RADIAL ACCESS TECHNIQUE

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The transradial approach is increasing in popularity worldwide and in many countries now represents the most common access for coronary procedures. As

compared to femoral access, the transradial approach carries a substantially lower risk of vascular complications, allows more rapid patient ambulation, and is associated with a reduced rate of myocardial infarction and death in high-risk patients.1, 2

Many patients undergoing left heart catheterization also require right heart catheterization. Despite the first-ever right heart catheter having been performed via an arm vein by Werner Forssmann in 1929,3 this approach has been large-ly discarded and the procedure is now most commonly per-formed via large central veins. Despite the well-documented advantages of the radial approach for arterial access, the need for concomitant right heart catheterization may be consid-ered a reason to choose the femoral arterial approach to facil-itate access to the femoral vein.

Right and left heart catheterization performed entirely via the arm, using the radial artery and either a forearm or antecubital fossa vein, has been previously described4-8 and offers the potential benefits of earlier patient mobilization and a reduced rate of vascular complications. However, there remain very few reported series using this approach and most of these have been retrospective in nature.

We sought to prospectively examine the feasibility and safety of right and left heart catheterization performed via the radial artery and an antecubital fossa vein at our institution.

MethodsA radial artery program commenced in our institution

in 2011. Between February 2012 and February 2013, all patients in which right and left heart catheterization was scheduled were prospectively planned for arm access if they had a good-quality radial pulse and an antecubital fossa vein that could be cannulated with a 20 gauge cannula. Allen’s test was not routinely performed.

Baseline characteristics, patient demographics, and proce-dural details including duration, screening time (fluoroscopy time), and radiation dose were recorded. The technique used was similar to that described by Gilchrist and colleagues,7 but with several modifications (primarily the preferred use of an antecubital fossa rather than forearm vein).

In brief, a 20 gauge venous cannula was placed in the most medial palpable antecubital fossa vein prior to the pro-cedure. The patient’s arm and cannula site were cleaned and draped, leaving the forearm and antecubital fossa exposed as a sterile field. Radial arterial access was obtained first. Local anesthetic was introduced around the antecubital fossa can-nula. To maintain sterility, the antecubital fossa vein cannula was held with two sterile swabs, one gripping the cannula hub and one gripping the cap. The cap was removed and discarded along with one of the swabs. A 0.020˝ wire was then carefully passed through the cannula hub, ensuring that it did not touch the outside of the cannula. The cannula was removed over the wire using the second sterile swab and also

Right and Left Heart Catheterization via an Antecubital Fossa Vein and the Radial Artery – A Prospective Study

Paul D. Williams, BM, BCh, MA, MD1; Sonny Palmer, MBBS2; Chris Judkins, MBBS, MClinRes2; Jack Gutman, MBBS2; Rob Whitbourn, MBBS2; Andrew MacIsaac, MBBS2; Bo Xu, MBBS2;

Andrew Burns, MBBS, MD2; Andrew Wilson, MBBS, PhD2

ABSTRACT: Right heart catheterization has been described via the arm but previous reports have been retrospective, performed for limited indications, and may not give an accurate assessment of the success rate or safety of this technique. We sought to prospectively examine the feasibility and safety of left and right heart catheterization entirely via the arm using the radial artery and an antecubital fossa vein for a broad range of indications. Fifty-eight consecutive procedures were included. Transradial ar-terial access was successful in 57 patients (98%), right heart catheterization via the antecubital fossa vein was successful in 54 patients (93%) and bilateral catheterization from the arm was achieved in 53 patients (91%). Standard diagnostic catheterization was the most frequent procedure (59%), although thermodilution (6.9%), percutaneous coronary intervention (33%), and coronary sinus sampling (16%) were also performed in selected cases. Compared to a historical cohort of patients undergoing right and left heart catheterization via femoral accesss, mean procedural time (38 vs 47 minutes; P=.03) and screening time (8.1 vs 11.2 minutes; P<.001) were significantly reduced. There was 1 venous forearm hematoma that was managed conservatively. Right and left heart catheterization can be performed routinely via the arm in a broad range of patients and is associated with reduced procedural and fluoroscopy time as compared to femoral access. This approach can be considered for all patients in whom right and left heart catheterization is planned.

J INVASIVE CARDIOL 2014;26(12):669-673KEY WORDS: vascular access complications, complications adult cath intervention, transradial cath, right ventricle

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discarded. The sheath and introducer were then advanced over the wire. The early cases were performed with standard 10 cm sheaths designed for femoral arterial access with a di-lator tip internal diameter of 0.040˝ (Medtronic). However, the later cases were performed with 7 cm uncoated tapered sheaths with a dilator tip internal diameter of 0.025˝ (Radi-focus; Terumo Corporation).

