Limb arteries involvement assessed by FDG/PET CT at diagnosis of giant cell arteritis and risk of relapse: an observational study.

Introduction Steroids and anti-IL6 biotherapy are highly effective in obtaining remission in patients with giant cell arteritis (GCA) but the risk of relapses remains high. We aimed to identify predictors of relapse in GCA. Methods All consecutive patients admitted with a new diagnosis of GCA - according to the 2022 American College of Rheumatology/EULAR (ACR/EULAR) classification criteria - between May 2011 and May 2022 were eligible for this study. The primary outcome was the GCA relapse rate over the 36-months follow up. Factors associated with the primary outcome and time to first relapse were analyzed. Results One hundred and eight patients (74 [69-81] years, 64.8% women) with a new diagnosis of GCA were studied. GCA was biopsy-proven in 65 (60.2%) cases. Ninety-eight (90.7%) FDG/PET CT scans performed at diagnosis were available for review. All patients received steroids given for 21.0 [18.0-28.5] months, associated with methotrexate (n=1, 0.9%) or tocilizumab (n=2, 1.9%). During a median follow-up of 27.5 [11.4-35.0] months, relapse occurred in 40 (37%) patients. Multivariable Cox regression model, including general signs, gender, aortic wall thickness, FDG uptake in arterial wall and IV steroid pulse as covariates, showed that both general signs (HR 2.0 [1.0-4.0, p<0.05) and FDG uptake in limb arteries (HR 2.7 [1.3-5.5], p<0.01) at diagnosis were associated with GCA relapse. Conclusion FDG uptake in limb arteries at diagnosis is a predictor of relapse in newly diagnosed GCA.

Assessment of anatomic variations of the brachial artery bifurcation using vascular Doppler ultrasound: a cross-sectional study.

Background: Anatomical variations in arteries of the upper limb, such as presence of an accessory brachial artery, are common and widely described in the literature, mainly in cadaveric studies, but it is now possible to diagnose them using vascular Doppler ultrasound. Objectives: To identify the incidence of accessory brachial artery using vascular Doppler ultrasound and compare the findings with cadaveric studies. Methods: This was a prospective study that examined 500 upper limbs of 250 volunteers assessed with vascular Doppler ultrasound using the Sonosite Titan portable ultrasound machine. Results: 15.6% of the participants in our study had the accessory brachial artery anatomical variation. Our percentage is in line with the average rates found in cadaveric studies, which ranged from 0.2% to 22%. Being aware of this variation is fundamental in procedures such as peripheral venipuncture, arteriovenous fistula creation, catheterization, forearm flaps, emergency surgeries on the limb and even correction of fractures by cast. Conclusions: The accessory brachial artery is a frequent variant in the upper limb. The percentage of individuals with an accessory brachial artery in our study was 15.6%, which agrees with data from the literature on cadaveric studies.

INCREASED DIAMETER AND STIFFNESS OF ELASTIC BUT NOT MUSCULAR ARTERIES IN MEN WITH ABDOMINAL AORTIC ANEURYSM.

It has been proposed that formation of abdominal aortic aneurysm (AAA) is part of a systemic arterial dilatative disease. However, arteries in the upper extremity are scarcely studied and it remains unclear whether both muscular and elastic arteries are affected by the proposed systemic arterial dilatation. The aim of this study was to investigate diameter and stiffness of muscular and elastic arteries in arterial branches originating from the aortic arch. Twenty-six men with AAA (69 ± 4 years) and fifty-seven men without AAA (70 ± 5 years) were included in the study. Ultrasound was used to examine the distal and proximal brachial artery, axillary artery, and common carotid artery (CCA), and measurement of diameter and diameter change were performed with wall-tracking software. Blood pressure measurements were used to calculate local arterial wall stiffness indices. The AAA cohort presented larger arterial diameters in the CCA and axillary artery after adjustment for body surface area (p=0.002, respectively), while the brachial artery diameters were unchanged. Indices of increased stiffness in CCA (e.g., lower distensibility, p=0.003) were seen in subjects with AAA, after adjustments for body mass index and mean arterial blood pressure. This study supports the theory of a systemic arterial dilating diathesis in in peripheral elastic, but not in muscular, arteries. Peripheral elastic arteries also exhibited increased stiffness, in analogy with findings in the aorta in AAA.

An Unusual High Bifurcation of the Brachial Artery: A Cadaveric Case Report.

