Peripheral vascular access from the arms for invasive cardiac investigation using ultrasound guidance

Introduction Vascular access for invasive cardiac investigations has traditionally been gained from the femoral vessels, however, a “radial-first” approach has become increasingly popular for coronary interventions [1]. Transradial access has shown lower complication rates, shorter admission times, and reduced healthcare costs for coronary interventions [4]. A “superior” approach via the jugular and subclavian veins have been reported for electrophysiology (EP) studies and radiofrequency catheter ablation (RFCA) but is associated with an increased risk of complications such as pneumo- and haemothorax [9]. Purpose EP procedures often require the use of both venous and arterial catheters, and the potential advantage of non-femoral peripheral access is yet to be investigated. This study was performed to provide comprehensive anatomical evidence that the vessels of the arms are suitable for use during EP procedures, as assessed by vascular ultrasound. Methods A portable ultrasound device was used to measure the diameter of the brachial artery, brachial vein, basilic vein & cephalic vein on the left and right upper limbs of 63 healthy adult volunteers. Measurements were also taken of the circumference at the elbow and at the mid-bicep level on both arms. A subgroup of 15 volunteers had additional measurements taken of the same veins and artery on both arms with a tourniquet at the upper bicep level. Results The basilic vein was found to have the largest diameter with a median of 4.6 mm and 4.5 mm (right and left diameter, respectively), followed by the cephalic (median of 3.1 and 3.0 mm) and the brachial vein (median of 2.8 mm for both arms). 100% of volunteers had at least one vein that was equal to a 3 mm diameter (which would allow for a 8F sheath insertion), with 98% having 2 suitable veins and >80% having 3 suitable venous vessels. More than 90% had a suitable diameter of more than 3 mm for both the right and left brachial artery. There was significant correlation between gender, and basilic vein and brachial artery diameters. There was no correlation between BMI, height, weight and elbow or bicep circumference. Conclusion To our knowledge, this is the first study to investigate the feasibility of adopting peripheral access in the electrophysiology lab. 100% of volunteers examined had one vein which was at least 3mm in size and would be suitable for 8F sheath insertion. We demonstrate the anatomic evidence that the vessels in the arm are capable of housing the size of sheath and catheters commonly used in the EP lab. FUNDunding Acknowledgement Type of funding sources: None. Figure 2. measurements Figure 3. Vessel diameters

Acute pulmonary embolism due to right basilic vein thrombosis

A 40-year-old African-American woman presented to the emergency room (ER) with right upper extremity pain for 3 hours after sleeping overnight on that side. She was diagnosed with basilic vein thrombosis; in the ER, she was tachycardic with minimal ambulation, prompting CT pulmonary angiogram, which confirmed right-sided pulmonary embolism. Bilateral upper and lower extremity venous Dopplers did not show any acute deep venous thrombosis. She received appropriate anticoagulation. Risk factors are a smoker and recently started contraceptive pills.

Severe injury to the brachial neurovascular bundle and muscles due to a horse bite: a case report

Introduction Only a small portion of horse injuries are related to horse bites. In the majority of these occurrences, injuries are minor and self-treated. However, in some cases, the injury may be destructive and limb- and life-threatening. In these instances, the patient requires complex surgery and compound perioperative care. Case report We present the case of a 35-year-old Albanian male farm-worker in whom a horse bite caused an extensive lacero-contusive and avulsive wound to the arm. The wound resulted in injury to the brachial artery, brachial and basilic vein, and biceps and brachialis muscles. Nerve structures and underlying humerus remained intact. The initial management of the severe hemorrhagic shock caused by the bleeding at the site of injury included reconstruction of the brachial artery by interposing saphenous graft and that of the brachial vein by termino-terminal anastomosis. Basilic vein was ligated. The wound was extensively debrided, and after a drain was placed in the wound, biceps and brachialis muscles were reconstructed. The patient received several units of red blood cells and fresh frozen plasma before and after surgery, as well as antibiotic, antitetanic, and antirabies prophylaxes. He had several consecutive necrectomies in the following days. However, due to postoperative sepsis and hemorrhagic shock at time of admission, the patient developed acute renal failure, therefore requiring several hemodialysis sessions. After his general and local condition was stabilized, the patient also underwent several reconstructive surgeries. Conclusion Horse bites of large extent require a multidisciplinary approach. The composition of the team of physicians needed for treatment varies depending on the degree of the injury and eventual complications. In the case of our patient, emergency department physicians, vascular and plastic surgeons, intensive care specialists, nephrologists, and infective care specialists were involved. In different instances, the inclusion of other specialists may be necessary to save and functionalize the limbs of the patient, or save his/her life.

