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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3597_Библиотеки_им_академика_М_И_Перельмана
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Arterial and
Venous Access
KIMBERLY A. SKELDING • JENNIFER A. TREMMEL
The most critical portion of the catheterization procedure is attaining
vascular access. Access can be obtained in femoral, brachial, and
radial arteries, but preprocedure planning, careful detail to technique,
proper equipment, and operator skill all are highly important. Although
in traditional teaching labs attaining access is left to the fellow, all
personnel in the lab should appreciate its importance and be aware
that the majority of complications resulting from catheterization
procedures are access related.
Some of the critical points of vascular access may not seem
important to the uninitiated, but they are crucial to the safety and
success of the procedure. Entry into the circulation is generally the
only painful part of the procedure. For best patient response, adequate
premedication and generous local anesthesia should be administered.
Local anesthetic should be done using a gentle approach. Pain during
entry into the vessel may cause a vagal reaction or artery spasm,
prolonging the procedure and potentially causing more significant
complications.
The site of access is determined by planned investigation and the
anticipated anatomic and pathologic conditions of the patient, in addition to anticipated bleeding risk. If possible, previous procedures and
any difficulties encountered therein should be reviewed from old
reports. Preprocedural assessment of the quality of all peripheral
pulses is mandatory.
The Radial Versus Femoral
Vascular Access Debate
The essence of the radial versus femoral vascular access debate can
be summarized as follows: (1) Femoral access is quicker, easier, but
has more complications, and (2) radial access is more difficult, takes
more skill and time, but has nearly no complications.
Studies have shown the safety of stenting from the radial artery
without the severe bleeding risks engendered by femoral artery access
in the intensely anticoagulated patient. Numerous studies have since
identified the improved safety, comfort, and lower cost of the radial
approach; however, the trade-off is often increased radiation exposure
and procedural length, particularly while the operator is in the learning cur ve of the procedure. Neither femoral nor radial access can be
used universally because of anatomic constraints, and hence there is
a requirement for operators to use both as well as an obligation of
catheterization laboratory trainers to teach both techniques.
A comparison of femoral versus radial catheterization can be
seen in Table 2-1. The greatest advantage of the radial approach is
reduction of bleeding and vascular complications, which has also
been associated with a mortality benefit. Because of this advantage,
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25%
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Table 2-1
Arterial and Venous Access
Comparison of Femoral and Radial Access for
Cardiac Catheterization
Feature Femoral Radial
Access site bleeding 3% to 4% Pseudoaneurysm,
Artery complications Rare local irritation,
Patient comfort Acceptable Great
Ambulation 2-4 hours Immediate
Extra costs Closure device Band
Procedure time* Perceived shorter Perceived longer
Estimated radiation
exposure*
Access to LIMA Easy Hard from RRA
Use of artery for
CABG surger y
Learning cur ve Short Longer
>8- F guide catheters
PVD, obese Problematic No problem
Modified from Ker n MJ, editor: Editor’s cor ner: radial artery catheterizatio n: the way
to go, Cath Lab Digest 17:4–5, 20 09.
AV, Arterioveno us; CABG, coronar y ar tery bypass gr aft; F, French; LIMA, left internal
mammar y arter y; N/A, not applicable; PVD, peripheral vasc ular disease; RRA, right
radial artery.
*Operator dependent.
retroperitoneal bleed,
AV fistula, painful
hematoma
Perceived shorter Perceived longer
N/A Unknown
No problem
0% to 0.6%
pulse loss 3%
to 9%
Maximum 7 F
(in men)
20.3%
1.30%
2007
National rates
15.3%
10.9%
5.3%
1.60%
2008 2009 2010 2011 2012 2013
2.90%
20%
15%
10%
5%
0%
Figure 2-1 Percentage of radial access use in percutaneous coronary
intervention (PCI) cases by calendar year. (Based on NCDR CathPCI Registry
data.)
use of radial access in the United States has risen dramatically in the
past several years. In 2007, 1.3% of all percutaneous coronary interventions (PCIs) were done via the radial artery, but now rates exceed 20%
(Fig. 2-1). Operators who use the radial approach only when “pressed”
have lower procedural success and higher rates of arterial spasm,
necessitating conversion to the femoral approach or prolonged trials
of antispasm regimens that add time to the procedure.