The human vascular system exhibits a remarkable degree of anatomical variability, with deviations from conventional arterial branching patterns occasionally encountered. Among these variations, the atypical bifurcation has drawn attention for its infrequent occurrence and potential clinical implications. This study investigates the rare anatomical variation of high bifurcation seen during cadaver dissection in the brachial artery. It emphasizes the relevance of understanding such variations in established vascular anatomy and their clinical implications. Detailed findings from the dissection of the upper limbs, which reveal a high bifurcation in a 40-year-old male cadaver, are presented. The report highlights unique anatomical variations, including a superficial path. The conclusion underscores the rarity of this high bifurcation and its potential impact on medical procedures. It stresses the importance of healthcare professionals being aware of and prepared for such anatomical variations for optimal patient care. In order to manage potential difficulties during medical operations affecting the circulatory system and eventually enhance patient outcomes, it is necessary to understand these deviations.

A comparative study on the transbrachial and transfemoral approaches for the treatment of superior mesenteric artery lesions.

BACKGROUND: Superior Mesenteric Artery (SMA) lesions present a significant challenge in endovascular surgery. Both the transbrachial (TBA) and the transfemoral (TFA) approaches have been employed for the treatment of these lesions, but the comparative effectiveness of these methods remains unclear. MATERIALS AND METHODS: A retrospective analysis was conducted on patients who underwent TBA and TFA at a tertiary center between June 2020 and February 2023. Key parameters including technical success, procedural details, and complication rates were examined. RESULTS: In a study of 99 patients, 66 underwent Transfemoral Approach (TFA) and 33 underwent Transbrachial Approach (TBA). No significant age or gender differences were noted between groups. TFA procedures were longer (90.0 vs 63.5 min, p = 0.002) and had higher fluoroscopy times (59.0 vs 43.0 min, p = 0.02) and selective SMA times (366.0 vs 245.0 min, p = 0.038) compared to TBA, especially with a smaller aortomesenteric angle (<90°). Technical success rates were high in both groups (TFA 97%, TBA 93.9%, p = 0.60). Complication rates were similar between groups, with no significant predictors for access site complications identified. CONCLUSION: Both the TBA and the TFA are effective for the treatment of SMA lesions, with TBA potentially offering advantages in terms of efficiency and patient recovery, particularly in cases with certain anatomy. No significant differences in complication rates were found between the two groups. Further research, including prospective randomized trials, is needed to confirm these findings.

Making the case for resistance training in improving vascular function and skeletal muscle capillarization.

Through decades of empirical data, it has become evident that resistance training (RT) can improve strength/power and skeletal muscle hypertrophy. Yet, until recently, vascular outcomes have historically been underemphasized in RT studies, which is underscored by several exercise-related reviews supporting the benefits of endurance training on vascular measures. Several lines of evidence suggest large artery diameter and blood flow velocity increase after a single bout of resistance exercise, and these events are mediated by vasoactive substances released from endothelial cells and myofibers (e.g., nitric oxide). Weeks to months of RT can also improve basal limb blood flow and arterial diameter while lowering blood pressure. Although several older investigations suggested RT reduces skeletal muscle capillary density, this is likely due to most of these studies being cross-sectional in nature. Critically, newer evidence from longitudinal studies contradicts these findings, and a growing body of mechanistic rodent and human data suggest skeletal muscle capillarity is related to mechanical overload-induced skeletal muscle hypertrophy. In this review, we will discuss methods used by our laboratories and others to assess large artery size/function and skeletal muscle capillary characteristics. Next, we will discuss data by our groups and others examining large artery and capillary responses to a single bout of resistance exercise and chronic RT paradigms. Finally, we will discuss RT-induced mechanisms associated with acute and chronic vascular outcomes.

Compressive median neuropathy caused by brachial artery pseudoaneurysm.

Background: Brachial artery pseudoaneurysms (PSAs) are a rare complication of trauma and medical intervention, estimated to constitute 0.3-0.7% of all PSAs. Although neurologic symptoms are common in patients undergoing hemodialysis, direct nerve compression by large PSAs is rare. Case Description: We report a case of median nerve compression by a brachial artery PSA treated by PSA resection and distal nerve transfer of the extensor carpi radialis brevis nerve to the anterior interosseous nerve. Conclusion: This case illustrates the successful use of distal nerve transfers for the treatment of median neuropathy secondary to brachial PSA. In addition, this case highlights the importance of imaging before any exploratory nerve surgery in the setting of a mass and/or prior vascular procedure. Embarking on a nerve release/ repair surgery in the absence of a vascular surgeon would be disastrous.

