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Arterial and Venous Access
gain, and the centerline guide should be turned on. The radial artery
is imaged in the axial plane by holding the probe perpendicular to the
course of the artery. The artery pulsates with gentle compression.
Align the artery with the centerline guide on the display, and insert
the radial needle directly underneath the center marking of the probe,
as close to the probe as possible. Using short in-and-out movements
in order to visualize the needle course, move the needle toward the
artery until it eventually compresses the artery and then punctures
through. This may take some practice but can become a time saver,
particularly for difficult access cases.
Medications for Radial Artery
Catheterization: The Radial “Cocktail”
After inserting the arterial sheath, infuse a radial “cocktail” for arterial
spasm prevention through the side arm. Numerous cocktails are used,
but they generally include some combination of verapamil and nitroglycerin (Box 2-1). Diltiazem, papaverine, or nipride may also be used.
Verapamil in doses of 2.5 or 5 mg has been given alone or within a
cocktail without unwanted side effects, such as hypotension or bradycardia. Nitroglycerin and nipride must be given cautiously in patients
with severe aortic stenosis or any LV outflow obstruction; many operators forgo these drugs altogether. Lidocaine added to the cocktail may
improve patient comfort during catheter manipulation. Heparin is
always given to prevent radial artery occlusion and is generally dosed
at 5000 U or 50 U/kg IV. Heparin may be given intraarterially (IA)
within the cocktail, but if doing so, it should be mixed with plenty of
blood to reduce burning. Alternatively, heparin can be given via IV to
reduce local irritation and pain. Bivalirudin is also an acceptable
alternative to heparin and should be standardly dosed in a weighbased bolus and infusion.
Repeat injections of antispasm medications are not necessary
with catheter exchanges or prior to sheath removal unless the patient
is developing spasm. If the operator notes the development of spasm
(the catheter becomes harder to manipulate and the patient reports
pain), another round of spasmolytic cocktail can be given. Spasm
occurs more commonly in females and with excessive catheter manipulation, multiple catheter exchanges, and less operator experience.
Navigating Up the Arm
Once the sheath is in place, advance the catheter up the arm over a
0.035-inch guidewire.
Generally, a standard J-wire with a very small J curve is sufficient,
although operators often use other preferred wires, such as the a shorttipped J-wire, a Wholey (Covidien ev3, Plymouth, MN) or a Bentson
(Cook Medical, Bloomington, IN). With coated wires, caution must be
used, because they can go into small branches (and potentially
Box 2-1 Medical Regimen for Radial Catheterization*
1. Before the procedure:
Topical anesthetic cream over the radial ar tery (optional)
2. Through the sheath (before catheter insertion):
Heparin 5000 U or 50 U/kg (better intravenously), verapamil 2.5 mg,
and/or nitroglycerin 100 to 200 mcg
1% lidocaine 1 to 2 mL (optional)
3. After the procedure and before sheath removal:
Verapamil 1 mg (optional)
*Other vasodilator cocktails can be used per labor atory rout ines.
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perforate) without the tactile feedback one would get from a standard
J-wire. To minimize radiation exposure, the wire is typically advanced
up the arm without fluoroscopy; however, if any resistance is encountered, use fluoroscopy. Usually, if the J-wire will not advance, a Glidewire (Terumo Medical Corp., Somerset, NJ) or one of the other coated
wires mentioned earlier can be maneuvered up the arm. On rare occasions, an angiogram of the arm will be necessary. Once the guidewire
has reached the shoulder, fluoroscopy is used to ensure safe passage
of the guidewire and catheter into the aortic root. If there is tortuosity
or looping in the innominate artery, having the patient take a deep
breath can help straighten out the anatomy and ease catheter motion.
