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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 2  |  Issue : 1  |  Page : 8-14

Ultrasound-guided transbrachial arterial access: A safe approach for hemodialysis arteriovenous fistula intervention


1 University Surgical Cluster, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
2 University Surgical Cluster, Yong Loo Lin School of Medicine, National University of Singapore; Department of Cardiac, Thoracic and Vascular Surgery, National University Health System, Singapore

Date of Submission09-Oct-2018
Date of Acceptance01-Dec-2019
Date of Web Publication24-Jul-2019

Correspondence Address:
Pei Ho
CTVS Office, 9F NUHS Tower Block, 1E Kent Ridge Road
Singapore
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/VIT.VIT_7_19

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  Abstract 

CONTEXT: Endovascular interventions for hemodialysis arteriovenous fistula (AVF) can be performed through transfistula, transradial, and transbrachial artery access (TBA), but many interventionists consider TBA a risky approach and thus avoid using it.
AIMS: We conducted a retrospective review to report the safety and applications of TBA for AVF interventions.
SETTINGS AND DESIGN: Consecutive endovascular procedures for AVFs with TBA applied during a 2-year period were retrospectively reviewed.
SUBJECTS AND METHODS: All brachial artery cannulations were performed under ultrasound guidance, either for fistulogram (20G cannula) only or for both angiogram and therapeutic purposes (4–6 Fr sheath). Demographics, comorbidities, antiplatelet and anticoagulant usage, indications of procedure, lesion sites, treatment outcome, and complication were reported.
STATISTICAL ANALYSIS USED: Excel version 2010.
RESULTS: One hundred AVF procedures that adopted TBA were performed for 73 patients during the study period (4 diagnostic fistulogram and 96 therapeutic interventions). Indications were dysfunctional AVF (n = 82), acute fistula thrombosis (n = 9), failure-to-mature (n = 8), and steal syndrome (n = 1). In 61 and 5 procedures, the patients were on long-term antiplatelet and anticoagulant agents, respectively. In 69 procedures, more than one lesion were identified in the AVF circuit. Stenosis over the anastomosis, juxta-anastomosis, and cannulation zone was found in 40.6%, 74%, and 67.7% of the AVFs, respectively. Thirty-two procedures had transbrachial 20G cannula inserted and 68 procedures had 4–6 Fr introducer sheath inserted. Technical success of the therapeutic interventions was 98.9%. Two patients developed limited hematoma at TBA site after the procedure and resolved with conservative management. No major complication (hemorrhage, nerve injury, pseudoaneurysm, and dissection) was noted from all the TBA procedures.
CONCLUSIONS: TBA is a safe approach for AVF endovascular therapy.

Keywords: Arteriovenous fistula, end-stage renal failure, hemodialysis, transbrachial artery access, ultrasound


How to cite this article:
Aung NN, Lim J, Xue J, Ho P. Ultrasound-guided transbrachial arterial access: A safe approach for hemodialysis arteriovenous fistula intervention. Vasc Invest Ther 2019;2:8-14

How to cite this URL:
Aung NN, Lim J, Xue J, Ho P. Ultrasound-guided transbrachial arterial access: A safe approach for hemodialysis arteriovenous fistula intervention. Vasc Invest Ther [serial online] 2019 [cited 2019 Oct 15];2:8-14. Available from: http://www.vitonline.org/text.asp?2019/2/1/8/263391


  Introduction Top


Endovascular intervention has well been accepted as an important treatment modality for dysfunctional hemodialysis arteriovenous fistula (AVF), failure-to-mature AVFs, and AVF-related complications. The access site for therapeutic AVF interventions could be through the fistula, radial artery, and brachial artery, with transfistula approach being the most preferred approach.[1],[2]

Transbrachial artery access (TBA) was previously reported to have high complication rate [3],[4],[5] and is not preferred. Nonetheless, TBA enables easy and good angiographic image and facilitates wire crossing in certain challenging anatomy. We conducted a retrospective study to evaluate the safety and application of antegrade ultrasound-guided TBA for either diagnostic fistulogram or therapeutic procedures during endovascular interventions for problematic AVFs.


