A rare clinical case of stenotic lesion of the brachial artery

Above the ulnar collateral artery

(
inferior to the profunda artery
), small in size, arising from the brachial artery just below the middle of the shoulder; it often arises from the top of a. profunda brachii.

It pierces the medial intermuscular septum, and descends on the surfaces of the medial head of the triceps humerus into the space between the medial epicondyle and the process, accompanied by the ulnar nerve and ends under the flexor carpi ulnaris by anastomosis with the posterior ulnar recurrent, and the inferior ulnar collateral.

Sometimes it sends a branch in front of the medial epicondyle to anastomose with the anterior recurrence of the elbow joint.

ARTICLE

Purpose of the study: to demonstrate a rare clinical observation of a stenotic lesion of the left brachial artery in a 69-year-old woman.

Material and methods. An ultrasound examination with simultaneous consultation with a vascular surgeon was carried out in November 2021 at the private clinic “Modern Medicine” (Balashov, Saratov region). Angioscanning was carried out on a stationary Mindray DC-7 device with a linear L2-4 MHz sensor.

Purpose of the study: to demonstrate a rare clinical observation of a stenotic lesion of the left brachial artery in a 69-year-old woman.

Material and methods. An ultrasound examination with simultaneous consultation with a vascular surgeon was carried out in November 2021 at the private clinic “Modern Medicine” (Balashov, Saratov region). Angioscanning was carried out on a stationary Mindray DC-7 device with a linear L2-4 MHz sensor.

Results. A 69-year-old woman consulted a vascular surgeon with complaints of pain with slight load in the only right lower limb (condition after amputation of the left lower limb in 2014 at the level of the upper third of the thigh due to steno-occlusive arterial lesion), as well as the inability to measure blood pressure on the left shoulder. Upon examination, the patient's condition is satisfactory. The lower leg on the right is cool to the touch, the pulsation is distinct in the iliac arteries on both sides, weakened at the level of the femoral and popliteal arteries on the right and absent in the tibial arteries. On examination, the limb is of normal color. During a general examination, systolic murmur in the projection of the right common carotid artery and the right subclavian artery (on the left - without features) attracts attention.

When performing ultrasound angioscanning of the branches of the aortic arch, a stable circular atherosclerotic plaque was revealed in the projection of the bifurcation of the right common carotid artery (stenosis no more than 50% according to NASCET), the subclavian artery is stenotic due to a thickened anterior wall of the artery (visualization is difficult) by 30-50% according to NASCET.

The next step was to examine the arteries of the upper extremities using standard methods. On the right, the arteries are passable at all levels, the main blood flow, the thickness of the intima-media complex (IMC) is no more than 0.4 mm (in places at the level of the lower third of the brachial artery (BA) IMT is up to 0.65 mm; Fig. 1). On the left, at the level of the middle third of the shoulder, attention is drawn to the thickening of the anterior wall of the VA for 4.5 cm (thickened hypoechoic layer of the media) with a maximum level of stenosis of up to 45% in diameter (uneven thickening; Fig. 2; Fig. 3). It is noteworthy that the inner layer of the VA (intima) did not have changes characteristic of atherosclerotic lesions. Distally, the bifurcation of the VA is not stenotic, the IMT is no more than 0.6 mm. The radial and ulnar arteries are without any features, main blood flow.

Thirdly, the arteries of the only right lower limb were examined. Signs of wall-occlusive lesions of the main branches with predominant damage to the distal sections were revealed (occlusion of the anterior and posterior tibial arteries due to hyperechoic calcified deposits, apparently of atherosclerotic origin). The patient was given recommendations from an angiosurgeon and a routine examination by a rheumatologist was recommended.

Discussion. The changes found in the left VA deserve special attention after an ultrasound examination of three vascular territories. The expansion of the middle layer of the VA wall, which does not quite fit into the general atherosclerotic picture, indicates the process of inflammation of the media (arteritis). The asymmetry of the process (changes were found only in the left hand) is also a big argument in favor of arteritis. Considering the presence of several publications that atherosclerotic narrowing of the VA does not occur in the population (for reasons unknown yet) [1,2], it is possible with a high degree of probability, even despite the patient’s advanced age, to assume an autoimmune genesis of damage to the arteries of the upper extremities.