Successful revascularization using a saphenous vein for a ruptured brachial artery aneurysm in a patient with neurofibromatosis type I.

Vasculopathy in patients with type 1 neurofibromatosis is known. Brachial artery aneurysms in patients with type 1 neurofibromatosis are rare, but any rupture can be extremely serious. A 56-year-old woman presented to our hospital with sudden pain in her right upper arm. Computed tomography revealed a ruptured brachial artery aneurysm, and operative reconstruction using a saphenous vein graft was performed. This is one of the few case reports of such successful revascularization using saphenous vein. The pathologic findings suggest neurogenic tumor invasion, and end-to-side anastomosis was effective in avoiding hemorrhagic complications.

Ischemic Complication of a Rare Traumatic True Brachial Artery Aneurysm: A Case Report.

True brachial artery aneurysms are rare. We present the case of a 47-year-old male who was referred to our clinic for the evaluation of progressive right arm claudication. He had suffered a gunshot wound in the right elbow 16 years before his symptoms. Computed tomography angiography revealed a thrombosed true brachial artery aneurysm. The patient was placed in the operating room, and aneurysm resection and reconstruction were performed using an interposition saphenous vein graft. His postoperative period was uneventful, and 1 year after the procedure, he remained asymptomatic. True brachial artery aneurysms associated with remote traumas are rare. This case illustrates the clinical presentation and successful management of arterial reconstruction using an autologous vein graft.

True brachial artery aneurysm: A systematic review.

Objective: To identify and critically appraise literature on true brachial artery aneurysm, exploring its demographic characteristics, aetiologies, clinical manifestations and different methods of repair along with complication rates to determine future treatment strategies. METHODS: The systematic review was conducted at Liaquat National Hospital, Karachi, from September 30, 2021, to November 30, 2022, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature was searched on MEDLINE, EMBASE and Cochrane databases for relevant studies in English language or with English translation published till May 31, 2022. The key words used for the search were "brachial artery aneurysm". Data was noted on a proforma and was subjected to descriptive analysis. RESULTS: Of 113 articles, 6 (5.3%) were retrospective studies, 7 (6.1%) were case series and 100 (88.4%) were case reports. The total number of patients involved was 157 with mean age 43.1±23.4 years (range: 2 months to 84 years). The gender was mentioned for 152(96.8%) patients; 111(73%) males and 41(27%) females. The mean diameter of true brachial artery aneurysm was 36.2 ±17.5mm and 106(67.5%) patients presented with localised swelling, 65(41.4%) with pain, 41(26.1%) with distal ischaemic symptoms, and 28(17.8%) with median nerve compression. True brachial artery aneurysms were more common in renal failure patients having a history of arteriovenous fistula creation in the affected limb and were on immunosuppressant drugs due to renal transplant 81(51.5%). Less common causes included primary/idiopathic 27(17.1%), trauma 13(8.2%), connective tissue disorders 8(5%) and vasculitis 7(4.5%). The treatment of choice was aneurysmectomy in 142(90.4%) cases, with revascularisation of limb primarily with reversed great saphenous vein graft 79(50.3 %), followed by end-to-end anastomosis of brachial artery 17(10.8%) and synthetic grafting 17(10.8%). Endovascular intervention was performed in 6(3.8%) cases to exclude true brachial artery aneurysm, and to re-establish adequate blood flow to the associated limb. Conclusion: True brachial artery aneurysm, although a rarity, may lead to significant neurological and vascular problems if ignored. Arteriovenous fistula and immunosuppression are identified as two significant risk factors in the development of true brachial artery aneurysm. Therefore, an effective long-term follow up in renal failure patients is recommended to prevent its complications. Open surgical repair has been the most preferred mode of treatment, but further significant studies are needed to explore and compare different modes of surgical intervention, like open versus endovascular, to plan future treatment strategies.

Use of the Superficialized Brachial Artery as Vascular Access for a Patient with Myasthenia Gravis with a Frequent Need for Plasmapheresis: A Case Report.

A 41-year-old woman diagnosed with seronegative myasthenia gravis struggled to maintain remission for a decade, facing crises every 3 months for several years. After repeated apheresis using a non-tunneled non-cuffed central venous dialysis catheter (NTNCC), complications such as catheter-related thrombus in the internal jugular veins and morbid obesity from steroids made the insertion of NTNCC increasingly difficult, leading to consideration of an alternative permanent vascular access (VA) approach. Thus, we created a subcutaneously superficialized brachial artery as the VA, which allowed the patient to undergo safe and uninterrupted apheresis therapy.

