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9 Balloons andStents
87
Fig. 9.14 The illustrative
case shows long segment
diseased SFA (a), where SES
made up of nitinol deployed
(c) after pre-dilatation with
balloon angioplasty (b)
a
b
c
9.3.10.3 Non-vascular Indications
• GI stenting.
• Biliary stenting.
• Ureteral stenting.
Biliary stenting is primarily indicated to restore biliary
drainage into the GIT. Most commonly used are the selfexpanding metallic stents (SEMS) made of nitinol.
Uses
1. Biliary strictures
• Malignant.
• Benign.
2. Bile leakage
9.3.11 Uncovered vs. Covered (PTFE) SEMS
• The chance of tumor ingrowth and occlusion is higher if
uncovered.
• Occlusion of side branches while stenting hilar lesions
more in covered.
• Occlusion of the cystic duct and MPD leading to chole-
cystitis and pancreatitis, respectively, in covered stents.
• Stent migration—an increased risk with covered stents.
9.3.12 Stent Grafts
These are also referred to as covered stents. It consists of a
stent, which acts as a metallic framework, and a graft, which
acts as a conduit and is inserted using catheter techniques
under image guidance. Initially, physicians handcrafted them
from stents and surgical tissues as graft materials. These
days, a wide range of stent grafts are available, featuring
various stent designs and metals in addition to many graft
material types. The stents can be positioned in a sandwich
made of graft material, outside, or inside. Stainless steel,
elgiloy, and nitinol are typical stent materials. The graft
material may be biological or synthetic (fabricated polyester,
expanded PTFE, or Dacron) [18, 28].
Stent grafts were originally used to treat vascular diseases
such as aneurysms by keeping the aneurysm sac out of circulation, as well as injuries such as an acute arteriovenous stula by covering the hole in the vessel wall. The basic idea is
to redirect blood ow to the stent graft. As a result, the
attachment sites must completely oppose the vessel’s inner
walls to be successful. If this is not done, blood will seep
between the intimal surface and the stent graft. Stent grafts
differ from surgical grafts because they are sewn to the vessel wall.
As new devices become available, so do their indications.
Transjugular intrahepatic portosystemic shunt (TIPS) proce-
88
D. J. Viswanathan et al.
dures and large aortic aneurysms are two common
indications.
The stent design, graft material, and delivery system size
all inuence the stent-graft delivery technique. The rst clinical stent grafts used balloon-expandable stents. Even though
most devices expand independently, “tacking” with a balloon after placement is still common. To “iron” the graft
material, gentle balloon ination along the length of the
device may be required. Every device has a unique delivery
system. The thickness of the graft material and the amount of
metal in the stent determine the size of the delivery system.
For small vessel occlusive disease, however, most stent
grafts fall short of BMS in terms of performance. The aneurysmal disease may potentially result in delayed graft dislodgement, kinking, or shifting if the aneurysm diminishes.
Indications for stent grafts include aortic, peripheral, and
visceral aneurysms, pseudoaneurysms, TIPSS, arterial
trauma, aortic dissection, venous anastomosis, stenosis, dialysis grafts, etc.
General Contraindications
• We have to remember that a stent cannot do anything that
an inated balloon cannot! For example, if chronic extrin-
sic compression of the lumen by extravascular structure is
the primary abnormality, then placement of a stent with-
out relieving compression can cause a stent fracture.
• It should not be placed at sites of anticipated surgical
anastomoses, as it may complicate surgery or render it
impossible, i.e., the stent will not provide any additional
benet if the lesion itself cannot be dilated with a
balloon.
9.3.13 Complications Unique toStent
Placement
Procedural complications are the same as those of balloon
angioplasty. However, there are a few that are unique to stent
replacement (Table9.1).
Other complications of stent placement include:
• Arterial dissection.
• Arterial occlusion.
• Arterial rupture.
• Migration or embolization of stent.
• Embolization of atherosclerotic material.
A second stent is inserted in the same spot if there is an
acute arterial dissection nearby. The lead point for arterial
dissection due to stents is often located within a centimeter
of the end of the stent. A stent is inserted in this segment even
though the exact position of the dissection’s lead point is
unknown. When a partially inated stent is inserted or an
artery is severed, the stented location may become occluded.
To make sure the stent has inated completely, further balloon dilation is typically done after stent implantation. If the
problem persists, thoroughly examine the outow and consider using a covered stent.
