Open Exposure Can Reduce Brachial Access Complications in Patients Undergoing Peripheral Vascular Interventions

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Arm access has become a common strategy for peripheral vascular interventions (PVIs) now that catheters and devices have increased in length. Access via the brachial artery has clear advantages over the radial artery, including the ability to upsize to a larger sheath.

The downside of brachial access is that complication rates are significantly higher with femoral access—as high as 12% in some series. Most PVIs performed via brachial access employ the percutaneous method, but some studies have found that open arterial access (the cutdown method) is associated with fewer brachial access complications.

In one of the largest studies examining patients undergoing PVIs via brachial access, Charles DeCarlo, MD, surgical resident, Samuel I. Schwartz, MD, vascular surgeon of the Division of Vascular and Endovascular Surgery at Massachusetts General Hospital, and colleagues determined that percutaneous brachial access appears safe overall, but certain risk factors may make open exposure more advisable. Their report appears in the Journal of Vascular Surgery.

Study Methods

The researchers made use of the Vascular Quality Initiative, a national, prospectively maintained registry that collects data on common vascular procedures performed at over 500 institutions in the U.S. and Canada. They identified 1,400 PVIs performed with brachial access on 1,242 patients between 2016 and 2019. Open exposure was used in 189 of those procedures (13.5%).

Primary Outcome

The primary outcome was brachial access complications, defined as the composite of hematoma, stenosis/occlusion, infection, pseudoaneurysm and arteriovenous fistula. Access complications occurred in three (1.6%) of the 189 cutdowns and 91 (7.5%) of the 1,211 percutaneous procedures (P=0.002).

Operative Complications

Operative brachial access complications were defined as those requiring interventional or surgical repair. All three access complications in the cutdown group were operative as were 37 of the 91 complications in the percutaneous group (41%; P=NS).

Individual Components of the Composite Outcome

The difference in complications between open exposure and percutaneous access was driven by hematomas, most of which were managed nonoperatively:

Hematoma—0.5% of open group vs. 5.9% of the percutaneous group (P=0.002)

• Operative—0.5% vs. 1.4% (P=NS)

Stenosis/Occlusion—1.1% vs. 1.1% (P=NS)

• Operative—1.1% vs. 1.1% (P=NS)

Pseudoaneurysm—0.0% vs. 1.6% (P=NS)

• Operative—0.0% vs. 1.0% (P=NS)

Multivariable Analyses

Brachial access complications were independently associated with:

• Percutaneous access (OR, 5.92)
• Female sex (OR, 2.23), presumably because of smaller vessels
• Heart failure (OR, 2.02)
• Increasing sheath size (OR, 1.36 per French size)

Diabetes was protective of brachial access complications (OR, 0.53).

When a 4 French sheath was used as a reference, the rates of brachial access complications in percutaneous cases were significantly higher for:

• 5 French (OR, 4.18)
• 6 French (OR, 5.73)
• 7 French (OR, 4.49)

Applying the Findings to Practice

The choice between percutaneous access or open exposure is one of the few controllable risk factors for brachial access complications. Therefore, a reasonable strategy is to base the decision on the presence or absence of other risk factors.

Percutaneous access should be used cautiously in women, patients with heart failure, those without diabetes and those undergoing interventions where a sheath 5 French or larger will be required.

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