Arterial and Venous Access in the Cardiac Catheterization Lab: Arterial and Venous Access in the Cardiac Catheterization Lab

Arterial and

Venous Access

IN THE CARDIAC

CATHETERIZATION LAB

Arterial and

Venous Access

IN THE CARDIAC

CATHETERIZATION LAB

Edited by Mazen Abu-Fadel

Associate Professor of Medicine

Director, Interventional Cardiology and Cardiac Cath Lab

Director, Interventional Cardiology Fellowship Program

Associate Director, Internal Medicine Residency Program

Director, Interventional Cardiology Research Group

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Rutgers University Press Medicine

New Brunswick, New Jersey, and London

Library of Congress Cataloging-in-Publication Data

Name: Abu-Fadel, Mazen, 1973–, editor.

Title: Arterial and venous access in the cardiac catheterization lab / edited by Mazen Abu-Fadel.

Description: New Brunswick, New Jersey : Rutgers University Press, [2016] | Includes bibliographical references and index.

Identifiers: LCCN 2015042990 | ISBN 9780813572161 (hardcover : alk. paper) | ISBN 9780813572178 (e-book (epub)) | ISBN 9780813572185 (e-book (web pdf))

Subjects: | MESH: Cardiac Catheterization—methods. | Arteries—surgery. | Endovascular Procedures—methods. | Laboratories, Hospital. | Ultrasonography, Interventional.

Classification: LCC RC683.5.C25 | NLM WG 141.5.C2 | DDC 616.1/20754—dc23

LC record available at http://lccn.loc.gov/2015042990

A British Cataloging-in-Publication record for this book is available from the British Library.

This publication was supported in part by the Eleanor J. and Jason F. Dreibelbis Fund.

This collection copyright © 2016 by Rutgers, The State University

Individual chapters copyright © 2016 in the names of their authors

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I would like to dedicate this book to all my colleagues and contributing authors, for their help and support in getting this manuscript ready, and to all my mentors, who pushed me hard during my training and post-training years to make me the physician I am today. I would also like to dedicate this book to all my trainees—past, present, and future—for keeping me interested and engaged in teaching and training future cardiologists. Last but not least, I would like to dedicate this work to my parents, my wife, Cynthia, and my three kids, Romy, Noah, and Luka, for their continued unconditional love, sacrifice, and support in everything I do.

Contents

Preface and Acknowledgments

Contributing Authors

1 Common Femoral Artery Access

Mazen Abu-Fadel

2 Complications of Common Femoral Artery Access

Fahmi Farah

Mazen Abu-Fadel

3 Common Femoral Artery Access: Hemostasis and Closure

Mazen Abu-Fadel

4 Radial Artery Access

Beau M. Hawkins

5 Brachial Artery Access

Faisal Latif

6 Popliteal Artery Access

Aneesh Pakala

Mazen Abu-Fadel

7 Pedal Artery Access (Dorsalis Pedis and Anterior Tibial)

Jose E. Exaire

8 Ultrasound-Guided Arterial and Venous Access

Arnold H. Seto

Ajay Patel

9 Vascular Access in Pediatrics

Anas Salkini

Index

Preface and Acknowledgments

Invasive cardiac and endovascular procedures are increasing in number and complexity on a daily basis. Most of these procedures are done in the cardiac or endovascular suits. The initial approach to all these procedures require vascular access into the arterial or venous circulation. While access is just a means to an end, it remains one of the most challenging and life-threatening procedures we perform. Newer equipment and techniques require larger than usual sheaths inserted into the vascular beds, and optimal access and regress techniques are crucial for the success of any of these procedures. In addition, due to the complex interventions we perform, many newer access sites that were not traditionally used are being accessed, such as the popliteal and pedal arteries.

In this book, the authors describe how to best access the arterial and venous beds in cardiac catheterization labs and endovascular suits. We touch upon the use of specific equipment to help facilitate the process and decrease complications. Multiple figures are available to help understand the anatomy and facilitate a step-by-step approach to vascular access. We also discuss the best use of vascular closure devices and help teach when and how best to use them.

This book is intended for every health care professional who will be seeing and working with patients in the procedural area. Understanding how to and where to obtain vascular access is the first and most important step in taking good care of our patients and keeping them out of harm’s way.

I would like to acknowledge Ms. Candice Edwards for her help in editing and formatting this book and Dr. Alain Waked for contributing an image to Chapter 4, Radial Artery Access.

