|Year : 2021 | Volume
| Issue : 4 | Page : 369-372
An unusual cause for median nerve palsy after brachial catheterization: Report of two cases
Thilina Gunawardena1, Manujaya Godakandage2, Rezni Cassim2, Mandika Wijeyaratne2
1 Department of Renal Transplant, Royal Liverpool University Hospital, Liverpool, United Kingdom; Department of Vascular and Transplant Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
2 Department of Vascular and Transplant Surgery, Faculty of Medicine, University of Colombo, Colombo, Sri Lanka
|Date of Submission||18-Jul-2021|
|Date of Decision||10-Aug-2021|
|Date of Acceptance||13-Aug-2021|
|Date of Web Publication||9-Dec-2021|
Department of Renal Transplant, Royal Liverpool University Hospital, Liverpool; Department of Vascular and Transplant Surgery, Faculty of Medicine, University of Colombo, Colombo
Source of Support: None, Conflict of Interest: None
Median nerve palsy is an uncommon complication of brachial artery catheterization. Compression from a pseudoaneurysm at the puncture site is rarely implicated as the cause for such median nerve dysfunction. Here, we report two patients who developed median nerve palsy secondary to compression from pseudoaneurysms after brachial catheterizations done for chronic lower limb ischemia. Both underwent operative repair of the culprit lesions. Despite months of aggressive physiotherapy, recovery of nerve function remains poor in both.
Keywords: Access-site complications, brachial artery catheterization, brachial pseudoaneurysm, median nerve palsy
|How to cite this article:|
Gunawardena T, Godakandage M, Cassim R, Wijeyaratne M. An unusual cause for median nerve palsy after brachial catheterization: Report of two cases. Indian J Vasc Endovasc Surg 2021;8:369-72
|How to cite this URL:|
Gunawardena T, Godakandage M, Cassim R, Wijeyaratne M. An unusual cause for median nerve palsy after brachial catheterization: Report of two cases. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Jan 27];8:369-72. Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/369/332058
| Introduction|| |
Minimally invasive percutaneous interventions for peripheral vascular diseases are on the rise. The femoral artery is the preferred site of arterial access for the majority of such procedures. The brachial artery provides an alternative route in certain situations. After brachial artery puncture, access-sit complications have been reported to occur in 6.5%. Median nerve dysfunction is one such uncommon but important complication because of its disabling nature. Median nerve palsy as a result of compression from a pseudoaneurysm arising from the puncture site is an extremely rare possibility. We present two patients who developed this complication following left brachial artery catheterization.
| Case Report|| |
The first patient was a 79-year-old male, a nonsmoker who presented with an ischemic ulcer at his left big toe. He was referred to the interventional radiology team for balloon angioplasty. After failed ipsilateral common femoral artery puncture, left brachial artery access was obtained. Ultrasound (US)-guided puncture was done at the mid-arm as the vessel wall was noted to have some minor calcifications at the level of the antecubital fossa. The initial entry was with an 18 G needle, and balloon angioplasty of the left external iliac, and left superficial femoral arteries was done through a 6 Fr sheath. At the end of the procedure, hemostasis was achieved by manual compression of the puncture site. On the same day evening, the patient complained of bruising and swelling of the left arm along with pain and numbness of the left hand [Figure 1]a. On examination, good volume ipsilateral radial and ulnar pulses were present and a pulsatile mass with indistinct borders was felt at the puncture site. A duplex scan showed a 1 cm × 1 cm size pseudoaneurysm arising from the brachial artery at the site of catheterization [Figure 1]c. Over the next 24 h, the pain worsened and the patient developed motor weakness compatible with median nerve dysfunction [Figure 1]b. Due to progressive symptoms, a decision was taken to repair the pseudoaneurysm.
|Figure 1: (1st patient): (a) The left arm with swelling and bruising, (b) median nerve motor weakness, (c) pseudoaneurysm (white arrow) on duplex), (d) the defect in the arterial wall (yellow arrow)|
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Proximal and distal control of the brachial artery was obtained, the hematoma evacuated and the defect in the arterial wall repaired [Figure 1]d. The median nerve appeared to be macroscopically intact, and neurolysis was done. After the surgery, the patient was started on physiotherapy. At 1 year from surgery, despite physiotherapy, the patient is suffering from residual motor weakness and numbness of his left hand [Figure 2].
|Figure 2: Follow-up in the first patient at 6-month depicting residual motor weakness and burn injury to the thumb (black arrow) due to numbness|
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The second patient was a 69-year-old male ex-smoker diagnosed with diabetes, hypertension, and disabling lower extremity intermittent claudication due to bilateral aortoiliac disease. He underwent bilateral lower limb angiography with intent for intervention via left brachial artery access. The artery was punctured at the mid-arm level as the vessel diameter at the elbow appeared too small. US-guided entry was with an 18 G needle and the procedure was done through a 6 Fr sheath. Angioplasty was not successful as it was technically difficult to cross the chronic, long segment occlusions in bilateral iliac vessels. The sheath was withdrawn and hemostasis was achieved by manual compression. On postprocedure day 1, there was a painful swelling of the left arm with preserved distal perfusion. On the next day, there was numbness and weakness attributable to left median nerve dysfunction. A duplex scan showed a 2 cm pseudoaneurysm arising from the brachial artery at the puncture site [Figure 3]. Operative repair was undertaken and the defect in the artery was repaired with 6-0 polypropylene. As in the first patient, the median nerve did not appear to have any external injuries. At the end of 6 months, despite aggressive physiotherapy, the patient has a poor recovery of his nerve function.