Each stent application has its own cost and complications,
such as:
• Sheaths typically need to be larger.
• A foreign body is inserted.
• The procedure usually takes slightly longer.
• Stents carry specic risks.
Though stents have revolutionized the treatment of many
pathologies, we also have to remember that each stent placement has its own cost and complications. Hence, we have to
choose them accordingly considering the patient, lesion, and
operator efcacy. So a desirable stent has:
• Low crossing prole.
• A high degree of adaptability.
• Higher host-stent biocompatibility.
• Increased radial strength.
• Minimal surface area of metal.
• Excellent visualization on imaging.
• Excellent traceability.
• Easy delivery.
References
1. Abele JE.Balloon catheters and transluminal dilatation: technical
considerations. AJR Am J Roentgenol. 1980;135(5):901–6.
2. Saab MA. Applications of high-pressure balloons in the medical
device industry. Med Device Diagn Ind Mag. 1999;
3. Kaufman JA, Lee MJ.Vascular and interventional radiology: the
requisites e-book. Elsevier Health Sciences; 2013.
4. Boshev M, Magdalena O. In-stent restenosis in drug-eluting
stents: issues and therapeutic approach. J Cardiol Curr Res.
2016;6(3):00206.
5. Fujihara M, Takahara M, Sasaki S, Nanto K, Utsunomiya M, Iida
O, et al. Angiographic dissection patterns and patency outcomes
after balloon angioplasty for supercial femoral artery disease. J
Endovasc Ther. 2017;24(3):367–75.
6. Ring ME. How a dentist’s name became a synonym for a lifesaving device: the story of Dr. Charles Stent. J Hist Dent.
2001;49(2):77–80.
7. Palmaz JC, Sibbitt R, Reuter S, Tio F, Rice W.Expandable intraluminal graft: a preliminary study. Work in progress. Radiology.
1985;156(1):73–7.
8. McKavanagh P, Zawadowski G, Ahmed N, Kutryk M. The
evolution of coronary stents. Expert Rev Cardiovasc Ther.
2018;16(3):219–28.
9. Castaneda-Zuniga WR, Formanek A, Tadavarthy M, Vlodaver Z,
Edwards JE, Zollikofer C, etal. The mechanism of balloon angioplasty. Radiology. 1980;135(3):565–71.
10. Jain K.Management of complications. 2020; 103–109.
9 Balloons andStents
89
11. Kudo T, Inoue Y, Nakamura H, Sugano N, Hirokawa M, Iwai
T. Characteristics of peripheral microembolization during iliac
stenting: Doppler ultrasound monitoring. Eur J Vasc Endovasc
Surg. 2005;30(3):311–4.
12. Hong H, Park UJ, Roh YN, Kim HT.Predictive factors of severe
dissection after balloon angioplasty for femoropopliteal artery disease. Ann Vasc Surg. 2021;77:109–15.
13. Saan RD, etal. Comparison of coronary angioplasty with compliant and noncompliant balloons (the Angioplasty Compliance Trial).
Am J Cardiol. 1995;76(7):518–20.
14. Mach M, Szalkiewicz P, Poschner T, Hasan W, Andreas M, Winkler
B, et al. The use of semi-compliant versus non- compliant balloon systems for predilatation during the implantation of selfexpandable transcatheter aortic valves: data from the VIenna
CardioThOracic Aortic Valve RegistrY (VICTORY). Eur J Clin
Invest. 2021;51(9):e13570.
15. Marciniuk P, Pawlaczyk R, Rogowski J, Wojciechowski J, Znaniecki
Ł. REBOA– new era of bleeding control, literature review. Pol J
Surg. 2019;91(5):1–5.
16. Worley SJ, Ellenbogen KA. 23 – Interventional techniques for
device implantation. In: Ellenbogen KA, Wilkoff BL, Kay GN, Lau
C-P, editors. Clinical cardiac pacing, debrillation and resynchronization therapy. Elsevier; 2017. p.618–718.
17. Ray S, Bandyopadhyay S, Bhattacharjee P, Mukherjee P, Karmakar
S, Mitra S, etal. Percutaneous coronary intervention of severely/
moderately calcied coronary lesions using single-burr rotational atherectomy: a retrospective study. Anatol J Cardiol.
2021;25(6):395.
18. Dubel GJ.Angioplasty balloons, stents, and endografts. Tech Vasc
Interv Radiol. 2000;3(4):214–25.
