Axilary Block Ultrasound Guiding in Patient with Pseudoaneurysm Regio Brachii

Sinistra pro Repair Pseudoaneurysm

Heri Dwi Purnomo1, Emmanuel N. Kurnia K.2

1
Department of Anesthesiology and Intensive Care Medicine,
Faculty of Medicine Sebelas Maret University, Indonesia
2
Department of Anesthesiology and Intensive Care Medicine,
Faculty of Medicine Sebelas Maret University, Indonesia

Correspondence:
Heri Dwi Purnomo
Faculty of Medicine Sebelas Maret University
Jl. Kolonel Sutarto, Jebres, Kec. Jebres, Kota Surakarta, Jawa Tengah 57126
E-mail: example@jap.com

Abstract

Background: An aneurysm may be a true aneurysm or a pseudoaneurysm. A true

aneurysm occurs when all layers of an arterial wall are dilated. On the other hand, a
pseudoaneurysm affects only one or more arterial wall layers and/or neointima,
fibrous tissue, and thrombus. Pseudoaneurysm is defined as a defect in the arterial
wall, making a connection between the lumen and the extraluminal space. The main
etiology of brachial artery pseudoaneurysm is incidental arterial puncture during
venous cannulation for hemodialysis.
Case: Anesthetic management was performed on a female patient 56 years old, body
weight 45 kg, height 150 cm. The patient had other comorbidities such as
hypertension, diabetes mellitus, chronic renal kidney with a diagnosis of left brachial
pseudoanuerysm. Pro Pseudoanurysm repair surgery. The anesthetic technique uses
axillary peripheral nerve block anesthesia with ultrasound guiding. The duration of
surgery is ± 120 minutes. After the operation, the patient was treated in the hospital
ward.
Conclusion: Choosing the most appropriate anesthetic technique for patients with
renal impairment is necessary to maintain normovolemia and normotension in order
to avoid unexpected complications. Using regional anesthetic technique for
sympathetic nerve block may be favorable in these patients. With ultrasound guiding,
the incidence of failure is lower, the time required is shorter, the latency is shorter,
the blockade is longer, and the risk of accidental vascular puncture is lower so that
vascular lesions are less likely
Keywords: pseudoaneurysm, hemodialysis, axillary block, ultrasound, ultrasound
guiding

Introduction

An aneurysm may be a true aneurysm or a pseudoaneurysm. A true

aneurysm occurs when all layers of an arterial wall are dilated. On the other hand, a

pseudoaneurysm affects only one or more arterial wall layers and/or neointima,

fibrous tissue, and thrombus. Pseudoaneurysm is defined as a defect in the arterial

wall, making a connection between the lumen and the extraluminal space. Thus,

blood can flow from the artery, then blocked by the soft tissue around it and the

compressed thrombus forming a sac. A narrow passage which is usually formed

from the arterial wall to this sac is named the “neck”. 1 Pseudoaneurysms in brachial

arteries generally develop after a trauma (0.5%) or an iatrogenic injury (3–7%). 2 The

main etiology of brachial artery pseudoaneurysm is incidental arterial puncture

during venous cannulation for hemodialysis, which is considered as a rare

complication of the procedure. The risk factors of this phenomenon are usage of

large-diameter needles, poor puncture technique, and early puncture of the fistula

after surgery3. Furthermore, other risk factors include penetrating trauma, blunt

trauma, catheterization, substance abuse and arterial gas sampling which usually

induce brachial artery pseudoaneurysms in weeks to months. 2

Upper extremity surgeries can be done under several types of anesthesia,

whether general anesthesia, regional anesthesia, or even combined. 4 The benefits of

regional anesthesia are great intraoperative muscle relaxation, decreased needs of

opioid use and possible adverse effects, reduced time for extubation, shortened

length of stay in post anaesthesia care unit (PACU), better hemodynamic stability,

improved post operative pain, and more patient satisfaction. 5,6 The main advantage

of regional anesthesia for upper extremity surgeries is that nerve blocks can prolong