For small caliber vessels, tortuosity/loops, or resistance due to
spasm/atherosclerosis, a technique called balloon- assisted tracking
(BAT) can be helpful. This involves dilating a coronary balloon at the
distal end of the catheter (generally, a 15- to 20-mm length balloon is
used, with 7 to 10 mm protruding distal to the catheter tip) to create
a nontraumatic tip that is more flexible or “pushable.” For more flexibility, the balloon can be dilated to 3 atm, whereas for more “pushability,”
it can be dilated to 6 atm. A 1.5-mm diameter balloon can be used in
a 5-F catheter/guide, and a 2-mm diameter balloon can be used in a
6-F catheter/guide. Then, advance the catheter/guide up the arm over
a 0.014-inch coronary wire.
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Arterial and Venous Access 65
Sheath Removal and Postprocedure Care
A number of devices have been designed to provide hemostasis from
a simple plastic hemodialysis band compressing a gauze bullet over
the radial arterial puncture to specifically designed compression
bands, such as the Radistop (St. Jude Medical, St. Paul, MN) or TR
Band (Terumo Medical Corp., Somerset, NJ). Regardless of the chosen
device, there are a few critical steps in this process.
Position the device snuggly around the wrist before sheath
removal; the compression portion of the device should be positioned
to cover both the skin nick and arteriotomy site (Fig. 2-8). Gauze can
be placed under the device as a wick to collect any blood leakage and
then pulled once hemostasis is achieved. The sheath should be
removed slowly and smoothly while slowly tightening the device. One
common mistake is tightening the devise too aggressively before the
sheath is removed, leading to patient discomfort. For both patient
comfort and adequate hemostasis, the removal of the sheath and the
tightening of the device should be done simultaneously. The device
should be tight enough to ensure hemostasis but not too tight as to
occlude the flow through either the radial or ulnar arteries. This is
called patent hemostasis, and it is an essential technique for reducing
radial artery occlusion. Once the device is in place and hemostasis is
achieved, perform a reverse Barbeau to ensure patent hemostasis.
Patent hemostasis of the radial artery will be confirmed by a Barbeau
type A, B, or C while the ulnar artery is being compressed. If there is
a Barbeau type D, try loosening the device. If the device cannot be
loosened any further without blood leakage, send the patient to recovery and try again in 15 minutes. Generally, further loosening can be
performed after a short period of time to obtain patent hemostasis.
Recovery room nurses should be adept at performing the Barbeau test
and maintaining patent hemostasis.
Numerous protocols have been used for removal of the hemostatic device. One protocol commonly used is to ensure (or achieve)
patent hemostasis upon arrival to the recovery room for 1 hour and
then to start loosening the device at 90 minutes. The device is loosened further at 105 minutes and then removed at 120 minutes, as long
as there is no active bleeding. If there is still bleeding, minimally
tighten the device to achieve hemostasis for an additional 15 minutes
and then make another attempt at removing the device. Repeat this
until successful. If late bleeding occurs (this is rare), give the patient
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Arterial and Venous Access
A
C
B
D
E
Figure 2-8 A, Radial sheath removal with Terumo band, which has an
inflatable compression pad for hemostasis. B, Band is applied around the
wrist with green dot over the ar terial (not skin) puncture. A thin gauze wick
is placed beneath the band to absorb blood when pressure is released to
assess proper compression pressure in pad. C, Compression pad is inflated.
D, Sheath is removed. E, Final result.
instructions on using the fingers to compress the puncture site. In
addition, instruct the patient to limit lifting any item more than 10
pounds for the next 3 days.
Complications: Radial
Artery Spasm
Some spasm during sheath withdrawal is common; it is wise to tell
patients that removal of the sheath will likely be associated with discomfort. Take the sheath out quickly (but gently); usually the duration
of discomfort (if any) is short. Despite all precautions, if radial artery
spasm occurs or persists, consider the next suggestions. Do not allow
the patient to experience significant pain; analgesics and sedation
should be administered. If spasm is severe and the sheath (or catheter)
is stuck, the following actions can be undertaken:
1. Administer nifedipine 10 mg orally.
2. Give more analgesia and sedation.
3. Place warm compresses over the forearm to relax the spastic artery.
4. Administer nitroglycerin 200 µg IA; repeat if necessary.
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5. Give verapamil 2.5 mg IA (diltiazem can also be used). This should
be mixed with blood prior to injection via the sidearm of the sheath
because direct injection will cause significant discomfort.
