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Arterial and Venous Access
operator can stabilize the artery with the index and middle fingers
placed below and above the puncture point. After seeing brisk bleeding from the needle, the guidewire is advanced into the artery, and the
sheath is placed as with radial artery cannulation. Additional lidocaine can be applied to the deeper tissue planes. Heparin (40 to 50 U/
kg) is given via IV. The brachial artery can accommodate up to size
8-F sheaths in large males. In most patients, especially smaller males
and females, smaller sheaths (e.g., 6 F) are preferred.
Hemostasis after Percutaneous Brachial
Artery Catheterization
A board is placed behind the patient’s elbow to facilitate pressure
application. Check the radial pulse before removing the sheath. If the
pulse is weak or absent, 0.2 to 0.4 mg of nitroglycerin can be delivered
into the artery through the sheath and then the pulse should be
rechecked. Remove the sheath while applying firm finger pressure
over the puncture site. A small amount of bleeding is allowed to purge
possible clots. The operator should not “strip” the sheath, pushing
thrombus into the artery. Continuously palpate the radial pulse either
with manual palpation or plethysmography and adjust the amount of
pressure applied over the artery to stop bleeding without completely
obliterating the radial pulse. After 15 to 20 minutes, slowly release the
pressure. Check and record the patient’s radial pulse. The arm circumference at the site of puncture can be measured to facilitate the detection of hematoma formation. Instruct the patient to keep the arm in a
relaxed but straight position for 2 to 4 hours. Sitting up in bed is permitted, but ambulation is restricted until after the hemostasis period of 2
to 4 hours.
Other Vascular Access
Access to the patient’s circulatory system is not limited to the previously mentioned techniques (Box 2- 4). Techniques that are used
rarely in the catheterization laboratory, such as axillary artery puncture, should be attempted only by experienced operators. Percutaneous subclavian vein puncture techniques are not explained here
because they are not used for routine cardiac catheterization.
Internal Jugular Vein Access
The internal jugular vein is lateral to the carotid artery, medial to the
external jugular vein, and usually just lateral to the outer edge of the
medial head of the sternocleidomastoid muscle. To identify landmarks, the operator instructs the patient to lie supine without a pillow
Box 2-4 Possible Vascular Access Routes
Arterial
1. Radial
2. Femoral
3. Brachial (least desirable)
4. Axillary
Venous
1. Brachial
2. Femoral
3. Internal jugular
4. Subclavian
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under the head and, in the case of the right internal jugular, with the
head turned 30 degrees to the left. Patients with low venous pressures
may be placed in the Trendelenburg (head lower than feet) position.
Ultrasound imaging to facilitate access is recommended by the Critical
Care Societies.
Several approaches to internal jugular vein access exist. Many
physicians and the Critical Care Societies recommend the use of ultrasound to guide access. A high anterior approach from the top of the
triangle formed by the two heads of the sternocleidomastoid muscle
and clavicle is recommended. This location moves the puncture site
away from the upper lung tip. In obese patients, the triangle can be
difficult to localize correctly, but it is helpful to put a finger in the
suprasternal recess and move the finger to the right (for right internal
jugular access). The first elevation palpated is the medial head of
the sternocleidomastoid muscle. Move the finger over the medial
head and follow the edge superiorly until the top of the triangle
is palpated.
After infiltrating the skin with lidocaine, insert the needle through
the skin, pointing slightly toward the ipsilateral nipple. When blood is
aspirated, the guidewire is inserted, followed by the sheath using a
standard Seldinger technique. The external jugular vein, which crosses
the same area superficially, should not be cut.
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Arterial and Venous Access 85
Vascular Access Through Synthetic
Graft Conduits
If possible, avoid access through synthetic peripheral vascular grafts.
Limited experience indicates that when grafts are at least 6 months
old, complications are less than 2% if 5- to 9-F sheaths are used
for diagnostic, but not interventional, procedures. If it is necessary to
use grafts for access, diligent care must be taken during hemostasis
so as not to occlude the graft completely, which can lead to graft
thrombosis.
Large-Bore Access
Large-bore access for valvular heart procedures introduces an
increased risk for bleeding and vascular complications. Although
many aortic balloon valvuloplasty procedures can be done through a
12-F arterial system, the current era of transcatheter aortic valve
replacement (TAVR) has increased the necessar y sheath size for
access to 18 F for the Medtronic CoreValve system or 24 F for the
Edwards SAPIEN system. The use of these large-bore sheaths necessitates thoughtful attention to procedural planning and postprocedural hemostasis.
