10 Vascular Access

Classification

Indications

Indications Based on Intent

Indications Based on Vessels: Venous

• Small upper extremity veins – radial and ulnar forearm veins
  
  
  
  • Peripheral intravenous (IV) access for medication – popular/common
    
  • Upper extremity venography/mapping (e.g., preop planning for fistula)
  
  
• Larger upper extremity veins – brachial and axillary veins
  
  
  
  • Peripheral IV access for blood transfusions and rapid medication delivery – popular/common
    
  • Upper arm, subclavian, and central venous venography
    
  • Long-term central venous access (peripherally inserted central catheter [PICC – popular/common] and arm port-a-catheters/reservoir catheters
    
  • Access for central venous therapeutic purposes
    
    
    
    • Vena caval filter placement
      
    • Upper extremity and central venous thrombolysis ± stent placement
  
  
• Subclavian vein
  
  
  
  • Long-term central venous access for implants (tunneled, nontunneled, and port-a-catheters/reservoir catheters, cardiac pacers)
    
  • Access for central venous therapeutic purposes
    
    
    
    • Vena caval filter placement
      
    • Central venous venoplasty/stent placement
    
    
  • Central venous venography
  
  
• Jugular vein
  
  
  
  • Long-term central venous access (tunneled, nontunneled, and port-a-catheters/reservoir catheters – popular/common)
    
  • Access for central venous therapeutic purposes
    
    
    
    • Vena caval filter placement – popular/common
      
    • Central venous venoplasty/stent placement
      
    • Transjugular hepatic procedures (transjugular intrahepatic portosystemic shunt [TIPS], liver biopsy, hepatic venography–portography) – popular/ common
      
    • Transjugular renal procedures (renal biopsy)
      
    • Transjugular cardiac procedures (endocardial biopsy, Swan-Ganz catheter placement, pacers)
      
    • Gonadal vein embolization/sclerosis
    
    
  • Central venous venography
  
  
• Femoral vein
  
  
  
  • Access for central venous therapeutic purposes
    
    
    
    • Vena caval filter placement – popular/common
      
    • Central venous venoplasty/stent placement – popular/common
      
    • Transfemoral hepatic procedures – not common, only when above-diaphragm veins are exhausted
      
    • Gonadal vein embolization/sclerosis
    
    
  • Central venous venography
    
  • Long-term central venous access (tunneled, nontunneled, and port-a-catheters/reservoir catheters) when above-diaphragm veins are exhausted/occluded
    
  • Endocrine venous sampling
  
  
• Popliteal and below-knee (tibial) veins
  
  
  
  • Access for central venous therapeutic purposes
    
    
    
    • Lower extremity venous thrombolysis ± venoplasty/stent placement _ vena cava filter placement – popular/common

Indications Based on Vessels: Arterial

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

• Look for vascular anomalies and anatomic variations
  
  
  
  • Some anomalies/variations may preclude accessing a particular vessel. For example, a sciatic artery should be identified as an anatomic anomaly.
    
  • Other anomalies may make the subsequent vascular procedure more difficult/impossible despite an initially successful access. For example, when planning a transjugular liver biopsy or TIPS procedure, a patent jugular vein may allow initial access, but an occluded superior vena cava would make it impossible to approach the liver from that successful jugular access.
  
  
• Look for adjacent structures that can be inadvertently traversed
  
  
  
  • This helps to plan the needle trajectory and evaluate other access vessels altogether.
    
    
    
    • For example, an enlarged inguinal hernia when planning a femoral vessel access
  
  
• Look for preexisting vascular injuries
  
  
  
  • Avoid accessing where there is a vascular injury from a prior access
    
  • These vascular injuries include pseudoaneurysms, arteriovenous fistulas, and large hematomas.

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

Alternatives

Procedural Risks

• Major complications (Tables 10.2, 10.3, and 10.4)
  
  
  
  • Bleeding with large expansile hematomas
    
    
    
    • Pain, drop in hematocrit, need for blood transfusion (an issue with arterial access, especially femoral artery access if high above the inguinal ligament)
      
    • Patient instability (an issue with arterial access, especially femoral artery access if high above the inguinal ligament)
      
    • Hematomas may grow and compress adjacent nerves and cause neuropathy (an issue with arterial access, especially axillary artery access if high above the inguinal ligament).
    
    
    
    

    
    

    

    
    
    
    
    

    
    

    

    
    
    
    
    

    
    

    

    
    
  • Arterial injuries
    
    
    
    • Pseudoaneurysms
      
    • Dissection
      
    • Arteriovenous fistula
    
    
  • Infections
    
    
    
    • Especially concerning implants such as tunneled central catheters and port-a-catheters
  
  
• Minor complications
  
  
  
  • Inadvertent transgression of adjacent vessel(s)
    
  • Minor infections not involving implants and not creating discharge or collections
    
  • Hematomas not requiring blood transfusion, surgical evacuation, or leading to patient instability

• This is for arterial access exams and not for venous access.
  
• A neurologic exam is required for carotid access or whenever the catheter reaches the aortic arch.
  
• This is to compare with the postaccess or postangiogram vascular exam.
  
• The mainstay of the distal vascular exam is examination of the distal artery pulses (palpation, auscultation, Doppler ultrasound), skin color, temperature, and capillary refill.

Equipment

Ultrasound Guidance

Standard Surgical Preparation and Draping

Local Infiltrative Analgesia Administration

Sharp Access

Coaxial Wires and Tubular Access

Tubular Access Devices

Technique

Intravenous Access and Medication

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).
    
    
    

    
    

    

    
    

    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.

    
    
    
    

    
    

    

    
    

    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.

    
    
    
    

    
    

    

    
    

    

    
    

    

    
    

    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.

    
    
    
    

    
    

    

    
    

    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.

    
    
    
    

    
    

    

    
    

    

    
    

    

    
    

    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.

    
    
    
    
    • Veins compress first.
      
    • Arteries are seen pulsating under compression exerting pressure greater than the diastolic pressure and less than the systolic pressure ( Fig. 10.4 ).
      
    • It is difficult to compress veins due to thrombosed veins, tense extremity edema, and extremity tenderness (or simply because the patient does not allow you to).
  
  
• 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).
  
  
  

  
  

  

  
  

  

  
  

  

  
  

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

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