Arteries of the upper limb. Brachial artery. Anatomy. Lecture for doctors

Lecture for doctors “Arteries of the upper limb. Brachial artery." A lecture for doctors is given by Doctor of Medical Sciences, Professor Edgar Sabirovich Kafarov

Additional material

Subclavian artery and its branches. Axillary, brachial arteries, their branches. Ulnar, radial arteries, their branches. Blood supply to the hand

Subclavian artery, a. subclavia, steam room, begins to the left of the aortic arch, and to the right - from the brachiocephalic trunk (Fig. 1).

Rice. 1. Branches of the aortic arch

Fig.2. Branches of the subclavian artery

In the first section, the vertebral, internal mammary arteries and the thyrocervical trunk depart from the subclavian artery. Vertebral artery, a. vertebralis, is the ascending branch of the subclavian artery. The vertebral artery passes through the transverse foramina from the sixth to the second cervical vertebrae, then pierces the posterior atlanto-occipital membrane, the dura mater of the spinal cord and enters the cranial cavity through the foramen magnum (Fig. 3).

Fig.3. Arteries of the head and neck

Here the right and left vertebral arteries approach the midline and unite at the posterior edge of the pons, forming the basilar artery (Fig. 4).

Rice. 4. Brain vessels

The vertebral artery gives off small branches to the muscles of the neck, spinal cord, and dura mater of the occipital lobes of the brain. The major branches of the vertebral artery are: the anterior spinal artery, a. spinalis anterior, which connects with the artery of the same name on the opposite side to form an unpaired artery; posterior spinal artery, a. spinalis posterior, posterior inferior cerebellar artery, a. cerebelli inferior posterior. Basilar artery, a. basilaris, is an unpaired artery, which is formed as a result of the fusion of the right and left vertebral arteries. It lies in the groove of the same name in the pons and at its anterior edge it divides into the right and left posterior cerebral arteries, a.a. cerebri posteriores. The branches of the basilar artery are paired arteries: the anterior inferior cerebellar artery, a. inferior anterior cerebelli, branching in the anterior part of the lower surface of the cerebellum; arteries of the bridge, aa. pontis, supplying the bridge; superior cerebellar artery, a. cerebelli superior.

Rice. 5. Arterial anastomoses at the base of the brain

Between the basins of the internal carotid and subclavian arteries there is an anastomosis located at the base of the brain in the form of the arterial circle of the cerebrum, circulus arteriosus cerebri [Wilisii]. The following are involved in its formation: a. carotis interna (left and right), initial sections aa cerebri anteriores, a. communicans anterior, aa communicans posteriores and a.a. cerebri posteriors from a. vertebralis (Fig. 5). On the anterior surface of the medulla oblongata, the terminal sections of both vertebral arteries and the initial sections of both anterior spinal arteries form a diamond-shaped anastomosis (Zakharchenko) (Fig. 5). Internal thoracic artery, a. thoracica interna, arises from the subclavian artery, goes down the posterior surface of the anterior chest wall lateral to the edge of the sternum and, at the level of the VII costal cartilage, branches into terminal branches: the muscular-phrenic artery, a.musculophrenica, to the diaphragm, and the superior epigastric artery, a.epigastrica superior, - to the muscles of the anterior abdominal wall. The internal mammary artery also gives off small branches: to the thymus gland; to the connective tissue and lymph nodes of the mediastinum; to the lower part of the trachea and to the main bronchi; to the chest muscles and mammary gland; pericardial phrenic artery, a. pericardiacophrenica, which accompanies the phrenic nerve and supplies the pericardium and diaphragm (Fig. 2,6).

Rice. 6. Internal thoracic artery and its branches

The thyrocervical trunk, truncus thyrocervicalis, is a thick trunk, 1.5 cm long (Fig. 6). The trunk branches into the inferior thyroid, suprascapular and ascending cervical arteries. Inferior thyroid artery, a. thyroidea inferior, goes to the posterior surface of the thyroid gland and also gives off branches to the trachea, esophagus, pharynx, and larynx. Suprascapular artery, a. suprascapularis, goes to the notch of the scapula, passes over the transverse scapular ligament and supplies the dorsal muscles of the scapula. Ascending cervical artery, a. cervicalis ascendens, supplies blood to the deep muscles of the neck and spinal cord (Fig. 2,3).

