S EVERAL procedures have been used to

Transcription

1 Direct Percutaneous Infraclavicular Catheterization of the Subclavian Artery* JORGE WEIBEL, M.D., AND WILLIAM S. FIELDS, M.D. Department of Neurology, Baylor University College of Medicine, and The Methodist Hospital, Texas Medical Center, Houston, Texas S EVERAL procedures have been used to inject opaque material for the purpose of visualizing the vertebrobasilar arterial system. These methods should enable one to visualize the entire course of the vertebral artery from its origin up to and including the basilar artery and its branches. The different techniques may be summarized as follows: 1. Countercurrent injection of opaque material into the common carotid artery. Introduced by Elvidge 5 in ~. Direct supraclavicular percutaneous puncture of the subclavian artery. This method was introduced by Shimidzu 1~ in 1937, Barbieri and Verdecchia 2 in 1957, and Crawford et al. 4 in Direct percutaneous infraclavicular puncture of the subclavian artery. This technique was reported by Pouyanne el al. 7 in 1960, and Amplatz and Harner 1 mentioned it in a paper published in 196~. 4. Direct percutaneous infraclavicular cathele,rization of the subclavian artery. This method was introduced by Amplatz and Harner 1 using a needle-catheter combination 6 inches in length. Their preliminary report was published in June 196~. 5. Indirect percutaneous catheterization of the subclavian artery through the brachial artery. This type of retrograde catheterization was reported by Pygott and Hutton s in 1959, Begg 3 in 1960, and Tatelman and Sheehan 12 in 196~. Other techniques have been described in the literature which we considered too complex and too time-consuming for our purpose. Received for publication September ~4, 196~. * This work was supported by U.S.P.H.S. Grant HE One hundred twelve direct percutaneous supraclavicular punctures of the subclavian artery have been performed. It has not been difficult to enter the artery except in obese patients. The quality of the films has been satisfactory in most cases, and adequate filling of the entire course of the vertebral and basilar arteries and their branches has been obtained. Unfortunately, this technique has several disadvantages. It does not permit study of the effect of turning of the head and neck on the circulation in the cervical portion of the vertebral artery. :It is difficult to keep the needle in situ when turning the head, especially in patients having short necks. Pneumothorax has been reported in 10 to ~0 per cent and mediastinal hemorrhage in 40 per cent of the cases with this technique. 6 In our experience, pneumothorax occurred in 7 per cent and intramural injection and extravasation of contrast material in 15 per cent of the cases. We have had very limited experience in the technique of retrograde catheterization of the subclavian artery through the brachial artery. Although it is a satisfactory procedure in many cases, spasm of the artery and tortuosity of the axillary artery may make it difficult. In addition, the presence of marked atherosclerosis may impede the passage of the catheter. Loss of pulsation of the radial artery because of thrombosis of the brachial artery has been reported by Amplatz and Harner 1 and by Tatelman and Sheehan. 12 This can be a very serious complication. Unaware of the reports of Pouyanne et al., 7 and Amplatz and Harner, 1 we began to use the direct percutaneous infraclavicular puncture of the subclavian artery early in 196~. About 1s subclavian angiograms were per- 233

2 ~34 Jorge Weibel and William S. Fields Fla. 1. Demonstration of anatomical positioning of Cournand needle used to perform direct percutaneous infraclavicular puncture of subclavian artery. The angiogram of the right vertebral artery reveals a slight narrowing at its origin and marked irregularity of caliber along its cervical course. formed with this method using the Cournand needle (Fig. 1). The results were unsatisfactory in ~0 to ~5 per cent of the cases because of nonfilling or poor quality of visualization of the vertebral and basilar arteries. This was caused by faulty positioning of the tip of the needle in relation to the longitudinal axis of the artery. In obese patients it was difficult to keep the needle in situ, and intramural injection or extravasation of the opaque medium often resulted. Present Technique Because of the undesirable features of this procedure, as mentioned above, we decided to catheterize the subclavian artery directly following percutaneous infraclavicular puncture. Seldinger's ~ technique of percutaneous arterial catheterization was adapted to the subclavian artery in the following manner: 1. The patient was placed on the table in a supine position without hyperextension of the neck. ~. The skin was prepared with Merthiolate and both superficial and deep infiltration with 1 per cent procaine was performed in the infraclavicular region, approximately at the point of the junction of the internal and middle third of the clavicle. 3. The subclavian artery was palpated in the supraclavicular fossa with the fingers of one hand, and with the free hand the Seldingcr needle was inserted beneath the clavicle and advanced upward, medially and posteriorly, toward the palpable subclavian artery. 4. Once the double needle was in the lumen of the artery, the inner needle was withdrawn and the outer needle was advanced into the artery until a satisfactory "back flow" was obtained. Then the flexible metallic guide was introduced through the outer needle. 5. After the metal catheter guide was in place, the outer needle was withdrawn. A polyethylene tube, PE-190 or PE-160 (Clay-Adams) in caliber, ~0 to s cm. in length, previously prepared according to Soila's technique, n then was introduced over the metallic guide employing some rotatory movements. Once the catheter had entered 4-5 cm. into the vascular lumen, the guide was removed. 6. The "free" end of the polyethylene tube was fitted to a tubing adapter (Clay-Adams, A-10~6), which was connected to the syringe through another long, flexible plastic tube. This latter tube was used to permit the operator to remain shielded from the field of radiation. 7. A small amount (5-10 ml.) of contrast material then was injected and the first film was taken in order to visualize the position of the tip of the catheter. The Tatter may be observed readily because of the very small amount of contrast material contained in the catheter itself. 8. Several films were taken at different levels, placing the tip of the catheter at the level of the vessel to be visualized. The amount of contrast material injected depended upon the vessel or vessels to be visualized with a single injection. At no time did the amount exceed ~5 ml. 9. In order to avoid formation of clots in the tubing, small and repeated injections of a solution of normal saline containing 50 rag./100 ml. of sodium heparin were made. Results Direct percutaneous infraclavicular catheterization of the subclavian artery proved, in our hands, to be a much more satisfactory approach than the supraclavicular puncture with the needle since the possibility of pneumothorax was minimized markedly. The

