Vascular Access

10 Vascular Access


Wael E.A. Saad

Classification


Vascular access is usually the “opening” step to myriad vascular procedures managing enumerable vascular and nonvascular diseases. Broadening this matter for discussion is the number of vessels, both arterial and venous, that can be used for access. Unfortunately, the scope of this book does not allow us to cover all of these procedures in detail. Indications, contraindications, and endpoints in this chapter are focused on vascular entry (access) only.


Indications


Vascular access is usually the “opening” step to myriad vascular procedures managing enumerable vascular and nonvascular diseases. As a result, indications are broad. They depend on intent and vessel type. The following is a briefing.


Indications Based on Intent


The intent of vascular access, in its simplest definition, is entry to the target vessel at a trajectory and in a particular vascular segment to be able to fulfill the greater aim of the procedure embarked on. Vascular access procedures can be classified into



  • Vascular entry for diagnostic purposes
  • Vascular entry with the intent of placing an indwelling tube/catheter
  • Vascular entry with the intent of implanting a longterm prosthesis or implantable device
  • Vascular entry with a remote therapeutic intent

Indications Based on Vessels: Venous



Indications Based on Vessels: Arterial



  • Radial artery

    • Arterial line for real-time pressure transduction – popular/common
    • Quick access ABG (arterial, blood, gas)

  • Brachial or axillary artery – popular/common with cardiologists, considered a second-line arterial access for radiologists and vascular surgeons

    • Diagnostic arteriography

      • Cardiac arteriography – popular/common
      • Aortography ± lower extremity runoff when femoral arteries occluded
      • Visceral/mesenteric arteriography when femoral arteries occluded

    • Access for arterial therapeutic purposes

      • Cardiac catheterization (angioplasty/stent placement) – popular/common
      • Visceral/mesenteric angioplasty/stent placement when femoral arteries occluded or when femorovisceral angles are not favorable for available wires/platforms/operator talent
      • One access as part of complicated thoracoabdominal endograft repairs

    • Arterial line for real-time pressure transduction

  • Carotid artery

    • Access for arterial therapeutic purposes

      • One access as part of complicated thoracic arch endograft repairs

  • Femoral artery – popular/common with radiologists and vascular surgeons

    • Diagnostic arteriography – popular/common

      • Aortography ± lower extremity runoff
      • Visceral/mesenteric arteriography
      • Upper extremity and cerebral arteriography
      • Cardiac arteriography

    • Access for arterial therapeutic purposes – popular/ common

      • Visceral/mesenteric angioplasty/stent placement
      • Main access of thoracoabdominal endograft repairs
      • Upper extremity and cerebral angioplasty/stent placement
      • Arterial thrombolysis procedures
      • Cardiac catheterization (angioplasty/stent placement)

    • Arterial line for real-time pressure transduction – popular/common
    • Long-term implantable arterial access (arterial Port-a-catheters/reservoir catheters or pumps for chemo-infusion) – popular/common in Japan and South Korea

Contraindications


There are no true absolute contraindications. All contraindications are relative to the type and urgency of the procedure. In addition, the location and longevity of the access affect the coagulopathy threshold. Table 10.1 gives some idea about suggested coagulation parameters. There are no clear values set based on evidence-based research. These are suggested thresholds and personal opinion of the author.



Preprocedural Evaluation


Evaluate prior cross-sectional imaging and laboratory values. Obtain informed consent and document a baseline vascular exam.



All coagulation parameter thresholds are relative to the type and urgency of the procedure. In addition, the location and longevity of the access affect the coagulopathy threshold. Table 10.1 lists suggested coagulation parameters. There are no clear values based on evidence-based research. These are suggested thresholds based on my experience; they should aid in the decision-making process regarding implants versus no implants (dwell catheters) and the urgency of the procedure.


Indications



  • Consent, not only to access (unless it is the only procedure), but to the entire procedure; part of it is its access.
  • See above for indications

Alternatives



  • To refuse the access or the procedure
  • The alternative to vascular access for diagnostic purposes is noninvasive cross-sectional imaging such as computed tomography angiography (CTA), computed tomography venography (CTV), magnetic resonance angiography (MRA), and magnetic resonance venography (MRV).

Procedural Risks




Equipment


Ultrasound Guidance



  • Ultrasound machine
  • Doppler capability is not necessary, but is good to have in case vascular injuries are encountered.
  • A linear higher frequency transducer (7.5–9 MHz) is usually good for all vascular accesses.
  • A multiarray 4–5 MHz ultrasound transducer is usually not required unless in the case of femoral vessel access in morbidly obese patients.
  • A transducer guide bracket is usually not required. Access/target vessels are usually superficial enough; they do not need needle guide brackets.
  • Sterile transducer cover