In the second section, the costocervical trunk, truncus costocervicalis, departs from the subclavian artery. Beginning in the interscalene space, it immediately divides into the deep cervical and highest intercostal arteries. Deep cervical artery, a. cervicalis profunda, goes to the semispinalis muscles of the head and neck. The highest intercostal artery, a. intercostalis suprema, branches in the first and second intercostal spaces, supplying blood to the spinal cord, soft tissues of the posterior neck and back. In the third section, the transverse artery of the neck, a. transversa colli, which pierces the brachial plexus, (Fig. 6) goes back and branches in the muscles of the back.

Axillary artery

Axillary artery, a. axillaris, is a continuation of the subclavian artery and is located in the axillary cavity. At the lower edge of the pectoralis major muscle, the axillary artery continues into the brachial artery (Fig. 7). Along the axillary artery, three sections can be distinguished: between the outer edge of the first rib and the upper edge of the pectoralis minor muscle, behind the pectoralis minor muscle, between the lower edge of the pectoralis minor muscle and the lower edge of the pectoralis major muscle.

In the first section, the following depart from the axillary artery: the superior thoracic artery, a. thoracica superior, - to the muscles of the two upper intercostal spaces; thoracoacromial artery, a. thoracoacromial, which supplies blood to the shoulder joint, acromioclavicular joint, deltoid and both pectoral muscles.

Rice. 7. Axillary artery

In the second section, the lateral thoracic artery branches off from the axillary artery, a. thoracica lateralis, which descends along the surface of the serratus anterior muscle, supplies it with blood and also gives off branches to the mammary gland. In the third section, three arteries depart from the axillary artery: a) subscapular artery, a. subscapularis, which branches into two branches: the circumflex scapular artery a. circumflexa scapulae, supplying blood to the muscles and skin of the scapular region of the back, and the thoracodorsal artery, a. thoracodorsalis, which branches in the thickness of the latissimus dorsi muscle; b) anterior circumflex artery of the shoulder, a. circumflexa humeri anterior, goes around the neck of the humerus in front and nourishes nearby muscles and the shoulder joint; c) posterior circumflex artery of the shoulder, a. The circumflexa humeri posterior passes through the quadrilateral foramen, wraps around the back of the surgical neck of the humerus and supplies nearby muscles and the shoulder joint.

Brachial artery

Brachial artery, a. brachialis, is a continuation of the axillary artery (Fig. 8). The artery passes on the shoulder along the medial edge of the biceps brachii muscle and at the level of the neck of the radius divides into two terminal branches: the radial and ulnar arteries. Branches depart from the brachial artery: 1. Deep brachial artery, a. profunda brachii, passes along with the radial nerve in the shoulder-muscular canal and spirals around the posterior surface of the humerus. Along its length, the artery gives off arteries that supply the humerus, deltoid muscle, shoulder joint, and shoulder muscles. The deep brachial artery gives off collateral arteries, a. collateralis radialis et a. collateralis media, which participate in the formation of the arterial network of the elbow joint (Fig. 8).

Rice. 8. Branches of the brachial artery

1 - axillary artery; 2 - superior thoracic artery; 3 - thoracoacromial artery; 4 - lateral thoracic artery; 5 - subscapular artery; 6 and 7 - anterior and posterior arteries that bend around the humerus; 8 - brachial artery; 9 - deep artery of the shoulder; 10 - superior ulnar collateral artery; 11 - radial collateral artery; 12 - inferior ulnar collateral artery; 13 - ulnar artery; 14 - radial artery; 15 - recurrent ulnar artery; 16 - recurrent radial artery; 17 - common interosseous artery; 18 - anterior interosseous artery; 19 - posterior interosseous artery

2. Superior ulnar collateral artery, a. collateralis ulnaris superior, arises from the brachial artery in the middle of the shoulder, lies on the posterior surface of the medial epicondyle of the shoulder and participates in the formation of the arterial network of the elbow joint. 3. Inferior ulnar collateral artery, a. collateralis ulnaris inferior, originates in the lower third of the shoulder, lies on the anterior surface of the medial epicondyle of the shoulder and participates in the formation of the arterial network of the elbow joint.

