This case is part of a series of transradial-focused reports directed by section editor Dr. Samir Pancholy. This case series is supported by an educational grant from Medtronic.
Many of us are familiar with the PICC (peripherally inserted central catheter) line nurse, who can be seen traveling all around the hospital with his or her trusted assistant, the ultrasound machine. They know that seeing an artery or vein makes it much easier to cannulate than just feeling for it. In this report, we demonstrate how ultrasound guidance can facilitate an otherwise challenging situation of upper extremity access for right and left heart catheterization.
An 82-year-old man presented with progressive dyspnea on exertion. He had chronic atrial fibrillation on anticoagulation with warfarin, moderate chronic obstructive pulmonary disease, and was found on echocardiography to have severe mitral regurgitation and moderate aortic insufficiency, moderate pulmonary hypertension, and severe left atrial enlargement. A brain natriuretic peptide was elevated at 332pg/mL. He achieved only 1.7 METs (metabolic equivalents of task) on a treadmill stress test before complaining of dyspnea. He was referred for left and right heart catheterization for evaluation of mitral regurgitation and pulmonary hypertension in preparation for mitral valve repair.
As per routine in our laboratory, we planned for radial artery and upper extremity vein access for this patient. The patient was instructed to continue warfarin anticoagulation for the procedure, so his INR (international normalized ratio) was 2.9. The groin was not prepped.
The patient’s right arm was prepped with chlorhexidine from the antecubital fossa to the hand. It was draped in a sterile fashion, with the patient inserting his arm through a radial/brachial drape and placing his hand in a sterile glove (Figure 1). An ultrasound probe was covered with a sterile drape and gel applied. Ultrasound imaging was used to review the available veins in the antecubital fossa (Figure 2). Multiple vessels were visualized, and veins distinguished from artery by compression and color Doppler (Figure 3: Video for Figure 3A, Brachial Vein Compression; Video for Figure 3B, Radial Tortuosity).
Cannulation of a lateral branch of the brachial vein was performed with ultrasound guidance using a 22-gauge needle (Video, Brachial Vein Puncture). Due to the collapsibility of the vein, particularly in the absence of a tourniquet, the double-wall puncture technique was used (Glidesheath access kit, Terumo). The needle was withdrawn and the included venous catheter was pulled back until a venous flashback was noted. A hydrophilic .021-inch guide wire was inserted without difficulty and a 5 French (F) hydrophilic sheath inserted. The position of the sheath was confirmed with venous blood aspiration and with visualization by ultrasound.
An incidental radial artery loop was visualized at the antecubital fossa, where it crossed over superficial and medial to the ulnar artery. Although the radial artery was large, the apparent tortuosity of the vessel suggested that the ulnar artery approach would be preferable. As a result, the ulnar artery was visualized and cannulated with ultrasound guidance with a single stick [Video, Ulnar Puncture]. A 5F French sheath was inserted. No heparin was administered because of the therapeutic anticoagulation. Advancement of a diagnostic Jacky catheter (Terumo) was initially limited by tortuosity causing the floppy-tipped .035-inch guide wire to reverse course down the radial artery (Figure 4), but this was resolved without difficulty. Coronary angiography demonstrated no significant coronary artery disease.
Right heart catheterization was performed with a 5F, 110cm balloon-tipped wedge catheter (Teleflex). This was inserted into the venous sheath, and advanced under fluoroscopic guidance into the cephalic and subclavian veins. The balloon was inflated, and from the upper extremity, the catheter followed the flow of blood to the superior vena cava, right atrium, right ventricle, pulmonary artery, and pulmonary capillary wedge pressure (Figure 5). Simultaneous left ventricular and pulmonary capillary wedge pressure waveforms demonstrated a large “V” wave consistent with severe mitral regurgitation (Figure 6).
Hemostasis of the ulnar artery access site was achieved with a rotated TR Band (Terumo). Hemostasis of the brachial vein sheath was achieved with gauze and gentle pressure from a self-adhesive tape wrapped around the arm (Coban, 3M) (Figure 7).
In 1929, Forssmann performed the first human heart catheterization by placing a urinary catheter through his own brachial vein using a cutdown technique. Similarly, the original Sones technique required a cutdown to the brachial artery. As cardiac catheterization migrated to the percutaneous approach via the femoral artery, concomitant right heart catheterization through the femoral vein became the predominant approach, even though advancing the catheter requires torqueing the catheter through the right ventricular outflow tract.