Many operators will also access the contralateral artery (to visualize the side to be used for the femoral artery) initially and cross over
to the ipsilateral femoral with a guidewire and exchange for a pigtail
catheter. After injecting contrast through the pigtail catheter and assuring absence of vascular disease and proper access site and vessel size
(although this is initially done via a preprocedural CT scan), access is
obtained for the large-bore sheath, often using the center of the pigtail
catheter as the needle target. The pigtail catheter is then exchanged
over a 0.035-inch guidewire that remains in place during the procedure. Following TAVR to control bleeding during VCD placement,
deployment of a peripheral balloon large enough to occlude the iliac
artery is advanced over the contralateral guidewire proximal to the
arteriotomy site and inflated temporarily, stopping blood flow down
the vessel. It is in this bloodless field that postprocedural hemostasis
is undertaken.
The most commonly used device for hemostasis in this setting is
the Perclose ProGlide SMC (Suture-Mediated Closure) System (Abbott)
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Arterial and Venous Access
12
10 2
First device
12
10 2
Third device
Potentially needed
Figure 2-17 Pre- close technique signifies that the Perclose ProGlide
suture is placed around the arteriotomy at the beginning of the procedure
and knot advancement is placed on hold until the procedure is complete.
The pre-close technique using at least two devices must be used when
closing sheath sizes from 8.5 to 21 F. See the text for more information.
(Redrawn with permission of Abbot Vascular, copyright 2013.)
12
10 2
Second device
using a pre-close technique. The pre-close technique uses two devices
placed after initial arterial access is achieved. The first device is
deployed oriented slightly off the vertical at the 10 o’clock position.
Use standard placement technique, but the suture knots are not tightened down on the arteriotomy but rather clamped and placed under
a sterile towel to be closed at the end of the procedure. The second
device is deployed oriented at the 2 o’clock position relative to vertical.
After the second device is deployed and in a fashion similar to the first
device, the sutures are set aside to be tied later. At this point, reintroduce a guidewire through the port of the VCD and exchange it for
the large-bore sheath ready to proceed with the main procedure
(Fig. 2-17).
After completing the main procedure, hemostasis begins. Place a
guidewire through the large-bore sheath. The contralateral balloon
catheter is now placed in the ipsilateral iliac artery and inflated to stop
blood flow. Aspirate and flush the sheath and tighten the first sutures
placed, but do not yet secure the sutures on the arteriotomy site while
the sheath is being removed with the guidewire position maintained.
The second set of pre-closed sutures is then similarly tightened on the
arteriotomy site. Deflate the occlusion balloon. The site is now assessed
for relative hemostasis. There may be some slight bleeding, but it
should not be pulsatile. This is repeatedly checked during these steps
by deflating the iliac balloon and assessing. If significant bleeding is
identified, advance the first suture set knot and then subsequent suture
knots until bleeding is minimized. Complete hemostasis is unlikely
with the guidewire in place, but if significant bleeding continues, a
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Arterial and Venous Access 87
A
B
Figure 2-18 A, With the device lever (marked #1) and the logo facing the
ceiling (12 o’clock), advance the device into artery until brisk pulsatile flow
(mark) is obser ved exiting the marker lumen. B, Rotate the device approximately 30 degrees toward the patient’s right side (~10 o’clock). (Used with
permission from Abbot Vascular, copyright 2013.)
third VCD can be deployed at 12 o’clock (Figs. 2-17 and 2-18). Once
bleeding is controlled, the guidewire can be removed, and the first
and then subsequent sutures tightened on the arteriotomy. Lastly, the
sutures should be held taut and recut in the order in which they were
deployed (Fig. 2-19). The balloon in the iliac artery can then be
deflated. If full hemostasis is achieved, perform a final angiogram to
assess vascular integrity. Having the balloon in place during the
deployment of the Perclose devices provides an additional measure
of safety should the closure not hold and additional procedures
become necessary to provide hemostasis.
Unfortunately, in a number of the TAVR patients, there are two
types of vessels: those that are heavily calcified and/or those that are
heavily fibrotic, in which the pre-close technique is more likely to fail.
If either of these conditions is present in the initial evaluation, a strong
consideration should be made for surgical cutdown to place sheaths
and control postprocedure hemostasis for the TAVR procedure.
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Figure 2-19 Illustration of 2 o’clock and 10 o’clock sutures. (Used with
permission from Abbot Vascular, copyright 2013.)
