Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 99-101

Role of brachial artery ligation as an emergency procedure in bleeding arteriovenous access


Department of Vascular and Endovascular Surgery, MS Ramaiah Medical College, Bengaluru, Karnataka, India

Date of Web Publication6-Jun-2019

Correspondence Address:
Dr. Luv Luthra
Department of Vascular and Endovascular Surgery, MS Ramaiah Medical College, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_86_18

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  Abstract 


Introduction: Bleeding from a ruptured or infected arteriovenous (AV) access is a life-threatening situation leading to increased mortality in chronic kidney disease (CKD) patients. All these patients need emergent and expeditious management. The procedures described for bleeding complications in AV access are associated with high morbidity and mortality. In some cases, there is a need for a major surgery or bypass. Aim: The aim was to evaluate the safety and efficacy of brachial artery ligation (BAL) in bleeding AV access. Materials and Methods: This was a single-center retrospective analysis of 106 patients who underwent BAL for bleeding AV access (AV graft [AVG]/brachiocephalic [BC] AV fistula [AVF]) from January 2007 to 2017. Results: During this study period, BAL was done in a total of 106 patients, out of which 51 patients underwent AVG explantation with BA ligation and 55 with ligation in BC fistulas. There were 73 males and 33 females with a mean age of 45 years (11–90). The primary etiology was hypertension (66%), diabetes (23.58%), and other causes (10.3%). Twenty patients presented with acute bleeding due to graft erosion and 31 patients had purulent discharge from puncture site with sepsis. Infection was involving anastomosis in all patients. Out of 55 patients who underwent AVF, 5 patients had infection at puncture site 3–4 cm near the anastomosis. Fifty patients had infected pseudoaneurysms at the anastomotic site that developed within 1 week of the creation of fistula. All patients were evaluated and assessed for signs of ischemia in the postoperative period till the time of discharge. Conclusion: BAL is a safe alternative in patients with access site bleeding as it reduces not only the operative time but also the morbidity and mortality associated with CKD patients. Ligation of the brachial artery at the elbow can be used as a primary approach in complicated vascular access.

Keywords: Arteriovenous access, bleeding, brachial artery ligation, pseudoaneurysm


How to cite this article:
Chandrashekhar A R, Luthra L, Desai SC, Prasad B R. Role of brachial artery ligation as an emergency procedure in bleeding arteriovenous access. Indian J Vasc Endovasc Surg 2019;6:99-101

How to cite this URL:
Chandrashekhar A R, Luthra L, Desai SC, Prasad B R. Role of brachial artery ligation as an emergency procedure in bleeding arteriovenous access. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jun 25];6:99-101. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/99/259662




  Introduction Top


Arteriovenous (AV) fistula is the primary approach for creation of AV access, but the need of long-term high efficiency has resulted in the increase in the proportion of patients requiring AV grafts. The most common cause of failure of AV access is infection of the fistula or graft at the puncture site.[1] It results in dehiscence of access site and bleeding from ruptured pseudoaneurysm.[2] Prompt control of bleeding is required in all these cases. The recognized techniques of vascular reconstruction are patch plasty,[3] subtotal excision, oversewing of graft,[4] and bypass.[5] Any complex procedure in these critically ill patients carries a high risk of morbidity and mortality.

Brachial artery ligation (BAL) has proved to be a limb-saving and effective treatment in bleeding AV Access.[2]

Aim

The aim was to evaluate the safety and efficacy of BAL in bleeding AV access as an emergency procedure.


  Materials and Methods Top


It was a single-center retrospective study of 106 patients who presented to the department of emergency medicine with uncontrolled bleeding from the access site and underwent BAL as an emergency procedure, from January 2007 to January 2016, in MS Ramaiah Medical College, Bengaluru. BAL was done in 55 patients with AV fistulas (AVFs) and 51 with AV grafts. All surgeries were done under regional anesthesia after taking proper consent and explaining the risks of surgery. Patients with infected AV grafts and bleeding pseudoaneurysms in our center and referred from other centers were included in the study. All patients received antibiotics depending on the type of access and were dialyzed as per nephrologist during hospital stay. A pneumatic tourniquet was used in the upper arm to control the excessive bleeding during surgery.

Brachial artery was exposed with a longitudinal incision placed above the elbow crease over the medial aspect of the arm. Only those patients who had good back bleed from the brachial artery were included in the study. Patients who required a bypass or major procedure were excluded from the study. Ligation of the brachial artery was done proximal and distal to the anastomotic site as shown in [Figure 1]. Repair of the brachial artery was not required in any of the cases. Regular clinical assessment was done to rule out any signs of ischemia in the postoperative period after BAL.
Figure 1: (a) Ruptured pseudoaneurysm. (b) Proximal and distal control of the brachial artery. (c) Closure of wound with placement of drain

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  Results Top


A total of 106 patients who presented to the emergency department with bleeding from the access site were included and underwent BAL. Fifty-five patients had uncontrolled bleeding from the puncture site or infected pseudoaneurysms. Fifty-one patients with upper-arm e Poly tetra fluoro ethylene (ePTFE) AV grafts underwent BAL. A total of 73 patients were male and 33 were females with the mean age of 45 years ± 6.4. Majority of the patients with chronic kidney disease (CKD) had hypertension. All patients received parenteral antibiotics depending on the time of access. All patients had no signs of ischemia at the end of 1 month in follow-up, and at the end of 3 months, 89.6% (95) had no signs of ischemia. The remaining did not turn up for follow-up, as shown in [Table 1].
Table 1: Details of patients who underwent brachial artery ligation

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  Discussion Top


In India, the estimated age-adjusted incidence rate of end-stage renal disease is 229 per million population (pmp), and >100,000 new patients enter renal replacement programs annually.