Femoral advocates argue that (1) fellows-in-training need to learn
the femoral access approach first; (2) femoral access is faster; (3)
femoral bleeding is reduced with vascular closure devices (VCDs)
(and rates are low in their individual laboratories); (4) there are more
options for PCI guide catheter sizes and support devices, such as the
intraaortic balloon pump (IABP); (5) the postprocedure radial artery
may not be suitable for coronary artery bypass graft (CABG) surgery;
and (6) the radial approach is not optimal for a highly tortuous
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Figure 2-2 Postprocedure comparison. Left, Man sitting up after radial
catheterization; right, groin compression after femoral access.
subclavian system, a small and vasospastic radial artery, or forearm
anatomic variants (e.g., a radial loop). Although these provide seemingly reasonable arguments, most technical radial problems can be
overcome with experience and persistence—much like that required
for conquering the occasional difficulties encountered with the
femoral approach. Superior operators and laboratories should be
quite efficient with both approaches. For this reason, we recommend
“radial first, then femoral” access whenever possible (Fig. 2-2). The
new generation of catheterization laboratory operators should be
able to do procedures using both approaches with the same facility
and safety.
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Arterial and Venous Access 57
Radial Artery Catheterization
Compared with the femoral artery, the radial artery is easily accessible
in most patients and is not located near significant veins or nerves
(Fig. 2-3, A). The superficial location of the radial artery enables easy
access and control of bleeding. No significant clinical sequelae after
radial artery occlusion occur in patients with a normal Allen or
Barbeau test because of the dual blood supply to the hand through
the ulnar artery (see Fig. 2-3, B). Lastly, patient comfort is enhanced
by the ability to sit up and walk immediately after the procedure.
Use of the Allen or Barbeau Test
A recommendation for the radial procedure is the performance of the
Allen or Barbeau test. Both tests assess ulnar flow into the palmar
arch. The Allen test is performed as follows: The patient makes a fist.
The radial and ulnar arteries are occluded simultaneously. When the
hand is opened, it appears to be blanched. Release of the ulnar artery
should result in return of pink hand color within 8 to 10 seconds. The
Barbeau test uses pulse oximetry and plethysmography and is felt to
be more sensitive, excluding only 1.5% of patients (Fig. 2-4). Using the
pulse oximeter on the thumb, the pulse wave is displayed with both
arteries open. The radial artery is then compressed and the pulse wave
of ulnar flow can be observed. If the pulse wave does not change, this
is classed as a Barbeau type A. If the pulse wave temporarily decreases
in amplitude but then returns to the original amplitude, this is a
Barbeau type B. If the pulse wave flat lines but then returns at a
decreased amplitude, this is a Barbeau type C. And finally, if the pulse
wave flat lines and there is no return of the pulse wave after 2 minutes,
this is a Barbeau type D. Radial artery cannulation can proceed with
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Arterial and Venous Access
Axillary
artery
Innominate
artery
Brachial artery
Ulnar artery
Radial artery
A
Proper palmar
digital arteries
Radial artery
of index finger
Common palmar
digital arteries
Superficial
Princeps
pollicis artery
Radial artery
palmar arch
Deep
palmar arch
Ulnar artery
B
Figure 2-3
types A, B, or C but is not recommended for type D. A reverse Allen
or Barbeau test can also be performed to check for radial artery
patency by occluding the ulnar artery. This is recommended for
patients with a history of previously accessed radial arteries, either for
catheterization or for arterial blood gases.
Arterial anatomy of the upper extremity (A) and hand (B).
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Type
Precompression Ulnar artery compression
A
B
C
D
Figure 2-4 The Barbeau test. (Courtesy James Bonnett. Adapted from
Barbeau GR, Arsenault F, Dugas L, et al: Evaluation of the ulnopalmar arterial arches with pulse oximetry and plethysmography: comparison with the
Allen’s test in 1010 patients. Am Heart J 147:489–493, 2004.)
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Arterial and Venous Access 59
Start Within 2 minutes
Patient Selection
Patients with a type A, B, or C Barbeau test are candidates for the
radial approach with 5-French (F) and 6-F sheaths and catheters. We
avoid patients who have forearm dialysis arteriovenous (AV) fistulae,
although there is little data on this subject. Consideration should also
be given as to whether the radial artery might ultimately be used as a
bypass conduit, in which case, the contralateral radial (or femoral)
artery should be accessed instead. Although the risk of spasm and
unsuccessful arterial access is higher in smaller and older females, this
group has the highest risk for bleeding and the most to gain from this
approach. Numerous series have reported high success in patients
older than 80 years. Similarly, patients with acute coronary syndromes,
particularly ST-segment elevation myocardial infarction (STEMI), have
higher bleeding risks and are excellent candidates for the radial
approach. However, the operator must be very comfortable with radial
procedures before attempting the same in these patients, for whom
time is of the essence. If the patient has bilateral mammary arteries,
the operator may choose to use the femoral artery because cannulating the contralateral mammary arter y from the wrist can be challenging. Likewise, if the patient has a known arteria lusoria (an
aberrant right subclavian artery arising from the descending aorta
posterior to the esophagus, producing dysphagia), or other anatomic
variation that will make the ipsilateral radial approach excessively
difficult, it makes sense to simply go to the contralateral side.