19. Matsumoto AH, Barth KH, Bayne Selby J, Tegtmeyer
CJ. Peripheral angioplasty balloon technology. Cardiovasc Interv
Radiol. 1993;16(3):135–43.
20. Schmidt W, Grabow N, Behrens P, Schmitz KP.Trackability, crossability, and pushability of coronary stent systems-an experimental
approach. Biomed Tech (Berl). 2002;47(Suppl 1 Pt 1):124–6.
21. Nichols AB, Smith R, Berke AD, Shlofmitz RA, Powers
ER.Importance of balloon size in coronary angioplasty. J Am Coll
Cardiol. 1989;13(5):1094–100.
22. Alfonso F, Pérez-Vizcayno MJ, Gómez-Recio M, Insa L, Calvo
I, Hernandez JM, etal. Implications of the “watermelon seeding”
phenomenon during coronary interventions for in-stent restenosis.
Catheter Cardiovasc Interv. 2005;66(4):521–7.
23. Lanzer P, Schmidt W. Instrumentation for coronary artery interventions. In: Lanzer P, editor. PanVascular medicine. Berlin/
Heidelberg: Springer; 2015.
24. Ramanath VS, Thompson CA. Guidewires and angioplasty balloons: the primer. In: Textbook of cardiovascular intervention.
London: Springer; 2013. p.91–8.
25. Industry ACR.Balloon catheter market- industry analysis, market
size, share, trends, application analysis, growth and forecast 2020
[Internet]. 2025. Available from: https://www.industryarc.com/
Research/Balloon-Catheter-Market-Research.
26. Rheude T, Rai H, Richardt G, Allali A, Abdel-Wahab M, Sulimov
DS, et al. Super high-pressure balloon versus scoring balloon to
prepare severely calcied coronary lesions: the ISAR-CALC randomised trial. Euro Interven. 2021;17(6):481–8.
27. Albiero DR, et al. Cutting balloon versus conventional balloon
angioplasty for the treatment of coronary artery disease. Eur
Cardiol Rev. 2005;1(1):48.
28. Jeger RV, Eccleshall S, Wan Ahmad WA, Ge J, Poerner TC, Shin
ES, etal. Drug-coated balloons for coronary artery disease. JACC
Cardiovasc Interv. 2020;13(12):1391–402.
29. Duerig T, Wholey M.A comparison of balloon-and self-expanding
stents. Minim Invasive Ther Allied Technol. 2002;11(4):173–8.
30. Schatz RA. A view of vascular stents. Circulation.
1989;79(2):445–57.
31. Duda SH, Wiskirchen J, Tepe G, Bitzer M, Kaulich TW, Stoeckel
D, etal. Physical properties of endovascular stents: an experimental
comparison. J Vasc Interv Radiol. 2000;11(5):645–54.
32. Poncin P, Proft J.Stent tubing: understanding the desired attributes.
In: Materials & process for medical devices conference; 2004.
p.253–9.
33. Palmaz JC, Bailey S, Marton D, Sprague E. Inuence of stent
design and material composition on procedure outcome. J Vasc
Surg. 2002;36(5):1031–9.
34. Karjalainen PP, Nammas W, Airaksinen JK.Optimal stent design:
past, present and future. Interv Cardiol. 2014;6(1):29.
35. Miki K, Fujii K, Shibuya M, Fukunaga M, Imanaka T, Kawai K,
et al. Impact of stent diameter on vascular response after selfexpanding paclitaxel-eluting stent implantation in the supercial
femoral artery. J Cardiol. 2017;70(4):346–52.
36. Borhani S, Hassanajili S, Ahmadi Tafti SH, Rabbani
S.Cardiovascular stents: overview, evolution, and next generation.
Prog Biomater. 2018;7(3):175–205.
Vascular Access
RupaliJain, JunaidKazimi, PriyankaNaranje,
andManishaJana
10
Key Messages
1. The vascular access plays a crucial role in the success of
any IR procedures.
2. Any IR procedure should be planned thoroughly, and the
right vascular access should be selected.
3. Prociency in different vascular accesses is essential for
interventional radiologists.
4. Knowledge of anatomy, variations, and hardware is necessary for obtaining vascular access.
5. Image-guided vascular access reduces the procedurerelated complications.
10.1 Introduction
A vascular access refers to a route of accessing any vessel,
either via the venous or the arterial channel, for several indications. It can be short-term or long-term access, before
some procedures or for treatment purposes. In this chapter,
we shall describe the common indications, techniques, and
associated complications of vascular access.
