Clinical Application of Ultrasound Guidance in Arterial and Venous Access

Abstract

The use of ultrasound by vascular specialists has continued to increase over the past two decades. Historically, access for venous and arterial cannulation has been guided by landmark techniques. This has slowly been either replaced or only selectively used. With the availability of portable ultrasound devices, most operating theaters and interventional suites are equipped with specified units for physician use. This chapter describes common percutaneous cannulation sites and how access can be assisted by ultrasound technology. In addition, available literature comparing this modality to other methods of vascular access is examined.

Introduction

Over the last decade, the use of ultrasound-guided imaging to obtain arterial and venous access has exponentially increased in most centers. Traditional techniques to access the vascular tree had relied on either anatomic landmarks or palpation. This can be limited and time-consuming in vessels that are deep in location or if they vary from normal anatomy. It is essential, therefore, for all vascular specialists to become familiar with sonographic-guided access.

At our institution, residents and fellows have experienced a substantial increase in the amount of hands-on training with ultrasound guidance. All residents are oriented thoroughly on the appropriate techniques utilized, and each is required to use a portable machine during any and all access attempts throughout their training. This has resulted in a decrease in our overall complication rate and led to significantly less patient discomfort.

This chapter is dedicated to providing information for practitioners involved in both simple and complicated vessel cannulation. The most commonly accessed vessels for diagnostic and interventional procedures are covered, with major emphasis on technique and available literature supporting ultrasound-guided intervention. Finally, our philosophy of ultrasound-guided access in specific case scenarios will, hopefully, provide an easy way to identify situations in which this method can be used as the only form of entry.

Central Venous Access

Internal Jugular Vein

Our group is commonly consulted for the placement of both tunneled and non-tunneled central venous catheters. The preferred site in such patients has always been the jugular vein. In predominantly non-emergent situations, it is easily cannulated at the bedside and offers a lower infection rate than when done in other locations. The vein is also used as an access site for the placement of inferior vena cava filters and subsequent retrieval. Although the latter is far more common, most filters do have a jugular delivery system for use if needed.

Ultrasound first identifies the vessel, with B-mode imaging, in a transverse orientation. In most patients, the vein is located lateral to the carotid artery, within the carotid sheath. In a standard gray-scale view, it has a larger diameter and more of an oval shape. Pulsations of the neighboring artery can also be seen, which helps preliminarily identify the correct structure to be targeted.

The vein should be assessed for compressibility and the presence of both acute and chronic thrombosis. An acute clot burden does not display the thickened vessel wall and hyperechoic thrombus that a chronic one will; however, it does demonstrate a significant lack of compressibility. When this occurs, confirmation with color Doppler is necessary, and a lack of spontaneous, phasic venous flow should lead the operator to choose a different site for access. Chronic deep venous thrombosis does not always mandate a similar approach; however, the vessel is not generally seen as a preferred option.

The vein can be accessed at the junction of the sternal and clavicular heads of the sternocleidomastoid, as in the traditional landmark method, or at the base of the neck via a lateral approach. Although techniques with two operators have been described, we prefer to use the “one-handed” technique in which the operator holds the ultrasound probe with one hand and inserts the needle with the other [1].

Here, the ultrasound probe is placed on the patient’s neck in a transverse orientation to the jugular vein and a local anesthetic is administered. A 19 gauge needle is used to enter the vessel while in the B-mode function. For standard central non-tunneled catheters , this is accomplished with the needle oriented at a 45° angle, just above the middle of the probe. Once access is attained, a guidewire is passed and the ultrasound probe can be used to follow the single echogenic point it creates for a short distance to the base of the clavicle. A catheter or sheath can then be placed (Figs. 60.1, 60.2, 60.3, and 60.4).

Fig. 60.1

Percutaneous insertion of needle into the jugular vein

Fig. 60.2

Color flow Doppler of jugular vein and carotid artery in short-axis plane. Carotid artery (red) jugular vein (blue)

Fig. 60.3

Color flow Doppler of jugular vein and carotid artery in long-axis plane. Carotid artery (red) jugular vein (blue)

Fig. 60.4

Echogenic tip of needle in the lumen of the jugular vein, transverse view

For tunneled catheters, our group prefers the lateral approach to the jugular vein, which was initially described by Silberzweig and Mitty in 1998 [2]. A standard transverse view is obtained at the base of the neck with the ultrasound probe placed parallel to and just above the clavicle. Both the anesthetic and access needle are inserted into the skin at a similar 45° angle, lateral to the transversely oriented probe. Following the needle point is essential to prevent a “through and through” puncture of the carotid artery, which occurs if the needle tip is out of plane with the ultrasound beam. We have found that this approach minimizes the risk of kinking by allowing a gentle curve of the catheter at the base of the neck into the lateral wall of the vein. The probe can also be reoriented to show a longitudinal plane, where insertion of the guidewire into the innominate vein can be followed (Fig. 60.5).

