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Arterial cutdown reduces arm-access complications in endovascular peripheral interventions
In endovascular peripheral vascular interventions, the use of arterial cutdown and smaller sheath diameters may reduce the risk for brachial access site complications.
For a recent study, researchers evaluated retrospective data from the peripheral vascular intervention database of the Society for Vascular Surgery Vascular Quality Initiative (SVS VQI). Included in the analysis were all patients who were treated with peripheral vascular interventions (n = 44,634) between 2010 and 2014. Of these, 732 procedures used brachial artery access and 43,902 used femoral access.
The primary outcome was access site complications, which included puncture site hematoma and access site stenosis/occlusion. The researchers evaluated this outcome in terms of the following patient-specific variables: age, BMI, sex, smoking status, diabetes, CAD, congestive HF, chronic obstructive pulmonary disease, chronic kidney disease, dialysis dependence, ambulatory status, and preoperative use of aspirin or clopidogrel or oral anticoagulation. Also included in the analysis were procedural variables such as access site, access guidance (none, fluoroscopy, ultrasound or cutdown), intraprocedural use of heparin, protamine and bivalirudin, largest sheath size (≤ 5F vs. > 5F) and closure device use.
The researchers found a significantly increased rate of overall complications with brachial access vs. femoral access (9% vs. 3.3%; P < .001). Analysis of individual complications also revealed that brachial access was associated with higher rates of access site hematoma (7.2% brachial access vs. 3% for femoral access; P < .001) and access stenosis/occlusion (2.1% brachial access vs. 0.4% for femoral; P < .001). Moreover, hospital admission was required for a higher percentage of brachial access complications vs. those related to femoral access (4% vs. 2.2%; P < .001).
Of the 732 patients with single brachial access, the use of arterial cutdown was more prevalent among patients on dialysis, patients receiving anticoagulation and procedures that needed sheaths greater than 5F. No association was seen between BMI, sex or age and cutdown for access. According to univariate analysis, age, BMI, female sex and diabetes were associated with access site complications, and trends were also seen for sheath size (P = .07) and access guidance (P = .07). Arterial cutdown was associated with a lower rate of complications (4.1%) vs. percutaneous access guided by ultrasound (11.8%) or fluoroscopy (7.3%).
Multivariate analysis revealed significantly reduced risks for access site complications in association with male sex (OR = 0.47; 95% CI, 0.27-0.83) and arterial cutdown (OR = 0.25; 95% CI, 0.007-0.87). Conversely, sheath size greater than 5F was correlated with an increased risk for access site complication (OR = 2.19; 95% CI, 1.07-4.49).
In a stratified analysis of the impact of surgeon experience on access site complications, the researchers grouped individual surgeons into quintiles of total case volume and percentage of cases using brachial access. Surgeon experience by total case volume ranged from 26 to 309 cases. The least experienced group had a 6.8% rate of arm access complications vs. a 9.8% rate in the most experienced group. No significant differences in complication rates were seen across all groups (P = .8). Likewise, brachial access experience did not influence complication rates (P = .02).
“Although used much less frequently than the femoral artery, brachial artery access offers an attractive option because of its typically superficial nature as well as its acceptable caliber for interventional sheaths and guiding catheters,” the researchers wrote. “Using the SVS VQI peripheral vascular intervention database, we have observed significantly increased overall complication rates with brachial vs. femoral access. … Both arterial cutdown and smaller sheath diameters are associated with decreased risk of brachial access site complications and should be considered when the brachial artery is used for peripheral vascular intervention.” – by Jennifer Byrne
Disclosure: The researchers report no relevant financial disclosures.