This document discusses accessing the right heart and central venous system through the radial vein as a safer alternative to traditional femoral access. It provides guidance on identifying and accessing forearm veins using ultrasound or non-invasive vein localization devices. Tips are given for navigating venous anatomy and potential issues like low pressure or valves. The presentation emphasizes that with practice of both arterial and venous radial techniques, operators can improve safety and efficiency in the cardiac catheterization lab.

1. Right Heart Access by Radial
Ian C Gilchrist, MD, FACC, FSCAI
Professor of Medicine
Penn State’s Hershey Medical Center
Heart & Vascular Institute
Hershey, PA
Dorsal Radial Artery/Vein Access
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2. Disclosure Statement
Nothing involve in this presentation
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3. Arm Veins: Original Cardiac Access
Forssmann Klinische Wochenschrift 1929;8(45)2085-7.
Werner Forssmann
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4. Why Bother?
Safety & Convenience
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5. Case & Point
Icg/HMC cath lab
Access:
Radial artery
RIJ vein
Complication:
Pneumothorax
There is room for a safer
way to the right heart &
central venous system
This is no longer paid for in the United States
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6. An Enlightened Radial Operator
Brachial
Artery
Cutdown
Percutaneous
Femoral
Access
Transradial
Arterial
Access
Complete Forearm
Vascular
Access
Transradial
Cutdown
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7. Venous System Access
Before entering the cath lab
Nurse Heparin LockIV Catheter (20 g)
+ +
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
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8. Heparin Locks, Needles & Wires
Heparin lock on angiocath
Micropuncture needle
Micropuncture needle impaled in Heparin Lock
(remove both in block off field for sterility)
Wire holder
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9. Try in cath lab ± tourniquet
Inspect arm carefully
Don’t forget the other arm
Floor nurses unable to get access?
°C
Christen, et al. J Cardiovasc Pharmacol. 2004;44:659–664
Trouble Shooting
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10. No Touch Technology
Use non-invasive (no touch) technology
to localize vein and its path for superficial
vessels
Uses absorption of hemoglobin to
localize vessels
AccuVein Device
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11. V
Photo’s by Mauricio Cohn, MD Miami, Fl
Ultrasound for
deep vessels
Photo’s by Mauricio Cohn, MD Miami, Fl
Photo’s by Mauricio Cohn, MD Miami, Fl
Pressure
Everyone has veins!
Trouble Shooting- No Veins
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12. Sheath in But No Return Flow
Source: Hadaway LC. Nursing 2005;35(8):54-61
Vein: low pressure system that
collapses easily
As long as everything flushes & perforation is not
otherwise a concern, it is probably in the lumen
Trouble Shooting
Veins also have valves
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13. 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.
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14. 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
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15. Navigating a Sticky RA
10cc H2O
Credit: Samir B. Pancholy, MD
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16. Jetting Across the RA
Initial approach to tricuspid valve 10cc of flush via lumen
Video Credit: Samir B. Pancholy, MD
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17. http://assets.families.com/Encyclopedias/gea2_02_img0132.jpg
Arm Trauma
EPS Devices Breast Cancer
Lymphodemia
Contraindications/Cautions
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18. Summary
Finish with hemostasis just like removing an IV
Can replace sheath with large angiocath if needed
It is simple & extends the potential arm access
Learning both arterial and
venous techniques will make
you a better cardiologist
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19. Thank you
icg1@psu.edu icg 2017