Upper Extremity Venous Access and Procedure

1. Upper Extremity Venous Access
&
Procedure
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Heart & Vascular Institute
Penn State/Hershey Medical Center
Hershey, PA

2. CME Disclosure Statement
Nothing

3. Arm Veins: Original Cardiac Access
Werner Forssmann
Forssmann Klinische Wochenschrift 1929;8(45)2085-7.

4. Provide a Safe Approach to the
Central Venous System
Access:
Radial artery
RIJ vein There is room for a safer
way to the right heart &
central venous system
Complication:
Pneumothorax
Icg/HMC cath lab

5. A New Playground
beyond the arterial tree
Right Heart Catheterization
Transvenous Pacemakers
Right Ventricular Biopsy
Venous Filters
Potentially any technology with the right length

6. Venous System: Typical Patterns
Radial (lateral)
veins lead equally to
either Cephalic or
Basilic veins
Ulnar (medial) veins
usually continue as
Basilic vein
Chun et al. Radiology. 2003;226:918-920.

7. Upper Venous Junction
Cephalic vein joins the Axillary
vein at a T-Junction.
– Defines start of the
subclavian & central venous
system
– Location most likely to cause
technical issues

8. Venous System Access
Before entering the cath lab
+ +
Nurse IV Catheter (20 g) Heparin Lock
Nurse places heparin lock in forearm for use in
the catheterization lab for venous sheath access.
• saves time
• improves cath lab efficiency
• fosters team building

9. Nurses unable to get access?
Try in cath lab ± tourniquet
°C
Inspect arm carefully
Ultrasound?
Levophase angiogram?
Don’t forget the other arm

10. Heparin Locks, Needles & Wires
Micropuncture needle impaled in Heparin Lock
(remove both in block off field for sterility)
Wire holder
Micropuncture needle
Heparin lock on angiocath

11. 5F Right Heart Catheters
(4 F also available)
Edwards Lifescience TS105F5 Arrow Balloon Wedge AI-07124
105 cm 110 cm
Examples from Penn State Hershey Medical Center
Really need 125-cm , but industry not interested

12. Left/Right Heart Procedures
Femoral vs Radial
250 Procedural Time Arterial Time
75±5.4 70±5.0 45±6.3 35±4.2
200
Time 150
(minutes) Less radiation time
p<.001
100
50
0
Femoral Radial Femoral Radial
(n=175) (n=105) (n=175) (n=105)
Gilchrist IC. Cathet Cardiovasc Intervent 2006;67:585-588.

13. Contraindications/Cautions
Obstruction to drainage
 Radial breast surgery
 Trauma
 SVC disease
Prior brachial cutdown
EP devices
Ref (July 2006): http://assets.families. com/Encyclopedias/gea2_02_img0132.jpg
No visible veins

14. Summary
Finish with hemostasis just like removing an IV
Its simple & extends the potential of transradial
Learning both arterial and
venous techniques will make
you a better cardiologist

15. Thank You you
Thank