Real-Time Ultrasound-Guided Venous Access of the Arm for Right Heart Catheterization

Abstract: Objective. Arterial access from the wrist for cardiac catheterization is increasingly being used. Right heart catheterization (RHC) is an integral part of many of these procedures. Reliable venous access from the arm allows avoidance of femoral or jugular venous access for RHC. It is uncertain if ultrasound guidance offers a benefit for venous access of the arm for RHC. This study sought to assess the efficacy of ultrasound-guided venous access of the arm (UGVAA) for RHC. Methods. A retrospective study was performed on consecutive patients undergoing RHC at a single institution between August 2015 and July 2016. Baseline data, procedural information, and success rates of UGVAA and RHC were assessed. Results. A total of 266 consecutive RHC procedures were identified, of which 253 (95.1%) were performed via arm venous access; of these, a pre-existing intravenous catheter was used in 3 cases, UGVAA was used in 241 cases, and UGVAA was probably used but not documented in 9 cases. There was 100% success of venous cannulation and sheath placement in these 253 patients. RHC via the arm vein was successful in 248 patients (98.0%) and failed in 5 patients (2.0%). Mean procedure time for RHC via arm access was 5.7 minutes. The femoral approach was used in 12 patients (4.5%). A jugular approach was used in 1 patient (0.4%). All patients had concomitant left heart catheterization via transradial access. Conclusions. UGVAA is a highly efficacious and safe technique, with a success rate of 98% for RHC in our consecutive series of 253 patients. UGVAA may allow for near-universal use of arm veins for RHC.

J INVASIVE CARDIOL 2019;31(7):E170-E176.

Key words: arm vein, real-time ultrasound, right heart catheterization, vascular access

Transradial arterial access (TRA) is widely used for left heart catheterization (LHC) and/or percutaneous coronary intervention (PCI) due to its clinical benefits.^1,2 A concomitant right heart catheterization (RHC) is needed in many of these patients. In such cases, access from the arm for both RHC and LHC has been increasingly reported,^3-5 and offers the potential benefits of greater patient comfort, earlier patient mobilization, and a reduced rate of vascular complications.^6-9 However, RHC via venous access of the arm using visualization or palpation has some unique challenges, with a failure rate that can reach 15.7%.¹⁰

Real-time ultrasound guidance for radial arterial access has been shown to decrease procedure time, improve first-pass success rates, and decrease crossover to an alternative access site.^11-13 It has been also used for many years to obtain central venous access of the internal jugular and subclavian veins, because of improved efficacy and safety over landmark-guided and palpation-guided access.^14-16 Ultrasound-guided peripheral venous access has been reported, with some finding a benefit and others finding no benefit.^17,18 However, no comprehensive data exist with regard to the impact of real-time ultrasound-guided venous access of the arm (UGVAA) for RHC, especially in “radial-first” operators experienced in ultrasound-guided TRA. In this study, we sought to retrospectively evaluate the efficacy of UGVAA in consecutive patients undergoing RHC at our institution.

Methods

Study populations and setting. This is an observational, retrospective study from Memorial Regional Hospital of the Memorial Healthcare System in Hollywood, Florida. All consecutive patients undergoing RHC from August 2015 to July 2016 by two radial-first operators experienced in ultrasound-guided vascular access were identified using current procedural terminology codes for cardiac catheterization and/or PCI. The data for patient demographics (age, gender, height, and body mass index), indications for RHC, use of ultrasound guidance, procedural details (diagnostic or PCI, sheath size, anticoagulation type, access site), and outcome data (initial successful vascular access rate, successful RHC, procedural time, fluoroscopy time, and access-site complications) were collected and entered in the database. This study was approved by Memorial Healthcare System’s institutional review board.

Primary endpoints for the study were success rates of UGVAA and RHC. Successful UGVAA was defined as successful placement of an introducer sheath into an arm vein without crossover to another venous site. Successful RHC was defined as successful advancement of the right heart catheter through the right heart chambers into the pulmonary artery. Secondary endpoints were use of ultrasound guidance, procedural time, fluoroscopy time, and complications. RHC procedure time was defined as the time between the RHC catheter introduction into the venous sheath until it reached the pulmonary artery. Complications were defined as access-site bleeding, hematoma, vessel dissection, and aneurysm formation.