Fig. 60.5

“Low and lateral” approach to sticking the jugular vein for tunneled catheters

One of the most compelling early studies to examine the effectiveness of using ultrasound was performed by Denys et al. in 1993. Their group prospectively analyzed over 300 patients accessed by both traditional landmark techniques as well as ultrasound guidance. A higher technical success rate was seen with ultrasound-guided access (100% vs 88.1%), with 78% of veins successfully punctured on first pass attempts as opposed to 38% with the traditional landmark-based group. The average time to access from the skin to vein was 9.8 s and 44.5 s, respectively, and complication rates were far less in the ultrasound group with regard to inadvertent carotid artery puncture, brachial plexus irritation, and access site hematomas [3].

Subsequently, several other prospective trials have compared the ultrasound-guided access with that of landmark techniques, most of which were randomized and controlled. A randomized trial of 450 critical care patients demonstrated a higher technical success rate with an ultrasound-guided access and higher complications with the landmark method. A carotid artery puncture rate of over 10% and a hematoma rate of 8.4% were seen, as compared to 1.1% and 0.4%, respectively, in patients with ultrasound-guided access. A direct correlation was also observed between bloodstream infection and the number of passes, which was substantially reduced by imaging-guided puncture [4]. Three years later, Turker et al. conducted a randomized study involving 380 patients comparing ultrasound-guided procedures to that of landmark techniques. This was one of the lowest reported carotid puncture and hematoma rates while using the landmark technique (4.73% and 3.68%); however, there was still a statistically significant increase as compared to ultrasound-guided access [5].

In 2003, a meta-analysis of central venous cannulation was performed, examining studies of the internal jugular, subclavian, and femoral veins. The jugular vein was the most studied access site, but all sites were included for analysis. A relative risk reduction of 86% was found for failed catheter placement, 57% for placement complications, and 41% for failure on the first attempt when ultrasound-guided access was used. Most series also showed fewer required attempts for successful cannulation and less time to achieve access when ultrasound was used as an adjunct [6].

Subclavian Vein

The subclavian vein has also been used for both temporary and permanent central catheters, albeit less frequently. It is accessed in the costoclavicular space of the thoracic outlet.

The subclavian vein, artery, and brachial plexus all pass through this space, in close proximity to the pleural cavity, making a precise puncture critical. Arterial cannulation is difficult to manage, especially once a sheath has been inserted, and pneumothoraxes have been reported much more frequently with subclavian vein access attempts than with the jugular vein.

A standard transverse view is more difficult to obtain, and longitudinal views below and above the clavicle are often employed. In addition, conventional compression is not usually feasible secondary to the bony architecture surrounding the vein. The presence of intraluminal echoes and respiratory phasicity with Doppler waveform analysis is generally all that is used to assess the vein for clot burden. The skin puncture is at the junction of the medial two-thirds and lateral one-third of the clavicle, and the needle is visualized in the same plane as it enters the lumen of the vessel. A classic Seldinger technique then ensues (Figs. 60.6 and 60.7).

Fig. 60.6

Subclavian vein , longitudinal (long axis) plane (B-mode)

Fig. 60.7

Subclavian vein, longitudinal (long axis) plane, color flow Doppler

Series comparing landmark with ultrasound-guided techniques are limited; however, the results have shown ultrasound guidance to be superior in certain outcomes. Between 1994 and 1998, three prospective, randomized trials by Branger et al., Gualtieri et al., and Lefrant et al. showed a statistically significant relative risk reduction of 86% of failed catheter placement, along with a lower complication rate [7,8,9]. The sample sizes were not as large as those seen in some of the series looking at the internal jugular vein, but ultrasound has shown itself to be of clear benefit in accessing the vein. We feel strongly that in both routine and complex situations, ultrasound should be considered for vessel cannulation. The difficulty with visualization around the clavicle can be more technically demanding, but the results with the use of two-dimensional imaging far outweigh the risks associated without it.