the postoperative analgesia.4

The brachial plexus originates from the anterior branches of C5-C8. Block of

this plexus is a great anesthetic choice for arm and hand surgeries. 7 The most

familiar approach of brachial plexus block is the axillary approach as it is easy to

perform. This approach may also result in lower complications compared to the

interscalene region approach, which can lead to spinal cord or vertebral artery

puncture and supraclavicular approach, which can cause pneumothorax. 8 Other

advantages are prolonged analgesia, lower incidence of postoperative nausea and

vomiting, and shorter in-hospital days. However, this procedure also has several

risks such as nerve injury and accidental vascular puncture. 9

Prior to the era of ultrasonography, possibility of exposure to the spinal cord,

lungs, and major blood vessels namely the subclavian and vertebral arteries with

more proximal approaches (interscalene and supraclavicular) was of particular

attention. For the last decade, ultrasound has been utilize as guide for nerve

localization in brachial plexus blockade procedures.9 Ultrasonography minimalizes

risks during needle puncture while visualizing spread of local anesthetic during the
block.4 This case study presents a pseudoaneurism repair surgery using anesthesia

technique of axillary peripheral nerve block with ultrasound guiding.

Case

A 56-year-old woman weighing 45 kg, with a height of 150 cm, came to the

RSUD Dr. Moewardi complaining that her left hand was getting bigger, starting 2

days after the last hemodialysis. The patient had other comorbidities such as

hypertension, diabetes mellitus, chronic kidney failure with a history of shunting

arteriovenous once. history of hemodialysis since 1 year ago for twice a week with

the last procedure on February 24, 2021 at 12.30, and cardiomegaly with pulmonary

edema.

Physical examination showed that the patient was in a conscious state of GCS

E4V5M6, with blood pressure 168/96 mmHg, pulse rate 85 bpm, strong lifting,

respiratory rate of 22 breaths/minute. Examination of the heart showed a widening of

the heart border in the mediocaudolateral direction with normal heart sounds I and

II, without murmur. Examination of lungs revealed vesicular basal voice with

pulmonary rales on the basal of the right lung. The extremities were warm, not pale

with CRT <2 seconds.

 Table 1. Laboratory Preoperation Examination Result

Laboratory Examination Result Unit

Hemoglobin 6.1 g/dl
Hematocrit 19 %
Leukocytes 4.5 /mcl
Trombocytes 171 /mcl
Eritrocytes 2

Blood type
A
Protrombin Time 13.2 detik
Activated Partial 29.1 detik
Thromboplastin Time
International Normalized 0.970
Ratio
Non-fasting glucose 159* mg/dl
testing
Albumin 3.7 g/dl
Creatinine 5 mg/dl
Ureum 116 mg/dl
Sodium 138 mmol/l
Potassium 3.6 mmol/l
Cloride 106 mmol/l
Hepatitis B surface antigen Non Reactive

Routine hematological laboratory (Table 1) showed moderate anemia, low

hematocrit, azotemia, and hyperglycemia. X-ray examination of the thorax showed

cardiomegaly with a cardiac-thoracic ratio of 70% with left ventricular hypertrophy

and right atrial hypertrophy configuration with pulmonary edema and a caudal

hemodialysis catheter was attached with a tip projecting at the level of the right
thoracic vertebral bones. ECG examination revealed a rhythmic synchrony, 80

beats/minute, hypertrophy without ischemia.

The patient with American Society of Anesthesiology (ASA) physical status 3

was then planned for pseudoaneurysm repair under ultrasound-guided axillary block

regional anesthesia. Education was given to the patient and her family regarding the

surgery under regional anesthesia. Preparation was done with 2 intravenous access

lines using IV cath number 18. The patient was then fasted and given premedication

of intravenous metoclopramide 10 mg and ranitidine 50 mg. Arriving at the

operating room, the patient's anesthesia team installed the monitor and sterilized the

patient's skin. Then, the transducer was positioned in a short axis orientation in order

to reveal the axillary artery, about 1-3 cm from the skin surface. The patient's arm

was abducted to 90 degrees and the transducer was placed. We avoided to abduct

the patient's arm excessively, as this could cause patient discomfort and traction on

the brachial plexus, increasing the risk of needle injury. The transducer was placed

distal to the insertion of pectoralis major muscle on the humerus bone. Moving the

transducer proximally located the axillary artery, conjoint tendons, and terminal

branches of the brachial plexus.