Infection at the puncture site is common in patients with AVF and arteriovenous graft (AVG) and is one of the most common causes of bleeding. However, increased venous pressure due to venous stenosis and pseudoaneurysms are also important causes of bleeding in AVF.[6] These patients usually present in poor general conditions, and performing any major procedure increases the risk of morbidity and mortality. The ligation of the brachial artery at the elbow appears to be a safe site because of rich arterial network and collateral circulation around the elbow.[2] The most common long-term symptom reported after BAL is exercise-induced ischemia.[7] In our study, this complication was not seen in any of the patients as the brachial artery was ligated distal to the origin of the deep brachial artery. None of the patients in our study had any signs of ischemia in the postoperative period and re-exploration was not required.

Taylor et al. reported two cases of bleeding after graft removal in their study of 19 patients. Both cases occurred within 2 weeks of the graft removal, and arterial reconstruction was done to control the bleeding.[8]

Wu et al. in their study concluded that the rate of postoperative arterial bleeding was 22.6% when arteriotomy or graft stump was simply oversewn and suggested definite repair.[9]

Padberg et al. in their study reported that stump oversewing was more reliable than direct arteriorrhaphy or venous patch angioplasty. In cases where there were no signs of infection, BAL was safe in most patients due to established collaterals after long-term dialysis.[10]

Chandrashekar et al. in their study showed that BAL in AVG infections is a safe alternative considering the critical general condition of CKD patients. It reduces the operative time significantly and avoids complex revascularization and anastomotic dehiscence without any ischemic or bleeding complication.[11]

It is a well-known fact that all CKD patients are at a high risk of bleeding due to uremia and bleeding diathesis.[12] Any major surgery in these patients would further worsen the condition of these patients resulting in high morbidity. Hence, BAL can be considered as a safe procedure in emergency for complicated bleeding AV access.

In our study, we found no signs of ischemia in all patients who underwent BAL for uncontrolled bleeding from access site. Patients were regularly followed up for any ischemic symptoms and signs by regular assessment of the patient during hospital stay and on follow-up.


  Conclusion Top


BAL is a safe alternative in patients with access site bleeding as it reduces not only the operative time but also the morbidity and mortality associated with CKD patients after complex revascularization procedures.

Ligation of the brachial artery at the elbow can be used as a primary approach in complicated bleeding vascular access in high-risk CKD patients, but close monitoring of patients is essential after surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Peng CW, Tan SG. Polyurethane grafts: A viable alternative for dialysis arteriovenous access? Asian Cardiovasc Thorac Ann 2003;11:314-8.  Back to cited text no. 1
    
2.
Tan YM, Tan SG. Emergency ligation of the brachial artery for complications of vascular access. Br J Surg 2005;92:244-5.  Back to cited text no. 2
    
3.
Tabbara MR, O'Hara PJ, Hertzer NR, Krajewski LP, Beven EG. Surgical management of infected PTFE hemodialysis grafts: Analysis of a 15-year experience. Ann Vasc Surg 1995;9:378-84.  Back to cited text no. 3
    
4.
Ryan SV, Calligaro KD, Scharff J, Dougherty MJ. Management of infected prosthetic dialysis arteriovenous grafts. J Vasc Surg 2004;39:73-8.  Back to cited text no. 4
    
5.
Walz P, Ladowski JS. Partial excision of infected fistula results in increased patency at 215 the cost of increased risk of recurrent infection. Ann Vasc Surg 2005;19:84-9.  Back to cited text no. 5
    
6.
Linda MH. Haemodislysis access: Nonthtrombotic complications. In: Cronenwett JL, Johnston KW, editors. Rutherford's Vascular Surgery. 8th ed. Philadelphia: Elsevier Saunders; 2014. p. 1135-6.  Back to cited text no. 6
    
7.
Lally KP, Foster CE 3rd, Chwals WJ, Brennan LP, Atkinson JB. Long-term follow-up of brachial artery ligation in children. Ann Surg 1990;212:194-6.  Back to cited text no. 7
    
8.
Taylor B, Sigley RD, May KJ. Fate of infected and eroded hemodialysis grafts and 231 autogenous fistulas. Am J Surg 1993;165:632-6.  Back to cited text no. 8
    
9.
Wu MY, Ko PJ, Hsieh HC, Chu JJ, Lin PJ, Liu YH, et al. Repair of arteriotomy after removal of infected hemodialysis access by venous graft. Chang Gung Med J 2003;26:911-8.  Back to cited text no. 9
    
10.
Padberg FT Jr., Lee BC, Curl GR. Hemoaccess site infection. Surg Gynecol Obstet 1992;174:103-8.  Back to cited text no. 10
    
11.
Chandrashekar AR, Hoskatti CR, Desai SC, Prasad RB. Role of brachial artery ligation in management of prosthetic arteriovenous graft infections. Ann Vasc Surg 2018;48:75-8.  Back to cited text no. 11
    
12.
Malyszko J, Malyszko JS, Mysliwiec M, Buczko W. Hemostasis in chronic renal failure. Roczniki Akademii Medycznej w Bialymstoku 1995;50:126-31.  Back to cited text no. 12
    


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