All patients received 5000 units of heparin and 200 µg of intraarterial glyceryl-trinitrate to reduce the risk of radial artery occlusion and spasm, respectively. Figure 1 shows the forearm following sheath insertion. Following completion of the pro-cedure, radial arterial hemostasis was achieved with a TR band (Terumo) and venous hemostasis was achieved with direct pres-sure for 2 minutes followed by application of a pressure bandage.

The mean procedural time, radiation dose, and screening time from a historical cohort of cases of diagnostic right and left heart catheterization performed between February 2012 and February 2013 from the femoral approach were analyzed. This group was then compared to the subgroup of patients undergoing diagnostic right and left heart catheter-ization alone via the arm.

ResultsIn the study period, left and right heart catheterization was

attempted via the arm in 58 cases. Baseline characteristics and patient demographics are shown in Tables 1 and 2. The majority of cases were elective (76%) and the most common indications for right heart catheterization were valvular heart disease (29%), heart failure (19%), pulmonary hypertension (12%), and as part of a research study (34%). Procedural characteristics are shown in Table 3. Standard right and left heart catheterization alone was most frequently performed (59%), although thermodilu-tion (6.9%), percutaneous coronary intervention (PCI; 33%), and coronary sinus sampling (16%) were also performed in se-lected cases. The most frequently used sheath sizes were 7 Fr (52%) and 5 Fr (39%), and the mean sheath size was 6.1 Fr.

The patient flow diagram is shown in Figure 2. Radial arterial access was successful in 57/58 cases (98%), with the single unsuccessful case converting to femoral arterial access. Antecubital vein access was successful in 54/58 cases (93%), with the 4 unsuccessful cases converting to femoral access. In total, successful left and right heart catheterization was achieved via the arm in 53/58 cases (91%), and all patients had at least one vascular access obtained via the arm.

The 4 cases of unsuccessful antecubital venous access are shown in Figure 3. In 2 cases, there was resistance to passage of the guidewire through the 20 gauge cannula. Venography through the cannula demonstrated marked venous tortuosi-ty, which proved impossible to wire (Figures 3A and 3B). In another case, there was undiagnosed subclavian vein occlusion (Figure 3C), presumed secondary to a Hickman catheter that had been used 5 years previously for chemotherapy. In the last case, there was brachial vein dissection from passage of the in-troducer wire (Figure 3D).

Table 1. Baseline characteristics.

(n = 58)

Clinical presentation

Elective 44 (76%)

Non-ST elevation MI 6 (10%)

ST-elevation MI (post thrombolysis) 4 (7%)

Heart failure 4 (7%)

Indication for right heart catheterization

Severity valve disease 17 (29%)

Heart failure 11 (19%)

Pulmonary hypertension 7 (12%)

Shunt 3 (5%)

Research study 20 (34%)

Data presented as number (percentage). MI = myocardial infarction.

Table 2. Patient demographics.

(n = 58)

Mean age (years) 63

Male 41 (71%)

Hypertension 34 (59%)

Diabetes 16 (28%)

Peripheral vascular disease 3 (5.2%)

Chronic kidney disease 6 (10%)

Cerebrovascular disease 11 (19%)

Previous PCI 4 (6.9%)

Previous CABG 1 (1.7%)

On aspirin 39 (67%)

On second oral antiplatelet 21 (36%)

Data presented as number (percentage). PCI = percutaneous coronary intervention; CABG = coronary artery bypass grafting.

Table 3. Procedural details.

Procedure

Right & left only 34 (59%)

Right & left (thermodilution) 4 (6.9%)

RHC & PCI* 19 (33%)

RHC & coronary sinus sampling* 9 (16%)

5 Fr sheath 21 (39%)

6 Fr sheath 5 (9.2%)

7 Fr sheath 28 (52%)

Medial aspect 45 (78%)

Lateral aspect 13 (22%)

Heparin 57 (98%)

Venogram required 6 (10%)

Data presented as number (percentage).*Some patients underwent percutaneous coronary intervention (PCI) and coronary sinus sampling. RHC = right heart catheterization.