  Subjects and Methods Top


The current study received ethical approval from the institutional review board, and informed consent waiver approval was obtained. We retrospectively reviewed consecutive endovascular procedures for hemodialysis AVFs using antegrade TBA performed by one vascular surgeon among all hemodialysis access endovascular procedures at a tertiary referral center between January 2015 and December 2016.

Indications of interventions included (i) dysfunctional AVFs with clinically weak thrill, decreased dialysis access flow rate, and difficulty in fistula cannulation;[6] (ii) thrombosed AVF; (iii) AVF failed to mature by 8 weeks with the presence of anastomotic and/or juxta-anastomotic stenosis; and (iv) dialysis access-related steal syndrome (DASS). For dysfunctional and failed-to-mature AVFs, all treatments were performed using percutaneous endovascular interventions only, whereas for thrombosed AVFs and DASS, small incision over the fistula was performed when necessary in addition to the endovascular intervention for thrombectomy and banding of the fistula, respectively. All interventions for dysfunctional and failure-to-mature AVFs were conducted as outpatient procedure, whereas those for thrombosed AVFs and DASS were performed as either outpatient or inpatient procedure. Heparin was not being routinely given in dysfunctional AVF interventions unless in complex cases where the risk of acute thrombosis of the fistula circuit was considered high. However, for all thrombosed AVF and DASS conditions, heparin was given according to the body weight (bolus 60 units/kg). Outpatient procedures were all performed under local anesthesia and sedation, whereas inpatient procedures were performed either under regional anesthesia or local anesthesia with sedation.

The decision to use TBA for AVFs interventions was based on the consideration of better angiographic image or easier wire crossing of the stenotic lesion(s) with this approach. All antegrade brachial artery puncture and cannulation were performed under ultrasound (USG) guidance using Seldinger technique over the cubital fossa or distal arm regions. The size, position, tortuosity, degree of calcification of the brachial artery, and its relationship to the surrounding deep vein and overlying fistula were assessed using ultrasound for suitability of needle puncture. A 20G cannula was inserted into the brachial artery for the purpose of angiogram to reveal the stenotic lesion(s) and assessment of AVF condition in-between the angioplasty therapies. In these procedures, an additional transfistula access was used to conduct the therapeutic procedure. An introducer sheath (ranging from 4 Fr to 6 Fr depending on the profile of the device used) was inserted through the brachial artery when the TBA was for both angiogram and therapeutic purposes. These include situations where (i) transfistula approach was considered not suitable in failure-to-mature AVFs with the venous fistula diameter being relatively small, (ii) difficulty in wiring to cross lesion with transfistula approach, (iii) transfistula approach was considered less favorable where the nondiseased segment of venous fistula was located deep over the obese proximal arm or in the usual needling site of fistula or unhealthy skin region, (iv) fistula was thrombosed, and (v) the treatment was for steal syndrome.

Demographic data, comorbidities, antiplatelet and anticoagulant usage, types of AVFs, lesion sites, procedural details, treatment outcome, and perioperative complications of all cases were retrieved and reviewed from electronic patient records. The demographic data of patients comprised age, gender, and ethnicity. Comorbidities including diabetes mellitus, hypertension, and ischemic heart disease were recorded. Long-term antiplatelet agent (aspirin and clopidogrel) and anticoagulant (warfarin) usage was reviewed. Antiplatelet agent(s) was not required to be stopped before the interventions. For those on long-term anticoagulation therapy, anticoagulant was withheld 3 days before the procedure, and the International Normalized Ratio (INR) value on the day of procedure was recorded. Procedural reports and angiographic images were reviewed to obtain data on the nature of AVFs, number and location of stenotic lesions, number and location of access site used as well as profile of the sheath inserted, treatment outcome, and perioperative complications.

