Ultrasound guided puncture of the brachial artery for haemodialysis fistula angiography

Kar-Wai Lui, Kee-Min Yeow, Yung-Liang Wan, Yun-Chung Cheung, Koon-Kwan Ng and Jeng-Hwei Tseng

First Department of Diagnostic Radiology, Chang Gung Medical Center at Linkou, College of Medicine, Chang Gung University, Taiwan



   Abstract
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 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Background. Arterio-venous (a–v) fistulae of haemodialysis patients frequently require function assessment by angiography. The purpose of the present study was to determine the efficacy and safety of ultrasound-guided transbrachial catheterization when a-v fistulae were evaluated.

Methods. Between July 1996 and December 1997, 208 dialysis patients, whose a-v fistulae (arterial inflow <50 ml/min or venous pressure >150 mm Hg in three consecutive HD sessions) were at the wrist or elbow, underwent transbrachial angiography using an ultrasound-guided 20-gauge IA needle to evaluate fistula function. Procedure-related symptoms or complications were noted in 28 patients and these were analysed.

Results. No apparent cases of vessel spasm or thrombosis were noted. Reported symptoms in 28 patients (13.5%) included local arm pain (3.3%), transient paresthesia (0.9%), mild ecchymosis (10.6%) and haematoma (0.9%). All complications were minor and none required surgical intervention.

Conclusion. Ultrasound-guided puncture of the brachial artery is a safe, reliable and effective procedure in skilled hands and should be the preferred means of catheterization whenever haemodialysis angiography is performed.

Keywords: brachial arteriography; haemodialysis fistula; ultrasound



   Introduction
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
In 1966, Brescia and Cimino created the first arteriovenous (BC a–v) radiocephalic fistula [1]. Since then, the number of patients undergoing chronic haemodialysis has increased significantly. Patency of the fistula is critical because dialysis patient treatment depends on its function. Amongst the various methods for assessing fistula patency, angiography remains the gold standard for access evaluation [2].

We are aware of no previous reports describing ultrasound-guided transbrachial catheterization for dialysis fistula angiography. The purpose of this study was to assess the efficacy and complications of this technique.



   Subjects and methods
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
From July 1996 to December 1997, 208 dialysis patients whose dysfunctional (arterial inflow <250 ml/min or venous pressure >150 mmHg in three consecutive HD sessions) dialysis fistulae had been made at the elbow or wrist underwent transbrachial arteriography for fistula evaluation using ultrasound-guided catheterization. The 208 cases comprised 176 cases with radial artery to cephalic vein fistulae at the wrist, 12 cases with brachial artery to antecubital vein fistulae, and 10 cases with polytetrafluoroethylene (PTFE) grafts from the brachial artery to the basilic vein in the upper arm. There were 106 males and 102 females, of which ~80% were outpatients. Their ages ranged from 11 to 90 years (mean±SD 53.1±16).

The arteriovenous fistula was first surveyed with high-resolution ultrasonography. The ultrasonography was performed using a commercially available scanner (Acuson 128XP/10, USA and Siemens Sonoline Elegra, Germany) with a 7.0 MHz linear array transducer. Using the free-hand technique, an antegrade puncture of the brachial artery at the elbow was performed with a 20-gauge IA needle (Angiocath, Becton Dickinson Vascular Access) under echo guidance (Figure 1Go). The 20-gauge IV needle was 1.1 mm wide and 5.1 cm long. For those patients with a-v fistulae at the wrist and the upper arm (proximal to the elbow), arterial punctures were performed at the antecubital fossa and the area ~5 cm proximal to the anastomosis, respectively. No local anaesthetic was used. The distance between the brachial artery and skin was ~1–1.5 cm, leaving ~3 cm of the IV catheter indwelling in the artery, which avoided the risk of dislodgement. Only one catheterization attempt was required for 96% of the patients, with the remainder requiring one additional puncture. Dr K. W. Lui, who has been biopsying superficial tumours and draining abscesses under ultrasound guidance on an almost daily basis, performed all examinations and procedures for the cases described in this article. Dr Lui has also acquired extensive experience in arterial catheterization procedures, in particular catheterization of the femoral artery.



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Fig. 1. Ultrasound-guided transbrachial catheterization. The hyperechoic tubular structure (arrow) on the left side is the needle.

 
Angiography was performed using a digital spot imaging machine (Integris V, Philips Medical system, Holland), and images were acquired at 2 frames/s. On average, 30–40 ml of contrast medium (Angiografin 65%, Schering, Berlin, Germany) diluted by an equal amount of distilled water, was administered to make the vessels radio-opaque with a bolus volume of 9 ml delivered at a rate of 3 ml/s in each injection. All vessels were well visualized. Angiograms of the forearm, humeral and central vein areas were then obtained in at least two vertical planes, except for the central vein. If the subclavian vein was patent, only one plane was viewed. Following removal of the catheter, compression was applied to the arterial puncture site until homeostasis was achieved. The patients were observed for a minimum of 10 min before discharge.



