Percutaneous high brachial aortography
1
CORRESPONDENCE 557 Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors Jbr shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue. Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors" at the front of the Journal. PERCUTANEOUS HIGH BRACHIAL AORTOGRAPHY SIR High brachial aortography is clearly a useful technique for gaining access to the arterial tree in patients where the femoral route is impossible (Gaines and Reidy, 1986) but is it 'relatively simple and safe' as claimed by the authors? One patient (2.2%) required surgery for severe haemorrhage from a false aneurysm which developed at the puncture site and two other patients (4.4%) sustained arterial damage which caused the procedure to be abandoned - a subintimal subclavian injection in one and guide wire perforation of the brachial artery in another. The technique failed in two patients (4.4%) as the catheter could not be manipulated from the subclavian artery into the descending thoracic aorta. There is no doubt that the 45 patients in the series posed considera- ble technical problems and that most, if not all, had widespread and severe arterial disease but even so, the incidence of complications and technical failures (11%) suggests that the procedure is not easy to learn and that it has a morbidity. The fact that Dr Reidy succeeded in four patients after failure by a more junior colleague is further evidence that expertise in vascular radiology is a considerable advantage when using the technique. My own feeling is that high brachial artery puncture, like axillary artery puncture, has a useful place in specialised departments staffed by experienced vascular radiologists but that radiologists with no experience of the brachial or axillary approach should continue to use the well tried translumbar technique when femoral catheterisation is impossible. JAMES McIVOR Department of Radiology Charing Cross Hospital London References Gaines, PA & Reidy, JF (1986). Percutaneous high brachial aorto- graphy: A safe alternative to the translumbar approach. Clinical Radiology, 37, 595-597. S~R- We arc grateful for the chance to comment on the points raised by Dr McIvor. We agree with him that our patients posed considerable technical problems as all were severe arteriopaths in whom the femoral approach was not possible. Also a high incidence of medical problems made them a high risk group for anaesthesia. We still contend that the procedure is 'relatively safe'. There was only one serious complication in a patient who was severely hypertensive, in renal failure and who had been on heparin. He had a very severe problem and we do not think he would have been a candidate for the translumbar route. Our other complications were detailed as minor. Since submitting our paper we note a further publication (Lipchik and Sugimoto, 1986) that suggests that a brachial approach very similar to ours is relatively safe. These authors noted complications in only two out of 110 procedures and concluded 'the brachial approach should be nearly as safe as the femoral approach for percutaneous catheterisation and should not be avoided if the femoral arteries cannot be used'. Also in the United States where medico-legal problems loom so large translumbar aor- tography has for many years been a rarely performed procedure. We agree that the brachial technique is technically more difficult than the femoral approach. Even using the femoral approach, when there is severe proximal disease (as those who do angioplasty know only too well) there will sometimes be problems in safely traversing the arteries so that it is not altogether surprising that in these patients with the smaller brachial arteries there was the occasional problem. That our registrars in training fairly rapidly became confident with the brachial approach attests that for those familiar with the femoral approach it should pose no great problems. P. A. GAINES Guy's Hospital J. F. REIDY St Thomas St London Reference Lipchik, EO & Sugimoto, H (1986). Percutaneous brachial artery catheterisation. Radiology, 160, 842-3. SIR Our own experience with percutaneous high brachial aorto- graphy may be of interest, in the light of the findings of Gaines and Reidy (Clinical Radiology, 1986). In an 18 month period we performed or attempted 15 transbrachial aortograms in 14 patients, each considered unsuitable for arterio- graphy via a transfemoral approach. In one patient, the indication for the procedure was a suspected saddle embolus, and in all other cases, advanced peripheral vascular disease. One patient had undergone a previous failed attempt at translumbar aortography. Arteriography was performed with a single piece 18 gauge