Contributing Authors

Mazen Abu-Fadel, MD, FACC, FSCAI

Associate Professor of Medicine

Director, Interventional Cardiology and Cardiac Cath Lab

Director, Interventional Cardiology Fellowship Program

Associate Director, Internal Medicine Residency Program

Director, Interventional Cardiology Research Group

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Jose E. Exaire, MD

Associate Professor of Medicine

Director, Coronary Care Unit

Veterans Affairs Hospital

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Fahmi Farah, MD

Cardiology Fellow

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Beau M. Hawkins, MD

Assistant Professor of Medicine

Cardiovascular Section

Director, Heart, Lung and Vascular Clinic

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Faisal Latif MD, FACC, FSCAI

Associate Professor of Medicine

Director, Cardiac Cath Lab

Veterans Affairs Hospital

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Aneesh Pakala, MD

Assistant Professor of Medicine

Cardiovascular Section

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Ajay Patel, MD

Cardiology Fellow

University of California Irvine Medical Center

Orange, California

Anas Salkini, MD

Assistant Professor of Pediatrics

Department of Pediatric Cardiology

University of Oklahoma Health Sciences Center

Oklahoma City, Oklahoma

Arnold H. Seto, MD, MPA

Section Chief, Cardiology

Long Beach Veterans Affairs Medical Center

Long Beach, CA

Assistant Clinical Professor

Director of Interventional Cardiology Research

University of California Irvine Medical Center

Orange, California

Arterial and

Venous Access

IN THE CARDIAC

CATHETERIZATION LAB

CHAPTER 1

Common Femoral Artery Access

MAZEN ABU-FADEL

Despite a steady increase in the number of cardiac and peripheral procedures performed from the radial approach, femoral access remains the most widely used technique in the United States. Mastery of femoral access is critical for any interventionalist as it remains necessary for procedures requiring larger sheaths and because transradial approaches are not feasible for many peripheral and structural interventions. In addition, a proper femoral access technique is crucial to decrease bleeding rates and vascular complications as well as allow the use of vascular closure devices. Multiple techniques have been described to facilitate proper access into the common femoral artery (CFA), including using anatomic landmarks, fluoroscopy, Doppler sound waves, and ultrasonography.

ANATOMY

The CFA is the continuation of the external iliac artery after it traverses the inguinal ligament, which extends from the spine of the anterior superior iliac crest to the pubic tubercle. From there, the artery follows the medial side of the head and neck of the femur inferiorly and laterally before splitting into the superficial femoral artery and deep femoral artery (also known as the profunda). The CFA artery traverses medial to the anterior crural nerve and lateral to the femoral vein in the femoral or Scarpa’s triangle comprising what is commonly referred to as the groin area. The artery is covered anteriorly with the inferior extension of the fascia of the transverse abdominal and iliac muscle. The most superficial part of the CFA lies at the level where the artery traverses over the head of the femur.¹ This is the area where the strongest femoral pulse can be palpated and the artery accessed. The CFA is a relatively large artery, making it an ideal site for access. The diameter of the CFA is related to age, body size, and sex. In a study of healthy human subjects by Sandgren et al, the mean and median diameters for the CFA were found to be 9.8 mm and 9.7 mm, respectively, in male subjects and 8.2 mm and 8.2 mm, respectively, in female subjects.² However, other studies that included patients coming to the cath lab for various procedures showed the mean diameter of the CFA to be smaller in both males and females (6.9 ± 1.4 mm).³

The CFA bifurcation may occur at any level along the course of the vessel. One study analyzed 972 femoral angiograms for the level of the CFA bifurcation and noted that, in 64.8% of patients, the bifurcation occurred below the inferior border of the head of the femur. In addition, the bifurcation was at or below the midline of the head of the femur in the study population in 98.5% of patients.⁴ This becomes very important when cannulating the CFA in order to avoid puncturing at or below the bifurcation as this may cause an increase in vascular access site complication.

Another important anatomic landmark is the take-off and course of the inferior epigastric artery (IEA) and its relation to the arteriotomy site. The origin of the IEA arises from the external iliac, immediately above the inguinal ligament. It curves forward in the subperitoneal tissue; it then ascends obliquely along the medial margin of the abdominal inguinal ring and continues its course upward. Multiple variations exist, and the origin may take place from any part of the external iliac between the inguinal ligament and a point 6 cm above it; less frequently, it may arise below this ligament, from the CFA.⁵

CONSIDERATIONS IN FEMORAL ARTERIAL ACCESS

Prior to any procedure in the catheterization lab, a thorough history and physical, as well as a review of prior angiograms, are of utmost importance. While the femoral artery provides an excellent access site, there are many factors that may persuade operators to consider an alternative access sites. Some of these considerations include the following:⁶

Body habitus, especially morbidly obese patients.

Inability to lie flat and cooperate post-procedure.

Signs or symptoms of peripheral arterial disease in the lower extremities.

Prior vascular surgery or intervention, especially femoral-femoral bypass.

Prior surgery and/or radiation to the groin area.

Prior femoral vascular access site complications or femoral bruit on exam.

Anticoagulation, bleeding, and transfusion issues.

Vessel tortuosity and/or aneurysmal dilatations.

Groin infection or skin breakdown.

Recent access and use of some vascular closure devices (Angioseal).

Nonpalpable femoral pulses.

Patient preference.

Sedation and Local Anesthesia

Like any other invasive procedure, it is very important to administer the correct amount of conscious sedation and local anesthetic. Many physicians give the sedation just before they attempt vascular access without allowing time for the sedation to take effect. Vascular access, especially in the groin area, is usually uncomfortable for the patient and, in some instances, may be painful; patients will then remember and fixate on the discomfort they experienced. We recommend that sedation be given 3 to 5 minutes prior to attempting access to allow enough time for the patient to be sedated and give more medications if needed.

