Trans – brachial Artery Access for Coronary Artery Procedures: A Feasible and Safe Option
In the realm of cardiovascular medicine, the choice of access site for coronary artery procedures is of utmost importance. Trans – radial artery access (TRA) has emerged as a preferred option in recent years due to its numerous advantages. However, when TRA fails, interventional cardiologists need to consider alternative access routes. This article delves into the feasibility and safety of trans – brachial artery access (TBA) for percutaneous coronary interventions (PCI) when TRA is not possible.
Introduction
Percutaneous coronary interventions (PCI) are crucial procedures for treating coronary artery disease. The access site for PCI plays a significant role in patient outcomes. Trans – femoral artery access (TFA) has been the traditional approach, but TRA has gained popularity. TRA offers several benefits such as reduced 30 – day mortality, lower in – hospital major adverse cardiac and cardiovascular events, decreased major bleeding, and fewer access site complications compared to TFA [1]. However, TRA has its limitations, including small diameter, arterial spasm, tortuosity, anatomic variants, a longer learning curve for junior operators, and the possibility of asymptomatic radial artery occlusion. Trans – ulnar artery access (TUA) shares similar benefits and limitations with TRA. When both TRA and TUA fail, TFA is often the alternative. But what about TBA?
Anatomy and Previous Concerns
Anatomically, the brachial artery, brachial vein, and median nerve are located in the medial brachial fascial compartment between the axilla and elbow. This anatomical arrangement makes adequate manual compression challenging on the limited underlying bone surface, leading to concerns about hemostasis and nerve injury, especially in patients on aggressive anticoagulation. Previous studies have shown a higher rate of vascular and neurological complications with TBA compared to other access routes [5]. For example, Kiemeneij et al. [6] conducted a randomized study of 900 patients undergoing percutaneous transluminal coronary angioplasty with size six – French catheters. They found that major puncture site complications were more frequent in the TBA group (2.3%) compared to the TRA group (0%) and the TFA group (2.0%). However, more recent studies have challenged these views.
The Current Study
Study Design and Patient Population
The current study was a single – center investigation from Centro Hospital Conde de Sao Januario in Macau. It included 1708 consecutive patients who underwent coronary angiography and PCI between January 1, 2013, and December 31, 2017. Out of these, 143 cases who failed to have TRA were enrolled. These patients were switched to either TBA or TFA according to the operator’s preference. The successful rate of TRA was 91.6% (1565/1708), and the successful rate of TBA was 96.2% (25/26), with one case being switched from TBA to TFA.
Procedure and Follow – up
During the percutaneous procedure, the modified Seldinger technique and size six – French sheaths were used for brachial and femoral artery puncture. Heparin was administered, and the sheath was removed at different times after angiography or PCI (2 hours for TBA group and 4 hours for TFA group after PCI). Direct compression was applied for hemostasis, followed by further compression with an elastic bandage. Elbows were immobilized for the TBA group. Patients were followed up in the cardiology clinic to assess vascular and neurological complications.
Outcomes
- In – hospital Procedural Outcome: There was no significant difference in vascular complication between the TBA group (8.0%) and the TFA group (3.4%) (P > 0.05). There were also no significant differences in cardiac death, non – fatal myocardial infarction, and stroke events between the two groups. After adjusting for various factors (age, gender, hypertension, diabetes mellitus, tobacco use, dyslipidemia, primary PCI, and glycoprotein (GP) IIb/IIIa inhibitors) using multiple logistic regression analysis, there was no statistical difference in the risk of in – hospital procedure outcomes between the TBA and TFA groups (odds ratio: 3.39, 95% confidence interval [CI]: 0.33 – 34.44, P = 0.302).
- Follow – up Clinical Outcome: The average follow – up interval in the cardiology clinic was 889.3 days (approximately 29.6 months). The clinic follow – up rates were 100.0% for the TBA group and 97.2% for the TFA group. Neither vascular nor neurological complication was observed in both groups during every cardiology clinic visit. After adjusting for the same factors using Cox regression analysis, there was no statistical difference in the risk of follow – up clinical outcomes between the TBA and TFA groups (hazard ratio: 1.36, 95% CI: 0.50 – 3.73, P = 0.551).
Comparison with Other Studies
- Sabbah et al. [7]: Studied 4955 cases of coronary revascularization. They found that forearm artery access (TBA and TRA) was associated with higher procedural success compared to TFA. TFA had a higher rate of major adverse cardiac events (MACE) and in – hospital cardiac death. TBA and TFA had a higher rate of access site pseudoaneurysm. However, they concluded that TBA for PCI could be a good alternative with considerable safety and efficacy.
- Gan et al. [8]: Studied 5110 cases of coronary procedures. They found that TBA had a slightly lower incidence of major complications compared to TFA (0.6% vs. 2.5%, P > 0.05), with no significant difference in minor complications (4.4% vs. 5.0%, P > 0.05). There was no incidence of brachial artery thrombosis and no puncture – related neurological dysfunction in the TBA group.
- Melon et al. [9]: Studied 16,438 cases of transradial coronary procedures. When TRA failed, TBA was as safe and effective as TFA. TBA was associated with shorter procedure and fluoroscopy time, resulting in a lesser dose of radiation for both patients and operators.
Advantages of Forearm Artery Access (Including TBA)
Compared to TFA, forearm artery access (TRA, TUA, and TBA) offers several advantages. Patients can ambulate earlier, which is especially beneficial for those with severe aorto – iliac disease (e.g., Leriche’s syndrome or aortic aneurysm) or difficulty in lying (e.g., heart failure or spine disease). It also decreases post – procedure nursing workload, hospital cost, and length of stay. Additionally, it expands the capability to perform complex procedures such as intra – aortic balloon pumping insertion via TBA.
Limitations of the Current Study
- Sample Size: The sample size of the TBA and TFA groups was relatively small as most patients underwent PCI by TRA, and the population in Macau is not large enough.
- Learning Curve: At the time of the study, the operators were at the beginning of the learning curve for TBA. All TBA cases were performed by one operator who had no previous experience.
- Non – Randomized Design: The decision to use TBA or TFA was based on the operator’s preference when TRA failed, and it was not a randomized control study.
- Primary PCI Consideration: Operators did not spend much time on TBA for primary PCI. When TRA or TBA was difficult, they switched to TFA quickly to shorten the door – to – balloon time in all primary PCI cases.
Conclusion
In conclusion, the current study from Macau shows that TBA is a feasible and safe alternative for PCI when TRA fails. Despite the limitations, the study provides valuable insights. With more experience and larger – scale studies in the future, TBA may become an even more established option in interventional cardiology. As the field of cardiovascular medicine continues to evolve, understanding the safety and feasibility of different access routes is essential for providing the best care to patients.
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doi.org/10.1097/CM9.0000000000000274
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