UGVAA procedure. All procedures were performed by two radial-first operators who perform all of their TRA procedures under ultrasound guidance. The primary access route for both arterial and venous access was at the discretion of the individual operator. UGVAA was performed using a SonoSite Edge portable ultrasound machine equipped with a 6-13 MHz vascular transducer (SonoSite, Inc.) (Figure 1A). The patient’s arm was prepped and draped from 4-5 cm proximal to the antecubital fold to the wrist, with wide exposure of the entire antecubital fossa, forearm, and wrist. This allowed for arterial access of either the radial or ulnar artery, and venous access of veins in the forearm, antecubital fossa, and distal brachial vein. The ultrasound probe was wrapped in a sterile plastic sleeve with gel inside, as previously described (Figure 1B).¹⁹ A previously placed tourniquet was then tightened around the upper arm, and short-axis views of the arm veins were visualized (Figure 1C). As arm vein anatomy is much more variable than arm arterial anatomy, a quick ultrasound scan of the arm veins was usually performed, searching for the “most appropriate” vein. The best arm vein was then confirmed by its easy compressibility (Figure 1D). Local anesthesia was infiltrated at the anticipated puncture site, typically 0.5-1 mL of 2% xylocaine. The operator then held the transducer in the transverse short-axis plane, cannulating the vein using a 20 or 21  gauge needle under direct ultrasound visualization. This was performed with the vein directly under the center marker of the transducer, with the needle then inserted under the center marker of the probe at a 45° angle to the skin (Figure 1E). Under direct visualization, the anterior wall of the vein was seen as it was compressed by the probe and/or needle, or at times the needle was not visualized, but the vein and soft tissue above it was seen as it was compressed (Figure 1F). Usually, the “white dot” of the access needle was seen just above, in, or below the compressed vein (Figure 1G). Occasionally a “pop” was felt as the needle entered the vein, and there was venous return through the needle. Often, there was no return of venous flow upon advancement of the needle through the entire vein, only to have return of blood when the needle was withdrawn through the posterior wall of the easily compressible vein. After return of venous blood through the access needle, a 0.018˝ wire was advanced through the needle (Figure 1H), with a 5 Fr or 6 Fr Terumo Glidesheath then advanced over the wire (Figure 1I). Radial arterial access was then obtained under direct ultrasound guidance, as described previously.^11,13 Figure 1J shows 6 Fr Glidesheaths in both the radial artery and median forearm vein. All patients received nitroglycerin either sublingually before the arterial puncture (JR) or intra-arterially after sheath insertion (JP), and all received 2.5 mg of intra-arterial verapamil via the arterial sheath. After arterial sheath insertion, intravenous (IV) heparin (70 U/kg) was given, with a minimum of 4000 U and a maximum of 7000 U for diagnostic procedures. Additional heparin was given for PCI, if needed, to achieve an activated clotting time > 250 seconds.

RHC procedure from the arm. After successful venous sheath insertion, one operator (JP) routinely first advanced a 0.014˝ Hi-Torque Whisper coronary wire (Abbott) to the superior vena cava (SVC), and then advanced the RHC catheter over this wire. The other operator (JR) routinely advanced only the RHC catheter through the sheath to about the 50 cm marker on the catheter without fluoroscopic guidance. If resistance was felt by either operator with either the wire or the catheter before it reached the SVC, a venogram was performed through the distal end of the RHC catheter, to guide further advancement of the wire or catheter. Once the RHC catheter was in the subclavian vein or SVC, the distal balloon was inflated, and routine RHC was then performed. At the completion of the RHC procedure from the arm, the venous sheath was removed in the cath lab or in the postprocedure area, with hemostasis achieved by manual compression. Femoral venous access was performed using modified Seldinger’s technique with or without ultrasound guidance. After the end of the procedure, the femoral venous sheath was removed and manual compression was applied to the puncture site until hemostasis was achieved.

Statistical analysis. Data are presented as the mean ± standard deviation and categorical variables are presented as the absolute number of patients and percentage of their group. Categorical variables for each group were compared using the Chi-squared test or Fisher’s exact test, and continuous variables were compared with the Student’s unpaired t-test. All tests were two tailed, and a P<.05 was considered significant for all tests. Statistical analysis was performed using Prism 7.0 (GraphPad Software, Inc.).