   Results
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 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 
Of the 208 examinations, the success rate of catheterization was 100%, with 96% catheterized on the first attempt, the remainder on the second attempt. A total of 28 patients (13.5%) had symptoms related to the procedure which are listed in the table. Seven patients (3.3%) complained of painful forearms, with symptoms resolving within a day. Two patients (0.9%) experienced paresthesia, which also resolved spontaneously. Mild ecchymoses and hematomas were found in 22 (10.6%) and 2 (0.9%) cases, respectively. None required specific treatment. There were no instances of arterial spasm or vascular occlusion noted on the angiogramsGo.


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Table 1. Summary of complications for all patients who underwent transbrachial catheterization

 



   Discussion
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 Abstract
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 Subjects and methods
 Results
 Discussion
 References
 
A surgically created arteriovenous fistula is essential to the end-stage renal disease (ESRD) patient as a reliable access site for dialysis. Stenosis of the access vein may ultimately occur due to frequent venipuncture and changes in blood flow. Maintaining patency is a critical issue, especially in an aging haemodialysis population [3]. Amongst the various methods of surveillance, angiography is still the best imaging modality for delineating the vascular anatomy, identifying obstruction, and for vascular mapping prior to surgical intervention [2].

If the dialysis a-v fistula is created at the elbow or wrist, the brachial artery usually feeds the dialysis shunt either directly or through a feeding artery such as the radial artery. In the past, venous (using the access vein) fistulograms were the preferred method of evaluating the dialysis fistula rather than the transbrachial approach due to fear of damaging the brachial artery [46]. If venipuncture was used, compression manipulation of the forearm using hands or a tourniquet was necessary to encourage reflux of contrast into the afferent artery, which affected the accuracy with which real fistula flow could be estimated. Although most complications of venipuncture are generally mild, the venous approach suffers from the fact that it is not a physiological study, since contrast is injected in the opposite direction to blood flow. In the series by Louis et al. [4], the fistula of a patient with recurrent clotting at the fistula site became completely filled with clot during a fistulogram using venipuncture for access. Additionally, radiation exposure of the examiner during manual compression cannot be avoided. In rare cases, the arteriovenous anastomosis is inadequately visualized in the intravenous (using venous access) digital substraction fistulogram [7]. This had to be rectified by direct puncture and injection of contrast medium into the distal brachial artery. In addition to these problems, stealing phenomena could not be assessed easily using venous fistulograms.

A potential problem with dialysis fistula angiography using brachial artery catheterization is poor visualization of the proximal arterial tree. For those patients with an a-v fistula at the wrist, misdiagnosis of proximal afferent arterial stenosis was unlikely because the whole afferent artery and efferent vein could be totally opacified on the angiograms, which was a distinct advantage over angiograms using a puncture at the anastomosis. For those patients with an a-v fistula or PTFE graft at the elbow, only part of the brachial artery proximal to the anastomosis and the distal portion could be identified because the puncture site was chosen in an area ~3 cm from the anastomosis. At any rate, the main problem for most of these patients was stenosis of the proximal vein; afferent artery stenosis was not the cause of a–v fistula dysfunction [5]. Additionally, the distal portion of the afferent artery could be screened using ultrasonography therefore the risk of misdiagnosing afferent arterial problems can be minimized. Transbrachial angiography was able to demonstrate the whole anatomical status of the dialysis access, and there was no need for puncture of the access vein or dialysis fistula. Another advantage is that the brachial artery can be easily catheterized because it is close to the skin in the antecubital fossa. Thus, the transbrachial approach has definite merits. There are some advantages of arterial puncture over venous puncture or direct puncture, including: (i) ready visualization of the anatomy of all the main arteries of the forearm and venous system; (ii) preservation and assessment of physiological function since the contrast injection occurs in same direction as blood flow; (iii) demonstration of steal phenomena; (iv) unnecessary compression manipulation of the afferent artery, which would otherwise confound estimation of the real fistula flow and expose the examiner to radiation during compression; and finally (v) it is well tolerated by the patient. If transluminal intervention was indicated, no another arterial access was required. A new antegrade or retrograde venous access could be created to carry out the interventional procedure. The puncture site for venous access could be determined using the angiograms at hand.

The main reason traditionally given for not using transbrachial angiography to examine a-v fistulae of chronic haemodialysis patients is the risk of brachial damage. In our series, no apparent vessel damage from ultrasound-guided transbrachial puncture occurred. With ultrasound guidance, the tip of the needle is well visualized and single wall puncture can usually be achieved with only one attempt. Unnecessary vessel wall injury and bleeding due to double wall puncture was avoided. For dialysis patients with BC fistulae at the elbow, access veins usually engorge and have arterial pulsation, making it difficult to differentiate artery from vein. With colour doppler, the direction of blood flow can be easily determined, after which brachial arteriography can be performed with ease. Additionally, ultrasound can play an important role in the accurate detection of non-palpable vessels and especially after failed attempts at puncture using palpation alone. The ultrasound-guided puncture technique, even the free-hand one stick method, is not difficult and echo transducers are available in most modern interventional suites.