Trans-Brachial TAVI in a Patient with Aortic Isthmus Stenosis: A Case Report.

BACKGROUND: TAVI indications expand not only to low-risk patients but also to patients with a more complex anatomy and comorbidities. Transfemoral retrograde access is recognized as the first preferred approach according to the current guidelines. However, this approach is not suitable in up to 10-15% of patients, for whom an alternative non-femoral access route is required. CASE PRESENTATION: An 83-year-old male patient with known aortic isthmus stenosis presented with severe symptomatic aortic stenosis. Computed tomography revealed a subtotal isthmus stenosis, directly after left subclavian artery origin, with many collaterals extending toward the axillary and subclavian arteries. Duplex ultrasound verified the proximal diameter of the left brachial artery to be 5.5 mm. A successful surgical cutdown trans-brachial TAVI with an Evolut prosthetic valve with a size of 29 mm was performed. On the fourth postoperative day, the patient was discharged, and the three-month follow-up was uneventful. CONCLUSION: In patients with aortic isthmus stenosis, the brachial artery could be a feasible alternative, as a less invasive access site, which can be determined after careful assessment of the vessel diameter. More data are required to evaluate the safety and efficacy of this access route and to achieve more technical improvements to increase operator familiarity with it.

Brachial artery aneurysm after hemodialysis fistula ligation: Case reports and review of literature.

INTRODUCTION: Brachial artery aneurysm (BAA) following long-standing arteriovenous fistula (AVF) ligation after renal transplantation is odd. CASE PRESENTATION: Two cases of brachial artery aneurysm treated with bypass (a saphenous vein graft and a PTFE graft). In the first patient no complications were recorded whereas an infection was diagnosed after 6 months from the procedure in the second treatment. CLINICAL DISCUSSION: Multiple factors activated by stress on the vessel wall followed by fistula ligation are the cause of vascular remodeling of the three layers making up the wall with possible evolution in aneurysmatic lesions. In literature the gold standard for this lesion is the surgical approach, only one endovascular procedure is reported. The traditional surgical approach uses the autologous vein or prosthetic PTFE grafts. CONCLUSION: Brachial artery aneurysm is a complication that affects patients undergoing renal transplantation who have already undergone AVF ligation. In our experience autologous vein graft represented the best solution.

Congenital brachial artery occlusion causing neonatal forearm compartment syndrome.

Congenital brachial artery occlusion is rare. We report four patients who presented at birth with absent wrist pulses. We propose management recommendations that include anti-coagulation, duplex ultrasound assessment and fasciotomy surgery as early as is safe and possible.

Aneurysmal Degeneration of the Brachial Artery Following Chronic Arteriovenous Fistula Ligation.

Introduction: Arteriovenous fistulas (AVF) are currently considered to be the best vascular access option for patients with end stage chronic kidney disease requiring haemodialysis. In rare cases of patients with chronic AVF, thrombosis or ligation of the access can lead to the development of brachial artery aneurysms. Despite being uncommon, reports of this phenomenon have arisen in recent decades due to an increase in the number of patients undergoing dialysis worldwide. This case presented with a brachial aneurysm that developed after AVF ligation. Case report: A 62 year old male presented to the emergency department with swelling of the medial aspect of his left arm associated with pain, inflammatory signs, and finger paraesthesia. Swelling had started two months previously but had worsened within the last week. He had history of kidney transplant 20 years ago and a chronic functioning radiocephalic fistula that had not been used since, and which had been ligated in the past year due to the development of venous aneurysms. Physical examination revealed a pulsatile mass in his left arm and absent radial and ulnar pulses, without signs of hand ischaemia. There was significant venous collateralisation of the arm and chest and numbness of the left fingers, suggesting venous and neurological compression. Computed tomography angiography showed a large left brachial artery aneurysm (108 x 87 x 180 mm). The patient underwent aneurysm sac emptying and collateral ligation followed by great saphenous vein interposition, with clinical improvement. Conclusion: The presence of a chronic AVF can lead to progressive changes in the arterial wall. Sudden ligation or thrombosis of a functioning AVF causes increased blood pressure within the artery, which may further contribute to its aneurysmal degeneration. In addition, immunosuppressive therapy following kidney transplant has been described as a synergistic risk factor leading to aneurysm formation. Despite being a rare complication, patients with a chronic AVF should be monitored closely after vascular access ligation.

Ultrasonographic assessment of brachial artery reactivity as a predictor of adverse outcome in patients undergoing emergency laparotomy for perforated peritonitis - Prospective observational study.