With transradial catheterization, right heart catheterization can be performed from the ipsilateral arm, which is easily prepped for both radial artery and forearm or antecubital vein access. Successful passage of a balloon-tipped catheter from the arm has been reported in 91% of cases.1,2 Although central venous access can be obtained in the femoral, subclavian, or internal jugular veins, patients generally prefer to avoid femoral and internal jugular vein cannulation, and subclavian access risks causing a pneumothorax. Both 5F and 6F balloon-tipped pulmonary artery catheters can generally be advanced from the arm veins to the pulmonary artery without difficulty. Some catheters are capable of thermodilution cardiac output measurements, but simple balloon wedge catheters can measure cardiac output by the Fick method and may be easier to advance. Contrast venography should be performed in case of any resistance to advancement, and a .014-inch coronary guide wire inserted to navigate around any tortuosity.
Venous access through the arm can be obtained outside of the catheterization laboratory, whereby a peripheral IV catheter is subsequently exchanged over a wire with a sheath.1 This method, while efficient, may complicate patient preparation both inside and outside the laboratory. The selection of the appropriate arm vein is also limited to what is visible to the nurse inserting the IV. With an ultrasound-guided technique, the operator is able to identify and cannulate the most suitable vein available. This might be the largest subcutaneous vein, or the basilic or deep brachial vein that tends to leads to the axillary rather than the cephalic vein. With ultrasound and a double-wall puncture technique, we have not typically needed to apply a tourniquet.
Ultrasound guidance has been recently shown to reduce access time, number of attempts, and the need to cross over to another access site in the 698-patient, multicenter RAUST trial.3 When ultrasound guidance is available, sterile preparation of the entire arm at and below the antecubital fossa4 allows the operator to scan for vessels throughout the forearm and track their course upwards. This can be useful to screen for radial tortuosity or loops, which affect up to 4.2% of cases5, such as the present case. Ultrasound guidance can also help screen for high bifurcation of the radial artery, radial calcification, or small radial arteries6, all of which can complicate radial artery access. Ultrasound guidance may lead the operator to cannulate more proximally along the radial artery, or avoid the radial artery altogether and use the ulnar artery. Using such a screening strategy, one operator has reported a remarkably low crossover rate of 0.3% in 1,000 patients undergoing cardiac catheterization from the wrist.7
With the assistance of ultrasound guidance, successful arterial and venous access from the arm should be the norm, and crossovers extremely rare. As the discomfort with arm access is often minimal, sedation can potentially be eliminated in selected cases, enabling easy access to the catheterization lab and expedited discharge. Patients can confidently be continued on their anticoagulation and literally keep their pants on.
- Gilchrist I. Right heart catheterization via the radial route. Cardiac Interventions Today. 2010 Mar/Apr: 41-45. Available online at http://citoday.com/2010/04/right-heart-catheterization-via-the-radial-route. Accessed November 16, 2015.
- Shah S, Boyd G, Pyne CT, Bilazarian SD, Piemonte TC, Jeon C, Waxman S. Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center. Catheter Cardiovasc Interv. 2014 Jul 1; 84(1): 70-74.
- Seto AH, Roberts JS, Abu-Fadel MS, Czak SJ, Latif F, Jain SP, Raza JA, Mangla A, Panagopoulos G, Patel PM, Kern MJ, Lasic Z. Real-time ultrasound guidance facilitates transradial access: RAUST (Radial Artery access with Ultrasound Trial). JACC Cardiovasc Interv. 2015 Feb; 8(2): 283-291.
- Kern M. The Armen glove for radial access prep – a better way. Cath Lab Digest. 2010 May; 18(5). Available online at http://www.cathlabdigest.com/articles/The-Armen-Glove-Radial-Access-Prep-%E2%80%93-A-Better-Way. Accessed November 16, 2015.
- Yoo BS, Yoon J, Ko JY, et al. Anatomical consideration of the radial artery for transradial coronary procedures: arterial diameter, branching anomaly and vessel tortuosity. Int J Cardiol. 2005; 101: 421-427.
- Chugh SK, Chugh S, Chugh Y, Rao SV. Feasibility and utility of pre-procedure ultrasound imaging of the arm to facilitate transradial coronary diagnostic and interventional procedures (PRIMAFACIE-TRI). Catheter Cardiovasc Interv. 2013; 82: 64-73.
- Baumann F, Roberts JS. Evolving techniques to improve radial/ulnar artery access: crossover rate of 0.3% in 1,000 consecutive patients undergoing cardiac catheterization and/or percutaneous coronary intervention via the wrist. J Interv Cardiol. 2015 Aug; 28(4): 396-404.
Disclosures: Dr. Seto reports no conflicts of interest regarding the content herein.
Dr. Arnold Seto can be contacted at firstname.lastname@example.org.