title: Bilateral brachial artery occlusion decreases internal carotid artery volume flow: a simple adjunct for cerebral protection?
abstract: OBJECTIVE
  To investigate if a decrease in internal carotid artery (ICA) blood flow occurs with bilateral brachial artery occlusion (BBO), which may improve the effectiveness of cerebral protection devices during carotid interventions.
  
  
  METHODS
  Thirty-two asymptomatic patients (21 men; mean age 67 years) with carotid atherosclerosis between 15% and 79% were enrolled in the study. Carotid duplex ultrasound was followed by volume flow rate (VF) determination in the right ICA, external carotid (ECA), and vertebral arteries. After baseline values were obtained, BBO was induced by bilateral arm pressure cuff inflation to 30 mmHg over the systolic pressure for no more than 3 minutes. VF measurements were repeated.
  
  
  RESULTS
  Seventeen patients (responders) had an ICA VF decrease from 406+/-109 mL/min (+/-SD) to 303+/-90 mL/min (p=0.005), while 15 patients (nonresponders) had no significant change in their ICA VF (340+/-192 versus 447+/-267 mL/min, p=0.22). In responders, ECA VF increased (190+/-65 to 232+/-125 mL/min), as did vertebral VF (77+/-53 to 95+/-60 mL/min; p>0.05). The ratio of ICA/ECA VF dropped from 2.13 to 1.31 in responders, but did not change in nonresponders. No patient exhibited any neurological symptoms during the study. Post cuff volume flows approximated baseline values. Cerebral magnetic resonance angiograms obtained in 10 responders revealed a complete circle of Willis in 8 (80%), while only 1 (16%) of 6 nonresponders had a complete pathway.
  
  
  CONCLUSIONS
  A transient decrease in ICA VF, with concomitant elevations of the ECA and vertebral VFs, occurs with occlusion of the brachial arteries in the setting of a complete circle of Willis. Since no flow reversal occurs, this maneuver is insufficient to provide complete cerebral protection, but it may improve the effectiveness of cerebral protection devices and serve as an adjunctive maneuver in selected cases. Furthermore, changes in ICA VF may prove to be a noninvasive test for evaluating the integrity of the circle of Willis.
authors.affiliation: Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA. KASHYAV@ccf.org
authors.forename: Vikram S
authors.initials: VS
authors.lastname: Kashyap
authors.forename: Kevin S
authors.initials: KS
authors.lastname: Franklin
authors.forename: Colleen M
authors.initials: CM
authors.lastname: Fitzpatrick
mesh_terms: D000328:Adult; D000368:Aged; D021721:Balloon Occlusion / Q000379:methods*; D001783:Blood Flow Velocity; D001916:Brachial Artery; D002340:Carotid Artery Diseases / Q000000981:diagnostic imaging* / Q000503:physiopathology / Q000628:therapy*; D002343:Carotid Artery, Internal / Q000000981:diagnostic imaging / Q000503:physiopathology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D016896:Treatment Outcome; D018616:Ultrasonography, Doppler, Duplex