Ultrasound based puncture - Mauricio G Cohen

1. Ultrasound based puncture
Mauricio G. Cohen, MD, FACC, FSCAI
Director, Cardiac Catheterization Lab
Associate Professor of Medicine
@DrMauricioCohen

2. Disclosure Statement of Financial Interest
I have no financial conflicts of interest related to this presentation

3. Integrating Ultrasound
• Radial arterial access
 Systematic use
 Bail out
• Anticipating difficulties
 Site selection (left vs right)
 Artery selection (radial vs ulnar)
• Venous access for RHC

4. Abdelaal E et al. JACC Interv 2013;6:1129-1137
1,654 patients, crossover to TFA needed in 30 (1.8%)

5. Issues with Radial Puncture
• Radial artery diameter is 2.8 – 3.1 mm
– Saito S et al. CCI 1999
• Fingertip palpation 2-point
discrimination limit approaches the 2-
to 4-mm
– DeJong's Neurologic Examination, 6th Edition
• The radial artery may be diminutive,
collapsible, calcified, mobile, or
associated with anatomic anomalies

6. Reasons why TR puncture may be
Difficult Someties
Radial Artery
ID 2.6 mm
Courtesy Arnold Seto

7. Runaway Vessel
Courtesy Arnold Seto

8. Access Technique

9. Ultrasound Imaging

11. Radial Artery Puncture

12. Radial Artery Puncture

13. Radial Access
US Tips:
• Keep probe near/over
needle
• Mark the center of the probe
and line up artery with
centerline
• Short jabs on the skin or
tissue to identify needle tip
• Compress the skin to close
the veins

14. When ultrasound should be used
• In every single case, if possible
• Weak radial pulse
 Hypotension, shock
• Women
• PVD, CABG
• Chronic renal insufficiency
• After 3-4 palpation attempts
 Attempts continue while machine is
prepped

15. Shiloh AL et al. CHEST 2011; 139(3):524–529

16. Shiloh AL et al. CHEST 2011; 139(3):524–529
71% increase in the likelihood of first
attempt success

17. In this multicenter randomized trial of transradial
catheterization, US, compared with palpation, guidance
increased the success and efficiency of sheath insertion.
Familiarity with the technique will likely benefit transradial
operators whether the technique is used routinely or as a
rescue technique after initial palpation attempts fail.
JACC Intervent 2015;8:283–91

18. RAUST Study
Design
DESIGN: Prospective, multicenter
randomized study
OBJECTIVE: To evaluate the
accuracy of ultrasound vs. palpation
guidance for radial access.
SITE LEAD INVESTIGATORS:
Arnold Seto, Jonathan Roberts,
Mazen Abu-Fadel, Zoran Lasic
SITES:
Jamaica / Lenox Hill Hospital (357)
Long Beach VA / UC-Irvine (193)
Miami Baptist (98)
Oklahoma VA (50)
698 patients with nonemergent radial
angiography enrolled and randomized
between December 2011 and March 2013
114 Censored*
Palpation
(n = 351)
Procedural / Clinical outcomes
Ultrasound
(n=347)
Palpation #attempts
(n = 237)
Ultrasound #attempts
(n=236)
111 Censored*
* First 225 patients from Jamaica Hospital censored due to first-pass success (96.5% P and 97.3% US) counted by # punctures

19. 3.05
1.65
0
1
2
3
4
Attempts
Palpation
Number of Attempts
p<0.0001
Ultrasound
N = 237 N = 236

20. 43.9%
64.8%
0%
20%
40%
60%
80%
100%
Percentage
First Pass Success Rate
p<0.0001
UltrasoundPalpation
N = 237 N = 236

21. 0
30
60
90
120
150
Seconds Time to access
UltrasoundPalpation
108
88
N = 351 N = 347
P=0.006

22. 0
10
20
Percent Difficult Access
≥ 5 attempts ≥ 5 minutes
UltrasoundPalpation UltrasoundPalpation
18.6%
6.8%
2.4%
3.7%
351 347237 236
P=0.07P<0.001

23. Clinical Outcomes
Characteristic
Palpation
N=351
Ultrasound
N=347
P-value
Spasm 12 (3%) 15 (4.3%) 0.56
Pain score (0-10) 0.71 0.69 0.85
Bleeding 4 (1.1%) 5 (1.4%) 0.75
Crossover to ultrasound rescue
attempts after >5 minutes
10 (8
successful)
N.A. N.A.
Crossover to other site after
successful sheath insertion
5 2 0.45
Crossover to other site before
sheath insertion / failed access
7 3 0.34
Failure of sheath insertion with
original technique
15 3 0.007
Any crossover 20 5 0.004
Seta A et al. JACC Intervent 2015;8:283–91

24. Chugh SK, et al. CCI 2013;82:64-73
1.5 2.4
97.6
12.512.1
7.8
90.6
24.1
0
25
50
75
100
Severe spasm Crossover Proc success Fluoro time
%
U/S No U/S
All P-values < 0.05
N=2344 patients at a single center

25. Pre-procedure ultrasound – Radial
Loop
Perlowski A, et. al. CIT 2011

26. Bauman F & Roberts JS. J Interv Cardiol. 2015;28:396-404
Integration of U/S in the CCL
workflow to maximize procedural
success

27. Anticubital Vein Access Technique
• Apply tourniquet
• Use real-time ultrasound

32. Right Heart Catheterization
via Antecubital Vein

33. Ultrasound can easily be integrated in
the procedural workflow
• Planning to decide right versus left or
radial versus ulnar
• Puncture guidance
• Right heart catheterization
 When peripheral vein access is difficult
 When wire does not advance through
peripheral IV