Procedures involving access to right side of the heart are typically performed from the internal jugular vein or, more commonly, the femoral vein. With the increasing adoption and use of the radial artery approach for left-sided cardiac catheterization, use of the brachial vein for right-sided cardiac procedures is gaining increased popularity as well due to its unique advantages. We describe a series of cases illustrating the safe and effective use of the brachial vein for several common procedures and appropriate techniques.
Key words: Brachial vein, right heart catheterization
Percutaneous procedures involving right heart catheterization (RHC) are typically performed via central venous access, mainly the common femoral vein (CFV) or the internal jugular vein (IJV) approach. This approach provides higher success rates but exposes patients to complications such as bleeding, deep vein thrombosis from immobility, major arterial injury, arteriovenous fistula, risk of pneumothorax, air embolism, and prolonged hospitalization. Patients sometimes have to forego procedures using a conventional approach if they cannot lie flat or are fully anticoagulated. Hoeper et al reported that the majority of complications in RHC procedures in pulmonary hypertension patients are related to the central venous access site.1
Venous access via the forearm for cardiac and vascular interventions, especially right heart catheterization, has been widely discussed but is still limited in the number of procedures being performed. Since Dr Frossman performed the first right heart catheterization in 1929 by a brachial vein cut-down,2 techniques and tools have been developed to improve the safety and success of the procedure. With the advent of the radial approach for left heart catheterization (LHC), the use of forearm veins for RHC complements and allows for complete cardiac catheterization through an arm approach.3-6
The forearm vein is safe and free of serious access site complications. It allows the procedure to potentially be performed in the recumbent position with postprocedure rapid ambulation in patients who cannot lie supine. Local bleeding complications are rare, so it can be performed in patients on full anticoagulation.7 The success rate of using forearm venous access is reported to be between 93% to 96% in the antecubital area.8,9
As a result of the low risk profile, the convenience of the forearm vein, and its potential advantages over other access sites, we have refined this approach at our institution beyond RHC to perform other procedures. These include temporary transvenous pacemaker placement, myocardial biopsy, intracardiac foreign body removal, inferior vena cava (IVC) filter placement, and rheolytic thrombectomy with the AngioJet catheter and EKOS ultrasound-assisted catheter-directed tissue plasminogen activator (tPA) administration for pulmonary embolism. This article describes the use of the forearm vein in procedures beyond right heart catheterization.
Basic Technique of Venous Access
Venous access via the forearm can occur either before or after arrival to the cardiac catheterization laboratory. The ideal location is above the elbow on the medial aspect of the arm. Our practice is to specify the access site in preprocedure orders. Instructions for nursing staff are to place the intravenous (IV) catheter in the right arm with the tip of the needle/catheter facing medially, towards the heart, above the elbow. A 20G or larger IV (an internal diameter 0.603 mm) is placed with manual palpation in the usual way as any other IV by experienced nursing staff in the preprocedure area, then flushed and capped. On the rare occasion when nursing staff is unable to secure an IV, the forearm area is draped in sterile fashion and access obtained with ultrasound guidance in the cardiac catheterization laboratory. The success rate is lower when the venous access site is close to the wrist. The basilic vein is considered an ideal site, as it allows easier navigation to the central venous system.
The venous entry site should be cleaned with antiseptic and anesthestized to avoid pain or discomfort at the skin entry site before exchanging for a vascular sheath. The IV is disconnected and the exchange wire (0.021 mm) that comes with the sheath kit is passed through the intravenous catheter into the arm vein. We use a hydrophilic Glidesheath (Terumo Medical Corp) between 5 and 8 Fr in size. After sheath insertion, procedure-specific catheters are advanced, and the procedure is initiated.
Typical Challenges and Techniques to
Initially when exchanging the IV to sheath, the wire should pass without resistance far enough to allow the exchange. When resistance is encountered, it is usually due to spasm or venous valves at the entry site. A limited angiogram (either from the IV catheter or partially inserted sheath) will lay out the anatomy and help to distinguish the problem. Small doses (100-200 mcg) of IV nitroglycerin can be used for venodilation and mitigate functional spasm in the venous system.
If the resistance is due to a venous valve or tortuosity of the vein, a coronary (0.014") workhorse wire or a peripheral workhorse wire (0.018") with gentle tip shape is useful to navigate difficult anatomy. A 5 Fr balloon-tipped swan catheter can be advanced over this wire into the right ventricle or pulmonary artery, and can then be exchanged for a procedure-specific catheter over a 0.025" J wire. Precautions should be taken not to inflate the balloon of the swan catheter while it is still in the arm. In selective cases where there are multiple venous valves in the arm, a 25 cm femoral sheath can be inserted over the 0.025" J wire to decrease the downstream difficulties. Alternatively, the procedure-specific catheter can be advanced over the initial workhorse wire itself, depending on operator’s preference, and based on anatomy and procedure specifics.
When the IV catheter is placed above the elbow but facing laterally, away from the heart, which is not uncommon, the direction of the IV and the wire course means the subsequent sheath will be into the cephalic vein. The procedure can still be performed without difficulties by following certain techniques. The most commonly encountered resistance point for the device catheter will be under the right clavicle region where the axillary vein (continuation of the basilic vein) and cephalic vein combine to form the subclavian vein. This is due to the presence of a venous valve when coming from the cephalic vein. This can very easily be navigated by using a coronary or peripheral workhorse wire as mentioned above.
Case 1: Right Heart Catheterization, Rheolytic Thrombectomy with an AngioJet Catheter and IVC Filter Insertion.