needle and a 5 French gauge pigtail catheter, in a manner similar to that described by Gaines and Reidy. The procedure was unsuccessful in only a single patient in whom puncture was attempted on one side only; this was our first transbrachial attempt at this hospital, and we would now normally proceed to puncture the opposite side at the same session. In one other case, cannulation was unsuccessful on one side, but successful on the other. The most serious complication encountered was a transient ischaemic attack lasting 10 minutes on withdrawal of the catheter, with slight unilateral facial weakness on the opposite side to the puncture and visual symptoms; this resolved completely. Two patients developed haematomata at the puncture site - one of these was the patient in whom the procedure was abandoned. In one other patient, weakness of the radial and brachial pulses was noted at the end of the procedure, but resolved 4 hours later. No other complications were observed. We saw patients prior to discharge, and reviewed records of their follow-up visits to the out-patient clinic 2 weeks to 6 months later; in no case was a delayed complication identified. We concur with Gaines and Reidy that high brachial aortography is a safe and preferable alternative to the translumbar approach. R. M. DAWOOD Department of Radiology P. SHAW University College Hospital Gower St London Reference Gaines, PA & Reidy, JF (1986) Percutaneous high brachial aorto- graphy: A safe alternative to the translumbar approach. Clinical Radiology, 37, 595-597. RECURRENT PYOGENIC CHOLANGITIS: ULTRASOUND EVALUATION COMPARED WITH ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY SIR The changes described in the article on this subject (Chau et al., 1987) are similar to those seen in patients developing late complica- tions following hepatodochojejunal anastomosis. At St James' and St George's Hospitals, we operate on and follow up a large number of patients with high bile duct strictures usually the result of damage sustained during cholecystectomy. The repair of these strictures usually involves the anastomosis of the hepatic ducts to
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Transcript of Percutaneous high brachial aortography
CORRESPONDENCE 557
Correspondence Letters are published at the discretion of the Editor. Opinions expressed by correspondents are not necessarily those of the Editor. Unduly long letters may be returned to the authors Jbr shortening. Letters in response to a paper may be sent to the author of the paper so that the reply can be published in the same issue.
Letters should be typed double spaced and should be signed by all authors personally. References should be given in the style specified in the Instruction to Authors" at the front of the Journal.
PERCUTANEOUS HIGH BRACHIAL AORTOGRAPHY
SIR - - High brachial aortography is clearly a useful technique for gaining access to the arterial tree in patients where the femoral route is impossible (Gaines and Reidy, 1986) but is it 'relatively simple and safe' as claimed by the authors?
One patient (2.2%) required surgery for severe haemorrhage from a false aneurysm which developed at the puncture site and two other patients (4.4%) sustained arterial damage which caused the procedure to be abandoned - a subintimal subclavian injection in one and guide wire perforation of the brachial artery in another. The technique failed in two patients (4.4%) as the catheter could not be manipulated from the subclavian artery into the descending thoracic aorta.
There is no doubt that the 45 patients in the series posed considera- ble technical problems and that most, if not all, had widespread and severe arterial disease but even so, the incidence of complications and technical failures (11%) suggests that the procedure is not easy to learn and that it has a morbidity. The fact that Dr Reidy succeeded in four patients after failure by a more junior colleague is further evidence that expertise in vascular radiology is a considerable advantage when using the technique.
My own feeling is that high brachial artery puncture, like axillary artery puncture, has a useful place in specialised departments staffed by experienced vascular radiologists but that radiologists with no experience of the brachial or axillary approach should continue to use the well tried translumbar technique when femoral catheterisation is impossible.
JAMES McIVOR Department of Radiology Charing Cross Hospital
London
References
Gaines, PA & Reidy, JF (1986). Percutaneous high brachial aorto- graphy: A safe alternative to the translumbar approach. Clinical Radiology, 37, 595-597.
S~R- We arc grateful for the chance to comment on the points raised by Dr McIvor.