Clinical outcomes of transposed brachial-basilic vein fistula: Tunneling versus elevation

Background: The Kidney Disease Outcome Quality Initiative (KDOQI) suggests a transposed brachial basilic vein fistula (TBBVF) in the patients who have good likelihood of long-term survival. To superficialize the basilic vein, a disconnected basilic vein is anterolaterally transposed inside a subcutaneous tunnel. A simple elevation in situ is an alternative technique. The aim of this study was to compare clinical outcomes of TBBVF according to the type of superficialization. Methods: A total of 42 patients (mean age of 66 years, male: 45%) who underwent a TBBVF from April 2014 to March 2019 at our hospital were retrospectively reviewed. The method of superficialization (tunneling ( n = 18) vs elevation ( n = 24)) was determined by the surgeon’s preference. It was done as a one-stage surgery. There was not any statistically significant difference in demographic or clinical characteristics of patients between the two groups. As early outcomes, postoperative mortality and morbidity were investigated. For clinical outcomes, primary patency, primary-assisted patency, and secondary patency were analyzed for both groups. Results: There was a case of a 30-day mortality in the elevation group. Regarding morbidities, there was a postoperative bleeding in the tunneling group and a steal syndrome in the elevation group. The mean follow-up was 28 months (range, 0–63 months). There was no significant difference in primary patency (64.8% vs 77.5% in 1 year and 54.0% vs 54.1% at 3 year; p = 0.816), primary-assisted patency (88.9% vs 86.5% in 1 year and 88.9 vs 81.4 at 3 year; p = 0.624), or secondary patency (100% vs 86.5% in 1 year and 100% vs 86.5% at 3 year; p = 0.126) between the two groups. Conclusions: Clinical outcomes of TBBVF showed no significant difference between tunneling and elevation groups. Thus, TBBVF can be done with either method.

First experience with percutaneous arteriovenous fistula creation using the Ellipsys® vascular access system

Objective Percutaneous creation of arteriovenous fistulae (pAVF) has been developed as an alternative to the creation of an upper arm cephalic or basilic vein fistula. Several studies have shown high technical success rates and comparable time of maturation. To our knowledge, the technique has not been used in Switzerland before. Methods Prospective data collection of the first consecutive patients undergoing the creation of pAVF between April and July 2020 at two vascular surgery centres. Results Seven patients underwent pAVF creation with the Ellipsys® vascular access system under regional anaesthesia for maximum vasodilation. The procedures were performed entirely under sonographic control without the use of fluoroscopy. The cephalic or basilic vein was punctured and the puncture needle advanced under sonographic control through the cubital perforator vein into the proximal radial artery. The Ellipsys® catheter was advanced over a guidewire and activated to create the fistula between the proximal radial artery and the perforator vein. The fistula was further dilated with a 5mm PTA balloon. We achieved technical success in 6 patients. In one patient with small and spastic vessels, the needle could not be advanced into the radial artery. A conventional upper arm cephalic fistula was created during the same procedure. In three patients primary maturation was achieved and the cephalic vein or distal basilic vein could be punctured for dialysis without any adjunct procedures. One patient required three additional procedures before the fistula could be used successfully (additional angioplasty of the fistula, superficialisation of the basilic vein and correction of a cubital vein stenosis by excision and end-to-end anastomosis). One patient required superficialisation of the basilic vein and one patient transposition of the arterialised brachial vein. Maturation was achieved in six pAVF after a mean of 158 days with a mean fistula flow of 920 ml/ min. Conclusion We achieved high technical success and maturation rates in our first patients undergoing pAVF creation with the Ellipsys® system. Prerequisites are suitable anatomy of the cubital perforator vein and good skills in sonography and endovascular techniques. We believe that pAVF is a promising alternative to the creation of a conventional upper arm fistula in patients unsuitable for a distal radio-cephalic fistula.