Technical success for dysfunctional, thrombosed, and failure-to-mature AVFs was defined by angiographically <30% residual stenosis [7],[8] of the treated stenotic or occlusive lesion. Clinical success of dysfunctional and thrombosed AVFs was achieved when clinically satisfactory thrill over the AVF was palpable and furthermore, the AVF was able to sustain hemodialysis after the procedure with adequate clearance, and reversal of the AVF clinical signs that led to the intervention.[7],[8] Clinical success for failure-to-mature AVFs was defined by successful two needle cannulations of the fistula to support hemodialysis and removal of the tunneled central venous catheter (if any) within 3 months after intervention. Technical success for DASS was defined by obtaining in-line arterial flow to the affected hand via radial, ulnar, or both arteries. Clinical success for DASS treatment was defined as successful relief of rest pain or healing of tissue loss after the intervention. After the procedure, hemostasis of all transbrachial accesses was achieved with manual compression.

Major (bleeding or large hematoma requiring admission or transfusion, pseudoaneurysm, median nerve injury, arterial dissection, and thrombosis) and minor (palpable hematoma managed conservatively) complications of TBA [3],[4],[9],[10] were reviewed and recorded. Postintervention, all patients were followed up in the clinic to review their AVFs and upper-limb condition within 2 to 6 weeks and then at intervals between 3 and 6 months.

Statistical analysis

Categorical data were represented by number and percentages. Continuous data were reported as means ± standard deviation (SD). Data entry and statistical analysis were performed using Microsoft Excel version 2010.


  Results Top


During the study period, 100 AVF-related endovascular procedures involving transbrachial artery access were performed for 73 patients (among 308 hemodialysis access endovascular interventions done during the same time period). The mean age of the patients was 62.8 years (SD: 11.4, range: 39–84). The demographics and medical comorbidities of the studied patients are listed in [Table 1]. In 61 procedures, the patients were on long-term antiplatelet use (42 on aspirin, 8 on clopidogrel, and 11 on dual-antiplatelet agents). In five procedures, the patients were on long-term oral anticoagulant, with the INR immediately before the procedure ranged between 1.06 and 1.8.
Table 1: Demographics and comorbidities of the studied patients (n=73)

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The indications of endovascular procedures were dysfunctional AVF (n = 82), thrombosed AVF (n = 9), failure to mature (n = 8), and DASS (n = 1). [Table 2] shows the types of AVFs being treated, the sites of stenoses, and the number of lesions in each AVF circuit. Majority of the fistulas treated were radiocephalic AVFs. The common sites of stenosis for dysfunctional, thrombosed, and failure-to-mature AVFs were juxta-anastomotic region (74%) seconded by dialysis cannulation zone (67.7%). Six patients had concomitant outflow vein and central vein stenosis on the top of an inflow stenosis which required treatment. Forty-three out of the total treated AVFs had double lesions, and 26 had more than two lesions.
Table 2: Summary of the types of arteriovenous fistulas being treated, lesion location, and number of stenotic lesions

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[Figure 1] illustrates the utilization of TBA in the 100 AVFs endovascular procedures and the respective outcomes. Thirty-two procedures had a 20G cannula inserted transbrachially for fistulogram only. In the 68 procedures where an introducer sheath was inserted through the brachial artery, 50 of those were 4 Fr, 14 were 5 Fr, and four were 6 Fr. Bolus heparin was administered in 16 procedures. In four procedures, no hemodynamically significant lesion was found. In the rest of the 96 procedures, balloon angioplasty was the therapeutic treatment. No bail-out stenting was required. For fistula cannulation zone lesions, 0.035” platform high pressure (Mustang 6–8 mm, Boston Scientific Corporation, Marlborough, Massachusetts, USA) and ultra-high-pressure (Conquest 6–8 mm, Bard Peripheral Vascular Inc., Tempe, Arizona, USA) angioplasty balloons were used. For inflow segment stenosis, 0.018” platform angioplasty balloons (Sterling 4–7 mm, Boston Scientific Corporation, USA) and 0.035” platform high-pressure balloons (Mustang, 4–6 mm, Boston Scientific Corporation, USA) were used. Forearm arterial stenosis was treated by 0.014” platform angioplasty balloons (Advance LP14, 2–3 mm diameter, Cook Medical, Bloomington, Indiana, USA). For concomitant outflow segment and central vein lesions, 0.035” high-pressure (Mustang 7–12 mm Boston Scientific Corporation, USA) and ultra-high-pressure (Conquest, 7–12 mm, Bard Peripheral Vascular Inc., USA) angioplasty balloons were used. Technical success of the 96 therapeutic interventions was 98.9%, with one thrombosed radiocephalic AVF failed to be salvaged after both transbrachial and transfistula approaches and required proximal surgical revision of the AVF in the same procedure. There was no acute thrombosis of AVF or major perforation of the fistula requiring stenting or fistula ligation for hemostasis. Postintervention, clinical success was achieved in all dysfunctional AVFs, in the seven thrombosed AVFs, as well as in the DASS condition. Seven failure-to-mature AVFs matured within 3 months' period postintervention. Only one still failed to mature and required surgical revision to more proximal region 3 months after the intervention. Clinical success was achieved in 97.9% (94 out of 96 therapeutic procedures) of the studied procedures.
Figure 1: Flowchart illustrating the utilization of transbrachial artery access in the 100 endovascular procedures and the respective outcomes

