Correspondence  |   March 2018
In Reply
Author Notes
  • Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio (A.E.D.).
  • (Accepted for publication November 13, 2017.)
    (Accepted for publication November 13, 2017.)×
Article Information
Correspondence   |   March 2018
In Reply
Anesthesiology 3 2018, Vol.128, 675-676. doi:10.1097/ALN.0000000000002030
Anesthesiology 3 2018, Vol.128, 675-676. doi:10.1097/ALN.0000000000002030
We thank Drs. Bowdle and Sheu for their interest and thoughtful comments on our recent article,1  which reported a low risk of complications from intraarterial brachial pressure monitoring during cardiac surgery.
Although use of ultrasound is increasing, we typically use direct palpation of the brachial arterial pulse for our first attempt at arterial catheter insertion. Ultrasound for vascular cannulation was not available during the early years of our study period, and our current practice reserves this technology for difficult arterial cannulation. It is possible, however, that increasing use of ultrasound may lower the rate of complications even further than our initial report.
We follow guidelines established by the Centers for Disease Control2  to prevent intravascular catheter-related infections. Our standard practice includes proper hand hygiene and aseptic technique, preparation of clean skin with a more than 0.5% chlorhexidine preparation with alcohol, use of sterile gloves and drape, and a sterile, transparent, semipermeable dressing to cover the catheter site. Appropriate sterile dressing regimens are continued postoperatively by the nursing staff. Nonetheless, our low incidence of infection was likely overestimated because we conservatively reported bloodstream infections as “possibly associated” with brachial arterial catheterization, although the more likely cause was an infection related to a coexisting central venous catheter.3 
We appreciate the suggestion from Drs. Bowdle and Sheu that an adequate collateral circulation may explain the low rate of brachial artery complications leading to hand ischemia and that embolic phenomena may have impaired the collateral circulation causing ischemia of the upper limb. Certainly, evidence of a collateral arterial network around the elbow exists,4  but whether this network is sufficient to adequately perfuse the hand after complete brachial artery occlusion in all patients is uncertain. It is possible that an adequate collateral circulation may have allowed a brachial arterial injury to remain undetected in some patients. However, multiple reports document hand ischemia as a result of reduced brachial arterial flow with inadequate collateral circulation, including patients suffering from supracondylar fracture with brachial arterial injury5  and after creation of a brachial-cephalic/basilic fistula,6,7  thus providing evidence that collateral circulation is not adequate in all patients. Later development of adequate collaterals in patients with arteriovenous fistulas explains why some patients tolerate brachial arterial ligation,8,9  although similar conditions do not occur in most elective cardiac surgical patients.
Although injury to the arterial wall during cannulation may create conditions conducive to thrombus formation,10  acute occlusion of the brachial artery may occur as a result of thrombus or emboli. It is thus unclear whether the collateral circulation was compromised in patients with an ischemic upper limb due to multiple emboli or whether its anatomical distribution was insufficient. Nevertheless, our data document that a thrombectomy of an occluded brachial artery restored perfusion to the hand and that the collateral circulation was inadequate in 18 patients.1 
Competing Interests
The authors declare no competing interests.
Asha Singh, M.D., Brett J. Wakefield, M.D., Andra E. Duncan, M.D., M.S. Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio (A.E.D.).
Singh, A, Bahadorani, B, Wakefield, BJ, Makarova, N, Kumar, PA, Tong, MZ, Sessler, DI, Duncan, AE . Brachial arterial pressure monitoring during cardiac surgery rarely causes complications. Anesthesiology 2017; 126:1065–76 [Article] [PubMed]
Centers for Disease Control and Prevention: Guidelines for the Prevention of Intravascular Catheter-Related Infections, 2011. Available at: Accessed December 6, 2017
Koh, DB, Gowardman, JR, Rickard, CM, Robertson, IK, Brown, A . Prospective study of peripheral arterial catheter infection and comparison with concurrently sited central venous catheters. Crit Care Med 2008; 36:397–402 [Article] [PubMed]
Wong, VW, Katz, RD, Higgins, JP . Interpretation of upper extremity arteriography: Vascular anatomy and pathology [published correction appears in Hand Clin 2015; 31:xv]. Hand Clin 2015; 31:121–34 [Article] [PubMed]
Benedetti Valentini, M, Martinelli, O, Irace, L, Di Giulio, L, Ippolito, E, Benedetti Valentini, F . Vascular injuries in supracondylar humeral fracture: An active approach to diagnosis and treatment. Int Angiol 2014; 33:540–6 [PubMed]
Misskey, J, Yang, C, MacDonald, S, Baxter, K, Hsiang, Y . A comparison of revision using distal inflow and distal revascularization-interval ligation for the management of severe access-related hand ischemia. J Vasc Surg 2016; 63:1574–81 [Article] [PubMed]
Papasavas, PK, Reifsnyder, T, Birdas, TJ, Caushaj, PF, Leers, S . Prediction of arteriovenous access steal syndrome utilizing digital pressure measurements. Vasc Endovascular Surg 2003; 37:179–84 [Article] [PubMed]
Kato, R . The influence of experimental arteriovenous fistula on the development of the collateral circulation and on the devascularized limb. Nagoya J Med Sci 1970; 33:55–67 [PubMed]
Schanzer, A, Ciaranello, AL, Schanzer, H . Brachial artery ligation with total graft excision is a safe and effective approach to prosthetic arteriovenous graft infections. J Vasc Surg 2008; 48:655–8 [Article] [PubMed]
Karmody, AM, Lempert, N, Jarmolych, J . The pathology of post-catheterization brachial artery occlusion. J Surg Res 1976; 20:601–6 [Article] [PubMed]