Patient Preparation
The patient should be well sedated and comfortably positioned.
Several positioning techniques have been suggested. Arm abduction
at a 70-degree angle on an arm board or placement immediately next
to the femoral access site has been used for sheath insertion. A
movable arm board allows the arm to be positioned at the patient’s
hip next to the femoral artery during the procedure, and placement
next to the leg allows decreased operator radiation exposure and
removes the need for specialized drapes. A roll of sterile towels or a
wrist splint is used to support and flex the wrist in a hyperextended
position (Fig. 2-5). A topical anesthetic cream placed over the planned
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puncture site early in the patient preparation area for highly sensitive
or anxious patients may help to decrease the amount of local lidocaine infiltration over the radial pulse, and small amounts of nitroglycerin added to lidocaine for topical infiltration may also reduce spasm.
Large amounts of injected lidocaine may obscure the pulse and make
cannulation more difficult.
cedurally. There should be no IVs near the hand or wrist that will get
in the way of obtaining access or achieving hemostasis. IVs that will
be used for infusions are preferably placed in the contralateral arm.
With radial access occurring in the ipsilateral arm and infusion IVs
being placed in the contralateral arm, blood pressure cuffs generally
need to be placed on the patient’s leg.
Arterial and Venous Access
Figure 2-5 Hyperextension of the wrist for radial access.
Placement of intravenous (IV) lines must be considered prepro-
Percutaneous Brachial
Vein Puncture
If right heart catheterization also needs to be done, access can be
obtained from the arm by placing a 20-gauge IV in an ipsilateral antecubital vein. All superficial veins lead to the deep veins, although a
medial antecubital vein is preferable over a lateral antecubital vein,
which courses through the cephalic venous system over the deltoid
muscles, making catheter advancement difficult through the relatively
sharp turns in the shoulder area. This IV is then prepped and draped
in the usual manner. Prior to giving heparin, a 0.018-inch guidewire is
advanced through the IV and up the arm. The IV is removed and a
sheath is placed over the wire. A small amount of 1% lidocaine to the
area prior to sheath insertion will reduce discomfort. Next, a hydrophilic sheath can be advanced through the skin with no knick needed.
The veins will generally take a 7-F sheath, but a 5-F sheath is preferable.
In this case, the lab needs to stock 5-F balloon-tipped PA catheters.
Advancing the catheter over the wire is often easier than simply
advancing it through the vein without a wire, because the veins can
be small and valves can get in the way. Continuous injection of saline
through the catheter during advancement can help negotiate venous
valves as a “liquid guidewire.” The balloon should not be expanded
until the catheter approaches the superior vena cava. If IV placement
was not done prior to the case, or was unsuccessful, the operator can
gain antecubital venous access using a micropuncture needle with
ultrasound guidance. Application of a tourniquet several centimeters
above the elbow may facilitate the identification of a suitable vein.
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Arterial and Venous Access 61
Right Versus Left Radial Approach
A right radial approach is typically used because it is the side at which
most operators are used to working. However, the left radial approach
has been shown to have a shorter learning curve and reduced radiation exposure, and it may be easier for patients who are short (<
or elderly (age >75 years), because these patients develop more tortuosity in their innominate artery. This is also the preferred side for
patients who have a left internal mammary artery (LIMA) graft that
must be cannulated. Once access is obtained on the left side, the left
arm should be brought over the abdomen so that the operator can
work from his or her usual position on the right side of the patient.
Early in the learning curve, it is also good practice to prepare the
femoral access site in case there is failure to access the radial artery
or successfully manipulate the catheters centrally. Once an operator
becomes experienced, prepping the groin will become unnecessary
except with STEMI patients, in which case ready access to the femoral
artery (particularly for IABPs or left ventricular [LV] assist devices)
will always be important.
165 cm)
Equipment Selection
There are two techniques for arterial puncture: the use of a micropuncture needle or the use of an angiocath needle. The choice is really
based on personal preference, although some data suggest that the
angiocath needle technique is easier to learn and decreases the time
and number of attempts used to gain access. Using the micropuncture
technique, the operator punctures the front wall of the radial artery
only, whereas with the angiocath technique, a through-and-through
puncture must be used—whereby the needle is sent through the posterior wall of the radial artery. This is done to ensure access to the
lumen and does not increase vascular complications as it might if the
same approach were used for the femoral artery.