In Bucker's publication, transbrachial catherization for dialysis angiography was performed using palpation. Spasm and aneurysm at the site of brachial artery puncture were reported in 2.3 and 0.2% of cases, respectively [2]. In our series, neither spasm nor aneurysm was encountered. We believe this may be attributable to the single-wall single puncture technique under ultrasound guidance. There are few published reports describing transbrachial catheterization. Gritter [8] reported that transbrachial intraarterial puncture produced complications including local arm pain (17.5%), transient paresthesia (7.3%), ecchymosis (50.4%) and haematoma (9.5%). In Mortin's publication, haematoma (1.4%) and cellulitis (1.4%) were also reported [9]. In our series, haematoma (0.9%) and mild ecchymosis (10.6%) at the puncture sites were the most frequent findings. These were probably due to the increased bleeding tendency resulting from heparinization during dialysis [8] and inadequate compression. Haematomas developed in two patients (0.9%), which may have been avoided since they resulted from inadequate compression because the use of thick swabs resulted in poor visualization of the puncture sites. Consequently, particular attention should be paid to technique during haemostasis. If radiologists or registered nurses are used to apply compression, the incidence of ecchymoses and haematomas may be further reduced.

One of the advantages of echo-guided puncture over palpation is the reduction in the risk of injury to the median nerve. The transient paresthesia during haemostasis in two (0.9%) patients may have been due to compression of the median nerve where it lies medial to the brachial artery in the antecubital fossa [8]; it resolved spontaneously after compression ceased. Because of the location of median nerve medial to the brachial artery, slightly more lateral compression should eliminate such problems. Given that only two patients described paresthesia during haemostasis, greater patient numbers are needed to fully evaluate the incidence of this. In our series, seven patients (3.3%) complained of a painful forearm. They all had BC fistulae at the wrist. Reviewing their angiograms, marked stenosis was noted at the anastomosis in five patients with narrowing venous return. The painful forearm might have been due to contrast present in the palmar areas, and may not have been directly related to the catheterization itself. The other two patients showed only focal narrowing at the access veins, and no definite evidence could be found to explain their forearm symptoms.

Percutaneous catheterization of the brachial artery has been reported to compromise the blood supply of the forearm [10], but no such phenomenon was seen in any of the 208 patients we followed.

In conclusion, fine needle ultrasound-guided catheterization of the brachial artery in the hands of an experienced doctor has been shown to be a safe, reliable and effective method of demonstrating the whole vascular status of dialysis shunting, and has multiple advantages over puncture by palpation alone. Owing to its high success rate and the quality of results produced, we feel that fine needle ultrasound-guided catheterization of the brachial artery is an ideal method of catheterization for haemodialysis fistula angiography, and further research is needed to confirm our encouraging results.



   Notes
 
Correspondence and offprint requests to: Kar-Wai Lui, MD, First Department of Diagnostic Radiology, Chang Gung Medical Center at Linkou, College of Medicine, Chang Gung University, 5 Fu-Hsing Road, Tao-Yuan Hsien, Taiwan. Back



   References
 Top
 Abstract
 Introduction
 Subjects and methods
 Results
 Discussion
 References
 

  1. Brescia JM, Cimino JE, Kenneth A et al. Chronic hemodialysis using venipuncture and a surgically created arteriovenous fistula. N Engl J Med1996; 75: 1089–1092
  2. Bucker A, Vorwerk D, Gunther RW. Transbrachial fine-needle arteriography with special focus on haemodialysis shunt imaging. Nephrol Dial Transplant1995; 10: 838–841[Abstract]
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  6. Anderson CB, Giluia LA, Harter HR. Venous angiography and the surgical management of subcutaneous hemodialysis fistulas. Ann Surg1978; 187: 198–204
  7. Pagano D, Green MA, Henderson MJ. Surveillance policy for early detection of failing arteriovenous fistulae for haemodialysis. Nephrol Dial Transplant1994; 9: 277–279[Abstract]
  8. Gritter KJ, Laidlaw WW, Peterson NT. Complications of outpatient transbrachial intraarterial digital subtraction angiography. Radiology1987; 162: 125–127[Abstract]
  9. Mortin ME, Willens BA, Kuss PA. Carotid artery: percutaneous transbrachial selective arteriography with a 4-F catheter. Radiology1989; 171: 868–870[Abstract]
  10. Gani JS, Fowler PR, Steinberg AW. Use of the fistula assessment monitor to detect stenoses in access fistulae. Am J Kidney Dis1991; 17: 303–306[ISI][Medline]
Received for publication: 8. 3.99
Revision received 29. 8.00.