for cardiac catheterization
It is used occasionally in special circumstances
This non routine use increase the incidence of complications
One member of the crew must develop the necessary skill to do the procedures
I do not recommend the axillary access