Abstract: Background. Traditional approaches to pediatric cardiac catheterization have relied on femoral venous access. Upper-extremity venous access may enable cardiac catheterization procedures to be performed safely for diagnostic and interventional catheterizations. The objective of this multicenter study was to demonstrate the feasibility and safety of upper-extremity venous access in a pediatric cardiac catheterization laboratory. Methods. A retrospective chart review of all patients who underwent cardiac catheterization via upper-extremity vascular access was performed. Results. Eighty-two cardiac catheterizations were attempted via upper-extremity vein on 72 patients. Successful access was obtained in 75 catheterizations (91%) in 67 patients. Median age at catheterization was 18.79 years (interquartile range [IQR], 13.02-32.75 years; n = 75) with a median weight of 59.4 kg (IQR, 43.3-76.5 kg; n = 75). The youngest patient was 4.1 months old, weighing 4.3 kg. Local anesthesia or light sedation was utilized in 46 procedures (61%). Diagnostic right heart catheterization was the most common procedure (n = 65; 87%), with intervention performed via the upper extremity in 8 cases (11%). Median fluoroscopy time was 10.02 min (IQR, 2.87-36.26 min; n = 75), with dose area product/kg of 3.765 µGy•m2/kg (IQR, 0.74-34.12 µGy•m2/kg; n = 64). Median sheath duration time was 48 min (IQR, 19.5-147 min; n = 57) and median total procedure time was 116 min (IQR, 80.5-299 min; n = 65). Median length of stay for outpatient procedures was 5.37 hr (IQR, 4.25-6.92 hr; n = 27). There were no procedural complications. Conclusion. Upper-extremity venous access is a useful, feasible, and safe modality for cardiac catheterization in the pediatric cardiac catheterization laboratory.
J INVASIVE CARDIOL 2019;31(5):141-145. Epub 2019 February 15.
Key words: pediatric cardiology, venous access
The origins of modern cardiac catheterization and fluoroscopy began with Dr Werner Forssmann’s self-catheterization via the antecubital vein.1 Subsequently, as interventions and techniques for access evolved, femoral vessels have become the standard access point for both diagnostic and interventional cardiac catheterization, although it is not without risk. The most common complications related to pediatric cardiac catheterization relate to vascular access.2 Known complications of femoral venous and arterial access include retroperitoneal hemorrhage, arteriovenous fistula formation, thrombus in the major vessels supplying or draining the leg, and the need for immobilization to prevent rebleeding at the entry site.3-7 Internal jugular access has also been utilized, and offers a decreased need for prolonged immobilization, but complicates technical portions of the procedure and carries risk of arterial puncture, fistula creation, lymphatic injury, pneumothorax, and brachial plexus injury.8-10 As such, utilization of the upper extremity for venous access offers several advantages in congenital cardiac catheterization. In addition, the ability to maintain vascular access is critical in congenital cardiology, particularly in patients with complex anatomic substrates that carry a need for multiple reinterventions. Venous recanalization procedures have proven useful in maintaining vascular access in these patients, with upper-extremity access proving invaluable for re-establishment of venous flow. The aim of this study was to retrospectively review the experience of upper-extremity access for cardiac catheterization and intervention in pediatric cardiac catheterization laboratories across three institutions.
This was a retrospective chart review study. Institutional review board approval was obtained from the member institutions prior to data collection. All patients who underwent upper-extremity venous access for cardiac catheterization from 1991 to 2018 were included in this analysis. Data collected included demographic data, such as patient age at the time of catheterization, weight, height, and underlying diagnosis. Procedural data included site(s) of vascular access and sheath type, procedures performed during catheterization, level of anesthesia and anticoagulation, contrast and radiation dose, concomitant procedures performed, sheath and catheterization procedure duration, recovery duration, total hospital time, and complications noted during catheterization or at the most recent follow-up. Study data were collected and managed using Research Electronic Data Capture (REDCap) tools hosted at the University of Iowa Stead Family Children’s Hospital. REDCap is a secure, web-based application designed to support data capture for research studies, providing: (1) an intuitive interface for validated data entry; (2) audit trails for tracking data manipulation and export procedures; (3) automated export procedures for seamless data downloads to common statistical packages; and (4) procedures for importing data from external sources. All continuous variables were described as median and interquartile range (IQR).
Upper-extremity venous access. Ultrasound was used to locate the upper-extremity vessels prior to prepping the patient. The basilic vein was the preferred vein for access. The site was marked and the arm was then placed in supine and extended position. A tourniquet was placed loosely in the arm close to the axilla. The site was prepped and draped (Figure 1A). Ultrasound was again used to access the upper-extremity vein (Figure 1B). The tourniquet was then tied, the needle was seen entering the vessel itself, and the sheath was placed using a modified Seldinger technique. A variety of sheath types were used based on practitioner preference and laboratory availability, although the Glidesheath (Terumo Corporation) has become the preferred sheath of most practitioners.
A total of 82 catheterizations were performed on 72 patients. Seven attempts at obtaining access for catheterization via the upper extremity were unsuccessful and converted to femoral access. Median age of catheterization was 18.79 years, and median weight was 59.4 kg. The youngest patient was 4 months old and weighed 4.3 kg. Forty-eight procedures (64%) were completed utilizing either local anesthesia or sedation. Ultrasound was utilized for accessing upper-extremity vessels in all cases.
