Evaluation of cardiovascular hemodynamics is a very important reason for referral for cardiac catheterization. Evaluation of pulmonary artery pressures and flow is frequently necessary when evaluating a cardiac patient. The majority of right heart catheterization procedures in the cardiac catheterization laboratory are performed via the femoral vein, even when left heart catheterization is performed transradially. Femoral vein puncture necessitates bed rest after hemostasis, with an increase in access site complications.1 Other access sites such as the internal and external jugular vein, and subclavian vein are less popular in the catheterization laboratory for a variety of reasons, including an increase in likelihood of major complications such as pneumothorax. Right heart catheterization from upper extremity veins was first described over a decade ago2, and has increased in adoption with the increasing utilization of transradial arterial access.
Accessing the central venous circulation from an upper extremity vein is most often a simpler procedure compared to venous access at other access sites. The common site of venous entry includes one of the veins in the vicinity of the antecubital fossa. A distal forearm vein can be used, especially in shorter patients, and occasionally, an upper arm vein can be used to enter the venous system. Venous catheterization can be performed in the majority of the patients, with the rare exception of those with lymphedema or a known proximal venous occlusion, usually a result of prior instrumentation such as trauma, implantation of electrophysiologic devices, and in rare instances, from ligation of the brachial vein from a previously performed brachial vein catheterization.
Upper extremity venous access is frequently obtained independently by nurses for a multitude of reasons necessitating intravenous therapy. For patients referred for a left and right heart catheterization, the pre-procedural nursing staff can place an intravenous catheter (20-gauge Teflon cannula) in one of the superficial veins in a sterile fashion before the patient is brought to the catheterization laboratory (Figure 1). Once in the cardiac catheterization laboratory, the venipuncture site can be re-prepped in a sterile fashion, anesthetized, and with an over-the-wire exchange of the Teflon cannula, a hydrophilic introducer can be introduced in the superficial vein using a micropuncture system (Figures 2A-C). Obviously, venous access can be obtained by the operator in the cardiac catheterization laboratory, although obtaining superficial venous access before the procedure significantly shortens the procedure duration and complexity.3
For those patients with difficult-to-access superficial veins, the operator may use adjuncts such as real-time ultrasound guidance. In patients undergoing a left and right heart catheterization, local circulatory physiology could be exploited to facilitate deep vein access, using the “Levogram technique”.4 After injection of diluted contrast in the radial arterial introducer sheath (Figure 3A), the deep and superficial venous vasculature can be visualized under fluoroscopy as it fills during the “levophase” (Figure 3B). The operator can then directly puncture the deep veins under fluoroscopic guidance (Figure 3C). This technique allows the operator to reliably puncture difficult-to-access veins without the need for additional equipment. It increases operator radiation exposure, and hence should be used if other techniques are unsuccessful or not available.
Balloon-tipped catheters suited for right heart catheterization are available in 5 to 8 French sizes. The majority of the prototypes have a thermodilution-capable version available. Usually a 5 French system is sufficient to obtain basic hemodynamic data. After placement of a hydrophilic introducer sheath, a balloon-tipped catheter is advanced through the upper extremity vein blindly without a guidewire. A gentle forward fluid flush may be used while advancing the catheter. If no resistance is felt while advancing, the catheter is advanced 30-40 cm without fluoroscopic guidance. At that point, the catheter tip is usually in the shoulder area, and fluoroscopy should be performed to further advance the catheter. If the catheter has travelled through the cephalic vein or its tributaries, it will encounter a “T” junction at the cephalic-subclavian bifurcation (Figure 4). Usually, a gentle forward push using fluoroscopic guidance is sufficient to enter the subclavian vein, which is a large caliber vein, and hence it is safe to inflate the balloon at this point, with further forward navigation, which may be performed with or without fluoroscopy, if the catheter passes through the desired path.
Difficult “T” junction
In patients with elevated venous pressures and deformation of normal anatomy, the normal perpendicular relationship of cephalo-subclavian junction may be lost and the angulation may become very unfavorable for entry into the subclavian vein, with the catheter making a “U” turn into the axillary vein. In this instance, simple maneuvers such as a deep breath, abduction of the shoulder, etc., could be used, although they infrequently succeed. A steerable guide wire with, preferably, a shapeable tip, should be used with fluoroscopic guidance and with gentle maneuvering, the subclavian vein can be entered with the guide wire and the catheter could be advanced over the wire into the superior vena cava.
Difficult entry from the right atrium to the right ventricle
In patients with a large, deformed right atrium either due to valvular heart disease, pulmonary hypertension, or atrial fibrillation, advancement of the balloon-tipped catheter from the right atrium to the right ventricle is difficult. The operator may choose to use a steerable guide wire to access the pulmonary artery, especially if the guide wire was needed earlier in the procedure and is already available. In other patients, a simple, recently described “hydraulic guidewire technique” may be used.5
The hydraulic guidewire technique is a simple method to stiffen the body of the flexible catheter by rapid injection of 10 ml of saline through the lumen of the catheter, rapidly increasing the intraluminal pressure or tension, which changes the conformation of the catheter body and tip, thus allowing successful advancement of the catheter through the tricuspid valve orifice into the right ventricle (Figures 5A-C).
After successful entry into the central venous circulation, all the necessary hemodynamic, oximetric, and interventional maneuvers can be performed in a standard fashion.
Upper extremity venous access for right heart catheterization provides many benefits compared to femoral and other venous access sites. It is associated with a significant reduction in access site complications. Hemostasis is rapid, simple, and cheap. Immediate ambulation allows for rapid throughput and increased patient comfort. A multitude of procedures could be accomplished using upper extremity venous access, including pulmonary artery catheterization, endomyocardial biopsy, and combined access for structural intervention from an upper extremity.6
- Lo TS, Buch AN, Hall IR, Hildick-Smith DJ, Nolan J. Percutaneous left and right heart catheterization in fully anticoagulated patients utilizing the radial artery and forearm vein: a two-center experience. J Interv Cardiol. 2006 Jun; 19(3): 258-263.
- Gilchrist IC, Kharabsheh S, Nickolaus MJ, Reddy R. Radial approach to right heart catheterization: early experience with a promising technique. Catheter Cardiovasc Interv. 2002 Jan; 55(1): 20-22.
- Gilchrist IC, Moyer CD, Gascho JA. Transradial right and left heart catheterizations: a comparison to traditional femoral approach. Catheter Cardiovasc Interv. 2006 Apr; 67(4): 585-588.
- Pancholy SB, Sweeney J. A technique to access difficult to find upper extremity veins for right heart catheterization: the levogram technique. Catheter Cardiovasc Interv. 2011 Nov 1; 78(5): 809-812.
- Pancholy S, Vayada N. A simple technique to facilitate right heart catheter placement from right atrium to right ventricle: virtual hydraulic guidewire technique. J Invasive Cardiol. 2016 (In press).
- Sanghvi K, Selvaraj N, Luft U. Percutaneous closure of a perimembranous ventricular septal defect through arm approach (radial artery and basilic vein). J Interv Cardiol. 2014 Apr; 27(2): 199-203.
Disclosure: Dr. Nanavaty reports no conflicts of interest regarding the content herein. Dr. Samir Pancholy reports he is a technical consultant for the transradial product line for Terumo and a speaker for Pfizer.
Dr. Pancholy can be contacted at firstname.lastname@example.org.