Standard Surgical Preparation and Draping



  • Chlorhexidine skin preparation/cleansing fluid
  • Fenestrated drape

Local Infiltrative Analgesia Administration



  • 21-gauge infiltration needle
  • 10–20 mL 1% lidocaine syringe

Sharp Access



  • 11 – blade incision scalpel
  • Access needle (21- to 18-gauge, usually 21- or 18-gauge)
  • A 21-gauge needle accepts a 0.018-inch coaxial wire
  • A 18-gauge needle accepts a 0.035- to 0.038-inch coaxial wire

Coaxial Wires and Tubular Access



  • A coaxial access wire is required to convert.
  • Access needle (21- to 18-gauge, usually 21- or 18-gauge)

Tubular Access Devices



  • Telescoped graduate dilation system to upsize 0.018-inch wire to 0.035-inch wire. This comes with micropuncture kit sets. It usually has a 2.5- to 3-French inner dilator and a 4- to 5-French outer dilator.
  • A fascial dilator that can be passed over a 0.035-inch guidewire may be used to dilate the soft tissue and fascia. The sizes of the dilators used go up as much as the subsequent catheter being placed.
  • A peel-away sheath is required for tunneled central venous catheters or implantable port-a-catheters.
  • A side-port vascular sheath (usually 4- to 5-French) is required for a stable arterial or venous access when contemplating diagnostic venography or angiography with or without interventions.

Technique


Intravenous Access and Medication



  • Required for moderate sedation and fluid replenishment/resuscitation
  • The vascular access that is being placed may be for this purpose. The patient may have a difficult venous access and only lidocaine can be given locally until the vascular access is established.

Preaccessment Ultrasound Exam



  • Determine easiest visibility of the target vessel
  • Identify the target segment of the vessel
  • Rule out any superficial structures in the way, especially arterial branches that can be injured by the needle on its way to the target vessel
  • The traditional/common transducer orientation is transverse to the vessel.
  • Differentiate between veins and adjacent arteries

    • This can be performed by pressing down on the vessels transversely using the transducer (compression) (Figs. 10.1, 10.2, 10.3, 10.4, and 10.5).


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      Fig. 10.1 (A) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right subclavian vessels (A, subclavian artery; V, subclavian vein). This ultrasound image is obtained without compression (C, clavicle). (B) Gray-scale ultrasound image (top) and schematic sketch of it (bottom) of the right subclavian vessels while compressing down. As can be seen, the subclavian vein (arrow) is compressed and the subclavian artery is not completely compressed (arrowhead); it has a higher pressure that keeps it open. If more pressure is exerted (more than the systolic pressure of the subclavian artery) on the shoulder girdle, the artery will also compress completely.




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      Fig. 10.2 (A) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the brachial vessels (A, brachial artery; V, brachial veins). This ultrasound image is obtained without compression. (B) Gray-scale ultrasound image (top) and schematic sketch of it (bottom) of the brachial vessels while compressing down. As can be seen, the brachial veins (arrows) are compressed and the brachial artery (A) is not completely compressed; it has a higher pressure that keeps it open. If more pressure is exerted (more than the systolic pressure of the brachial artery) on the arm, the artery will also compress completely.




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      Fig. 10.3 Ultrasound-guided jugular vein access. (A) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right jugular vein (V) and its adjacent carotid artery (A). This ultrasound image is obtained without compression. (B) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right jugular vein and its adjacent carotid artery (A) with compression using the linear ultrasound transducer. As can be seen, the jugular vein collapses (arrows) and the carotid artery is open. This helps the operator differentiate between vein and artery. Incidentally noted is a venous collateral (asterisk) and an external carotid artery branch (#). (C) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right internal jugular vein (IJ) to right subclavian vein junction (SC). The operator has paned down behind the clavicle to evaluate the distal internal jugular vein. This is where most internal jugular vein occlusions or stenoses occur. A nonocclusive thrombus (T) is seen in the jugulo-subclavian vein junction (between arrows). (D) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right jugular vein and its adjacent carotid artery (A). A lidocaine needle is seen approaching the jugular vein (arrowhead). Lidocaine has not yet been injected. Incidentally noted is a nonocclusive thrombus (T) in the jugular vein (V). Nonocclusive thrombus should not preclude jugular venous access. Also incidentally noted are venous collateral (asterisk) and external carotid artery arterial branches (#). (E) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right jugular vein (V) and its adjacent carotid artery (A). A lidocaine needle is seen near the jugular vein (arrowhead). Lidocaine is being injected and forming a wheal (between arrows). (F) Gray-scale ultrasound image (top) and schematic sketch (bottom) of a right jugular vein (V) and its adjacent carotid artery (A). The lidocaine needle tip is again seen near the jugular vein (arrowhead). Lidocaine continues to be injected and creates a larger wheal (between arrows). (G) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right jugular vein (V). A 21-gauge needle has been advanced by the operator and the needle tip is pushing down and indenting the superficial wall of the jugular vein (arrowhead at needle tip). Again noted is a nonocclusive thrombus in the jugular vein. The carotid artery (A) is deeper than the jugular vein. (H) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right jugular vein (V). The 21-gauge needle has been advanced further by the operator and the needle tip is still pushing down and indenting the superficial wall of the jugular vein (arrowhead at needle tip) and has not yet impaled the superficial wall. Again noted is a nonocclusive thrombus in the jugular vein (T). The carotid artery (A) is deeper than the jugular vein. (I) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right jugular vein (V). The 21-gauge needle has been advanced even further by the operator and the needle tip is still pushing down and indenting the superficial wall of the jugular vein (arrowhead at needle tip) and has not yet impaled the superficial wall. The needle tip (arrowhead) has been pushed almost down to the deep wall of the jugular vein. Again noted is a nonocclusive thrombus in the jugular vein. The carotid artery (A) is deeper than the jugular vein. (J) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right jugular vein (V). The 21-gauge needle has been advanced deeper by the operator into the lumen of the jugular vein. The superficial wall of the jugular vein (V) has rebounded to its normal/original position once it has been impaled by the 21-gauge needle (arrowhead at needle tip). The needle tip is inside the lumen adjacent to the deep wall of the jugular vein. At this time, the procedure is converted to a fluoroscopy. Again incidentally noted is the nonocclusive thrombus (T) in the jugular vein.




