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Branham's Sign (A-V Malformation)

Exams and Signs

Historical Overview

  • Three surgeons independently observed cases in which bradycardia occurred in response to manual compression of an arteriovenous fistula (AVF): Nicoladoni in 1875, Israel in 1877, and Branham in 1890. As a result, the terms “Nicoladoni-Israel-Branham sign,” “Nicoladoni sign,” “Nicoladoni-Branham sign,” and “Branham’s sign” have all been used to describe it.1
  • In 1890, Branham treated a patient who had accidentally shot himself in the thigh with a .32-caliber bullet during a failed prison escape. Upon observing him several days later and palpating the swelling at the site of the injury, Branham noticed a phenomenon in which the patient’s heartbeat slowed down when he compressed the common femoral artery. This led to his publishing of a paper that would come to be used as the basis of Branham’s sign.1 Also know as Branham test or reflex. The Branham's sign is the bradycardia produced by digital closure of an artery proximal to an A-V fistula.

Description

  • Branham’s sign is the standard clinical test used to determine the hemodynamic significance of an AVF. This is accomplished by applying a compressive force to an artery proximal to the AVF and then evaluating the patient’s heart rate and blood pressure.1-3

Pathophysiology

  • An AVF is an abnormal channel between an artery and a vein, which allows blood to flow from the artery into the vein, bypassing the capillaries in the process. AVFS can be either congenital or acquired, but congenital AVFs are quite rare.
    • Acquired AVFs can be caused by any injury that damages an artery and vein that are lying side by side. The injury is typically a piercing wound, such as from a knife or bullet, and the fistula may either appear immediately or develop after a few hours.

Instructions2,4

  1. Obtain an accurate and complete patient history.
  2. Apply a compressive force to occlude an artery that is proximal to the AVF and supplying its blood flow.
  3. Measure the patient’s heart rate and blood pressure.

Variations

  • Administering an adequate dosage of atropine can prevent the slowing of the heart rate that follows the AVF occlusion.5

Related Signs and Tests

  • Bezold-Jarisch reflex
Definition of Positive Result
  • A positive result occurs when the patient experiences bradycardia and increased blood pressure in response to arterial occlusion.
Definition of Negative Result
  • A negative result occurs when the patient does not experience bradycardia and increased blood pressure in response to arterial occlusion.
Comments and Pearls
  • Although the validity of Branham's sign is generally accepted, there have been reports of patients who did not exhibit Branham's sign but had seemingly significant AVFs for unclear reasons.2
Diagnoses Associated with Exams and Signs
References
  1. Sharma, A and Swan, KG. Branham's bradycardic reaction. Ann Vasc Surg 2010;24(2):295-8.PMID: 20178140
  2. Wattanasirichaigoon, S and Pomposelli, FB, Jr. Branham's sign is an exaggerated Bezold-Jarisch reflex of arteriovenous fistula. J Vasc Surg 1997;26(1):171-2. PMID: 9240342
  3. Velez-Roa, S, Neubauer, J, Wissing, M, et al. Acute arterio-venous fistula occlusion decreases sympathetic activity and improves baroreflex control in kidney transplanted patients. Nephrol Dial Transplant 2004;19(6):1606-12. PMID: 15034165
  4. Bassan, MM. Branham's sign and atrial fibrillation. Am Heart J 1980;100(3):411-2. PMID: 7405816
  5. Kramer, ML and Kahn, JW. Effect of atropine on the Branham sign in arteriovenous fistula. Arch Intern Med (Chic) 1946;78(28-30. PMID: 20994316
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