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There was no major complication recorded for the 100 transbrachial artery accesses. Only two cases with hematoma developed over the brachial artery puncture site (both had 5 Fr sheath inserted) and resolved with conservative management. One of these two patients was taking long-term aspirin and the other one was not on any antiplatelet or anticoagulant agent. No unplanned admission was required for all outpatient procedures. No delay in the onset of bleeding, pseudoaneurysm, nerve palsy, brachial artery thrombosis, or dissection was detected during patients' follow-up.


  Discussion Top


The circuit of a hemodialysis AVF consists of an inflow artery, arteriovenous anastomosis, venous fistula, as well as outflow and central veins. This special anatomy of the AVFs enables interventionists to use various different approaches, namely transfistula, transbrachial, and transradial arteries and trans-deep vein to access into the system percutaneously and conduct the treatments. In endovascular therapies, the access site plays an important role to influence procedural success. In lower-limb interventions for peripheral arterial disease, the adoption of retrograde popliteal and tibial artery access had greatly improved the procedure's success rate [11],[12] in crossing difficult chronic occlusion lesions. In AVF endovascular interventions, transfistula access is usually the preferred access because of the ease to puncture, accommodation of larger size sheath, and ease of hemostasis. Nevertheless, the anatomy of AVFs including the angle of arteriovenous anastomosis, size, and aneurysmal change of venous fistula; degree of tortuosity; number and size of collaterals; severity of calcification; and diameter of the inflow artery varies greatly among the AVFs. Furthermore, different disease conditions of AVFs namely dysfunctional, acute thrombosis, failure to mature and DASS require different strategies of endovascular intervention. A single approach of access may not be good enough for the successful intervention of all kinds of AVFs and pathologies.

It has been a long-time controversy whether transbrachial artery access is a risky approach for various endovascular interventions. Grollman and Marcus [3] in 1988 reported a 7% major complication rate over the TBA performed for various kinds of endovascular interventions and discouraged the use of TBA. Watkinson et al.[4] reported an even higher (11%) major complication rate associated with TBA for endovascular treatment of aorto-iliac occlusive disease. Whereas for AVF interventions, a much lower major complication rate (4%) was reported by Manninen et al.[5] in 2001. On the contrary to the previously mentioned studies, Gritter et al.[10] and Basche et al.[13] reviewed an extensive number of TBA procedures (660 and 2555, respectively) and reported major complication rate of only 0.3% and overall complication rate of 0.47%. In the current study, 2% of minor complication rate and 0% of major complication rate were recorded from the 100 AVF endovascular procedures using TBA approach, despite the study being conducted on a group of patients with significant medical comorbidities and high percentage of long-term antiplatelet agent usage. The result of this study further showed that TBA for AVFs can be safely done in an outpatient procedural setting. The wide discrepancies of TBA complication rate indicate that TBA has potential risk but can be done safely with certain maneuvers. Watkinson and Hartnell [4] suggested a change in practice using introducer sheath rather than direct catheter access through brachial artery which prevented most of the arterial complications. The authors believe that the adoption of routine USG guidance for percutaneous brachial artery puncture is one of the ways to minimize complications arising out of TBA. USG-guided brachial artery access enables an interventionist to fully interrogate the brachial artery before the actual puncture. The interventionist needs to avoid the puncture of brachial artery with unfavorable features including heavy calcification, small caliber, situated deeply, tortuous, or situated underneath the brachial vein or venous fistula. In the presence of those hostile features, a better segment of the brachial artery can be chosen for needle puncture, or the TBA should be abandoned.