If these do not work, wait for an hour and try again. During this
time, maintain proper anticoagulation (heparin), sedation, and analgesia. If nothing helps, an axillary block, propofol, or general anesthesia might be required to relax the radial artery. One should never apply
excessive force. This might result in rupture or avulsion of the radial
artery.
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Arterial and Venous Access 67
Bleeding and Vascular
Complications
Although vascular complications are rare, early recognition of a
problem is vital. In the early stages of a transradial program, an unrecognized hematoma can develop even under the watchful eyes of a
provider. These can be more subtle than those seen from the femoral
approach, and no overt bleeding occurs. Patients complaining of pain
or paresthesias (numbness) warrant a close evaluation. Developing
hematomas can be averted with gentle manual pressure followed by
a careful arm-wrapping technique. While maintaining the wristband
in place, wrap the arm loosely with gauze and secondarily with elastic
tape or an ACE bandage, providing compression to the forearm. After
several minutes, remove the tape and recheck the forearm; it should
be softer. If not, rewrap with slightly higher tension. An unnoticed and
untreated hematoma can produce a forearm compartment syndrome,
threatening the viability of the forearm and hand. Figure 2-9 diagrams
a schema for easy recognition and treatment of arm bleeding after
radial artery catheterization and PCI.
Dissection or perforation of the radial or brachial artery can occur
from wires or catheters. In this situation, the initial reaction is often to
abort the procedure, but in fact, if the procedure can be continued
safely, it is best to do so. The catheter will serve to tamponade the
vessel, and the dissection/perforation will typically resolve by the end
of the procedure. This can be confirmed by arteriography at the end
of the case.
Postprocedure radial arterial occlusion rates are reported to be
<1% to 10%. These are usually asymptomatic but can cause arm soreness and discomfort. A vascular ultrasound can be used to evaluate
patency and adequacy of ulnar flow. If ulnar flow is adequate, supportive treatment with acetaminophen and warm compresses are all
that is necessary. With the preventive measures discussed earlier,
including use of heparin, a small sheath, and patent hemostasis, radial
artery occlusion rates can be minimized. Brachial arterial thrombosis
is a rare complication that should be treated by thrombectomy followed by an evaluation for hypercoagulable state.
Catheterization from the
Percutaneous Femoral
Artery Approach
Percutaneous femoral arterial catheterization is still the most widely
used technique in the United States. In patients with a significant
history of claudication, signs of chronic arterial insufficiency, diminished or absent pulses, or bruits over the iliofemoral area, the physician should use an alternate entry site to avoid the risk of further
impairment of the arterial circulation in the legs (Box 2-2). The presence of arterial conduit grafts or previous balloon angioplasty of the
iliofemoral system is not an absolute contraindication to the percutaneous femoral technique. Prosthetic graft puncture has been shown
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Grade
Incidence
Definition
Treatment
Notes
Remarks
Arterial and Venous Access
EASY HEMATOMA CLASSIFICATION
AFTER TRANSRADIAL/ULNAR PCI
Radial
Ulnar
5 cm
10 cm
Forearm
Arm
I II
≤5% ≤0.1%
Local
hematoma,
superficial
• Analgesia
• Additional
abracelet
• Local ice
Observation
only
• Control BP (importance of pain management)
• Consider interruption of any anticoagulation and/or antiplatelet infusion
• Follow forearm and arm diameters to evaluate requirement for additional
bracelet and/or BP cuff inflation
• Additional bracelet(s) can be placed alongside artery anatomy
• Ice cubes in a plastic bag or washcloth are placed on the hematoma
• Finger O
• To inflate blood pressure cuff, select a pressure of 20 mm Hg < systolic
pressure and deflate every 15 minutes
• After bracelet removal, use “Velpeau bandage” around forearm/arm for a
few hours to maintain mild positive pressure
saturation can be monitored during inflated blood pressure cuff
2
I
<3%
Hematoma
with moderate
muscular
infiltration
• Analgesia
• Additional
bracelet
• Local ice
Inform
physician
II
III
<2%
Forearm
hematoma
and muscular
infiltration
below the
elbow
• Analgesia
• Additional
bracelet
• Local ice
• Inflated BP
cuff
Inform
physician
III
IV V
Hematoma
and muscular
infiltration
extending
above the
elbow
• Analgesia
• Additional
bracelet
• Local ice
• Inflated BP
cuff
Inform
physician
IV
<0.01%
Ischemic threat
(compartment
syndrome)
• Consider
surgery
STAT call to
physician
Figure 2-9 Schema for easy recognition and management of arm hema-
toma after radial arter y catheterization. BP, Blood pressure; PCI, percutaneous coronar y intervention; STAT; statium (immediately). (Courtesy Dr. Oliver
Bertrand, Laval Hospital, Quebec, Canada.)