3 Catheterization of Subclavian Artery ~85 Fra. 3 (left). Initial fihn taken with 10 ml. of contrast material showing (c) the catheter, (1) innominate artery (3) right common carotid artery and its branches up to the base of the skull, (8) right vertebral, and (4) left common carotid artery and its bifurcation. FIa. 8 (right). Second film taken after injection of 35 ml. of contrast material showing (1) more nearly complete visualization of innominate artery, (~2) right common carotid artery and its branches, (8) right vertebral, (4) proximal and (5) the distal segments of left common carotid artery including its bifurcation, and (6) right subclavian artery. Fla. 4 (left). The catheter (c) is withdrawn to place its tip in the proximal segment of the right subclavian artery in order to obtain selective filling of the right vertebral artery (8). This demonstrates marked stenosis at the origin of the vertebral artery and irregularity of caliber along its cervical course. Twenty ml. of contrast material were injected. FIG. 5 (right). Selective filling of right vertebral artery from its origin up to and including the basilar artery following injection of 15 ml. of contrast material. Arrow shows the external segment of the polyethylene tubing.

4 ~36 Jorge Weibel and William S. Fields FIG. 6. (left). Lateral view of head and neck showing distal segment of right common carotid, right internal carotid and its intracranial branches, upper cervical and intracranial segments of right vertebral, basilar and both posterior cerebral arteries following a sing]e injection of ~5 ml. of contrast material. The tip of the catheter was placcd in the innominate artery. FIG. 7 (right). Visualization of entire course of left vertebral artery and basilar artery following injection of ~0 ml. of contrast material. Arrow shows external segment of the catheter. pleura can be avoided when the puncture is made in the third portion of the subclavian artery laterally and parallel to its longitudinal axis over the first rib. Formation of hematoma can be controlled readily by manual pressure over the supraclavicular region. In the first 50 patients in whom this technique has been employed, there have been no cerebral or systemic complications, either transitory or otherwise. The only local problem has been minimal intramural injection of contrast medium in 3 cases without sequelae. Pneumothorax has not occurred in any of these cases. This approach has, in addition, greater technical advantages than the indirect percutaneous catheterization through the brachial artery since the subclavian is of larger caliber than the braehial artery and the catheter can be advanced more easily to the origin of the vertebral artery. If the catheter is of sufficient length, it may reach the proximal segment of the innominate artery and also the aortic lumen, permitting the injection of the proximal segment of the vessels which originate therefrom (Figs. ~ through 7). If the catheter is placed in the proximal segment of the left subclavian artery, adequate visualization of its origin may be obtained. This method has some technical advantages over that described by Amplatz and Harner, because a single cathcter of sufficient length can be placed initially and withdrawn or advanced at will and it is not necessary to change it in order to get the proximal portion of the innominate artery, the aorta, or the proximal segment of the left subclavian artery as they suggest. Direct percutaneous catheterization permits turning of the head and neck to study its effects upon the circulation of the verte-

5 Catheterization of Subclavian Artery ~87 bral artery. Intramural (sheath) injection has not occurred with this technique. References 1. AMPLATZ, K., and HARNER, R. A new subclavian artery catheterization technic. Preliminary report. Radiology, 196~, 78: ~. BARBIERI, P. L., and VERDECCHIA, G.C. Vertebral arteriography by percutaneous puncture of the subclavian artery. Acta radiol., Stockh., 1957, 48: BEGO, A.C. Some radiologieal aspects of ischaemia of the brain. Brit. J. Radiol., 1960, 33: CRAWEORD, E. S., DE BAKEY, M. E., and FIELDS, W.S. Roentgenographic diagnosis and surgical treatment of basilar artery insufficiency. J. Amer. reed. Ass., 1958, 168: ELVIDGE, A. R. The cerebral vessels studied by angiography. Res. Publ. Ass. herr. ment. Dis., 1938, 18: (see p. 1~5). 6. ]KEIRNS, M. IV[. The angiographic demonstration of cerebral occlusive disease. South. reed. J., 1961, 54: POUYANNE, H., CAILLON, F., LEMAN, r., GOT, IV[., SALLES, M., and GovAz~, A. L'angiographie vertdbrale par vole sous-clavisre sous-claviculaire. Neurochirurgia, 1960, $: PYGOTT, F., and HUTTON, C.F. Vertebral arteriography by percutaneous brachial artery catheterisation. Brit. J. Radiol., 1959, 32: SELDINGER, S. I. Catheter replacement of the needle in percutaneous arteriography. A new technique. Acta radiol., Stockh., 1958, 39: SHIMIDZU, K. Beitri~ge zur Arteriographie des Gehirns--einfache percutane 1V[ethode. Arch. klin. Chir., 1987, 188: ~ ll. SOILA, P. Preparation and use of polytetrafluorethylene catheters and cannulae in diagnostic radiology. Acta radiol., Stockh., 196~, 57: ~18-~6. 1~. TATELMAN, IV[., and SHEEHAN, S. Total vertebralbasilar arteriography via transbrachial catheterization. Radiology, 196~, 78: 919-9~9.