Results

During the study period, RHC was performed in 266 consecutive patients. Patient demographics and indications for RHC are summarized in Table 1. The mean age of the study population was 69.3 ± 13.7 years, and 52% were men. The mean body weight and body mass index were 84 ± 22.9 kg and 29.5 ± 6.7 kg/m², respectively. The most common indications for RHC were valvular heart disease (44.2%), heart failure (17.2%), cardiomyopathy (12%), pulmonary hypertension (6.8%), and dyspnea of uncertain etiology (19.8%). Procedural characteristics are shown in Table 2. All patients had both RHC and LHC. PCI was performed in 24 cases (9%). Heparin was given in 262/266 cases (98.5%), heparin with eptifibatide was given in 3/266 cases (1.1%), and bivalirudin was given in 1 case (0.4%). The average dose of heparin was 6120 U for diagnostic-only cases and 9300 U for cases with concomitant PCI. The mean procedural and fluoroscopy times were 49.9 ± 25.8 minutes and 9.2 ± 6.2 minutes, respectively, for diagnostic-only cases, and 86.6 ± 38.1 minutes and 19.7 ± 8.6 minutes, respectively, for cases with concomitant PCI. Arterial access from the arm under direct ultrasound guidance was successful in 264/266 cases (99.2%), with the 2 unsuccessful cases (0.8%) converting to femoral arterial access.

The patient flow chart for RHC is shown in Figure 2. Of the 266 consecutive RHCs, a total of 253 were attempted initially from the arm (94.8%). Three of the 253 patients (1.2%) used a pre-existing IV catheter for venous access, and the other 250 patients (98.8%) had venous access obtained in the cath lab. UGVAA was documented in 241/250 patients (96.4%), and not documented, but most likely used, in 9/250 cases (3.6%). The right arm was used for venous access in 165/253 patients (65.2%) and the left arm was used in 88/253 cases (34.8%). Sheath sizes for venous access were 6 Fr (74.4%) and 5 Fr (25.6%) (Table 2). Completed RHC via venous access from the arm was successful in 248/253 patients (98.0%) and failed in 5/253 cases (2.0%). The reasons for failure of RHC from the arm in the 5 cases included thrombosis of the left subclavian vein from pre-existing implantable cardioverter defibrillator (ICD) wires in 1 case, friction from left subclavian vein ICD wires preventing passage of the RHC catheter in 1 case, inability to advance/maneuver the RHC into the pulmonary artery in 2 cases, and kinking of the venous sheath secondary to venous tortuosity preventing passage of the RHC catheter, requiring crossover to a femoral vein in 1 case (Figure 2). The mean procedure time for RHC via arm access was 5.7 ± 3.4 minutes. The femoral approach was used in 13 patients, of which 11 used the femoral vein as the primary access site with concomitant radial artery access, 1 had a pre-existing femoral venous sheath, and 1 was switched to the femoral vein from the above-mentioned unsuccessful arm attempt. The remaining patient had a jugular approach used due to a need to leave a triple-lumen catheter in place. One patient complained of arm discomfort during the RHC procedure via venous access of the arm. No bleeding, edema, pain, or other immediate or delayed complications occurred in any other subjects.

Additionally, both the procedural times and fluoroscopy times were comparable for right arm access vs left arm access (Figures 3A and 3B). In the hands of the two experienced radial-first operators, both procedural time and fluoroscopy time were comparable between the two operators (Figures 3C and 3D).

Discussion

This case series describes a single-center experience with UGVAA for RHC. Our data demonstrated that UGVAA was a safe, feasible, and efficient technique for RHC, with venous access and sheath insertion being successful in 253 consecutive patients (100%), and successful completion of RHC in 248 of 253 consecutive patients (98%).

As TRA has become the arterial access site of choice in many cath labs, there has been a shift in performing RHC from the femoral or internal jugular veins to the arm veins. Almost all series of reported RHCs from the arm have obtained venous access by visualizing or palpating veins of the arm, usually an antecubital vein. Failure of obtaining venous access from the arm using visualization or palpation can be substantial. Lee et al reported the inability to obtain arm venous access in 13.9% of patients, requiring subsequent use of the femoral vein.²⁰ Shah et al reported RHC failure from an antecubital venous access route in 9 of 106 patients (8.5%).²¹ Recently, Roule et al reported initial “venous puncture failure” in 151 of 964 consecutive patients (15.7%) undergoing RHC from the arm, requiring crossover to a second venous access site.¹⁰

Many interventional cardiologists and cath lab nurses have experienced not being able to see or palpate a peripheral arm vein. If this occurs, and RHC is desired via the arm, it will not be possible if only visualization and/or palpation is used to access an arm vein, and crossover to another access site is needed. The two radial-first operators in this study, who have extensive ultrasound-guided TRA vascular access experience, elected to obtain venous access under ultrasound guidance in all patients, and forego any attempts at venous access in the precatheterization area by the nursing or IV team staff. With experience, they have now been able to obtain venous access in the arm in almost every patient. In the time frame for this study, there was 100% success in obtaining venous access and sheath placement using UGVAA. To the best of our knowledge, this is the first report to investigate the feasibility, safety, and efficacy of UGVAA in a series of consecutive patients undergoing RHC.