|Figure 3 (2nd patient): (a) Duplex imaging of the pseudoaneurysm, (b) computed tomography angiogram (pseudoaneurysm marked with the white arrow)|
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| Discussion|| |
The femoral artery is the preferred access site for peripheral arterial endovascular procedures due to the technical ease of puncturing, low complication rate, and the feasibility of achieving hemostasis with direct compression. The brachial artery is an alternative access route in situations where the femoral artery is not suitable. The reasons can be a nonpulsatile femoral artery, recent surgery on the femoral artery, or an abnormal vessel wall due to the presence of severe atherosclerosis or aneurysmal degeneration. In the presence of prosthetic graft material within the vicinity, femoral punctures are generally avoided to prevent infection. Some believe that brachial catheterization provides certain advantages over the femoral route, such as improved patient comfort, decreased nursing requirements, and early mobilization.
When the brachial artery is used for arterial access, the left is preferred over the right as it provides a direct route to the descending aorta and the lower extremity vasculature, avoiding passage through the aortic arch. Traversing the aortic arch theoretically increases the risk of embolic stroke. The right brachial artery is accessed when ipsilateral upper limb disease needs to be treated or when there is a contraindication to use the left such as the presence of an arteriovenous fistula.
Alvarez-Tostado et al. reported a 6.5% complication rate after analyzing 289 patients who underwent peripheral diagnostic or interventional procedures via brachial artery access. Pseudoaneurysms, brachial artery thrombosis, and hematoma formation were the complications reported in their case series. No median nerve injuries were reported by them. According to Kennedy et al., 0.2%–1.4% of patients who underwent cardiac catheterization via brachial artery punctures suffered a median nerve injury. As reported by Tamanaha et al., the incidence of pseudoaneurysm was significantly higher in brachial access compared to femoral. This was probably because manual compression of the brachial artery tends to be less effective as it is more mobile compared to the latter. Armstrong et al. reported a 1.28% incidence of complications after using the brachial route for peripheral angiography. In their case series which had >1000 procedures, the incidence of pseudoaneurysm was 0.3% and there were no median nerve injuries.
Pseudoaneurysm of the brachial artery is rarely implicated as the cause for median nerve dysfunction following brachial catheterization. Compression of the median nerve by hematoma, direct nerve damage due to faulty puncture technique, ischemia of the nerve by thrombosis of the brachial artery, and compression of the nerve by scar tissue have been reported as other possible mechanisms of median nerve injury after brachial access. Direct trauma to the nerve is likely to manifest with immediate symptoms. Both of our patients developed nerve dysfunction hours after the procedure, and the nerve appeared to be macroscopically intact during operative exploration. Hence, we believe that compression from the pseudoaneurysms was the most likely cause for the median nerve palsies seen in both of them.
Anticoagulant use, hypertension, obesity, use of large sheaths (≥7 Fr), hemodialysis, incorrect technique, inadequate compression, puncture of the artery at a site that is difficult to compress, concomitant catheterization of the artery and the vein, and the presence of vessel wall calcification have been identified as risk factors for pseudoaneurysms after femoral catheterization. According to Alvares-Tostadao, pseudoaneurysm following brachial puncture was more common in females, but this association was statistically insignificant. Factors such as the diameter of the sheath used, the method of achieving postpuncture hemostasis, and US-guided versus blind puncture have not been identified as significant risk factors for access-site complications after brachial artery catheterization.
Asymptomatic, small pseudoaneurysms that occur following brachial catheterization can be managed conservatively. Presence of median nerve dysfunction warrants intervention. In the handful of the reported cases, surgery was the preferred therapeutic approach. Alternative minimally invasive techniques of managing pseudoaneurysms are not suitable in this situation as repair of the arterial defect should be accompanied by evacuation of the hematoma to relieve the pressure effect on the nerve. According to Ochi et al., repair of the pseudoaneurysm combined with median nerve neurolysis leads to better functional outcomes. After surgical repair of the pseudoaneurysm, aggressive physiotherapy is mandatory to achieve better functional results.
The majority of those who suffer from medial nerve injury as a result of complicated brachial artery access do not achieve complete functional recovery of the nerve.,, This phenomenon was seen in both of our patients. This contrasts with femoral neuropathy after groin catheterization, where complete recovery of the nerve function can be expected. The consequences of long-term median nerve dysfunction can be devastating as reported by Colville and Colin, where a patient thus affected was unable to resume her occupation.
With advances in endovascular techniques, now, it is feasible to perform lower extremity revascularizations procedures through a transradial approach. A meta-analysis involving 638 patients that underwent percutaneous treatment for aortoiliac and femoropopliteal lesions reported an overall complication rate of 1.9%, which is comparatively lower than that for the brachial access route. However, the transradial approach has certain disadvantages such as a prolonged learning curve and technical difficulties in maneuvering endovascular devices over long distances, through small-caliber arteries.
Alternative methods of access-site closure such as open suture closure or utilization of closure devices may potentially minimize the complications after brachial access. However, robust studies that provide level-1 evidence on the comparative efficacy and safety of these different techniques are not available at present. The use of proprietary closure devices for achieving hemostasis after brachial access is on the rise, and the results from large case series appear to be promising.
| Conclusions|| |
Although rare, median nerve dysfunction as a result of compression by a pseudoaneurysm is a devastating complication of brachial catheterization. Those who perform diagnostic or therapeutic procedures via brachial access should be aware of this complication and patients should be adequately counseled. The median nerve function should be evaluated before and after the procedure, and if median nerve dysfunction is detected, prompt action should be taken to identify and treat correctable causes.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]