The anesthesia technique began with injection of levobupivacaine 0.375% 20

mL and Lidocaine 1.5% 10 mL (total 30 mL). One third of the total dose (10 mL) was

constantly injected to block the ulnar, median, radial, and musculocutaneous nerves.

The anesthetic agent was injected posteriorly to the artery first, as starting with

injection of the median or ulnar nerves might displace the aimed structure deeper
and cloud the nerve. The needle was then pulled just under the skin, directed to the

median and ulnar nerves. Lastly, the injection was completed with spread around the

median nerve.

The last step was to withdraw the needle and direct it back to the

musculocutaneous nerve to make the final injection. The musculocutaneous nerve

sometimes is located near the median nerve. In this case, double injection is not

necessary. Ten minutes after the injection, the patient felt hypesthesia in the surgery

area. Prior to the operation, the sensory and motor functions of each nerve were

reassessed, then surgery was started after confirming that the nerve block was

successful. The operation lasted approximately for 2 hours.

Postoperatively, the patient did not state any complaints of pain. The visual

analog scale (VAS) was assessed in 2, 8, 12, and 24 hours postoperatively. The result

was 1-2.

Discussion

Patients with chronic renal failure require routine hemodialysis. However, the

site of the hemodialysis puncture can be a risk for the formation of brachial artery

pseudoaneurysms.2 Patients with renal dysfunction usually have accompanying co-

morbidities, namely hypertension, diabetes, and cardiovascular diseases. Due to

reduced erythropoietin production in the kidneys, anemia is also commonly found in

these patients. Patients with renal failure also have a higher risk of bleeding due to

impairment of thrombocyte function and von Willebrand factor. Another problem is

altered homeostasis such as electrolyte imbalance which can affect many organ

systems. Thus, the intraoperative management of these patients can be challenging

for anesthesiologists.10

As a requirement for elective surgery, patients with chronic kidney disease

should undergo hemodialysis a day in advance to improve electrolyte, metabolic, and

volume status. Administration of intravenous fluid should be limited in such patients

for minor surgery and euvolemia state should be controlled to maintain adequate

preload, in order to avoid hypotension and hypoperfusion to organs. Volume

overload can cause pulmonary edema and hypoxia. Another crucial thing is to

maintain normovolemia and normotension, preventing reduced renal perfusion.

Volatile anesthetics can reduce renal perfusion pressure by decreasing systemic

vascular resistance (eg, isoflurane or sevoflurane) or cardiac output (eg halothane),

thus lowering the glomerular filtration rate (GFR). Several factors can exacerbate this

phenomenon, such as pain which may induce responses like hypovolemia and

release of catecholamines and vasopressin hormone during surgery. 11 Administration

of general anesthesia can lower the renal blood flow, affecting the excretion of

nephrotoxic agents.12

During general anesthesia, positive-pressure ventilation can reduce cardiac

output, renal blood flow, and GFR. A low cardiac output activates the

sympathoadrenal system, stimulating the release of catecholamines, renin, and

angiotensin II by activating and resulting in decreased renal blood flow. 13

 The use of regional anesthetic techniques for sympathetic nerve block

attenuates catecholamine-induced renal vasoconstriction and suppresses release of

cortisol and epinephrine release. Thus, this block may be helpful for patients with

renal failure or patients with higher risk for postoperative AKI. 14

Advantages of brachial plexus block include prolonged analgesia, lower inci

dence of postoperative nausea and vomiting, and shorter in-hospital days.9 However,

it holds the risk for procedure-related complications such as accidental nerve injury

and vascular puncture.