A 64-year-old man presented with severe hypoxia and hypotension requiring mechanical ventilation and multiple vasopressors. He was found to have central and multiple segmental pulmonary emboli. Tissue plasminogen activator (tPA) was administered, but later he became more unstable and so was referred to the cardiac catheterization laboratory for percutaneous thrombectomy. Since he was given tPA and there was a significant bleeding risk, access was obtained via the forearm vein. Through a preexisting 20 G peripheral IV, a 6 Fr Glidesheath (Terumo Medical Corp) was placed. Pulmonary angiography revealed subocclusive thrombi in both the proximal right and left pulmonary arteries. Rheolytic thrombectomy was performed with a 6 Fr Solent Omni - AngioJet Catheter (Medrad Interventional). An Optease Vena Cava Filter (Cordis) was placed in the usual fashion. Forearm access allowed the entire procedure, including IVC filter placement, to be done with minimal bleeding risk, despite the recent administration of tPA.
Case 2: Temporary Transvenous Pacemaker Insertion
A 56-year-old man with past medical history of mitral valve endocarditis status after mechanical mitral valve replacement presented with syncope due to significant bradycardia. He was referred for temporary transvenous pacemaker placement. He was fully anticoagulated; therefore, the forearm vein was used. Through a preexisting 20 G peripheral IV, a 5 Fr Glidesheath (Terumo Medical Corp) was placed. A venogram was performed to assess vasculature. The temporary wire was placed and position was confirmed in the usual fashion. This technique allowed the procedure to be performed on an emergent basis with a minimal risk of bleeding.
Case 3: Intravascular Foreign Body Retrieval
A 67-year-old woman with a history of colon cancer had a Port-a-cath placed. On a routine PET study, part of her Port-a-cath had broken off and migrated into the right ventricle. She was referred for percutaneous foreign body extraction. The right forearm vein was used. A 6 Fr Glidesheath (Terumo Medical Corp) was placed, and a liberal dose of nitroglycerin given. A 9 to 15 mm 6 Fr EN Snare catheter (Merit Medical System) was introduced over a coronary workhorse wire. The catheter tip was captured and removed without complications. The patient was discharged home later the same day.
An intracardiac foreign body is a rare complication. Most cases are typically referred to cardiothoracic surgery for definitive therapy. This case demonstrates, with suitable anatomy, the ability to remove an intracardiac foreign body via a snare technique under fluoroscopy using the forearm vein.
Case 4: Endomyocardial Biopsy
A 40-year-old man with no past medical history was found to have a right ventricular mass on CT scan and referred for biopsy of the intracardiac mass. Biopsy was performed using fluoroscopy and echocardiographic guidance using a forearm vein and a 6 Fr Glidesheath (Terumo Medical Corp). A 6 Fr JR 4 guide catheter was advanced to the right ventricle. A right ventricular angiogram and echocardiogram were used to position the catheter. Biopsy was performed with a 6 Fr Biotome (Cordis) with 7 samples taken. The patient was observed overnight and discharged the next morning
Myocardial biopsy is typically performed via an internal jugular vein or a femoral vein. Moyer et al reported a series of endomyocardial biopsy using a 7 Fr system in cardiac transplant patients.10 This case shows the feasibility of cardiac biopsy via the forearm vein using a 6 Fr system.
Case 5: Ultrasound-assisted Catheter-directed Thrombolysis for Acute Intermediate Risk Pulmonary Embolism
A 64-year-old African-American man was transferred to our institution for management of submassive pulmonary embolism (PE). The patient had saddle embolus on CTA of chest, extending mostly in the left lower lobe, RV>LV and interventricular septum bowing into LV, suggestive of right heart strain. He also had elevated troponin I and BNP levels, borderline low blood pressure, and junctional bradycardia. Thus, medical history was suggestive of high-risk submassive PE. The patient was taken to the cardiac catheterization laboratory, and his right forearm antecubital IV was cleaned and exchanged to a 6 Fr Glidesheath (Terumo Medical Corp). The patient then underwent right heart catheterization using a 5 Fr Arrow balloon wedge catheter (Teleflex), followed by placement of EKOS Ekosonic 30 cm endovascular ultrasound catheter (EKOS Corporation) for local tPA administration. The tip of the catheter was delivered into the left lower pulmonary artery and distal half of the catheter in the main pulmonary artery. He was given tPA over the next 18 hours, resulting in resolution of right heart strain on the echocardiogram the following day. The patient did not have any bleeding complications, and his cardiac rhythm changed to normal sinus rhythm and blood pressure quickly recovered to normal range.
The use of the EKOS catheter has become more popular recently as a result of the the SEATTLE II and ULTIMA trials establishing its safety and efficacy in reversing the right heart strain.11,12 Most commonly, the femoral vein is used for these catheters, and 1 or 2 are placed depending on the thrombus burden and physician discretion. These catheters are usually left in place for the treatment period of 12 to 24 hours during tPA administration and can cause significant patient discomfort owing to activity restrictions.
Right heart catheterization by the forearm vein is being increasingly used in the radial artery era. Our case series describes the safety and potential of this technique for other procedures in the cardiac catheterization lab.
Disclosure: The authors report no financial relationships or conflicts of interest regarding the content herein.
Manuscript submitted on December 30, 2018; accepted on February 6, 2019
Address for correspondence: Arun Nagabandi, MBBS; Mount Sinai Hospital, 4300 Alton Road; Miami Beach, Florida, 33140. Email: email@example.com
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