Box 2-2 Indications for Alternative Routes to Femoral
Arterial Catheterization
Claudication
Absent dorsalis pedis and posterior tibialis pulses
Absent popliteal pulses
Femoral bruits
Absent femoral pulses
Prior femoral ar tery graft surger y
Extensive inguinal scarring from r adiation therapy, sur gery, or prior
catheterization
Excessively tortuous or diseased iliac ar teries
Severe back pain, inability to lie flat
Patient request
Morbid obesity
to be safe if small-diameter sheaths are used and careful management
for hemostasis is followed at the end of the procedure. Nonetheless,
an alternative route should be strongly considered.
In patients with diminished pedal pulses, the femoral arterial
approach using small (<
6 F) sheaths and catheters is possible.
However, even partial occlusion of the femoral artery may cause
a significant drop in distal perfusion pressure and blood supply to
the already compromised foot. A small embolus in a patient with
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diminished pedal pulses may not be tolerated as well as in patients
with patent distal vessels.
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Arterial and Venous Access 69
Artery Location
Femoral arterial entry is usually begun using the patient’s right femoral
artery with the operator standing at the right side of the patient. The
common femoral artery is defined as that portion of the femoral artery
below the lowest margin of the inferior epigastric artery and above the
bifurcation of the superficial and profunda branches of the femoral
artery. The goal is to access the common femoral artery over the mid
portion of the femoral head so that there is a hard surface against
which to compress the femoral artery when achieving hemostasis (Fig.
2-10). The mid portion of the femoral head is located approximately
2 cm below the inguinal ligament. The inguinal ligament is located by
palpating the anterior superior iliac spine and the pubis and drawing
an imaginary line between them. Then, using the middle and index
fingers placed parallel to the long axis of the femoral artery, find the
arterial pulse ~2 cm below this imaginary line (Fig. 2-11). A metal
clamp can also be placed over the proposed entry site and the site
can be confirmed by fluoroscopy (Fig. 2-12). Some operators put the
tip of the clamp at the lower border of the femoral head to indicate
where they will numb the patient and then angle their needle such
that they access the artery approximately 1 cm above this skin entry
location. Use of the skin crease is no longer advocated because of its
variability, particularly in obese patients.
Local Anesthesia
With a 25-gauge needle, the skin is infiltrated superficially with 1%
lidocaine ~1 cm below (caudal to) the desired arterial entry site. This
point is the skin entry site. In obese patients with thick subcutaneous
tissue, the entry site should be slightly lower to ensure a needle entry
angle of 45 degrees or less. Because large amounts of lidocaine may
obscure the pulse, inject small amounts repeatedly instead of administering a large bolus. Next, with a 21-gauge needle, further introduce
1% lidocaine into the deep tissue planes on each side of the artery.
During lidocaine infiltration, palpate the arterial pulse with the middle
and index fingers to avoid accidental puncture of the artery and
ensure infiltration of tissue above and around the artery.
Figure 2-10 Manual compression over the femoral head.
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Arterial and Venous Access
Figure 2-11
below the inguinal ligament and aiming medially toward the umbilicus. (From
Tilkian AG, Daily EK: Cardiovascular procedures: diagnostic techniques and
therapeutic procedures, St Louis, 1986, Mosby.)