To treat AVF inflow problems, retrograde transfistula access is usually the first choice of access for endovascular interventions. Nonetheless, retrograde transfistula angiogram through the sheath is against the flow; one has to compress the outflow vein and sometimes also the inflow artery together during contrast injection to achieve a good image of the fistula's inflow segment. Despite that, sometimes, the angiographic image of the inflow segment might still be unsatisfactory if there are numerous collaterals of the fistula over the region [Figure 2]a. A catheter can be parked into the inflow artery to perform an angiogram provided the guidewire has crossed through the inflow segment into the artery. This could be difficult in situations with long-segment juxta-anastomosis stenosis, extensive aneurysmal change next to the stenotic site, or highly tortuous inflow segment. TBA and transradial access enable simple and good angiographic images as the contrast media will go with the blood flow rather than against [Figure 2]b. 20G cannula insertion into the brachial artery allows interventionist to perform angiogram easily at any stage of the intervention without the need of repeatedly exchanging the diagnostic catheter into the inflow artery and yet only adding minimal hemostasis risk or time to the procedure. Lui et al.[14] reported that no major complication and no surgical intervention were required for AVF interventions where transbrachial 20G cannula was inserted under ultrasound-guidance for angiogram purpose.
Figure 2: (a) An example of transfistula angiogram of the right radiocephalic fistula showing large amount of collateral vessels affecting the proper interrogation of the juxta-anastomotic segment. (b) Transbrachial artery access angiogram (20G cannula) of the same fistula as of Figure 2A reveals high-grade juxta-anastomotic stenosis

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In situation of failure-to-mature AVFs, the pathologies are usually due to neointimal hyperplasia of the anastomosis or juxta-anastomosis segment.[15],[16] Transfistula access may induce trauma to the relatively small-caliber, immature venous fistula and result in future stenosis. The cannulation may also be technically difficult. In such cases, TBA and transradial access could be the more preferred accesses.

Transradial access is being advocated for AVF interventions as it provides good imaging of both the artery and the venous fistulas, with low bleeding and limb ischemia risk.[1],[17] Usually, the radial artery could accommodate up to 6 Fr sheath, thus enabling the commonly used angioplasty balloons to pass through. Nonetheless, in some occasions, transradial access may not be feasible e.g. radiocephalic anastomosis very close to the wrist, heavily calcified and small caliber distal radial artery, or occluded distal radial artery. Furthermore, in patients with significant calcified plaque present near the AV anastomotic region, transradial balloon angioplasty might shift the plaque toward the inflow artery. This may not be easily detectable on angiogram during the procedure.

Anatomical variations of AVFs are extensive. Although majority of lesions can be easily traversed using transfistula approach, in some specific anatomical conditions, transfistula crossing could be much difficult than TBA or transradial approach. [Figure 3]a illustrates a patient with radial artery to swing forearm loop basilic vein AVF developed several regions of stenosis: two over the swing segment of the fistula (single arrow) and another over a juxta-anastomotic segment (double arrow). It was difficult to cross the juxta-anastomotic stenosis via transfistula approach because of the adjacent aneurysmal area [Figure 3]b. Additional TBA approaches enabled successful crossing of the juxta-anastomotic lesion and effective treatment of the stenosis [Figure 3]c. Transfistula, transradial, and transbrachial artery access is not a mutually exclusive technique. A combination of these access methods enables effective and successful treatment of wide varieties of dysfunctional AVFs. As the need of an additional access might arise unpredictively during the intervention, interventionists should clean and prepare the upper limb in a way able to accommodate additional access any time during the procedure.
Figure 3: (a) Angiogram of the left forearm radio-basilic fistula showing juxta-anastomosis (double arrow) and swing segment stenosis (single arrow). (b) Difficult wire crossing of the juxta-anastomotic stenosis via transfistula approach due to adjacent aneurysmal segment. (c) Additional transbrachial artery access enables wire crossing of the juxta-anastomotic stenosis and successful fistuloplasty of all lesions