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There were no procedural arterial complications. There was 1 arm hematoma and, as discussed previously, 1 vein dis-section related to venous access. The hematoma occurred ear-ly on in the experience with the use of a standard femoral 7 Fr sheath, and was felt to be related to inadvertent venous laceration using a scalpel to enable passage of the sheath di-lator. The procedure itself was performed without incident, but a hematoma was noted on the ward following the case. A pressure bandage was applied and ultrasound scan showed no ongoing bleeding. The patient did not require transfusion and was discharged home the following day. After this case, tapered sheaths designed for radial access, which do not require a skin incision, were used. The venous dissection is shown in Figure 3D. The patient had successful venous access from the femoral vein and did not have any clinical sequelae.

The cases in which diagnostic right and left heart cathe-terization alone was performed via the arm were compared with historical controls, in which left and right heart cath-eterization was performed via the femoral artery and vein

during the 12 months prior to this study (Table 4). The mean procedure time, screening time, and radiation dose for the 38 diagnostic cases in this study and 41 historical controls are shown in Table 4. Mean procedural time (38 vs 47 minutes; P=.03) and screening time (8.1 vs 11.2 min-utes; P<.001) were significantly reduced for arm access vs femoral access.

DiscussionIn this series, we demonstrate that bilateral cardiac cath-

eterization can be performed entirely via the arm in a very high proportion of cases and is associated with a reduction in procedural and screening time. This series differs from previous reports in the following ways: (1) it was prospective; 2) there was a broad case mix, including patients undergo-ing PCI and coronary sinus sampling; and (3) large-caliber sheaths were used in the majority of cases.

Despite the growth in popularity of radial arterial access for coronary procedures, there have been very few published

FIGURE 1. Right forearm following radial artery and antecubital fossa vein sheath insertion.

FIGURE 2. Diagram of patient flow.

FIGURE 3. Venograms of failed antecubital venous access. (A, B) Two cases of marked venous tortuosity preventing wire passage. (C, arrowhead) One case of undiagnosed subclavian vein occlu-sion. (D) One case of venous dissection.

Table 4. Comparison of femoral and arm access for diagnostic left and right heart catheterization.

Femoral (n = 41)

Arm (n = 38)

P-Value

Fluoroscopy dose (G/cm2) 99.9 65.5 .07

Screening time (min) 11.2 8.1 .01

Procedure time (min) 46.7 38.0 .03

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series of right and left heart catheterization via the arm to date. Gilchrist and colleagues first described a series of 29 cas-es of right and left heart catheterization performed using the radial artery and a distal forearm vein in 20026. The same group later described a further 105 cases performed via the radial artery and distal forearm vein using mostly 5 Fr sheaths (mean diameter, 5.2 Fr).7 All patients were heparinized. Two unsuccessful procedures were reported in this series (both due to previous shoulder trauma). Subsequently, 8 cases of cardiac biopsy performed using a 7 Fr sheath via a forearm vein were reported.9 All of these series were retrospective.

Lo and colleagues described 28 cases of right and left cath-eterization via the arm in patients on oral anticoagulation therapy.5 An antecubital fossa vein was used and 6 Fr sheaths were inserted in all cases. Successful access was achieved in 27/28 cases (96%), but in 1 patient a cutdown was required to identify a suitable vein. Finally, Shah and colleagues recently described 106 patients who underwent right heart catheter-ization via antecubital fossa vein access, without concomitant left heart catheterization.8 No patients were anticoagulated and 5 Fr sheaths were used in most cases.

An important finding of our study is that both procedure time and screening time were reduced with antecubital access compared to historical controls. This has not been shown in all previous studies. For instance, Lo and colleagues reported an increased procedural time with arm venous access related to finding an appropriate vein;5 in their study, venous access was obtained in the lab once the patient was draped. This stresses the importance of obtaining venous access prior to the case commencing. Similarly to our study, Shah and col-leagues showed that fluoroscopy time was shorter with arm venous access compared to central venous access when the venous cannula was sited preprocedure.8

In addition to the reduction in time taken to obtain ac-cess, the other likely explanation for shorter procedure and fluoroscopy times with arm access is that entering the right atrium via the superior vena cava (SVC) provides a more fa-vorable approach to cross the tricuspid valve and enter the

pulmonary artery than if the catheter enters the right atri-um via the inferior vena cava. This may significantly reduce the need for catheter manipulation (Figure 4). Entering the right atrium via the SVC also enables easier cannulation of the coronary sinus than via the inferior vena cava approach (Figure 5).