Arterial and Venous Access
2 o’clock
suture
10 o’clock
suture
Tips and Tricks: Options to
Achieve Success
“Save time: Do it right the first time.” A thoughtful and systematic approach to the catheterization procedure decreases problems of
access. The order of arterial or venous access is often a matter
of personal preference. For novice operators whose stereotactic “view”
through their fingers needs refinement, attempts at femoral venous
entry before arterial sheath insertion are recommended for the following reason: If the arterial sheath is inserted first, firm palpation to
establish the landmarks for venous entr y may cause the formation of
a generous hematoma that may crimp the arterial sheath. This rapidly
forming hematoma makes venous location more difficult. If the artery
is punctured inadvertently during venous access attempts, the arterial
sheath can be inserted as long as the precautions described in the
section on the percutaneous femoral approach (see Catheterization
from the Percutaneous Femoral Artery Approach earlier) are observed.
Vessel Tortuosity
The most commonly encountered difficulty in advancing guidewires
or catheters into the aorta is iliac or subclavian vessel tortuosity, a
condition often found in elderly patients. A 0.035-inch Wholey or
hydrophilic Glidewire have excellent characteristics (flexibility and an
atraumatic steerable tip). In cases of extreme tortuosity, it might be
necessary to advance a catheter close to (within several centimeters
of) the guidewire tip in order to increase the torque control of the
guidewire. A Judkins right (JR) or a multipurpose (MP) coronary catheter can also be used to change the direction of the guidewire tip.
In patients with tortuous iliac vessels, a long (>
be used, recognizing the tradeoff of multiple friction points for some
straightening of the vessel. Catheter exchanges over a long (300 cm)
stiff exchange guidewire may be required to avoid undue prolongation
20 cm) sheath may
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of the procedure by repeated attempts to advance catheters across
tortuous atherosclerotic segments.
In patients with extreme tortuosity in the iliac or subclavian
system, the torque control of the catheter is markedly decreased.
Preshaped catheters rather than MP catheters are preferred in these
cases because less manipulation is required to engage the coronary
arteries. In addition, advancing a pigtail catheter into the left ventricle
of these patients may be difficult and involve loss of catheter length
and control across the tortuous segments. Problems with catheter
engagement may be partially overcome by keeping the 0.035-inch
J-tipped guidewire in the catheter after advancing the catheter to the
central aorta and manipulating the catheter with the wire in place to
engage the coronary artery. In some cases, an extra-stiff (Amplatztype) guidewire can straighten tortuous vessels, but vessel folding and
kinking at the curves may cause pain. In the upper extremities, trauma
with extra-stiff guidewires is also a concern. A deep breath, as already
mentioned, can dramatically ease difficulties of catheter passage to
the central aorta when the catheter is coming from the radial artery.
Remember: Wire contact with blood forms thrombi despite anticoagulation. Limit wire-loaded catheter manipulations to 2 to 3
minutes, maintain adequate ACT, and use meticulous wire wipe and
sheath flush techniques.
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Arterial and Venous Access 89
Complications of Arterial Access
The most common complication of femoral cardiac catheterization is
local hematoma formation. Other common complications (in order of
decreasing frequency) include retroperitoneal hematoma, pseudoaneurysm, AV fistula formation, arterial thrombosis secondary to intimal
dissection, stroke, sepsis with or without abscess formation, and cholesterol or air embolization. The frequency of these complications is
increased in females, the elderly, those with renal failure and peripheral arterial disease, those undergoing high-risk procedures, and those
receiving anticoagulation, antiplatelet, and fibrinolytic therapies.
In addition, although there is an increased risk in the morbidly
obese, patients with a small body mass index (BMI) are actually at the
highest risk.
Small women, particularly those with a high puncture (above the
upper third of the femoral head) are at greatest risk for retroperitoneal
hematoma. A retroperitoneal hematoma is the diagnosis in patients
with hypotension, tachycardia, pallor, a rapidly falling postcatheterization hematocrit, lower abdominal or back pain, or neurologic changes
in the leg in which the puncture was made.
Pseudoaneurysm presents as a painful palpable mass and is associated with a low puncture (usually below the femoral head). In the
past, all femoral pseudoaneurysms were routinely repaired by the
vascular surgeon to avoid further neurovascular complication or
rupture. With ultrasound imaging techniques, these false channels
can be easily identified and nonsurgical closure pursued. Manual
compression of the expansile growing mass guided by Doppler ultrasound with or without thrombin or collagen injection is an acceptable
therapy for femoral pseudoaneurysm (Fig. 2-20).
AV fistula formation is also associated with a low puncture. Most
go undetected, but if the formation is large enough, patients can experience pain and swelling in the lower extremity. Very large AV fistula
can lead to high-output heart failure. In such cases, a stent graft or
vascular surgery may be required.
