Right heart catheterization by radial, IC Gilchrist

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
Disclosures: None
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2. Arm Veins: Original Cardiac Access
Forssmann Klinische Wochenschrift 1929;8(45)2085-7.
Werner Forssmann
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3. Why Bother?
Safety & Convenience
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4. 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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5. An Enlightened Radial Operator
Brachial
Artery
Cutdown
Percutaneous
Femoral
Access
Transradial
Arterial
Access
Complete Forearm
Vascular
Access
Transradial
Cutdown
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6. 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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7. 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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8. 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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9. 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
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AccuVein Device

10. 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
Trouble Shooting- No Veins
Everyone has veins!
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11. 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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12. 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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13. 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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14. Navigating a Sticky RA
10cc H2O
Credit: Samir B. Pancholy, MD
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15. Jetting Across the RA
Initial approach to tricuspid valve 10cc of flush via lumen
Video Credit: Samir B. Pancholy, MD
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16. Contraindications/Cautions
http://assets.families.com/Encyclopedias/gea2_02_img0132.jpg
Arm Trauma
EPS Devices Breast Cancer
Lymphodemia
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17. 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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18. Thank you
icg1@psu.edu icg 2015