Radial artery

Radial artery, a. radialis, is a direct continuation of the brachial artery. The radial artery descends along the radius in the radial groove. In the lower third of the forearm, the artery lies just under the skin and fascia and can be pressed against the radius to determine the pulse (Fig. 9). At the level of the styloid process, the artery bends around the lateral edge of the wrist, enters the “anatomical snuffbox”, where its pulsation can be felt, then exits to the back of the hand, from where it penetrates the palm through the first interosseous space. In the palm, the artery turns medially and participates in the formation of the deep palmar arch, arcus palmaris profundus.

Rice. 9. Arteries of the forearm

Branches depart from the radial artery: Radial recurrent artery, a. recurrens radialis, arises at the beginning of the radial artery, and anastomoses with the radial collateral artery. Superficial palmar branch, r. palmaris superficialis, is directed to the palm, where it participates in the formation of the superficial palmar arch.

Palmar carpal branch, r. carpalis palmaris, begins in the distal forearm, anastomoses with the branch of the same name of the ulnar artery, forming the palmar wrist network (rete carpale palmare). Dorsal carpal branch, r. carpalis dorsalis, begins on the dorsum of the hand, anastomoses with the branch of the same name of the ulnar artery, forming, together with the branches of the interosseous arteries, the dorsal carpal network, rete carpale dorsale. Artery of the thumb, a. princeps pollicis, arises from the radial artery in the first interosseous space. This artery divides into two terminal branches that supply the palmar surface of the thumb and gives off the radial artery of the index finger.

Ulnar artery

Ulnar artery, a. ulnaris, descends in the ulnar groove of the forearm to the wrist joint, passes through the ulnar canal of the wrist to the palm, where it participates in the formation of the superficial palmar arch, arcus palmaris superficialis (Fig. 9). Branches depart from the ulnar artery: Ulnar recurrent artery, a. recurrens ulnaris, goes up to the elbow joint and is divided into two branches involved in its blood supply: anterior and posterior. The anterior branch anastomoses with the inferior ulnar collateral artery, and the posterior branch anastomoses with the superior ulnar collateral artery. Common interosseous artery, a. interossea communis, is a short trunk that branches into the anterior and posterior interosseous arteries.

Anterior interosseous artery , a. interossea anterior, runs along the anterior surface of the interosseous membrane of the forearm, and participates in the formation of the dorsal radiocarpal network.

Posterior interosseous artery , a. interossea posterior, passes through the hole in the upper part of the interosseous membrane to its posterior surface and descends to the dorsal radiocarpal network.

Palmar carpal branch , r. carpalis palmaris, just below the pronator quadratus and joins the palmar carpal reticulum.

Dorsal carpal branch , r. carpalis dorsalis, is directed to the back of the hand and joins the dorsal radiocarpal network.

Deep palmar branch , r. palmaris profundus, branches from the ulnar artery at the pisiform bone and connects with the terminal part of the radial artery, forming a deep palmar arch.

Arterial arches of the hand

There are two palmar arches on the palmar surface of the hand: superficial and deep. The superficial palmar arch, arcus palmaris superficialis, is formed by the ulnar artery and the superficial palmar branch of the radial artery. The superficial arch is located under the palmar aponeurosis, at the level of the middle of the bodies of the metacarpal bones (Fig. 10).

Four common palmar digital arteries, aa, depart from the convex surface of the arch. digitales palmares communes, three of which go in the second, third and fourth interdigital spaces, and the fourth along the ulnar side of the little finger. At the level of the interdigital folds, the arteries are divided into their own palmar digital arteries, aa. digitales palmares propriae, supplying blood to the surfaces of the II-V fingers facing each other.

The deep palmar arch, arcus palmaris profundus, is formed by the terminal part of the radial artery and the deep palmar branch of the ulnar artery. The deep arch is located at the level of the bases of the II-V metacarpal bones under the flexor tendons of the fingers. Three palmar metacarpal arteries, aa, depart from the deep palmar arch. metacarpales palmares, flowing into the common palmar digital arteries.