Femoral Vein

The common femoral vein is viewed as the simplest access point to the deep venous circulation. This is predominantly due to its location and the lower risks associated with access, compared to others. The vein lies medial to the common femoral artery and travels with the artery proximally under the inguinal ligament. It can be easily cannulated while the patient lies in the supine position and is currently the site most amenable to emergency access.

The ultrasound probe is oriented transversely over the femoral vessels, parallel to the groin crease. Similar to the jugular vein, the vein is compressed and B-mode assessment of intraluminal thrombus is done. Once patency is confirmed, the needle is positioned inferior to the midportion of the probe and directed at a 45° angle into the plane of the ultrasound beam. The echogenic tip is followed as it advances through the anterior wall of the vein.

Success rates have been well established for a number of years. In 1990, Mallory et al. were one of the first to show a significant decrease in the amount of time to cannulation (2.5 min vs 6 min), as well as a higher number of successful cannulations with the first pass [10]. Since then, five different studies, both prospective and retrospective, have confirmed their group’s results. For the most part, retrospective series have reported better technical success, including more successful first attempt punctures, along with lower hematoma rates and inadvertent femoral artery punctures [11, 12].

A prospective study by Hilty et al. evaluated femoral cannulation in patients undergoing cardiopulmonary resuscitation, showing a relative risk reduction of failed catheter placement by 71% [13]. Another prospectively randomized trial of 110 patients undergoing femoral vein dialysis catheter insertion reported improved technical success (98.2% vs 80%) and reduced complications (18.2% vs 5.5%) in patients randomized to ultrasound-guided access [14].

We have previously published our institutional experience with central venous access for inferior vena cava filter placement. The focus of our study was on the safety of using the subclavian vein for access during inferior vena cava filter placement. A striking finding during our review, however, was how fast the procedures were when performed using the femoral vein for access [15]. During filter placement, we also routinely assess the femoral veins with the probe. This helps visualize any clot burden, acute or chronic, in addition to reducing the number of passes for successful cannulation and inadvertent punctures. The later can be devastating in this clinical scenario in that some patients may already be on anticoagulation.

Popliteal and Tibial Veins

The popliteal vein is clearly the least accessed of all deep veins. It is most commonly used in patients with acute deep venous thrombosis undergoing thrombolysis. The popliteal veins lie on either side of the popliteal artery and branch distally into the tibial veins, similar to the corresponding arterial anatomy. Intraluminal thrombus is often present, making access to either popliteal vein challenging, and avoidance of inadvertent arterial puncture is paramount in patients undergoing lytic therapy.

The most common technique to access the vein is via prone positioning, and ultrasound insonation should occur by a transverse orientation. A standard angle of 45° is used; however, a steeper angle of approximately 60° may be required. In the popliteal fossa, the veins are deeper during a prone approach, and we have found that identifying the small saphenous vein can sometimes be helpful. Following its course as it empties into the popliteal vein can make access easier by identifying a more superficial vein to cannulate, especially if there is already a significant thrombus burden in the popliteal veins. Once the needle has entered the lumen, the procedure can continue (Fig. 60.8).

Fig. 60.8

Popliteal veins (transverse view, B-mode)

The anterior tibial and posterior tibial veins are accessed even less than the popliteal. They may be of some use in ascending venography, when peripheral intravenous catheters in the feet cannot be attained. The patient is usually in a supine position, and the ultrasound image helps identify both tibial veins for each corresponding artery. Accessing one will allow for a suitable catheter injection and ascending venogram. Occasionally, we have even used the posterior tibial vein for lytic access, but this is only done if attempts at cannulating the popliteal vein are unsuccessful.

Peripheral Venous Access

Great and Small Saphenous Veins

With the advent of radiofrequency and laser ablation, endovenous procedures for great saphenous vein (GSV ) ablation can now be performed without surgical intervention in the majority of patients. It produces similar results, with significantly decreased morbidity. Ultrasound only aids in providing safe access to accomplish these various procedures.