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Problems associated with AVFs requiring endovascular therapies are predominately stenosis or thrombosis along the circuit. Nevertheless, angiogram and endovascular therapy play an important role in the management of some of the fistula-related complications such as DASS. DASS is a complex syndrome with many different causes as well as a variety of treatment options.[18],[19] Among the various key investigations for DASS, angiogram of the upper-limb arteries provides valuable information on disease diagnosis and the mechanism of steal syndrome. A detailed whole upper-limb angiogram requires femoral artery retrograde access and catheter contrast injection from the origin of the subclavian artery all the way to the digital arteries of the hand. In regions with a high incidence of diabetes-induced renal failure, small-vessel disease involving the radial and ulnar artery obstruction is common. When proximal artery obstruction is being excluded with noninvasive bilateral brachial pressure measurement, antegrade TBA is a good and convenient method to diagnose and treat radial and ulnar artery obstruction. In the single procedure for DASS in this study, transbrachial angiogram revealed the patency of the radial and ulnar arteries as well as evaluated the competitive blood flow between the fistula and the forearm arterial system. Ulnar artery occlusion was detected and through the TBA sheath, balloon angioplasty of the ulnar artery lesion was performed (Advance LP14 2 mm/80 mm, Cook Medical, USA). Banding of the AVF juxta-anastomotic segment (to 4 mm) was also performed during the same procedure because contrast flow to the treated ulnar artery was still sluggish compared to the fistula after ulnar artery angioplasty. After the banding of AVF inflow segment, improved contrast flow through the ulnar artery into the hand was observed.

When an introducer sheath is being inserted into the brachial artery, postprocedure hemostasis must be performed meticulously with firm digital pressure for 5–15 min depending on the sheath size, severity of arterial calcification, blood pressure, and coagulation status of the patient. Many hemodialysis patients have hypertension. Effective control of systolic blood pressure before sheath removal facilitates hemostasis.[20] Bolus nitroglycine (200 μg) was routinely given by the author before TBA sheath removal if the systolic blood pressure is >160 mmHg. Limiting the size of sheath used in TBA by using smaller profile therapeutic devices (e.g., 0.018” platform angioplasty balloon) also minimizes bleeding complication after brachial artery access. Nonetheless, the choice of angioplasty balloon has to balance between device profile and the adequacy of balloon pressure to dilate the stenotic lesion. Some clinicians apply compression devices (e.g., TR Band radial compression device, Terumo Interventional Systems, Somerset, New Jersey, USA,[21] BS Hemostasis Device, Dairin, Japan) to achieve hemostasis and reduce the manual compression time. Clinicians may choose the appropriate method based on their institution's resources and logistics for brachial artery hemostasis.

Hemodialysis access circuit involves both artery and vein, and the anatomical variation is extensive. Problems associated with hemodialysis access also come with different varieties. Interventionists specialized in endovascular therapies for hemodialysis access should acquire the skill of all different access methods and be able to perform all of them safely so as to expand the armamentarium to tackle challenging anatomy and difficult-to-treat lesions.

This study reviewed only a single clinician's work in a tertiary health-care center. The result may or may not be implied to the wider interventional community. Multicentric, large-scale review of ultrasound-guided TBA AVF interventions is required to give more representative information.


  Conclusions Top


Ultrasound-guided TBA is a safe approach for endovascular intervention of hemodialysis AVFs. It can be used to provide fistulogram during the intervention or for therapeutic purpose. TBA shall be considered as an important armamentarium for endovascular treatment of diseased AVFs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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