Rice. 10. Arterial arches of the hand. A-surface arc. B-deep arc

The dorsal surface of the hand is supplied with blood from the dorsal carpal network, rete carpale dorsale. Four dorsal metacarpal arteries, aa, depart from the network in the distal direction. metacarpales dorsales, which are divided into two dorsal digital arteries, aa. digitales dorsales, to fingers II-V. The dorsal metacarpal arteries connect to the palmar metacarpal arteries through the interosseous spaces with the help of perforating branches (rr. perforantes).

Literature

1. Bakhmetyev A.S., Chekhonatskaya M.L., Dvoenko O.G., Loiko V.S., Sukhoruchkin A.A. Frequency of atherosclerotic lesions of the brachial arteries in patients with multifocal atherosclerosis in other arterial basins // Electronic collection of the All-Russian scientific and practical conference of students and young scientists of the scientific and educational cluster “Nizhnevolzhsky” “YSPR-2016”, 2016.

2. Bakhmetyev A.S., Sukhoruchkin A.A., Loiko V.S. Frequency of occurrence of atherosclerotic lesions of the brachial arteries in patients with multivessel stenosing atherosclerosis // Scientific forum: Medicine, biology and chemistry: collection. Art. based on materials of the 1st international. scientific-practical conf. — No. 1(1). - M., Ed. "MCNO", 2021.

Patients who have undergone coronary artery bypass grafting (CABG) represent a special subgroup of interventional cardiology with widespread and complex atherosclerotic lesions, requiring a more complex procedure of selective catheterization of bypass grafts, which is often accompanied by the use of additional catheters, a larger volume of contrast agent, as well as increased time and radiation doses. Due to its complexity, shuntography is traditionally performed through the femoral approach (FA). Currently, radial arterial access is increasingly being chosen for diagnostic and therapeutic interventions on the coronary artery (CA) [1–3]. Its advantages include the possibility of effective hemostasis even while taking anticoagulants and inhibitors of platelet glycoprotein IIb/IIIa receptors due to the superficial location of the radial artery (RuA) [4, 5]. The result of this is a very low incidence of hemorrhagic complications (less than 1 in 1000), no need for strict bed rest after the procedure and early mobilization of the patient [6, 7]. Selective catheterization of coronary bypass grafts using access through the arteries of the forearm (FAA) is more difficult than BD, especially at the initial stage of development.

The purpose of this study is to evaluate the feasibility of diagnostic and therapeutic endovascular interventions using bypasses to the coronary artery through the LUA and ulnar artery (ULA) in patients undergoing CABG surgery, as well as to evaluate the safety and effectiveness of this technique compared with access through the femoral artery (FA).

Material and methods

The study included 90 patients who underwent CABG surgery; from March 2009 to March 2011, diagnostic coronary artery bypass grafting (CABG) and stenting of coronary bypass grafts and coronary arteries were performed on the basis of the laboratory of X-ray endovascular methods of diagnosis and treatment of NDO RKNPK. Patients were divided into two groups (Fig. 1):

Figure 1. Flowchart of study and intervention implementation.
in the 1st (main) group, interventions were performed through the arteries of the forearm (n=50), in the 2nd (control) group - through the BA (n=40). The clinical characteristics of the patients are presented in Table. 1.

Before the intervention, all patients underwent a clinical and instrumental examination, including assessment of pulsation of the LoA, LuA and BA, duplex ultrasound scanning (USD) of the arteries of the upper and lower extremities, as well as direct and reverse Allen tests.

When performing ultrasound scanning of the arteries of the upper extremities, the diameter of the LuA and LoA, the level of bifurcation of the brachial artery, the presence of pronounced bends, stenoses, anatomical features and developmental anomalies of the arteries of the arm and subclavian segment were determined.

Allen test procedure.

The LuA and LoA are compressed at the same time, the patient squeezes the hand several times until the skin becomes pale (ischemia), after which the compression is removed from the LoA (direct test) or LuA (reverse test). When the normal color of the hand is restored within 8-10 s due to the “switching on” of collateral blood flow, the test is considered normal (positive); if the skin remains pale (ischemia), it is considered negative.

For access, as a rule, the dominant artery was chosen (the artery with the best pulsation and larger diameter), which does not have pronounced stenoses and bends according to ultrasonography. A prerequisite was the presence of positive results of the direct Allen test when using LuA and a normal reverse Allen test when using LoA.