10.2 Indications
Depending on the indication, vascular access can be obtained
into the venous or arterial system. Central venous access is
covered in Chap. 17.
The indications of temporary venous/arterial vascular
access are listed in Table10.1.
Table 10.1 Indications of temporary venous/arterial vascular access
Temporary
venous access
Temporary
arterial access
Diagnostic
indication
Therapeutic
indication
Therapeutic
indication
Venous blood sampling
Central venous pressure
monitoring
Adrenal venous sampling
Inferior petrosal sinus sampling
IVC and hepatic venous
interventions, TIPS/DIPS
Administration of total
parenteral nutrition
Chemotherapy
Hemodialysis
Prior to any interventions via
arterial route (i.e.,
embolizations, stenting, coil
placements, angioplasty)
10.3 Hardware
Various hardware required for gaining vascular access is
mentioned in Table10.2.
10.3.1 Intravenous Cannula
It is the most common mode of obtaining vascular access.
Plastic cannula is inserted using a catheter over a needle
device into the blood vessel. It is color coordinated with
diameter in gauges, which ranges from 26G to 16G
(Fig.10.1).
R. Jain · J. Kazimi · P. Naranje · M. Jana (*)
Department of Radiodiagnosis and Interventional Radiology, All
India Institute of Medical Sciences, Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_10
91
92
Table 10.2 List of hardware for vascular access
Hardware Indications
Intravenous cannula Temporary access, sampling,
Puncture needle To gain initial access prior to
Arterial access sheath Vascular interventions
Peripherally inserted central
catheter
Central venous access devices
(tunneled and non-tunneled)
Hemodialysis catheters
(tunneled and non-tunneled)
uid administration
placement of arterial sheaths/
venous catheters
Chemotherapy
Prior to hemodialysis
R. Jain et al.
Fig. 10.1 Intravenous cannulas of various gauge sizes. A 16G cannula
may also be used for vascular access for passage of 0.035″ guidewire
and further placement of sheaths
10.3.2 Puncture Needle
Puncture needles are color coordinated with diameter in
gauges; lower gauge has a larger diameter. 18G is used for
large targets (large vessel such as femoral artery/vein/internal jugular vein) and 22G for small targets (small vessels
such as basilic/cephalic veins). 18G or above is required for
accessing the 0.035-inch guidewire (Fig.10.1b) and 22G of
above for 0.018-inch wire. Various types of needle are single
wall (hollow core with beveled edge [Fig. 10.2]), trocar
(two-part needle system), and chiba (long length).
Fig. 10.2 Single wall puncture needle (18G) consists of hollow core
with beveled edge (arrow)
The commonly preferred two-part needle system consists
of outer plastic cannula and inner metallic stylet with short
bevel. It is less traumatic and hydrophilic wire can be used
with this needle to navigate tortuous vessels. Metallic needle
with long bevel reserved for patients with local site scarring
and obesity. A non-hydrophilic wire is used with this needle
as it can strip off the coating of hydrophilic wire.
10.3.3 Arterial Access Sheath
It provides constant controlled access, lends support, and
allows exchange of multiple wires and catheters. Sheath size is
color coded with French size representing its inner diameter for
catheters to t in. Commonly used sizes in adults are 5F (gray)
and 6F (green) (Fig.10.3). It also comes in variable length.
Sheath assembly includes sheath and dilator. Sheath has a
side port which is used for ushing, delivering contrast and
drugs like heparin, and has a hemostatic valve at hub to prevent retrograde ow of blood but allowing passage of wires
and catheters. Sheath should always be ushed before use
and advanced over the guidewire along with the inner
dilator.
ab
10 Vascular Access
Fig. 10.3 Vascular access
sheaths. (a) 6Fr (green color)
sheath (arrow) with
hemostatic valve (arrowhead)
and 6Fr fascial dilator. (b) 5Fr
sheath (grey color) with a
similar conguration
93
10.4 Local Anesthesia
10.5 Peripherally Inserted Central Catheter
andCentral Venous Access Devices
Local anesthesia before the vascular access should always be
used to provide analgesia and provide comfort to patient during insertion of access device. Lignocaine with 1–2% epinephrine is used. The dose is 5–7mg/kg, and the maximum
dose is 500 mg. Typically, 10–20 ml is sufcient in adult
patients. It provides local analgesia and also helps relieves
vascular spasm. After giving dermal injection, deep injection
is given around the vessel, and subsequently, the needle is
withdrawn supercially and injected. One must ensure that
the blood is not aspirated prior to injection.
