From the Guidelines
Placing an arterial line in the brachial artery should generally be avoided if alternative sites like the radial or femoral arteries are available. The brachial artery is not an ideal location for arterial cannulation due to several important anatomical and clinical considerations. The brachial artery lacks collateral circulation, unlike the radial artery which is protected by the ulnar artery backup via the palmar arch. This increases the risk of limb ischemia if thrombosis occurs. Additionally, the brachial artery's proximity to the median nerve creates a significant risk of nerve injury during cannulation, potentially causing permanent neurological deficits. The brachial artery's deeper location compared to the radial artery makes it technically more challenging to access and increases the risk of hematoma formation. If brachial artery cannulation is absolutely necessary, ultrasound guidance should be used to minimize complications, as recommended by recent evidence-based guidelines 1, and the site should be monitored frequently for signs of compromised circulation, nerve damage, or bleeding.
The healthcare team should perform regular neurovascular checks of the affected limb, including assessment of distal pulses, capillary refill, temperature, color, sensation, and motor function. The arterial line should be removed as soon as clinically feasible to reduce complication risks. It is also important to note that intra-arterial catheters generally should not remain in the same arterial site for prolonged periods of time, certainly no longer than is clinically necessary and never for >48 to 72 h without being changed, as suggested by earlier guidelines 1. However, the most recent and highest quality study 1 emphasizes the importance of ultrasound guidance in reducing complications and improving outcomes, which should be the primary consideration in clinical decision-making.
Key considerations for brachial artery cannulation include:
- Risk of limb ischemia due to lack of collateral circulation
- Risk of nerve injury due to proximity to the median nerve
- Technical challenges and increased risk of hematoma formation due to deeper location
- Importance of ultrasound guidance in minimizing complications
- Need for regular neurovascular checks and prompt removal of the arterial line to reduce complication risks.
From the Research
Implications of Arterial Line Placement in the Brachial Artery
The placement of an arterial line in the brachial artery has several implications, including:
- High complication rates, with studies suggesting that complications can occur in up to 40% of cases 2
- Risk of distal ischemia, thrombosis, and dissection, as well as bleeding and infection 2, 3
- Potential for long-term vascular or neuropathic complications, although some studies have found that these complications can be minimized with proper technique and care 3
- Increased risk of complications with increasing sheath size, with larger sheaths associated with higher rates of bleeding and thrombosis 3
Comparison to Other Arterial Sites
The brachial artery is not typically the first choice for arterial line placement, with the radial and femoral arteries being more commonly used:
- The radial artery is often preferred due to its accessibility and lower risk of complications 4
- The femoral artery is also commonly used, particularly in patients who require larger sheaths or have limited access to the radial artery 4
- The brachial artery may be used as an alternative when other sites are not available, but its use is associated with a higher risk of complications 5, 2
Patient Population and Outcomes
The implications of brachial artery catheterization may vary depending on the patient population:
- In neonates and small children, the brachial artery may be considered for cannulation due to the small diameter of the radial artery 6
- In critically ill patients, the use of the brachial artery for arterial line placement has been associated with high mortality and prolonged ICU length of stay 2
- In patients undergoing endovascular interventions, the use of the brachial artery has been associated with a higher risk of complications, particularly with larger sheaths 3