Trans-brachial Artery Access for Coronary Artery Procedures is Feasible and Safe: Data from a Single-Center in Macau
Trans-radial artery access (TRA) has become the preferred approach for percutaneous coronary interventions (PCI) due to its significant advantages over trans-femoral artery access (TFA). TRA has been shown to reduce 30-day mortality, in-hospital major adverse cardiac and cardiovascular events, major bleeding, and access site complications. Additionally, TRA allows for immediate patient ambulation post-procedure, potentially shortening hospitalization and even enabling same-day discharge in some cases. Despite these benefits, TRA has limitations, including the small diameter of the radial artery, arterial spasm, tortuosity, anatomic variants, a longer learning curve for operators, and the risk of asymptomatic radial artery occlusion. These limitations can restrict future cardiac catheterization, bypass grafts, and dialysis fistulae. When TRA fails, TFA is typically the alternative, but trans-brachial artery access (TBA) is increasingly being considered as a viable option. This study evaluates the feasibility and safety of TBA for PCI when TRA fails.
The study was conducted at Centro Hospital Conde de Sao Januario in Macau, involving 1708 consecutive patients who underwent coronary angiography and PCI between January 1, 2013, and December 31, 2017. Of these, 143 cases (8.4%) where TRA failed were enrolled in the study. These patients were switched to either TBA or TFA based on the operator’s preference. The study collected data on risk factors, comorbidities, procedural outcomes, and follow-up clinical outcomes for both TBA and TFA groups.
During the procedure, the modified Seldinger technique and size six-French sheaths were used for brachial and femoral artery puncture. A total of 3000 units of unfractionated heparin was administered for angiography, and 100 units/kg body weight was given for PCI. The sheath was removed immediately after angiography (2 hours for TBA and 4 hours for TFA post-PCI). Hemostasis was achieved through direct compression, followed by further compression with an elastic bandage, allowing palpation of the distal pulse under oximetry monitoring. Elbows were immobilized using arm boards for the TBA group. In-hospital procedural outcomes, including vascular complications, cardiac death, non-fatal myocardial infarction, and stroke events, were recorded. Follow-up clinical outcomes, including vascular and neurological complications, were assessed during cardiology clinic visits.
The study found that the successful rate of TRA was 91.6% (1565/1708). Of the 143 cases where TRA failed, 25 (17.5%) underwent TBA, and 118 (82.5%) underwent TFA. The successful rate of TBA was 96.2% (25/26), with one case switched from TBA to TFA. In terms of in-hospital procedural outcomes, the TBA group had no significant difference in vascular complications compared to the TFA group (8.0% vs. 3.4%, P > 0.05). There were no significant differences in cardiac death, non-fatal myocardial infarction, or stroke events between the two groups. After adjusting for age, gender, hypertension, diabetes mellitus, tobacco use, dyslipidemia, primary PCI, and glycoprotein (GP) IIb/IIIa inhibitors, multiple logistic regression analysis showed no statistical difference between TBA and TFA groups regarding the risk of in-hospital procedure outcomes (odds ratio: 3.39, 95% confidence interval [CI]: 0.33–34.44, P = 0.302).
The average follow-up interval in the cardiology clinic was 889.3 days (approximately 29.6 months). The clinic follow-up rates for TBA and TFA groups were 100.0% and 97.2%, respectively. Neither vascular nor neurological complications were observed in both groups during follow-up visits. Cox regression analysis, after adjusting for the same variables, found no statistical difference between TBA and TFA groups concerning the risk of follow-up clinical outcomes (hazard ratio: 1.36, 95% CI: 0.50–3.73, P = 0.551).
Regarding vascular complications, there were two cases in the TBA group: one minor bleeding on the puncture site requiring re-admission and one major bleeding on the puncture site that was managed with blood transfusion and discharge. In the TFA group, there were four cases of vascular complications: one femoral vein thrombosis and three cases of major bleeding requiring blood transfusion, one of which resulted in death due to acute myocardial infarction. No deaths occurred during hospitalization or due to vascular complications during the follow-up period.
The study highlights that TBA is often considered outdated and risky due to higher rates of vascular and neurological complications compared to other access sites. However, with proper technique and experience, TBA can be a safe and effective alternative when TRA fails. The brachial artery, brachial vein, and median nerve are contained within the medial brachial fascial compartment, making hemostasis challenging and increasing the risk of nerve injury, especially in anticoagulated patients. Despite these challenges, the study demonstrates that TBA can achieve high procedural success rates with minimal complications when performed by experienced operators.
Previous studies have shown mixed results regarding TBA. Kiemeneij et al. found that while procedural and clinical outcomes of PTCA were similar among TRA, TBA, and TFA groups, major access site complications were more frequent in TBA and TFA groups. Sabbah et al. reported that TBA and TRA were associated with higher procedural success compared to TFA, with lower rates of major adverse cardiac events (MACE) and in-hospital cardiac death. Gan et al. found that TBA had a slightly lower incidence of major complications compared to TFA, with no cases of brachial artery thrombosis or neurological dysfunction. Melon et al. concluded that TBA was as safe and effective as TFA, with shorter procedure and fluoroscopy times.
In the context of this study, TRA was the default access for most coronary angiography and PCI procedures, even in primary PCI. TFA was typically used for post-coronary artery bypass graft cases or those with complicated coronary anatomy. The study suggests that forearm artery access, including TRA, TUA, and TBA, offers advantages such as earlier ambulation, reduced post-procedure nursing workload, lower hospital costs, and shorter length of stay. It also expands the capability to perform complex procedures, such as intra-aortic balloon pumping insertion via TBA.
The study acknowledges several limitations, including the small sample size of TBA and TFA groups, the initial learning curve for TBA, the non-randomized nature of the study, and the preference for TFA in primary PCI cases to shorten door-to-balloon time. Despite these limitations, the study concludes that TBA is a feasible and safe alternative for PCI when TRA fails in Macau. Further experience with TBA is expected to enhance its adoption and safety in the future.
doi.org/10.1097/CM9.0000000000000274
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