Femoral artery (or vein) puncture with needle entering ~2 cm
Gentle aspiration before the injection of lidocaine is essential to
ensure that the needle tip is not in a blood vessel. Inserting the needle
first to the deepest level desired and then continuing infiltration at
several more shallow layers may decrease the patient’s discomfort.
Local anesthesia should cover the whole depth of the expected skinto-artery path. Give sufficient lidocaine (~15 to 20 mL of a 1% solution)
over 2 to 3 minutes for the full anesthetic effect to take place. Hint:
Give lidocaine early and while the anesthetic is taking effect, other
preparations such as connecting tubing and flushing catheters can be
completed. During access, listen to the heart rate monitor or watch the
electrocardiogram (ECG) for slowing of the rate as an early warning
of a vagal reaction. Alternatives to lidocaine are shown in Box 2-3.
Skin Entry and Access Channel Preparation
Some operators perform a small skin incision before inserting a Seldinger needle. Other operators prefer to nick the skin over the entry
needle or guidewire after the puncture. The latter approach usually
results in only one nick if the operator does not obtain access on the
first attempt. With the fingers placed over the artery as described previously, the operator makes a skin incision of 2 to 3 mm with a No. 11
scalpel blade, holding the blade perpendicular to the skin and penetrating 2 to 3 mm into the subcutaneous tissue. For large-diameter
sheaths (and for anticipated large-diameter VCDs), make a subcutaneous tunnel with blunt dissection using straight forceps. This channel
makes the catheter and sheath entr y easier and, more importantly,
permits blood to drain outside of the leg if the puncture site opens
after the catheters have been removed. It is important to avoid extensive disruption of skin and subcutaneous tissue while creating the
channel because these are the natural barriers to infection.
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Arterial and Venous Access 71
1
4
2
3
Figure 2-12
femoral arter y in the anteroposterior projection. Bottom, Correct positioning
is seen relative to angiographic landmarks. 1, Common femoral ar tery; 2,
bifurcation of profunda; 3, super ficial femoral arter y; 4, midpoint of femoral
head; 5, iliac-symphysis pubis ridge (inguinal ligament line). Upper limit of
common femoral ar tery is lower margin of the inferior epigastric arter y.
Femoral artery landmarks. Top, Angiogram of sheath in the
5
Arterial Puncture
The single anterior arterial wall entr y (modified Seldinger) is the preferred technique (Fig. 2-13). This is especially important in patients
treated with anticoagulants (e.g., heparin), antiplatelet agents, or
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Arterial and Venous Access
Box 2-3 Anesthetic Alternatives to Lidocaine
Group I
Procaine (ester prototype)
Benoxinate (Dorsacaine), benzocaine, butacaine (Butyn), butethamine
(Monocaine), but ylaminobenzoate (Butesin), chloroprocaine
(Nesacaine), procaine (Novocain), tetracaine (Pontocaine)
Group II
Lidocaine (amide prototype)
Amydricaine (Alypin), bupivacaine (Marcaine), cyclomethycaine
(Surfacaine), dibucaine (Nupercaine), dimethisoquin (Quotane),
diperodon (Diothane), dyclonine (Dyclone), etidocaine (Duranest),
hexylcaine (Cyclaine), mepivacaine (Carbocaine), oxethazaine (Oxaine),
phenacaine (Holocaine), piperocaine (Metycaine)
Pramoxine (Tronothane), prilocaine (Cit anest), propar acaine (Ophthaine),
pyrrocaine (Endocaine)
From Tilkian AG, Daily EK: Cardiovascular procedures: diagnost ic techniques and
therapeutic procedures, St Louis, 1986, Mosby.
A B
C
D
E
Figure 2-13 A, Femoral artery has been entered by a large-bore needle
with backflow of blood. Note the operator’s finger positions. As soon as the
needle passes into the vessel through the anterior wall, brisk pulsatile flow
occurs. This technique, called the “front wall stick,” prevents occult bleeding
through the posterior wall. B, The flexible tip of the guidewire is passed
through the needle into the vessel. C, A valve sheath is introduced into the
artery. The needle is withdrawn, the ar tery is compressed, and the wire is
pinched and fixed. D, The valve sheath is advanced over a guidewire, and
the dilator and guidewire are removed. E, Arrows: Shown is position of
sewing rings to attach valve to skin, should prolonged inser tion be required.
