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Cardiovascular therapy —The art and the science
Letters to the Editors
Post-catheterization of the brachial
occlusion artery
To the Editor: In our paper entitled “Effect of brachial artery catheterization on arterial pulse and blood pressure in 203 patients” (AM. HEART J. 76:481, 1968), we stated that because of rich collateral circulation, brachial artery (BA) occlusion can be missed if an absent radial pulse is used as the sole criterion for this occlusion. We also stated that “in our patients who had no BA pulses and no obtainable BP by auscultatory method, the presence of satisfactory collateral circulation is probably responsible for the presence of a radial pulse albeit diminished and of a BP obtainable by radial palpation.” We postu-
lated that relatively low auscultatory blood pressure may be due to total BA occlusion with absent BA pulses, palpable radial pulses, and blood pressures via collateral circulation. We have recently examined a 36-year-old man patient who underwent right brachial artery catheterization in another hospital a year and a half earlier and who was complaining of coldness, weakness, and occasional claudication of the right forearm and hand. The right BA pulse was not palpable, but the right radial pulse was l-2+/4+. The auscultatory BP was 125/70 in the left arm and 110/70 in the right arm. The systolic BP by radial palpation was 125 in the left arm and 80 in the right arm. A transfemoral right subclavian arteriogram revealed segmental occlusion of the right brachial artery (Fig. 1) which was successfully treated with a saphenous vein bypass graft. In summary, arteriography in this patient confirmed our hypothesis that the radial pulse can be felt and that blood pressure, albeit low, can be obtained in patients with brachial artery occlusion. The development of collateral circulation would explain these findings. Robert M. Jeresaty, M.D. Assistant Professor of Medicine Joseph P. Liss, M.D. Assistant Professor of Medicine University of Connecticut School of Medicine Section of Cardiology St. Francis Hospital Hartford, Cam. 06117
Atria1
Fig. 1. Selective transfemoral right subclavian arteriogram showing occlusion of the right brachial artery (between arrows), with filling of the distal brachial artery segment by means of collateral channels.
8.50
arrhythmias
To the Editor: The article “Atrial arrhythmias and lipomatous hypertrophy of the cardiac interatrial septum,” by Drs. Hutter and Page (AM. HEART J. 89:16, 1971) reminds me of some unpublished electrocardiographic observations made during the conduct of moderate generalized hypothermia for patients undergoing surgical resection of ruptured intracranial aneurysms during the late 1950’s at the University of Miami School of Medicine. In these cases, general anesthesia was induced with a standard thiopental-succinylcholine intubation sequence, and maintenance was carried out with ether and oxygen. When the third plane of surgical anesthesia had been reached, the patients were immersed in an ice water bath and allowed to remain until body temperature reached a suitable level, allowing for drift, to produce a final temperature of approximately 28” C. In the vast majority sinus rhythm prevailed, except for sinus bradycardia accompanying temperatures below 33.5” C. Intravenous
Post-catheterization of the brachial
occlusion artery
To the Editor: In our paper entitled “Effect of brachial artery catheterization on arterial pulse and blood pressure in 203 patients” (AM. HEART J. 76:481, 1968), we stated that because of rich collateral circulation, brachial artery (BA) occlusion can be missed if an absent radial pulse is used as the sole criterion for this occlusion. We also stated that “in our patients who had no BA pulses and no obtainable BP by auscultatory method, the presence of satisfactory collateral circulation is probably responsible for the presence of a radial pulse albeit diminished and of a BP obtainable by radial palpation.” We postu-
lated that relatively low auscultatory blood pressure may be due to total BA occlusion with absent BA pulses, palpable radial pulses, and blood pressures via collateral circulation. We have recently examined a 36-year-old man patient who underwent right brachial artery catheterization in another hospital a year and a half earlier and who was complaining of coldness, weakness, and occasional claudication of the right forearm and hand. The right BA pulse was not palpable, but the right radial pulse was l-2+/4+. The auscultatory BP was 125/70 in the left arm and 110/70 in the right arm. The systolic BP by radial palpation was 125 in the left arm and 80 in the right arm. A transfemoral right subclavian arteriogram revealed segmental occlusion of the right brachial artery (Fig. 1) which was successfully treated with a saphenous vein bypass graft. In summary, arteriography in this patient confirmed our hypothesis that the radial pulse can be felt and that blood pressure, albeit low, can be obtained in patients with brachial artery occlusion. The development of collateral circulation would explain these findings. Robert M. Jeresaty, M.D. Assistant Professor of Medicine Joseph P. Liss, M.D. Assistant Professor of Medicine University of Connecticut School of Medicine Section of Cardiology St. Francis Hospital Hartford, Cam. 06117
Atria1
Fig. 1. Selective transfemoral right subclavian arteriogram showing occlusion of the right brachial artery (between arrows), with filling of the distal brachial artery segment by means of collateral channels.
8.50
arrhythmias
To the Editor: The article “Atrial arrhythmias and lipomatous hypertrophy of the cardiac interatrial septum,” by Drs. Hutter and Page (AM. HEART J. 89:16, 1971) reminds me of some unpublished electrocardiographic observations made during the conduct of moderate generalized hypothermia for patients undergoing surgical resection of ruptured intracranial aneurysms during the late 1950’s at the University of Miami School of Medicine. In these cases, general anesthesia was induced with a standard thiopental-succinylcholine intubation sequence, and maintenance was carried out with ether and oxygen. When the third plane of surgical anesthesia had been reached, the patients were immersed in an ice water bath and allowed to remain until body temperature reached a suitable level, allowing for drift, to produce a final temperature of approximately 28” C. In the vast majority sinus rhythm prevailed, except for sinus bradycardia accompanying temperatures below 33.5” C. Intravenous