The success rate of arm venous access in our study (93%) is in keeping with other recent studies. For instance, Shah and colleagues reported a success rate of 91% via initial ante-cubital fossa vein access. The reasons for swapping to another approach were similar to those in our study, ie, venous tortu-osity or small vein caliber prevented catheter passage in 5 pa-tients and there was an occluded proximal vein in 1 patient.

Unlike previous studies, which have predominantly used 5 Fr sheaths often inserted into forearm veins, we have demon-strated that 7 Fr sheaths can be readily inserted into antecubi-tal fossa veins, presumably because of the larger vessel caliber. Our series also shows that arm access can be used for more advanced procedures than diagnostic right and left heart cath-eterization. For instance, concomitant PCI was performed in 19 cases and coronary sinus sampling was performed in 9 cases (Figure 5).

Although the technique of arm venous access is relatively straightforward, a few practical points can be made. First, it is important to avoid standard femoral vascular sheaths, which are designed to advance over a 0.038˝ wire. The only venous hema-toma occurred early on in our series as a result of difficulty in-troducing a femoral sheath over a 0.020˝ wire. Sheaths designed

FIGURE 5. Percutaneous coronary intervention and coronary si-nus sampling via arm access. The angiogram shows a 6 Fr EBU guide catheter in the left coronary artery and an AL-1 diagnostic catheter in the coronary sinus.

FIGURE 4. Access to the right heart. The catheter angulation re-quired to cross the tricuspid valve and enter the pulmonary ar-tery from the superior vena cava (A) is less tortuous than from the inferior vena cava (B), potentially reducing the need for cath-eter manipulation. Copyright 2014 HMP

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for radial arterial access are easily inserted and do not require a skin nick, thus reducing the potential for venous laceration. Second, if there is resistance to wire passage though the cannula prior to sheath implantation, a venogram should be performed through the cannula. This can identify the reason for difficulty and potentially allow successful access (Figure 6). Finally, lateral veins should be avoided if possible given the tendency to enter a small-caliber vein and also because there may be tight an-gulation into the subclavian vein at the level of the shoulder as the vein traverses the clavipectoral fascia. In our series, all 4 failures were in cases in which a lateral vein had been can-nulated. Nonetheless, lateral access is usually still successful if a suitable medial vein is not available, but in some cases may require the use of a wire (0.035˝ diameter with a standard pulmonary artery catheter; 0.025˝ diameter with a thermo-dilution catheter) to traverse tortuosity at the subclavian level (Figures 6 and 7).

Study limitations. There are a few limitations to this study. First, although this was a prospective series, the historical control group of femoral procedures was retrospectively identified and may be subject to bias. Second, the overall number of patients is relatively small and it is not possible to draw any definitive conclusions on the vascular complication rate from this study.

ConclusionRight heart catheterization can routinely be performed

via the arm in a high proportion of cases and is associated with reduced procedural and fluoroscopy times as compared with femoral access. If an antecubital fossa vein is selected, then 7 Fr sheaths can be used in the majority of cases and this technique can be performed for a wide variety of pro-cedures, including patients also undergoing PCI.

References

1. Jolly SS, Yusuf S, Cairns J, et al. Radial versus femoral access for cor-

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6. Gilchrist IC, Kharabsheh S, Nickolaus MJ, Reddy R. Radial approach

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7. Gilchrist IC, Moyer CD, Gascho JA. Transradial right and left heart

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cubital venous access: feasibility, safety and adoption rate in a tertiary

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FIGURE 6. Venogram of lateral arm vein. Following unsuccessful passage of a 0.020˝ wire through the cannula, a venogram showed that the cannula tip was in a tiny tortuous vein (A). On withdrawing the cannula, a larger vein became visible (B, arrowheads), which was successfully wired (C) and a 7 Fr sheath was inserted.

FIGURE 7. Venograms taken because of resistance to catheter passage. Access in both cases was via a lateral antecubital fos-sa vein and the small venous caliber and tight angulation into the subclavian vein can be appreciated. Both cases were com-pleted using a standard 0.035˝ J-tipped guidewire to negotiate the area of tortuosity.

From the 1James Cook University Hospital, Middlesbrough, United Kingdom; and 2St. Vincent’s Hospital, Melbourne, Australia..

Disclosure: The authors have completed and returned the ICMJE Form for Disclo-sure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted April 28, 2014 and accepted June 23, 2014.

Address for correspondence: Paul Williams, BM, BCh, MA, MD, Consultant Car-diologist, James Cook University Hospital, Marton Road, Middlesbrough, United Kingdom TS4 3BW. Email: dr.pdwilliams@gmail.com

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