Technique for puncturing the arteries of the forearm.

The hand is moved to the side by 30-45°, a cushion is placed under the wrist, while the hand is in the position of extension (70°) and abduction (15-30°) during puncture of the LuA, and in the position of extension (70-90) during puncture of the LuA. °) and adduction (15°).
Skin infiltration anesthesia was performed with 1-3 ml of 2% lidocaine solution over the palpable artery 2 cm proximal to the pisiform bone. For puncture and catheterization of the LoA and LuA, special Transradial Kit kits (Cordis Jonson & Johnson, USA) were used. The artery was punctured with an open-type needle with a diameter of 21G until a pulsating stream of blood appeared, then a 45 cm long guide was inserted through the needle, a skin incision was made along the needle and an introducer with a diameter of 5-6 Fr and a length of 23 cm was installed (Fig. 2).

Figure 2. Technique for puncture of the ulnar (a - f) and radial (b, g - l) arteries. a, g — position of the forearm and hand (top view); b — position of the forearm and hand (side view); c, h — anesthesia with a thin needle and a small amount of anesthetic; d, i - puncture of the artery; d, j - skin incision using a needle; f, l — installation of the introducer, final view. To prevent arterial spasm, 250 μg of nitroglycerin was administered intraarterially through an introducer. Heparin was administered into the introducer at the rate of 70 IU per 1 kg of patient body weight for CABG and 100 IU/kg for stenting. During the procedure, the activated blood clotting time was determined every 30 minutes, and when the value decreased to less than 250 s, heparin was additionally administered intravenously at the rate of 35 IU per 1 kg of the patient’s body weight. At the end of the procedure, the introducer was removed immediately and an aseptic pressure bandage was applied.

BA puncture was performed according to the generally accepted Seldinger technique [8].

The principle of catheter selection and angiography technique did not depend on the chosen access. For catheterization of coronary arteries, catheters of the Judkins Left and Judkins Right types were used. After angiography of native coronary arteries, selective catheterization of the venous shunts and internal mammary artery was attempted with a Judkins Right 4 catheter; if necessary, catheters such as Amplatz, IM, etc. were used. If selective catheterization of the mouth of one or more shunts was unsuccessful, aortography of the ascending aorta was performed to identify the localization of proximal anastomoses shunts or confirmation of occlusion.

Management of patients after the procedure.

Within 2 hours after the end of the procedure, a doctor or nurse monitored the condition of the bandage and examined the puncture site every 10-15 minutes. When performing diagnostic CABG on an outpatient basis, patients were discharged on the same day 2-3 hours after the end of the procedure; patients who underwent stenting were discharged after 1–3 days. The next morning, all patients underwent an examination of the puncture site with palpation of the access artery and ultrasound control in case of suspected complications.

When assessing effectiveness and safety, the following concepts were used. The dominant artery was considered to be a forearm artery that exceeded the second artery in diameter by more than 0.33 mm (1F), which allowed the use of an introducer one size larger. The time of arterial puncture was considered to be the time from anesthesia to insertion of the sheath. The total study time was considered to be the time from the onset of anesthesia to the removal of the sheath and application of a pressure bandage. Complications of surgical access were considered to be conditions that arise during or after the procedure, requiring special treatment and/or prolonging the period of patient stay in the hospital.

results

Diagnostic CABG was performed in all patients, stenting was performed in 8 (16%) in group 1 and 12 (30%) in group 2. In group 1, the procedure was outpatient in 22 (44%) cases and inpatient in 28 (56%), group 2 included only hospitalized patients. In 35 (70%) patients in the DHAP group, procedures were performed through a 5F sheath, in 15 (30%) through a 6F sheath, in the BD group in 40 (100%) patients a 6F instrument was used.

Successful completion of the procedure through the planned approach was noted in 49 (98%) in the DHAP group and in 40 (100%) in the BD group. Only 1 (2%) patient in the DHAP group required conversion to a BD due to insufficient support of the guide catheter; however, the support was also poor and the stent could not be advanced into the stenotic segment.

The direct Allen test was normal (positive) in 45 (90%) patients, the reverse test - in 49 (98%).