(A, B, C, and E, From Uretsky B, editor: Cardiac catheterization: concepts,
techniques, and applications, Walden, MA, 1997, Blackwell Science.)
thrombolytic agents. The original Seldinger double-wall puncture
technique is not explained here. The single-wall technique begins with
the operator’s fingers positioned over the femoral artery as described
earlier. Hold the arterial needle (without an obturator) between the
index and middle fingers (as if holding a pencil), with the tip of the
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bevel directed upward. Introduce the needle through the skin and
advance slowly toward the artery at a 30- to 45-degree angle to the
horizontal plane. An entry into the artery that is too vertical creates
problems in advancing the guidewire and promotes sheath and catheter kinking. Pulsation may be felt when the needle contacts the arterial wall. A slight resistance to the needle can be felt as it passes
through the arterial wall. At this point, a jet of blood from the needle
hub confirms arterial puncture. Maintain the immediate strong spurt
of pulsatile arterial blood by stably holding the needle hub. Resting
the wrist on the patient’s thigh is helpful. Straighten the J-tipped guidewire and introduce it into the needle. Introduce the wire only when
good pulsatile blood flow is present.
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Arterial and Venous Access 73
Guidewire Insertion
Advance the guidewire gently into the artery. A soft J-tipped guidewire
is the safest. Although straight-tipped guidewires have been used, the
potential is high for subintimal dissection or tearing of the blood vessel
wall. The wire should move without resistance. If the operator encounters resistance, pull the wire out and confirm that pulsatile blood
returns. Use fluoroscopy often to check wire movement. Repositioning
of the needle may be necessary if the wire cannot be advanced freely.
Sometimes the needle tip partially penetrates the posterior wall. In this
case, there is good blood return, but the wire cannot be advanced
because it is directed into the posterior wall of the artery rather than
the arterial lumen. Withdrawing the needle 1 to 2 mm usually solves
this problem. Move the needle hub a few millimeters laterally or medially, after which the guidewire is slowly readvanced. It is important not
to move the needle hub excessively in either direction, which could
slice the arterial lumen. In the case of a very vertical (>45-degree
angle) entry into the artery, as is sometimes encountered in obese
patients, lowering the needle hub several millimeters may improve the
artery and needle tip alignment and permit easier guidewire passage.
The operator should attempt to puncture the artery close to the midline
of the anterior vessel wall. Puncturing the lateral arterial wall may
create a problem in advancing the guidewire or, worse, in controlling
bleeding after the procedure.
If it is not possible to advance the wire or if the needle comes out
of the artery, withdraw the needle from the skin and apply pressure
over the puncture site for at least 2 minutes to ensure hemostasis.
Repeat the procedure using a slightly different angle or direction. If
the artery is not encountered, completely withdraw the needle again,
flush it of clot or fat, and advance in a different direction. Because of
the sharp edge of the needle used for single-wall entry, the direction
of the needle generally should not be changed when the needle tip is
in the subcutaneous tissue. If the artery cannot be located by palpation, use a Doppler-tipped needle (Smart Needle) (which differentiates
the high-pitched [arterial] or low-pitched [venous] flow velocity
sounds) or two-dimensional (2D) ultrasound imaging to localize and
enter the artery (Fig. 2-14).
From Guidewire to Catheter Insertion
If you encounter no resistance, advance the guidewire several centimeters at first and then farther into the abdominal aorta using fluoroscopy. Fluoroscopy of the guidewire moving through the iliac artery
identifies large arterial plaques and excessive tortuosity, which complicates later catheter manipulation. As noted earlier, use of a J-tipped
soft-spring guidewire is recommended because a straight wire may
pass under a plaque, resulting in dissection. After the guidewire is well
positioned above the iliac artery, remove the arterial needle. Apply
firm pressure over the puncture site (to control bleeding) with the last
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