Peripherally inserted central catheters and central venous
access devices including hemodialysis catheters are discussed in Chap. 17. These are the devices used for both
short-term and long-term access in the central venous system
for several indications as described in Table10.3.
94
Table 10.3 Double-wall vs single-wall puncture (kaufman, 10.21037/qims-20-694)
Technique Advantages Disadvantages
Double- wall puncture The needle is passed into the
vessel, beyond the opposite
vessel wall and then the needle is
slowly withdrawn till good
pulsatile ow is noted
Single- wall puncture The needle is passed slowly into
the vessel, and when good ow
from lumen is achieved, the
guidewire is passed
Useful with palpation- based
method
Minimal damage to vessel
Decreased risk of bleeding
complication
Can be used with USG guidance
R. Jain et al.
More risk of bleeding
complication
Difcult with palpation-based
method
More risk of passage of
guidewire in subintimal layer if
needle tip is only partially within
lumen in palpation-based method
10.6 General Considerations Before Procedure
Relevant history must be taken, especially history of peripheral arterial disease or venous thrombosis, hypertension,
back pain, COPD, or prior surgery. Prior imaging studies
should be evaluated; coagulation parameters and platelet
count should be checked, especially in patients with bleeding
diathesis and liver disease.
Limit oral intake 8h prior to procedure. Oral medications
can be taken with a small amount of water.
Peripheral pulses should be palpated and local sites examined. Certain factors must be taken care of before puncture,
which includes adequate patient position for the easiest and
direct access, patient’s comfort, physician’s best access to
artery, catheters, and table controls. The tools and angiographic table must be checked prior to the procedure.
10.7 Arterial Access
There are few prerequisites prior to arterial access that must
be evaluated prior to placement of sheath; these are patency
of the vessel, access artery communication with artery of
interest, large enough to accommodate catheters and diagnostic devices, supercial location over bone, and healthy
overlying skin.
The common arterial puncture sites include common
femoral artery (most common), high brachial artery, axillary
artery, popliteal artery, radial artery, and translumbar abdominal aorta in very rare cases.
Ivan Seldinger. The basic mechanism is exchanging hollow
tubes over guidewire. The rst step is the introduction of hollow needle into a blood vessel, and then atraumatic guidewire is introduced through the hollow needle into the vessel
lumen. It is followed by removal of needle and passage of
another catheter/sheath over guidewire.
Arterial punctures are characterized as single walled or
double walled. In double-walled puncture, the needle is
slowly advanced at 45° angle, puncturing both anterior and
posterior walls until the femoral head is encountered. The
stylet is then removed, and the needle is slowly withdrawn
until there is a spurt of blood, while in a single-walled puncture, only the anterior wall is punctured (Fig.10.4).
10.7.2 Arterial Access Sites
10.7.2.1 Common Femoral Artery
Principles The most common access site for angiography is
the common femoral artery. It can be easily palpated, has
large diameter to accommodate diagnostic devices, easily
compressible over femoral head and also contained within
femoral sheath which limits peripuncture bleed. It can be
done either against the arterial ow (retrograde) or in the
direction of ow (antegrade) depending on the indication.
The added advantages in antegrade femoral approach are
shorter working distance, shorter guidewires and catheters,
and better pushability/torqueability; however, it may be difcult in obese patients and with variant anatomy. Contralateral
retrograde femoral access can also be used in place of antegrade femoral access for lower limb procedures.