Infections are more common in patients who undergo repeat
ipsilateral (same site) femoral punctures or prolonged femoral sheath
maintenance (within 1 to 5 days). Cholesterol embolism, manifesting
with abdominal pain or headache (from mesenteric or central nervous
system ischemia), skin mottling (“blue toes”), renal insufficiency, or
lung hemorrhage, may be a clinical finding in 30% of high-risk patients.
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Arterial and Venous Access
Skin
PSA
SFA
PFA
Figure 2-20 Noninvasive technique for closure of a femoral artery pseu -
doaneur ysm (PSA) by external compression. Arrows: Course and direction of
blood flow. Left: Blood is shown flowing from the common femoral artery
(CFA) into a large PSA through a large tract (T). Right: External application
of pressure using a vascular clamp guided by Doppler ultrasound color flow
probe results in obliteration of the tract and clot formation in the pseudoaneurysm. PFA, Profunda femoris ar tery; SFA, superficial femoral arter y.
(Redrawn from Agrawal SK, Pinheiro L, Roubin GS, et al: Nonsurgical closure
of femoral pseudoaneurysms complicating cardiac catheterization and percutaneous transluminal coronary angioplasty. J Am Coll Cardiol 20:610–
615, 1992.)
T
CFA
Clamp
Clot
T
Probe
Compared with the femoral approach, the brachial (but not
radial) approach has a higher risk of bleeding and vascular complications. On the other hand, such complications are rare when the transradial approach is used. A bleeding complication in a radial case can
easily be recognized and controlled, as discussed earlier. The Bleeding Academic Research Consortium (BARC) has published new
bleeding definitions in an attempt to standardize such definitions
among clinical trials. With this scoring system, it is hoped that one
would be able to compare results from one clinical trial to another.
Access and Hemostasis:
Nurse-Technician Viewpoint
The nursing and technical staff play an integral role in obtaining safe
and successful arterial and venous access and hemostasis. Their
knowledge of anatomy, patient positioning, and equipment is essential
to providing optimal patient care and support during all phases of the
cardiac catheterization procedure.
Precatheterization Assessment
Any procedure may be complicated by the inherent vascular trauma
associated with bleeding. Therefore, planning ahead is important.
Before the procedure, a staff member should describe to the patient
the sensations that he or she might experience while the physician is
obtaining vascular access. On the patient’s arrival to the cardiac catheterization laboratory, the nursing and technical staff must (1) assess
the patient’s baseline peripheral vascular status, including an Allen/
Barbeau test for radial procedures, (2) position the patient properly
on the procedure table for the femoral or radial approach, and (3)
prepare the access site in a manner that facilitates vascular access by
the physician. Alternative access sites may also need to be prepared
in advance for unanticipated entry problems. All pulses should be
palpated or, when necessar y, Doppler assessment should be performed. Information concerning the presence and stability of the pulse
must be conveyed to the physician. Even the uninvolved lower extremity may lose pulse from a central embolus or dissection.
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Arterial and Venous Access 91
Baseline Vascular Assessment
The patient’s preprocedure peripheral vascular status (i.e., pulse
quality) should be assessed and documented on the catheterization
chart before the start of the procedure. In some laboratories, assessment is the responsibility of the nurse, whereas in other laboratories,
all personnel share this duty. It is a good idea for the person responsible for postcatheterization care to perform the initial assessment so
that any changes in vascular status can be recognized easily. Many
laboratories are set up so that the same staff members manage patient
entry and preparation and recovery areas. This setup is ideal because
the staff member responsible for precatheterization assessment and
postcatheterization care can easily assess any change in the patient’s
baseline status.
If the radial arterial approach is used, a precatheterization assessment of the radial and ulnar pulses must be performed. Mark the
location and document the grade on the chart. If the femoral approach
is used, the femoral artery, dorsalis pedis artery (top of the foot), and
posterior tibial artery (inside behind the ankle) pulses should be
assessed, graded, and recorded on a scale of 0 to 4+ (4 being maximal
or a bounding pulse). It is helpful to use a marking pen to indicate the
location and grade of the pulse on the patient’s foot to facilitate postcatheterization assessment.
Patient Positioning
Radial Artery Approach
For the radial artery approach, the arm can be positioned on an arm
next to the body on a pillow in an arm cradle. Most x-ray tables have
accessory arm boards that mount on the side of the x-ray table. Proper
orientation of the radial artery occurs if the arm is placed with the
hand secured in the palm-up position and the wrist is hyperextended
with a small pad underneath it. Place the drape so that it exposes only
the area targeted for access. Because the physician will be going
~2 cm proximal to the bony prominence of the distal radius, the distal
edge of the drape hole can start there, leaving more of the forearm
exposed and available for access (Fig. 2-21). After obtaining vascular
access, bring the arm to the patient’s side near the femoral artery if an
arm board is used, and catheter insertion and manipulation can
proceed as with femoral access.