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      Fig. 10.4 (A) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the right femoral vessels (A, femoral artery – seen lateral; V, femoral vein – seen medial). This ultrasound image is obtained without compression. (B,C,D) Gray-scale ultrasound images (top) and schematic sketches (bottom) of the right femoral vessels while compressing down. The pressure exerted is higher than the diastolic pressure and lower than the systolic pressure. Figures 10.4B-10.4D are in series. As can be seen, the femoral vein is always compressed (arrows) and the femoral artery partly compresses depending on what stage in the cardiac cycle the image was obtained. Figure 10.4B was obtained during diastole, Fig. 10.4C was in systole, and Fig. 10.4D was in the end of systole (starting to collapse). The pressure exerted by the ultrasound probe is high to compress the vein at all times, and is high enough to compress the artery during diastole but not in systole.




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      Fig. 10.5 (A) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the left femoral vessels (A, femoral artery – seen lateral; V, femoral vein – seen medial). This ultrasound image is obtained without compression. (B,C) Grayscale ultrasound images (top) and schematic sketches (bottom) of the femoral vessels while compressing down. As can be seen, the femoral vein (arrow) is compressed and the adjacent femoral artery (A) is not completely compressed; it has a higher pressure that keeps it open. The operator has now identified/confirmed which vessel is a vein and which is an artery, and that the femoral vein is not thrombosed. Thrombosed veins do not compress. (C) The operator has exerted more pressure compared with (B). (D) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the left femoral vessels (A, femoral artery; V, femoral vein). A 21-gauge needle has been advanced by the operator and is now tenting the superficial wall of the femoral vein (arrowhead at needle tip). (E) Gray-scale ultrasound image (top) and schematic sketch (bottom) of the left femoral vessels (A, femoral artery; V, femoral vein). A 21-gauge needle has been advanced by the operator into the femoral vein. The superficial wall of the femoral vein has rebounded to its normal/original position once it has been impaled by the 21-gauge needle (arrowhead at needle tip). At this time, the procedure is converted to a fluoroscopy. (F) Fluoroscopic image of the left hip and pelvis after the 21-gauge needle has been placed into the left femoral vein (arrowhead at needle tip). A radiopaque ruler is placed to aid in femoral access for an inferior vena cava filter placement. (G) Fluoroscopic image of the left hip and pelvis after the 21-gauge needle has been placed into the left femoral vein (arrowhead at needle tip). A 0.018-inch wire has been passed coaxially through the needle. The leading tip of the wire (arrow) is seen projecting in the vicinity of the left iliac vein. (H) Fluoroscopic image of the left hip and pelvis. The 0.018-inch wire has been advanced further and has curled in the specious left iliac vein (arrowhead). Incidentally noted is a right femoral vein central line (arrow at central catheter tip), which delineates the anatomy of the confluence of the common iliac veins. (I) Fluoroscopic image of the upper pelvis and lumbar spine. The 0.018-inch wire has been advanced further and is now in the inferior vena cava (IVC; arrows). Wires that go smoothly to the right side of the vertebral column are most likely venous (IVC is to the right of midline) and less likely arterial (aorta is to the left of midline). Again, incidentally noted is the right femoral vein central line (arrow at central catheter tip), which delineates the anatomy of the confluence of the common iliac veins. RV refers to the level of the renal veins.



  • By anatomy, for example, the femoral vein is medial to the femoral artery and the carotid is medial to the internal jugular vein (Figs. 10.4, 10.5, 10.6, 10.7, 10.8, and 10.9).


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    Fig. 10.6 (A) Gray-scale ultrasound image (top) and schematic sketch (bottom

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Mar 10, 2016 | Posted by in ULTRASONOGRAPHY | Comments Off on Vascular Access

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