10.7.1 Gaining Access/Placement ofCatheter:
Seldinger Technique
A simple and the most useful technique for introduction of
almost all vascular devices was described in 1953 by Sven
Site Selection CFA must be accessed over the middle third
of the femoral head to ensure adequate compression post
procedure. Multiple techniques help to localize CFA for
punctures, like inguinal crease as reference, bony landmark,
point of maximum pulsation, and uoroscopic and ultrasound guidance. Inguinal crease does not always represent
ab
10 Vascular Access
Fig. 10.4 Double wall and
single wall puncture
techniques. (a) Double wall
puncture involves passage of
needle beyond posterior wall
followed by slow withdrawal
till spurt of blood is seen
(arrow). (b) Only anterior
wall punctured in single wall
puncture technique (arrow)
95
inguinal ligament, and CFA bifurcation is above the inguinal
crease in ~75.6% patients. An imaginary line can also be
drawn between anterior superior iliac spine and pubic symphysis, and CFA can be punctured ~2.5cm below the midpoint of this line; however, this bony landmark technique is
also not very reliable. Although the artery is commonly
localized by palpation at the point of maximum impulse followed by marking over the femoral head using uoroscopy
or ultrasound guidance. Ultrasound guidance is preferred in
cases of non-palpable arteries in obese and hypotensive
patients. In postoperative groin, information about the type
and duration of surgery is necessary prior to puncture, especially in cases of vascular anastomosis. Scarring may cause
difculty in catheter introduction; mild overdilatation of the
tract may help.
Technique The position over the femoral head can be
checked uoroscopically after placing blunt metallic instrument at the anticipated point of access (Fig.10.5a). The skin
incision should be 1–2cm away (below for retrograde and
above for antegrade approach), which allows 45 degree angle
between artery and needle during access. Local anesthesia is
96
R. Jain et al.
a
Fig. 10.5 Common femoral artery access. (a) Location of the femoral head is marked on uoroscopy. (b) Following the puncture using the needle,
guidewire is manipulated into the common iliac artery and aorta (arrow). (c) Access is secured with a sheath (arrow) passed over the guidewire
given with lidocaine (1–2%) after aspirating prior to skin
inltration to avoid intravascular injection. Skin incision of
about 3–5mm is made using scalpel blade (No. 11) along the
natural skin line. The subcutaneous tract is later dilated using
artery forceps; it helps in easy catheter insertion and also
contains hematoma in case of bleeding. By one hand, the
b
Retrograde femoral access can also be converted to antegrade femoral access. The technique would be similar by
redirecting wire in the opposite direction and repositioning
the sheath; however, puncture should be vertical in such
cases so that arterial sheath can be advanced in either
direction.
c
access needle is held rmly by the hub, and by the other, the
skin incision is straddled using second and third nger tips.
The pulse should be palpated, and the needle is slowly
advanced at 45° angle along the direction of the vessel until
the femoral head is encountered. The stylet is then removed
and needle slowly withdrawn until there is a spurt of blood.
When the needle tip enters lumen, a “pop” sound is commonly felt. The blood ow should be vigorous and pulsatile;
Complications Complications of common femoral artery
puncture include local site hematoma, dissection, pseudoaneurysm, arteriovenous stula, and occlusion (thrombosis is
rare). Complications are primarily caused by trauma and
deranged coagulation parameters. Dissection is frequently
subclinical in retrograde puncture because antegrade blood
ow usually compresses the false lumen.
otherwise, the needle tip might be malpositioned in the arterial wall, side branch, plaque, or vein. The needle is kept
steady with one hand, while the guidewire is gently introduced with the other hand through the hub (Fig.10.5b). In
case of any resistance, it is mandatory to stop immediately.
The tip of the needle may be malpositioned with guidewire
abutting wall or plaque, gentle retraction with repositioning,
changing needle angulation along a long axis of artery might
be needed sometimes. If resistance still persists, withdraw
the guidewire and check for backow. A small amount of
10.7.2.2 High Brachial or Axillary Artery
Principles This approach is an alternative access method in
certain conditions like occluded femoral vessels, altered
anatomy of groin precluding access, upper extremity
intervention, and when antegrade approach to visceral arteries is needed. However, the vessels in upper extremity are
small and have more tendency for spasm limiting the size of
devices to be used. Axillary artery can accommodate ~7
French sheath without difculty.
contrast can be injected to identify the problem. Forceful
advancing may cause dissection, kinking, etc. A guidewire
that moves freely or forms “J” shape is usually intravascular,
while a spiral or crumple-shaped guidewire is usually extravascular or intramural. In case this occurs, the guidewire
must be pulled back and readvanced. If the obstruction
persists, remove everything as a unit, compress for a few
minutes, and repeat the access. After successfully passing
the guidewire, the needle is removed and access secured
using an arterial sheath (Fig.10.5c).