With the use of ultrasound guiding, the incidence of failure is lower, the time

required is shorter, the latency is shorter, the blockade is longer, and the risk of

accidental vascular puncture is lower, resulting in less chance of vascular lesions.

superior for guiding peripheral nerve blocks. In a meta-analysis, comparison of

ultrasound-guided peripheral nerve blocks and conventional techniques (paresthesia

and neurostimulation) showed a lower risk of accidental vascular puncture when

ultrasound was used.15

Conclusion

Patients with renal impairment usually have accompanying co-morbidities,

namely hypertension, diabetes, and cardiovascular diseases. Another obstacle is

altered homeostasis such as electrolyte imbalance which can affect many organ

systems. Thus, the intraoperative management of these patients can be challenging

for anesthesiologists. Choosing the most appropriate anesthetic technique and agent

is necessary to maintain normovolemia and normotension in order to avoid

unexpected complications. Regional anesthetic techniques for sympathetic nerve

block may be favorable for such patients. With the help of ultrasound, the incidence

of failure is lower, the time required is shorter, the latency is shorter, the blockade is

longer, and the risk of accidental vascular puncture is lower, resulting in less chance

of vascular lesions.

Acknowledgement

The authors report no conflict of interests.

References

1. Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ.

Pseudoaneurysms and the role of minimally invasive techniques in their

management. Radiographics. 2005. Suppl 1:S17389

2. Deşer SB. Management of iatrogenic brachial artery pseudoaneurysm: surgical

treatment of iatrogenic brachial artery pseudoaneurysm. International Journal of

the Cardiovascular Academy. 2017 Mar 1;3(1-2):9-10.

3. Wang A, Silberzweig JE. Brachial artery pseudoaneurysms caused by inadvertent

hemodialysis access needle punctures. American Journal of Kidney Diseases. 2009

Feb 1;53(2):351-4

4. Mirza F, Brown AR. Ultrasound-guided regional anesthesia for procedures of the

 upper extremity. Anesthesiology research and practice. 2011 May 30;2011.

5. J. G. D’Alessio, M. Rosenblum, K. P. Shea, and D. G. Freitas,. A retrospective

comparison of interscalene block and general anesthesia for ambulatory surgery

shoulder arthroscopy. Regional Anesthesia and Pain Medicine,vol. 20, no. 1,1995.

6. A. R. Brown, R. Weiss, C. Greenberg, E. L. Flatow, dan L. U. Bigliani, Interscalene

block for shoulder arthroscopy: comparison with general anesthesia Arthroscopy,

vol. 9, no.3 1993.

7. Lopera-Velásquez LM, Restrepo-Garcés C. Ultrasound and nerve stimulation-

guided axillary block. Colombian Journal of Anesthesiology. 2016

8. Hadzic A, editor. Hadzic's textbook of regional anesthesia and acute pain

management. 2nd ed. New York, USA: McGraw-Hill Education. 2017

9. Chan VW, Perlas A, McCartney CJ, Brull R, Xu D, Abbas S. Ultrasound guidance

improves success rate of axillary brachial plexus block. Canadian Journal of

Anesthesia. 2007 Mar;54(3):176-82.

10. Wagener G, Brentjens TE. Anesthetic concerns in patients presenting with renal

failure. Anesthesiology clinics. 2010 Mar 1;28(1):39-54.

11. Kusudo K, Ishii K, Rahman M, et al. Blood flow-dependent changes in intrarenal

nitric oxide levels during anesthesia with halothane or sevoflurane. Eur J

Pharmacol. 2004;498:267–73

12. Salifu MO, Otah K. Perioperative management of the patient with chronic renal

failure. 2021

13. Annat G, Viale JP, Bui Xuan B, et al. Effect of PEEP ventilation on renal function,
 plasma renin, aldosterone, neurophysins and urinary ADH, and prostaglandins.

Anesthesiology 1983;58:136–41.

14. Li Y, Zhu S, Yan M. Combined general/epidural anesthesia (ropivacaine 0.375%)

versus general anesthesia for upper abdominal surgery. Anesth Analg. 2008;106:

1562–5.

15. Martins LE, Ferraro LH, Takeda A, Munechika M, Tardelli MA. Ultrasound-guided

peripheral nerve blocks in anticoagulated patients–case series. Brazilian Journal of

Anesthesiology (English Edition). 2017;67(1):100-6