Successful sheath placement in an arm vein, but inability to complete the RHC due to failure to advance a catheter to the pulmonary artery, is well reported.^10,20,21 In our study, we were able to obtain venous sheath access in all patients, but were unsuccessful in completing the RHC in 5 of the 253 patients (2.0%) for the reasons listed above (Figure 2). The reasons for RHC failure in these patients are in accordance with previous reports, which indicate that the incidence of incomplete RHC procedures via arm vein access may reach 5%-10% in older subjects.^6,9 Potential reasons for inability to complete a RHC include tortuous and/or calcified venous anatomy (especially in the elderly), prior injury or surgery to the arm, shoulder or upper-chest deformities distorting venous anatomy, pacing or ICD wires narrowing or occluding the subclavian vein, thrombotic vein occlusion from prior central venous catheters, peripherally inserted central catheter lines, rare congenital anomalies, external venous compression from tumor or  hematoma, or just the inability to adequately torque a catheter into position. If any of the above anatomic issues are present, a screening venous ultrasound study prior to cardiac catheterization may be helpful. If a severely stenosed, distorted, or occluded vein is seen, then use of the contralateral arm should be considered.

Several advantages of arm venous access over femoral venous access for RHC have been suggested. Most importantly, fewer vascular complications and hematomas are reported with arm vs femoral RHC.^10,21 There may be less discomfort for the patient by reducing the amount of time to ambulation.⁸ Also, RHC performed via venous access of the arm has been associated with shorter procedure duration and fluoroscopy time, as well as a lower radiation dose compared with femoral access.^6,8,10,21

We have found that UGVAA may be more challenging than ultrasound-guided radial or ulnar artery access. Reasons include the significant variations in venous arm anatomy compared with straightforward and less variable radial and ulnar artery anatomy. Access of either the radial or ulnar artery is almost always at the same position on the wrist. However, access of the “best” arm vein, especially by UGVAA, can be in a wide area of the arm. When imaging deeper veins in the forearm, it is important to follow the vessels up to the antecubital fossa. Some will have marked tortuosity before reaching the antecubital fossa, which could make wire advancement difficult, and should be avoided. Rarely, there are no “good” veins seen in the forearm or antecubital fossa. In this instance, the brachial vein can be accessed. There will almost always be a plump brachial vein running directly adjacent to the brachial artery proximal to the antecubital fossa. With experience with ultrasound guidance, the brachial vein can be reliably punctured, avoiding the brachial artery.

Veins of the arm can spasm, as intense and painful as an arm artery. If there is resistance to advancing the wire or sheath, a venogram should be taken. If there is spasm, IV and/or sublingual nitroglycerin works well to relieve it. Waiting for 2 minutes to let the drug work is beneficial, as opposed to injecting the nitroglycerin IV and then immediately advancing the wire or catheter. It may take time for spasm to resolve, but it almost always does if given a chance.

Study limitations. There are a few limitations to our study. First, this was a retrospective, observational study, with the inherent limitations of this study design. We cannot state with certainty that the high success rates were due to UGVAA, as we did not prospectively randomize patients to ultrasound-guided vs standard-access techniques. Second, the procedures were performed by two radial-first operators with extensive experience using ultrasound guidance for radial and ulnar arterial access. There is a learning curve for ultrasound-guided vascular access, and the results of this study may not be generalizable to operators/centers with less ultrasound-guided vascular access experience. Also, we did not have a sufficient number of patients with RHC performed via a femoral venous approach for comparison. It was therefore not possible to draw any definitive conclusions on the procedure time, fluoroscopy time, complication rate, early ambulation, or patient comfort comparing arm vs femoral access.

Conclusion

UGVAA is a highly efficacious and safe method for RHC in this retrospective study. Venous access and sheath insertion were successful in 253 consecutive patients (100%), with successful RHC in 248 of 253 patients (98.0%). UGVAA may allow avoidance of femoral or jugular venous access in almost all patients when TRA is used and RHC is needed, which may improve the safety and comfort of cardiac catheterization. Larger prospective trials will be needed to assess the true safety and efficacy of UGVAA for RHC.

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From the Memorial Cardiac and Vascular Institute, Memorial Regional Hospital, Memorial Healthcare System, Hollywood, Florida.

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

Manuscript submitted January 8, 2019, accepted January 21, 2019.

Address for correspondence: Jonathan S. Roberts, MD, Memorial Regional Hospital, 1150 N. 35th Avenue, Suite 605, Hollywood, FL 33021. Email: jonathanroberts@mhs.net