The most frequently inserted sheath size was 6 Fr (range, 4-11 Fr). The sheath types used are shown in Table 1, and the procedures performed are listed in Table 2. Eighty-seven percent of catheterizations included a right heart catheterization, with additional interventions performed via upper-extremity access in 20 procedures (27%). Interventions included attempted or successful venous recanalization procedures with balloon angioplasty (n = 17), foreign body removal (n = 2), and coil occlusion of venovenous collateral vessels (n = 1).
Procedural characteristics are listed in Table 3. Documentation of sheath and procedure duration was available in 57 patients, with median sheath duration of 48 min (IQR, 20-139 min) and total procedure time of 116 min (IQR, 81-287 min). Median fluoroscopy time was 10 min, with dose area product/kg of 3.765 µGy•m2/kg. Twenty-six patients underwent 29 outpatient-only procedures (Table 4). In those who underwent outpatient catheterization without intervention, median recovery time was 1.01 hr (IQR, 0.42-1.57 hr), with total hospital time of 5.37 hr (IQR, 4.25-6.87 hr).
There were no procedural complications in patients who had completed catheterization using upper-extremity vein. There was 1 patient who underwent a venous recanalization procedure and later demonstrated occlusion of the left internal jugular. Follow-up was available in 32 patients, at a median follow-up duration of 10 months. One patient demonstrated pain related to the access site, and 3 patients later died secondary to multiorgan failure unrelated to catheterization.
To our knowledge, this is the first study describing the safety and feasibility of cardiac catheterization via upper-extremity venous access in pediatric cardiac catheterization laboratories. We found that upper-extremity venous access for right heart catheterization is a safe and reproducible procedure that affords many advantages over traditional femoral or internal jugular access. Using upper-extremity venous access, we were able to perform diagnostic catheterizations with minimal sedation. This mode of access also facilitated complex recanalization interventions in a number of patients. Right heart catheterizations are frequently performed in pediatric cardiac catheterization laboratories to assess hemodynamics, obtain anatomical information, or assess clinical responses to therapy or monitoring.
Right heart catheterizations are indicated in many patients with pulmonary arterial hypertension to confirm the diagnosis, to perform vasoreactivity testing, and to assess the severity of the disease.11 With increased concern for complications of femoral access, there has been a renewed interest in performing right heart catheterization using the antecubital vein in adults.12-15 Antecubital access is associated with shorter fluoroscopy time, decreased radiation dose, fewer access-site complications, and decreased time to ambulation in adults.13,14
Most procedures in the current study were performed with only local anesthesia or mild sedation, avoiding the need for higher levels of anesthesia. While an anesthesiologist was present for all procedures as a precaution, minimization of anesthetic medications reduces the risk of anesthesia-related complications, including hypotension, mucus plugging, endotracheal tube dislodgment, and postextubation airway events.16 This is of particular importance in patients undergoing right heart catheterization who have pulmonary arterial hypertension or advanced heart failure, which increase the risk for anesthetic complications.17,18 Additionally, by minimizing anesthetic exposure, hemodynamic effects of anesthetic agents are mitigated and hemodynamic assessments more closely approximate baseline waking conditions. Furthermore, patients can exercise or undergo other dynamic cardiac testing with continuous real-time assessment of their cardiac response to changes in oxygen consumption. Post procedure, without the need for prolonged immobilization to ensure hemostasis at the catheterization site, total hospital duration for outpatient procedures was often less than 6 hours in our cohort, with many patients discharged shortly after presentation to postanesthesia care or from the catheterization laboratory directly. Although our outpatient population was not sufficient to perform cost analysis, we speculate that upper-extremity catheterization will decrease the overall cost related to the procedure and decreased overall hospital duration.
Additionally, patients with prolonged hospitalizations or prothrombotic conditions, particularly renal dysfunction, are frequently at risk of vascular occlusions and inability to maintain stable vascular access. Pediatric cardiac patients have a variety of risk factors for venous thrombotic diseases, including prolonged placement of central venous access catheters, low-cardiac output state, surgical or catheter manipulation of venous structures, cardiopulmonary bypass, and a variety of other factors that contribute to Virchow’s triad, thereby contributing to the development of both acute and chronic venous occlusions.19,20 As such, maintenance of venous vascular access is critical in the pediatric cardiac population. Percutaneous transluminal angioplasty (PTA) and subsequent vascular recanalization therapy has thus become a necessary procedure for patients in a variety of circumstances in congenital heart disease, including aortopulmonary shunts, atrial baffles, superior vena caval syndrome, postoperative chylothorax, and more recently, occluded systemic venous structures.21-25 Particularly in the setting of chronic thromboembolism, medical therapy with streptokinase or tissue plasminogen activator therapy alone demonstrates low efficacy with significant risks in the pediatric population.26,27 The first PTA for peripheral lesions was performed in 1964, with the first vascular stent placed in 1987. Subsequently, PTA has been performed in adults with encouraging results for deep venous thrombosis. Given the evolution in balloon and stent technologies, this technique is now able to be adapted to the pediatric population. With the need for visualization of both the proximal and distal ends of the obstructed portion, multiple access points are often required for assessment.28 As such, upper-extremity venous access is frequently required for recanalization of occluded venous structures, and it should be noted that the upper extremity is able to accommodate larger sheaths.