Several radial artery sheath systems (10 to 36 cm) with a graduated dilator system are available, although there are no data demonstrating an advantage to using a longer sheath (Fig. 2-6). In fact,
because the sheath has the largest outer diameter of any piece of
equipment entering the artery, one could argue that minimizing its
length is preferable. It is certainly known that one of the steps to reducing radial artery occlusion is minimizing the sheath-to-artery ratio.
Sheathless systems have also been developed, but these are not
available in the United States. Instead, a “homemade” system must be
made if one wants to use this approach. Several variations have been
proposed, and each involves the creation of a distal transition so that
the guide can be passed smoothly through the skin and into the artery.
An example is the insertion of a 5-F × 125-cm Shuttle Select (Flexor)
catheter into a 6-F guide.
A final important aspect of any sheath used is that it must be
hydrophilic. This minimizes spasm, patient discomfort, and trauma to
the vessel wall. Careful catheter selection for the radial approach is
also important and is discussed in Chapter 3. Minimizing catheter
exchanges has been shown to decrease the incidence of spasm, and
all catheter exchanges should be done over a wire to maintain access
in the ascending aorta and avoid trauma to the great vessels.
Radial Artery Access and Sheath
Introduction
Once the arm is draped, the radial pulse is palpated (Fig. 2-7). The
point of puncture should be 1 to 2 cm proximal to the bony prominence of the distal radius. Inject a small (≤1 cc) amount of 1%
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Arterial and Venous Access
Figure 2-6 Equipment used for radial artery access.
lidocaine into the superficial skin. Hold the needle at a 30- to 45-degree
angulation and slowly advance until blood pulsates out of the needle
(in the case of a micropuncture technique) or advance until blood
stops filling the reservoir in the angiocath needle. With the micropuncture needle, there is not a strong pulsation because of the small bore
of the needle. With the angiocath needle, there is generally no blood
return after withdrawal of the needle. Instead, blood pulsations are
obtained once the small catheter is pulled back into the lumen. Once
in the lumen, carefully introduce the guidewire; there should be little
or no resistance to the wire introduction. As with the femoral approach,
investigate any resistance with fluoroscopy. Care must be taken if a
hydrophilic-coated guidewire is used, because these wires can easily
perforate small branch vessels and lead to hematoma. Remove the
needle and, if necessary, make a small skin incision over the wire (or
prior to needle insertion) in preparation to introducing the sheath,
although this is generally not necessary with hydrophilic sheaths
unless a patient’s skin is particularly tough. Advance the sheath over
the wire into the artery. If the sheath moves in easily, advance it to the
hub. If resistance is felt with the sheath halfway in the artery, remove
the wire, administer the vasodilator cocktail, and potentially make a
small injection of a 50/50 contrast mixture under fluoroscopic guidance. Reinsert the wire and dilator and continue to advance the sheath
under fluoroscopic guidance. After the sheath is positioned and
flushed (and an antispasm cocktail is given, if not already given), one
can secure the sheath with clear plastic dressing or a suture. The arm
is now ready to be moved to the patient’s side for catheter
introduction.
Ultrasound is an easy facilitator of radial artery access. Studies
have demonstrated improved first-pass rates, reduced number of
attempts, and lower times to achieve success when using ultrasound
compared with palpation alone. The ultrasound probe can be set up
prior to access so as not to prolong the procedure. The ultrasound
should be set at a minimum of depth penetration (i.e., 2 cm) and high
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Arterial and Venous Access 63
A
C
E
G
B
D
F
H
I
Figure 2-7
the radial pulse is palpated. The point of puncture should be 1 to 2 cm
cranial to the bony prominence of the distal radius. A, Administer a small
amount of lidocaine into the skin. B, Use the needle (micropuncture needle
shown here) at a 30 - to 45-degree angulation. Slowly advance until blood
pulsates out of needle. It is not a strong pulsation because of the small
bore of the needle. C, Fix the needle position and carefully introduce 0.018inch guidewire with a twirling motion. There should be lit tle or no resistance
to wire introduction. Remove the needle. D, Make a small incision over the
wire in preparation to introduce sheath (this step is optional). E, Advance
the sheath over the wire into the artery. If sheath moves easily, advance to
hub. If resistance is felt with the sheath halfway in arter y, remove the wire
and administer the vasodilator cocktail. Reinser t the wire and continue to
advance sheath. F and G, After the sheath is positioned and flushed, secure
the sheath with clear plastic dressing or suture (also optional). H and I, The
arm can now be moved to the patient’s side for catheter introduction.
Radial artery access and sheath introduction. Once draped,
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