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Gilchrist IC - AIMRADIAL 2014 Technical - Right heart


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Right heart catheterization by radial

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Gilchrist IC - AIMRADIAL 2014 Technical - Right heart

  1. 1. icg 2014 Right Heart Catheterization TransRadial Ian C Gilchrist, MD, FACC, FSCAI Professor of Medicine Penn State’s Hershey Medical Center Heart & Vascular Institute Hershey, PA
  2. 2. icg 2014 CME Disclosure Statement Nothing Relevant to this Presentation
  3. 3. icg 2014 Evolution of Technique Brachial Artery Cutdown Percutaneous Femoral Access Transradial Arterial Access Complete Forearm Vascular Access Transradial Cutdown
  4. 4. icg 2014 Arm Veins: Original Cardiac Access Forssmann Klinische Wochenschrift 1929;8(45)2085-7. Werner Forssmann
  5. 5. icg 2014 Bilateral Cardiac Catheterization 1950 Circulation 1950;1;357-359 Henry Zimmerman Ulnar artery & forearm vein
  6. 6. icg 2014 Why Bother? Safety and Convenience
  7. 7. icg 2014 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
  8. 8. icg 2014 A New Playground beyond the arterial tree Right Heart Catheterization Transvenous Pacemakers Right Ventricular Biopsy Venous Filters Potentially any technology with the right length Compliments the eloquence of the transradial procedure
  9. 9. icg 2014 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.
  10. 10. icg 2014 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
  11. 11. icg 2014 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
  12. 12. icg 2014 Heparin Locks, Needles & Wires Micropuncture needle impaled in Heparin Lock (remove both in block off field for sterility) Micropuncture needle Heparin lock on angiocath Wire holder
  13. 13. icg 2014 Right Heart Catheters (4-8 F available) 5F-Edwards Lifescience TS105F5 4F-Arrow Balloon Wedge AI-07122 105 cm 110 cm Examples from Penn State Hershey Medical Center Really need 125-cm , but industry not interested
  14. 14. icg 2014 Passing Catheter to Central System Do not push! X-ray to confirm approach to T Junction Do not inflate balloon in cephalic For problems: Venogram, deep breath, wires Similar to other central venous approaches once in the subclavian system
  15. 15. icg 2014 Finishing the Procedure Remove catheter with balloon Remove sheath Hemostasis with local compression (elastic) Right heart catheter may be left in place, but historical experience suggests a hazard of thrombosis
  16. 16. icg 2014 Left/Right Heart Procedures Femoral vs Radial Procedural Time Arterial Time Gilchrist IC. Cathet Cardiovasc Intervent 2006;67:585-588. 250 200 150 100 50 0 Time (minutes) 75±5.4 70±5.0 Femoral (n=175) Radial (n=105) 45±6.3 35±4.2 Femoral (n=175) Radial (n=105) Less radiation time p<.001
  17. 17. icg 2014 European Experience Anticoagulated Arms vs Routine Femoral Procedures 100 80 60 40 20 0 Arm access outside of cath lab Might improve this difference? Arm Femoral Ted et al, J Interven Cardiol 2006;19:258-263 (n=28) (n=31) (P<.05) NS NS NS
  18. 18. icg 2014 What else from the Arm? Endomyocardial Biopsy Temporary Pacing Caval Filters Veins are large Industry needs to give us the length Moyer CD, Gilchrist IC. Cathet Cardiovas Intervent 2005;64:134-137.
  19. 19. icg 2014 Problems
  20. 20. icg 2014 Nurses unable to get access? Try in cath lab ± tourniquet Inspect arm carefully Don’t forget the other arm °C Christen, et al. J Cardiovasc Pharmacol. 2004;44:659–664)
  21. 21. icg 2014 V Photo’s by Mauricio Cohn, MD Miami, Fl Ultrasound for No Access Ultrasound for deep vessels Photo’s by Mauricio Cohn, MD Miami, Fl Photo’s by Mauricio Cohn, MD Miami, Fl Pressure
  22. 22. icg 2014 Levophase Venogram Contrast injection in radial artery, delayed imaging of venous phase Source: S. Pancholy
  23. 23. icg 2014 Sheath in But No Return Flow Vein is a low pressure system that will collapse easily Source: Hadaway LC. Nursing 2005;35(8):54-61 As long as everything flushes and perforation is not otherwise a concern, it is probably in the lumen
  24. 24. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  25. 25. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  26. 26. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  27. 27. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  28. 28. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  29. 29. icg 2014 Catheter will not Advance Take a limited venogram!!!!
  30. 30. icg 2014 Contraindications/Cautions Obstruction to drainage – Radical breast surgery – Trauma – SVC disease Prior brachial cutdown EP devices No visible veins Ref (July 2006):
  31. 31. icg 2014 Summary Finish with hemostasis just like removing an IV It is simple & extends the potential of transradial Learning both arterial and venous techniques will make you a better cardiologist
  32. 32. icg 2014 Thank you