In group 1, 27 (54%) patients underwent interventions through the LuA and 23 (46%) through the LoA; the left-sided approach was used in 46 (92%) patients. In group 2, 28 (70%) patients had hemostasis performed using manual compression; in 12 (30%) patients, the BA puncture site was sutured using the Angio-Seal device.

The puncture time in the DHAP group was 2.6±0.5 minutes versus 2.7±0.5 minutes in the BD group, the fluoroscopy time was 11.2±5 minutes versus 11.2±4.4 minutes, and the total study time was 42.8±15.5 min versus 43±12.9 min. The X-ray dose was 1938.5±541.3 and 1865.7±646.7 mGy in groups 1 and 2, respectively. The volume of contrast agent administered was also approximately the same: 183 ± 60 and 178 ± 48.4 ml in the DchAP and BD groups, respectively. The difference in indicators in all cases was statistically insignificant (Table 2).

The data obtained from shuntography are given in table. 3.

The BD group was distinguished by a greater number of proximal shunt anastomoses compared to the DHAP group: 3.3±0.8 versus 2.9±0.9 (p=0.03), however, when comparing subgroups including patients with 3 proximal anastomoses or more , there were also no differences in fluoroscopy time (11.7±4.9 and 11.4±4.3 minutes; p=0.8), X-ray dose (2048.2±478.5 and 1918.3±656 .6 mGy; p=0.3), total study time (44.1±15.6 and 43.2±12.4 minutes; p=0.8), volume of contrast agent (193.9±56.6 and 176.5±42.3 ml; p=0.2) and the number of catheters used (3.3±0.7 and 3.1±0.7; p=0.2), in the 1st and 2nd y groups, respectively
(Table 4).

In the DHAP group, aortography was performed in 10 (20%) cases, in the BD group - in 14 (35%). The number of diagnostic catheters used per patient did not differ significantly between groups and was 3.2 ± 0.7 in the DP group and 3.1 ± 0.6 in the BD group (p = 0.5). The number and types of catheters used are presented in Table. 5.

There were no cardiac complications in the DHAP group; in the BD group, one (2.5%) patient experienced ventricular fibrillation during shunt stenting, which was treated with electrical cardioversion (a single shock of 300 J with restoration of sinus rhythm). There were no occlusions of LuA and LoA after the interventions performed in our study.

In 1 (2.5%) patient, a control ultrasound scan on the 2nd day revealed a pulsating BA hematoma. Manual compression of the hematoma was performed under ultrasound control, followed by re-application of a pressure bandage for 24 hours. During control ultrasound on the next day, there were no signs of a pulsating hematoma.

In 1 (2%) patient in the DHAP group and 1 (2.5%) in the BD group, a vagotonic reaction in the form of bradycardia and hypotension was noted during access.

Discussion

In our study, when performing the procedure through the arteries of the forearm, success was achieved in 98% of cases, which did not differ significantly from the indicator when using a BD. At the same time, the time required to perform the access (puncture time), fluoroscopy time, total examination time, the volume of contrast agent used and the number of catheters used were also not statistically significantly different. There are only a few studies in the literature that evaluate the possibility of performing diagnostic and therapeutic interventions on coronary artery bypass grafts through the LuA [9–14]; We have not found any similar studies using the ulnar approach. The success of the procedure in these studies was achieved in 93.9-97% of cases. In our study, the procedure was successfully completed in 49 (98%) of 50 patients, with a success rate of LuA and LoA puncture of 100%. High success rates with access through the arteries of the forearm can be explained by the specialization of our laboratory in the use of LuA and LoA as access and the experience of our staff, since we perform more than 90% of all diagnostic and endovascular interventions through the arteries of the forearm.

There were no occlusions of the forearm arteries after interventional procedures in our study. N. Han et al. [14] report one (1.5%) occlusion of the LuA; other publications on CASH do not provide these data. The frequency of LuA and LoA occlusions after interventional procedures is approximately the same and, according to various authors, is 3-9% [5, 15-17]. The absence of thrombotic occlusions of both the LoA and LuA in our study is associated with the tactics of choosing the dominant artery of the forearm for access, in contrast, for example, to the PCVI-CUBA study, in which randomization was carried out into groups of access through the LoA or through the LuA.