Background and Aims: This study aimed to assess if pre- and postoperative parameters of brachial artery reactivity (BAR), like flow-mediated dilation (FMD) and hyperaemic velocity (HV), could predict in-hospital mortality in perforation peritonitis patients undergoing emergency laparotomy. Methods: In this prospective observational study, adult patients with perforation peritonitis undergoing emergency laparotomy were recruited. FMD and HV were measured preoperatively, postoperatively and at 24 and 48 h post-surgery. Adult patients undergoing elective laparotomy served as the control group. The primary outcome was in-hospital mortality. Baseline and BAR parameters were compared between survivors and non-survivors. Risk factors for mortality were identified by univariate analysis. Prognostic performances of BAR parameters were assessed by different models using logistic regression. All statistical analyses were performed on STATA version 13 for Mac OS. Results: Seventy-six emergency laparotomy patients were recruited, and 26 died during the hospital stay. FMD and HV were comparable at all time points between survivors and non-survivors, except that HV was higher in survivors at 48 h post-surgery (median [interquartile range] 1.28 [1.16-1.49] vs. 1.16 [0.86-1.35], P = 0.010]. HV at 48 h predicted mortality (adjusted odds ratio [OR] [95% confidence interval] 21.05 [1.04-422.43], P = 0.046), and a model consisting of age, Acute Physiology and Chronic Health Evaluation (APACHE) score and HV at 48 h was the best predictor of mortality (area under the receiver operating characteristic (AUROC) curve 0.82). Conclusion: HV, as measured by ultrasonography of the brachial artery at 48 h postoperatively, is a good predictor of mortality in patients undergoing emergency laparotomy for perforation peritonitis.

Melatonin supplementation does not alter vascular function or oxidative stress in healthy normotensive adults on a high sodium diet.

High sodium diets (HSD) can cause vascular dysfunction, in part due to increases in reactive oxygen species (ROS). Melatonin reduces ROS in healthy and clinical populations and may improve vascular function. The purpose was to determine the effect of melatonin supplementation on vascular function and ROS during 10 days of a HSD. We hypothesized that melatonin supplementation during a HSD would improve vascular function and decrease ROS levels compared to HSD alone. Twenty-seven participants (13 M/14 W, 26.7 ± 2.9 years, BMI: 23.6 ± 2.0 kg/m2 , BP: 110 ± 9/67 ± 7 mmHg) were randomized to a 10-day HSD (6900 mg sodium/d) supplemented with either 10 mg of melatonin (HSD + MEL) or a placebo (HSD + PL) daily. Brachial artery flow-mediated dilation, a measure of macrovascular function, (HSD + PL: 7.1 ± 3.8%; HSD + MEL: 6.7 ± 3.4%; p = 0.59) and tissue oxygenation index (TSI) reperfusion rate, a measure of microvascular reactivity, (HSD + PL: 0.21 ± 0.06%/s; HSD + MEL: 0.21 ± 0.08%/s; p = 0.97) and TSI area under the curve (HSD + PL: 199899 ± 10,863 a.u.; HSD + MEL: 20315 ± 11,348 a.u.; p = 0.17) were similar at the end of each condition. Neither nitroxide molarity (HSD + PL: 7.8 × 10-5 ± 4.1 × 10-5 mol/L; HSD + MEL: 8.7 × 10-5 ± 5.1 × 10-5 mol/L; p = 0.55) nor free radical number (HSD + PL: 8.0 × 1015 ± 4.4 × 1015 ; HSD + MEL: 9.0 × 1015 ± 4.9 × 1015 ; p = 0.51) were different between conditions. Melatonin supplementation did not alter vascular function or ROS levels while on a HSD in this sample of young healthy normotensive adults.

Thrombosis related to true axillo-brachial arterial aneurysm following ligation of longstanding arteriovenous fistula for hemodialysis.

A 52-year-old man who had received hemodialysis via a left radial-cephalic arteriovenous fistula (AVF) for 18 years presented with severe ischemic symptoms in the left upper arm 12 years after occlusion of the AVF. Diagnostic imaging revealed thrombotic occlusion from a left axillary-brachial artery aneurysm, which required distal bypass surgery. The inflow artery of an AVF can develop aneurysmal degeneration, resulting in upper limb ischemia by embolization or decreased flow, especially with a ligated or occluded AVF or immunosuppressive therapy after renal transplantation. In such cases, the AVF should be monitored, even if ligated or occluded.