Site Selection The preferred site is the high brachial
artery since it lies against the proximal humeral shaft. The
axillary artery puncture should be done over the proximal
humerus (neck) along the lateral axillary fold. Another
site is low brachial artery ~1 cm above the antecubital
crease; however, it is less preferred due to its supercial
location with little soft tissue support, frequent variant
anatomy, close proximity to nerve, and tendency to
undergo spasm.
10 Vascular Access
97
Technique Pulses should be palpated and blood pressure
measured in both arms prior to the procedure, as a pressure
difference more than 10–20mm Hg might suggest occlusion
on the lower side. The elbow is exed, and the arm is
abducted ~90° with the position of the patient’s hand over
and behind the head for the duration of the procedure, but it
may be difcult in patients with joint pathology. The preferred site is the high brachial artery since it lies against the
humerus. The overlying skin is anaesthetized; however, deep
anesthesia is avoided to prevent nerve block. The artery is
punctured using a 21-gauge microaccess needle by either
manual palpation or ultrasound guidance. In cases of manual
palpation, we should remember the position of the humerus
is superior and posterior to the artery rather than just posterior in lower extremity. The needle tip should be accordingly
handled. The guidewire should be oppy 3-J to prevent accidental selection of branch vessels. Post-procedure manual
compression is done and arm immobilized for 6h, and the
back of the bed should be minimally 30° elevated. Periodic
neurological examination should be done during this period.
Complications Upper extremity access has a relatively
higher rate of complication than the lower extremity approach
mainly because of increased occlusive and neurologic incidents secondary to hemorrhage as described above.
Hematoma formation can occur without active bleeding and
cause neurological compression, so signs and symptoms of
neural compression should be watched for, and urgent surgical decompression is needed in case of hematoma formation.
To limit the complications, the left arm should be used for
imaging of the abdominal aorta and lower extremity and the
right arm for ascending thoracic aorta and cerebral vessels.
10.7.2.3 Radial Artery
Principles and Technique Radial access approach is pre-
ferred for cardiac catheterization. It may be used for lower
extremity arteries using long devices. Radial artery can
accommodate long catheters and up to 6 French sheaths. The
hand perfusion should be normal and assessed with Allen
test or modied Allen’s test (Barbeau test) prior to procedure. A pulse oximeter sensor is placed on the thumb, and
plethysmography waveforms (Barbeau A through D) are
recorded before and 2min after radial artery compression.
The absolute contraindication is Barbeau type D waveform,
and relative contraindications are small diameter (inner to
inner wall diameter <2 mm) and in patients who might
require dialysis stula [1, 2]. The success of transradial
access is comparable to transfemoral access. The advantages
and disadvantages of radial artery access over femoral artery
access are described in Table10.4 [2].
Site Selection The preferred site is left hand for lower
extremity arteries and abdominal aorta. The artery is punctured using a micropuncture needle ~2–3 cm proximal to
radial styloid process. Antispasmodic cocktail mixture (heparin, nitroglycerine, and calcium channel blockers) should
be given to prevent thrombosis and spasm of small vessels.
An alternative access in distal radial artery at anatomical
snuffbox on the dorsum of hand has also been proposed [2].
Complications Radial artery puncture is associated with
lower rate of complication, and bedrest is not mandatory
after compression. The most common complication is occlusion in about 1–10% of patients. It usually occurs immediately after procedures and is mostly asymptomatic due to the
dual supply in hand. Also, spontaneous recanalization is seen
in up to 50% of patients within 1–3months. Other complications are pseudoaneurysm (<1%), radial artery perforation
(~1%), spasm, hematoma, arteriovenous stula, hand ischemia and rarely compartment syndrome, stroke [1, 2].
Radial pulse, forearm pain, plethysmography signal, skin
temperature, and color should be monitored in the post procedure care. Early ambulation is encouraged.
Table 10.4 Advantages and disadvantages of radial access
Advantages Disadvantages
Radial artery access Lower access site complications
Easier post-procedural hemostasis useful in patients
with coagulopathies
Early patient mobilization
More favorable approach for few anatomic landmarks,
such as mesentric (antegrade approach in acute angle
origin), iliofemoral, and uterine arteries.
Can be done in prone position, so feasible with
combined approach, e.g., simultaneous percutaneous
renal ablation or biopsy
Greater patient satisfaction
Long learning curve
Long length catheters
Angioplasty or stenting can be limited by maximum
diameter
Difculty in using larger PVA particles (>900μm) due
to frequent occlusions of long catheter
Radial artery cocktails are necessary to prevent
thrombus and vasospasm