An important role in protecting the hand from ischemia during occlusion of one of the arteries is played by the superficial (formed predominantly by the LoA) and deep (formed predominantly by the LuA) palmar arches. However, the superficial arterial arch is more likely than the deep one to be defective, as shown in anatomical studies [18, 19]. According to our study, the direct Allen test was positive in 90% of patients, the reverse test - in 98%. According to an angiographic study by R. Vogelzang [20], the deep palmar arch was complete in 95% of the patients examined, and the superficial palmar arch was complete only in 40-80%. Similar data are provided by G. Barbeau et al. [21], based on the results of the Allen test in 1010 patients. The presence of functioning collaterals to one of the arteries of the forearm in the absence of collateral pathways to the second artery expands the possibility of using DPAP, while maintaining the safety of the procedure.

The number of interventions on coronary artery bypass grafts using DHAP increases with experience. According to M. Sanmartin et al. [10], LuA was chosen as an access in only 11% of patients in 2001, in 34% in 2002, and in 2003 and 2004. - in 76 and 67% of patients, respectively. In our laboratory, this figure was initially more than 60%.

An important advantage of using DPA is the reduction in the length of stay of patients in the hospital for diagnostic procedures and interventions. N. Han et al. [14] reported a statistically significant reduction in the length of hospital stay from 10.4 ± 7.3 days in the BD group to 8.9 ± 4.9 days in the radial access group. In our study, this indicator was 8.3±4.4 and 4.1±2.7 days, respectively (p<0.0005), while during the calculation, patients who underwent procedures without hospitalization (outpatient) were excluded from the DchAP group. .

CABG surgery is effective and safe, allowing for a long time to ensure normal myocardial perfusion through venous and arterial shunts. However, the duration of effective functioning varies among different types of shunts. Thus, mammary coronary shunts are less susceptible to atherosclerotic damage [22, 23], while the viability of autovenous shunts is more limited. According to various authors [24, 25], in the first year after CABG surgery, occlusion of 15-20% of venous shunts is observed, and in each subsequent year, an additional 1 to 4% are closed. In addition to occlusive lesions, shunts are subject to intimal hyperplasia and atheromatosis [26, 27]. Consequently, a large group of patients who have undergone CABG surgery require repeated myocardial revascularization at various times after it. The operation of repeat CABG is associated with great risk and technical difficulties, so endovascular treatment of patients in this group is becoming an increasingly pressing problem.

An alternative method for visualizing coronary artery bypass grafts is multislice computed tomography, which has a sensitivity of 97.6–100% and a specificity of 94–99% [28–32]. The advantage of the technique compared to CABG is that the procedure is performed on an outpatient basis. The concept of performing coronary angiography on an outpatient basis dates back to 1968, when M. Judkins [33] first reported performing 240 coronary angiographies on an outpatient basis, which significantly “reduced the cost of a patient’s hospital stay.” However, this approach was not immediately widespread due to the high risk of complications associated with the use of BD. Technological advances in the development of medical instruments have led to the emergence of new endovascular instruments with improved technical characteristics combined with smaller sizes. This has led to the widespread use of radial access for endovascular interventions. A significant reduction in the incidence of complications at the puncture site opened up the possibility of performing endovascular interventions with short-term hospitalization of the patient and in an outpatient setting [4, 6, 34—36]. In European countries, in 30% of cases, coronary angiography is performed on an outpatient basis with discharge home 3-4 hours after the study [37]. In our study, 22 (44%) patients in the DHAP group underwent diagnostic tests on an outpatient basis, which is accompanied by high comfort for the patient, whose presence in a medical facility is minimized.

conclusions

Endovascular interventions on coronary artery bypass grafts using access through the arteries of the forearm are safe and effective. The success of the procedure is achieved in 98% of cases. The low incidence of complications allows the technique to be used when performing procedures on an outpatient basis and during short-term hospitalization.

Images

The non-thickened thickness of the intima-media complex is visualized - no more than 0.4 mm.

Right brachial artery.

Along the anterior wall there is a hypoechoic thickening of the middle layer of the artery - the media.

Left brachial artery in B-mode.

The color mode eliminates possible artifacts found in B-mode. There is a filling defect.

Left brachial artery in color mapping mode.

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