Once the patient is well sedated, and after identifying the point of needle entry by one of the methods subsequently described, local anesthetic is ready to be given. In the author’s opinion, it is important to locate the point of skin entry before giving anesthetic to decrease the total number of skin punctures with the anesthesia needle and to decrease the overall volume of lidocaine given, especially in patients with feeble or deep pulse, because the lidocaine may obscure the arterial pulsations. Once this is done, a 25-gauge needle is used to administer local anesthesia. Many ways have been described to inject the medication, but, in general, while the pulse is located between your index and middle finger, local anesthesia is given below the skin to form a wheel or bleb followed by advancing the needle deeper into the tissue toward the CFA. It is important to draw back on the plunger before injecting in the subcutaneous space to avoid injecting into a vascular structure. We then inject lidocaine at a constant rate while drawing the needle backward toward the skin, thus anesthetizing the track that the access needle is going to take all the way to the CFA. We believe that injecting local anesthesia in multiple planes at multiple angles does not provide any benefit and may increase the likelihood of skin ecchymosis.

If using ultrasound-guided access, first start by locating the ideal access site, then use the local anesthesia needle to deliver the medication in the track that the access needle is going to take all the way down to the CFA. With ultrasound, the operator can actually observe live the lidocaine being injected and may be able to give it just on top of the CFA without entering the artery and then all the way back to the skin.

Ideal Puncture Site of the CFA

Ideally, the anterior wall of the CFA should be punctured 1 to 2 cm below the inguinal ligament but proximal to its bifurcation into the superficial femoral and profunda arteries. At this site, the CFA can be easily compressed against the head of the femur to achieve manual hemostasis. Puncture below the CFA bifurcation—even if the bifurcation is anterior to the femoral head—will increase the risk of vascular complications (such as hematoma and pseudoaneurysm) and may prevent the use of larger sheaths if needed. Because it is well established that the origin of the IEA in most cases is immediately above the inguinal ligament, the author believes femoral access should occur below the origin of the IEA. The ideal access site should be below the level of the most inferior horizontal reflection of the IEA. The IEA descends to, but does not cross, distal to the inguinal ligament. Entry above the most inferior point of the course of the IEA can be used to define an unmistakably high puncture. Thus, access should be below that point but above the CFA bifurcation. (See Figure 1.1.)

The puncture above the level of the most inferior horizontal reflection of the IEA may predispose patient to an increased risk of potentially life threatening retroperitoneal bleed due to the lack of an underlying bony structure to help with hemostasis during compression.⁷ In a review of 989 femoral angiograms from the FAUST study, the most inferior reflection of the IEA occurred 92.2% of the time below the superior border of the head of the femur.⁸ In addition, the CFA bifurcated below the most inferior border of the head of the femur in almost 65% of patients.⁴ In this case, the length of the CFA that extends from the inferior border of the femoral head to its bifurcation is considered a suboptimal access site because there is no bony structure to help compress the CFA after the sheath is pulled, and thus, the risk of hematoma and pseudoaneurysms increases significantly.

FIGURE 1.1   Femoral angiogram showing ideal access site into the common femoral artery (CFA). Arteriotomy should be below the most inferior border of the inferior epigastric artery (IEA) and above the CFA bifurcation but still anterior to the head of the femur. Zone 1 and above represent a high access site above the most inferior boarder of the IEA, even though the access site may still be anterior to the femoral head. An arteriotomy in zone 1—and especially above zone 1—will increase the risk of retroperitoneal bleeding significantly. Zone 2 represents a low access site. Even though the arteriotomy may still be in the CFA (above the bifurcation), this location does not provide the femoral head as a support when compressing the artery to achieve hemostasis, thus increasing the risk of a hematoma or pseudoaneurysm.

Taking all this into consideration, the ideal access site into the CFA should be below the most inferior point of the IEA and above the CFA bifurcation anterior to the femoral head. As such, in the majority of patients, the ideal access site falls midway between the superior and the inferior borders of the head of the femur.⁹ This may be accomplished more easily in patients with previous femoral angiography where the relationship among the head of the femur, the CFA bifurcation, and the most inferior border of the IEA can be seen. In patients with no previous femoral angiography, multiple methods have been described to assist the operator achieve an ideal access site.

FLUOROSCOPY VS. TRADITIONAL ANATOMIC LANDMARKS GUIDANCE FOR CFA ACCESS

Anatomic landmarks have been utilized to identify the CFA, including the inguinal skin crease, maximal femoral pulse, and bony landmarks.¹⁰ Even though many operators use it, the inguinal crease—which is wrongly considered a marker of the inguinal ligament—is the least reliable among these landmarks. In patients with lean body habitus, the skin crease may be on top of the inguinal ligament. However, in the majority of patients, especially the obese, it may be as low as 11 cm (mean 6.5 cm) from the ligament and below the CFA bifurcation in as many as 75.6% of patients.¹¹ Using