Sridevi R. Pitta, MD, MBA, FSCAI; and Rahul Sharma, MD, FSCAI
Access to the central venous system from a vein in the forearm was first reported in 1929 by Dr. Werner Forssman, and its utilization has been revitalized with the increasing use of transradial cardiac catheterization. At least 10–15 percent of cardiac catheterizations require right heart catheterization (RHC).1 Potential applications of arm venous access include not only RHC, but also temporary transvenous pacemakers, endomyocardial biopsy, and placement of catheters in the pulmonary arteries for pharmacomechanical thrombolysis.2, 3, 4 In this Tip of the Month, we provide a summary of relevant anatomy, tips, and adjunctive techniques for the safe and effective use of arm veins to access the right heart.
Venous Anatomy:
Anatomically, veins run adjacent to arteries, with some variability. Medially located forearm veins are superior for access in comparison to laterally situated veins, due to their straighter course for wire and catheter navigation. Medial forearm veins, such as the median cubital over the antecubital fossa, drain into the basilic vein, which continues as the axillary vein and then the subclavian vein.1, 5 Laterally located veins generally drain into the cephalic vein, which forms a “T” junction with the axillary vein. This sharp angle can potentially make wire-catheter manipulation challenging. However, successful RHC can also be safely performed via the lateral arm veins using soft-tipped steerable wires and road map fluoroscopy. Image 1 illustrates the venous system of the forearm.
Antecubital Venous Access and Equipment Navigation:
1. Venous access in holding room
The right arm is used preferentially due to easier access for the operator and to overcome the possibility of a persistent left-sided superior vena cava (SVC). Placement of a 20G angiocath, preferably in a medial forearm vein, in the holding room helps to makes the procedure more efficient. This can be facilitated using ultrasound or by inflating a manual blood pressure (BP) cuff at supravenous pressure. In the cath lab, after sterile preparation, a 0.018-inch wire can be placed through the angiocath rubber stopper using a micropuncture needle or hub, and the angiocath can be exchanged for a 5-8 French sheath over a short 0.035-inch wire inserted via a micropuncture sheath. A 5F or 7-8F sheath can be used for a 5F or 7.5F Swan-Ganz catheter, respectively. Instead of inserting the 8F sheath all the way into the vein, the sheath can be partially inserted and pulled out of the vein once the Swan-Ganz catheter has entered the vein. Due to low venous pressure, there is no bleeding noted. The side arm of the sheath should be allowed to bleed back rather than withdrawing blood since that causes the vein to collapse. A hydrophilic radial sheath can also be used. The sheath is then secured in place using a Tegaderm.6
2. Venous Access in the Cath Lab
a. Ultrasound-Guided Access: Ultrasound guidance can help visualize and facilitate purposeful venous access in medially situated and larger caliber arm veins with adjunctive use of a tourniquet or BP cuff placed on the upper arm. Given the limitations of available pulmonary artery catheter lengths (<110 cm), the preference is to obtain access. Distal veins at the level of the wrist may be used if longer-length catheters are available.
b. Contrast-Guided Access: Forearm and antecubital veins can also be accessed using contrast guidance by injecting contrast through a pre-existing radial arterial sheath and filming into the levo phase to identify veins. The contrast in the vein can be “trapped” with a BP cuff inflated at supravenous pressure in the arm and the contrast-filled vein then accessed under fluoroscopic guidance.7
3. Equipment Selection and Navigation
After placement of a 5-8 French sheath in the arm vein, a venodilator, such as nitroglycerin, can be administered if needed. Calcium channel blockers are generally ineffective venodilators. Currently available soft-tipped flexible pulmonary artery catheters are less likely to cause venous spasms compared to the prior generation’s stiffer catheters. While the advancement of a 5F or 6F catheter is easier from the arm vein, these catheters may require a 0.025-inch wire to advance them into the pulmonary artery, as they are floppy. Thermodilution cardiac output measurement is not possible with a 5F Swan-Ganz catheter. Infusing saline by turning on a constant saline flush or injecting saline during initial catheter advancement helps by distending the vein. Fluoroscopy is not required until the catheter reaches the subclavian vein unless there is resistance.
4. Troubleshooting
If resistance is encountered during advancement, a 0.025-inch wire is advanced under fluoroscopy to the expected location of the subclavian and innominate vein. If the wire cannot be maneuvered to the subclavian or SVC, a venogram can be performed to rule out stenosis or occlusion after ensuring blood can be aspirated. Care should be taken not to inflate the catheter balloon until the catheter is within the subclavian to minimize the risk of venous perforation in a smaller vein. At the end of RHC, the catheter should be withdrawn from the arm after the balloon is deflated.
5. Hemostasis
Since the venous system has low pressure, the sheath can be removed at the end of the procedure with manual pressure, even in anticoagulated patients.
Conclusion:
Forearm vein access for right heart procedures can be performed safely and without complications akin to jugular or femoral venous access. Use of forearm and arm veins for RHC is complementary to transradial cardiac catheterization.8 Arm vein access can be formed efficiently prior to cath lab arrival and is especially useful in patients at high risk of venous access complications or issues (morbid obesity, mechanical ventilation, chronic obstructive pulmonary disease [COPD], claustrophobia, neck or groin scar, anticoagulation, known occluded jugular or femoral vein, chronic femoral arteriovenous fistula [AVF], and/or inferior vena cava [IVC] filter). Arm venous access should be used with caution in patients with prior chest radiation; indwelling catheters, such as for chemotherapy or dialysis; or ipsilateral/multiple pacemaker leads given the possibility of stenosis or occlusions. Long-term catheter placement may be associated with thrombosis, and anticoagulation should be considered.
References:
- Gilchrist IC. Right Heart Catheterization Via the Radial Route. Transradial access to the central venous system. Card Interv Today. 2010 Mar/Apr.
- Harwani N, Chukwu E, Alvarez M, Thohan V. Comparison of Brachial Vein Versus Internal Jugular Vein Approach for Access to the Right Side of the Heart With or Without Myocardial Biopsy. Am J Cardiol. 2015 Sep 1;116(5):740-3.
- Kusick J, Salamat J, Sanghvi K. Thrombolysis for pulmonary embolism using the superficial veins of the upper extremity. Catheter Cardiovasc Interv. 2017 Nov 15;90(6):996-999.
- Gilchrist IC. Right heart catheterization and other venous cardiovascular procedures from the arm. Interv. Cardiol. 2014 6(3), 309–318 ISSN 1755.
- Kern M. Forearm Vein Access for Radial Procedures: An Easy Method for Right and Left Heart Catheterization. Cath Lab Digest. 2011 Dec;19(12).
- Gilchrist IC. Techniques for Right Heart Catheterization in Conjunction With Radial Artery Left Heart Procedures. Peripheral access for successful right heart catheterization. Card Interv Today. 2014 May/Jun.
- Gilchrist IC. Levophase venogram: a solution for localizing peripheral venous access for right heart catheterization. Catheter Cardiovasc Interv. 2011 Nov 1;78(5):813-4.
- Gilchrist IC, Moyer, CD, Gascho JA.Transradial right and left heart catheterizations: a comparison to traditional femoral approach. Catheter Cardiovasc Interv. 2006 Apr;67(4):585-8.
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