Femoral Approach
Proper positioning of the patient on the catheterization table by laboratory personnel is important to facilitate arterial and venous access.
For the femoral approach, the patient should be in the supine position. In some laboratories, the patient’s arms are placed behind the
head, ensuring that the hands and arms are away from the sterile
field and will not be in the way of the C-arm of the x-ray unit. However,
the problem with placement of the arms above the head is that the
patient will likely become uncomfortable (and fatigued) during a
long procedure. Positioning the arms at the patient’s side is the most
common method. Instruct patients to keep their arms as close to the
body as possible and under the sterile drape at all times. Instructing
patients to tuck their hands under their hips may help remind them to
keep their arms at their sides and aid in maintaining a comfortable
position during the procedure. Positioning of the patient’s arms at
their sides causes the arms to appear in the x-ray field and compromises angiography performed in severe oblique (angled) projections.
For a lateral projection, arms should be raised and placed behind
the head.
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A
Arterial and Venous Access
B
Figure 2-21
is placed so that the most distal end is at the bony prominence of the distal
radius. B, A full sterile radial drape is placed prior to the arm being moved
to the right hip for catheter insertion.
Positioning of wrist drape for radial procedures. A, The hole
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Position patients with their legs spread slightly so that their knees
are 8 to 12 inches apart. This position facilitates access to the groin by
pulling the skin folds apart at the inguinal crease and creates a space
on the catheterization table to hold equipment, syringes, gauze, and
so forth.
Position the patient as far toward the head of the catheterization
table as possible. This positioning allows travel of the C-arm to cover
the inguinal area and fluoroscopic landmarks (e.g., the femoral head).
If access is difficult because of vessel obstruction or tortuosity, it may
be necessary to use the fluoroscope over the insertion site. If the
patient is positioned too far toward the foot of the x-ray table, fluoroscopic visualization of this area may be impossible.
The Obese Patient for the Femoral Approach. Obese patients
present a challenge to the staff in terms of positioning and site preparation; the operator should consider the radial approach first. If proceeding with femoral access, the first problem usually encountered is that
most catheterization tables are narrow, which leaves no room for
comfortable positioning of the patient’s arms. A Plexiglas arm retainer
gives some support and helps keep the patient’s arms at his or her
sides. Positioning the arms above the head for short procedures is
recommended for obese patients.
The second challenge is that of groin preparation. The protruding
abdomen and panniculus of the obese patient usually extend and rest
over the groin area, presenting an obstacle to access and preparation.
The abdomen wall can be retracted toward the chest and retained in
this position by using 3- to 4-inch-wide tape. The tape can be crisscrossed over the retracted abdomen and secured to the sides of the
catheterization table. When the abdominal folds are retracted, the
groin can be prepared in the usual fashion. Because excessive skin
folds in the obese patient may result in higher than normal amounts
of skin bacteria, extra care should be taken when cleaning the skin
and applying antiseptic solutions.
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Arterial and Venous Access 93
Positioning the Morbidly Obese Patient for the Radial Approach.
Morbidly obese patients may exceed standard weight limits on catheterization tables. Some manufacturers indicate that the highest
current weight recommended is 220 kg. Placing a patient who is larger
than the table weight limit makes the procedure difficult for both the
patient and the laboratory staff. Catheterization tables are built for
efficiency, not comfort. Some tables measure as little as 18 inches wide
and are thus unable to accommodate the larger width of an obese
patient. Panning, angulation, x-ray penetration, and performing cardiopulmonary resuscitation (CPR) are all compromised in this setting.
Dr. Kimberly A. Skelding of the Geisinger Clinic recommends using the
following patient placement approach, in which patients are safely
catheterized regardless of their weight through a radial approach.
Here are the steps for setup:
1. Place patient on a stretcher instead of a hospital bed.
2. Wheel the stretcher to the left side of the catheterization table; the
head of the stretcher should be at the shoulder area of the catheterization table, with the stretcher and catheterization table facing
perpendicular to each other.
3. Ensure that both beds are locked and attach a support board under
the x-ray mattress and under the top of the stretcher mattress.
This helps to allow the beds to move together and support the
patient.
4. The patient then moves himself or herself, with help of the staff if
necessary, north toward his or her head so that the patient resides
half on the catheterization table and half on the stretcher. This
allows the arm to fall at the center of the catheterization table
(Fig. 2-22).
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