Study limitations. This study is limited by its retrospective nature, lack of an adequate control population, and relatively small sample size. Nevertheless, we feel this study demonstrates the safety and feasibility of utilizing the upper-extremity venous approach for cardiac catheterization in pediatric cardiac catheterization laboratories.
Upper-extremity venous access can be a useful access modality in a pediatric catheterization laboratory for both children and adults. This access mode facilitates diagnostic catheterizations, resulting in quicker recovery times. In addition, complex interventions can be facilitated by this access mode. Further studies at additional institutions will be helpful in further quantifying the risks and benefits inherent to this novel approach.
- Heiss HW, Hurst JW. Werner Forssmann: a German problem with the Nobel prize. Clin Cardiol. 1992;15:547-549.
- Mehta R, Lee K-J, Chaturvedi R, Benson L. Complications of pediatric cardiac catheterization: a review in the current era. Catheter Cardiovasc Interv. 2008;72:278-285.
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- Altin RA, Flicker S, Naidech HJ. Fistula after femoral artery catheterization: with low femoral punctures. AJR Am J Roentgenol. 1989;152:629-631.
- Tiroch KA, Arora N, Matheny ME, Liu C, Lee TC, Resnic FS. Risk predictors of retroperitoneal hemorrhage following percutaneous coronary intervention. Am J Cardiol. 2008;102:1473-1476.
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- Bhatty S, Cooke R, Shetty R, Jovin IS. Femoral vascular access-site complications in the cardiac catheterization laboratory: diagnosis and management. J Interv Cardiol. 2011;3:503-514.
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- Feltes TF, Bacha E, Beekman RH, et al. Indications for cardiac catheterization and intervention in pediatric cardiac disease: a scientific statement from the American Heart Association. Circulation. 2011;123:2607-2652.
- Shah S, Boyd G, Pyne CT, et al. Right heart catheterization using antecubital venous access: feasibility, safety and adoption rate in a tertiary center. Catheter Cardiovasc Interv. 2014;84:70-74.
- Roule V, Ailem S, Legallois D, et al. Antecubital vs femoral venous access for right heart catheterization: benefits of a flashback. Can J Cardiol. 2015;31:1497.e1-1497.e6.
- Speiser B, Pearson K, Xie H, Shroff AR, Vidovich MI. Compared to femoral venous access, upper extremity right heart catheterization reduces time to ambulation: a single center experience. Catheter Cardiovasc Interv. 2017;89:658-664.
- Yang C-H, Guo GB-F, Yip H-K, et al. Bilateral cardiac catheterizations: the safety and feasibility of a superficial forearm venous and transradial arterial approach. Int Heart J. 2006;47:21-27.
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- Twite MD, Friesen RH. The anesthetic management of children with pulmonary hypertension in the cardiac catheterization laboratory. Anesthesiol Clin. 2014;32:157-173.
- Carmosino MJ, Friesen RH, Doran A, Ivy DD. Perioperative complications in children with pulmonary hypertension undergoing noncardiac surgery or cardiac catheterization. Anesth Analg. 2007;104:521-527.
- Giglia TM, Massicotte MP, Tweddell JS, et al. Prevention and treatment of thrombosis in pediatric and congenital heart disease: a scientific statement from the American Heart Association. Circulation. 2013;128:2622-2703.
- Lowe GD. Virchow’s triad revisited: abnormal flow. Pathophysiol Haemost Thromb. 2003 Sep-2004 Dec;33:455-457.
- Law MA, McMahon WS, Hock KM, Zaccagni HJ, Borasino S, Alten JA. Balloon angioplasty for the treatment of left innominate vein obstruction related chylothorax after congenital heart surgery. Congenit Heart Dis. 2015;10:E155-E163.
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- Ries M, Singer H, Hofbeck M. Thrombolysis of a modified Blalock-Taussig shunt with recombinant tissue plasminogen activator in a newborn infant with pulmonary atresia and ventricular septal defect. Br Heart J. 1994;72:201-202.
- Sreeram N, Emmel M, Ben-Mime L, Brockmeier K, Bennink G. Transcatheter recanalization of acutely occluded modified systemic to pulmonary artery shunts in infancy. Clin Res Cardiol. 2008;97:181-186.
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From the 1University of Iowa Stead Family Children’s Hospital, Iowa City, Iowa; 2Texas Children’s Hospital/Baylor College of Medicine, Houston, Texas; and 3University of Minnesota Masonic Children’s Hospital, Minneapolis, Minnesota.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
The authors report that patient consent was provided for publication of the images used herein.
Manuscript submitted November 14, 2018, final version accepted November 28, 2018.
Address for correspondence: Manish Bansal, MD, Texas Children’s Hospital, 6651 Main Street, E1920, Houston, TX 77030. Email: email@example.com