We agree with him that our patients posed considerable technical problems as all were severe arteriopaths in whom the femoral approach was not possible. Also a high incidence of medical problems made them a high risk group for anaesthesia. We still contend that the procedure is 'relatively safe'. There was only one serious complication in a patient who was severely hypertensive, in renal failure and who had been on heparin. He had a very severe problem and we do not think he would have been a candidate for the translumbar route. Our other complications were detailed as minor. Since submitting our paper we note a further publication (Lipchik and Sugimoto, 1986) that suggests that a brachial approach very similar to ours is relatively safe. These authors noted complications in only two out of 110 procedures and concluded ' the brachial approach should be nearly as safe as the femoral approach for percutaneous catheterisation and should not be avoided if the femoral arteries cannot be used'. Also in the United States where medico-legal problems loom so large translumbar aor- tography has for many years been a rarely performed procedure.
We agree that the brachial technique is technically more difficult than the femoral approach. Even using the femoral approach, when there is severe proximal disease (as those who do angioplasty know only too well) there will sometimes be problems in safely traversing the arteries so that it is not altogether surprising that in these patients with the smaller brachial arteries there was the occasional problem. T h a t our registrars in training fairly rapidly became confident with the
brachial approach attests that for those familiar with the femoral approach it should pose no great problems.
P. A. GAINES Guy's Hospital J. F. REIDY St Thomas St
London
Reference
Lipchik, EO & Sugimoto, H (1986). Percutaneous brachial artery catheterisation. Radiology, 160, 842-3.
SIR - - Our own experience with percutaneous high brachial aorto- graphy may be of interest, in the light of the findings of Gaines and Reidy (Clinical Radiology, 1986).
In an 18 month period we performed or at tempted 15 transbrachial aortograms in 14 patients, each considered unsuitable for arterio- graphy via a transfemoral approach. In one patient, the indication for the procedure was a suspected saddle embolus, and in all other cases, advanced peripheral vascular disease. One patient had undergone a previous failed attempt at translumbar aortography.
Arteriography was performed with a single piece 18 gauge needle and a 5 French gauge pigtail catheter, in a manner similar to that described by Gaines and Reidy. The procedure was unsuccessful in only a single patient in whom puncture was at tempted on one side only; this was our first transbrachial attempt at this hospital, and we would now normally proceed to puncture the opposite side at the same session. In one other case, cannulation was unsuccessful on one side, but successful on the other.
The most serious complication encountered was a transient ischaemic attack lasting 10 minutes on withdrawal of the catheter, with slight unilateral facial weakness on the opposite side to the puncture and visual symptoms; this resolved completely. Two patients developed haematomata at the puncture site - one of these was the patient in whom the procedure was abandoned. In one other patient, weakness of the radial and brachial pulses was noted at the end of the procedure, but resolved 4 hours later. No other complications were observed.
We saw patients prior to discharge, and reviewed records of their follow-up visits to the out-patient clinic 2 weeks to 6 months later; in no case was a delayed complication identified.
We concur with Gaines and Reidy that high brachial aortography is a safe and preferable alternative to the translumbar approach.
R. M. D A W O O D Department of Radiology P. SHAW University College Hospital
Gower St London
Reference
Gaines, PA & Reidy, JF (1986) Percutaneous high brachial aorto- graphy: A safe alternative to the translumbar approach. Clinical Radiology, 37, 595-597.
RECURRENT PYOGENIC CHOLANGITIS: ULTRASOUND EVALUATION COMPARED WITH ENDOSCOPIC RETROGRADE C H O L A N G I O G R A P H Y
SIR - - The changes described in the article on this subject (Chau et al., 1987) are similar to those seen in patients developing late complica- tions following hepatodochojejunal anastomosis.
At St James' and St George 's Hospitals, we operate on and follow up a large number of patients with high bile duct strictures usually the result of damage sustained during cholecystectomy. The repair of these strictures usually involves the anastomosis of the hepatic ducts to