The GSV lies within the saphenous sheath and runs down the medial border of the entire lower extremity. It is a superficial vein, with four or more large sets of perforators throughout its course. Typically, in reflux surgery, the vein is larger than 3 mm in its entirety and is accessed at the level of the medial condyle of the femur. The needle is inserted at a 45° angle to the skin surface, directly beneath the probe. In a transverse view, the needle tip is identified superior to the vein, and puncture can occur in either this view or a longitudinal one, as the needle is advanced. Upon blood return, a standard Seldinger technique is used for sheath placement. An ablative catheter is then inserted, and visualization of its tip should always be ensured. Here, a longitudinal view of the saphenofemoral junction is imperative. In this view, the inferior epigastric vein is visualized, and the catheter should be withdrawn to a point inferior to this branch. Finally, a transverse projection is employed again, and tumescence anesthesia is injected within the saphenous sheath along the entire course of the vein (Figs. 60.9 and 60.10).

Fig. 60.9

Saphenofemoral junction ) ) (longitudinal plane, B-mode)

Fig. 60.10

Transverse view of common femoral artery, common femoral vein, and great saphenous vein (transverse view, B-mode)

The small saphenous vein is only cannulated in ablative procedures and lower extremity deep venous thrombosis. Ultrasound can be used to identify the small saphenous vein approximately three to four fingerbreadths below the level of the lateral femoral condyle on the lateral aspect of the lower extremity, and a standard image-guided technique is utilized. The literature regarding the use of ultrasound to access this vein is limited; however, it is clearly less invasive and is likely associated with a lower complication rate.

Basilic Vein

The superficial veins of the upper extremity are most often accessed by nursing or ancillary staff during peripheral intravenous access. At our institution, specialty nurses also achieve access for peripherally inserted central catheters. Portable ultrasound units are used at the bedside to do so, and they are present in each hospital for use by all staff, if needed.

It is only on occasion that our group needs to access the basilic vein in the interventional suite, with the most common case being thrombolysis for upper extremity deep venous thrombosis. The basilic vein is identified in the transverse plane just above the antecubital fossa. It lies on the medial portion of the upper arm over the groove between the bicep and tricep muscles (Figs. 60.11 and 60.12).

Fig. 60.11

Basilic vein (BV) and brachial artery (BA) —(short axis view, B mode)

Fig. 60.12

Basilic vein (short axis view, color flow)

Arterial Access

Common Femoral Artery

The common femoral artery is the most common artery accessed for percutaneous-based arterial procedures. Several techniques have been used, including “the best pulse,” fluoroscopic guidance, and ultrasound guidance. Our group routinely utilizes the fluoroscopic-guided principle in patients with palpable femoral pulses. We do, however, recommend ultrasound-guided arterial access in several specific case scenarios. These include endovascular aortic aneurysm repair, planned thrombolysis, a nonpalpable pulse, and antegrade access. If access is not achieved in the proper location, devastating complications can be seen. Accessing the superficial or deep femoral arteries may result in either a groin hematoma or pseudoaneurysm upon removing the intra-arterial sheaths. This is secondary to lack of a bony surface to compress the artery against posteriorly. Punctures occurring above the common femoral artery can lead to significant retroperitoneal bleeding. Severe pain, extensive transfusion requirements, and operative exploration can all result.

In the majority of patients, the common femoral artery is located anterior to the medial one-third portion of the femoral head. Proximally, the transition from the external iliac artery to the common femoral artery is divided anatomically by the inguinal ligament. Distally, it bifurcates into the superficial femoral and profunda femoris arteries at variable levels. Fluoroscopic-guided access is performed by solely identifying the medial border of the femoral head. This method allows for the artery to be punctured in what is most likely the common femoral portion, with only a small percentage of vessels displaying a high bifurcation where the superficial femoral artery may inadvertently be cannulated. In this situation, pressure can often still be held due to the fact that the femoral head is still present to hold the vessel against. Doppler needles and visualization of calcium in the wall of the vessel can sometimes aid in this type of access, especially with arteries that are not palpable.

Ultrasound offers the unique benefit of identifying atherosclerotic plaque within the evaluated vessel, in addition to accurate placement. It is our practice to identify the bifurcation first and trace up to the common femoral artery in a transverse view. Then, the probe is turned to create a longitudinal projection through which the needle can be advanced into the common femoral artery. The standard 45° angle of needle entry into the skin is employed, and the entire body of the needle is seen in the longitudinal view, entering at a point just above the bifurcation. In an effort to decrease both periprocedural embolization and thrombosis, any areas of the artery that display severe plaque are avoided (Figs. 60.13, 60.14, 60.15, and 60.16).

Fig. 60.13

Superficial femoral artery , profunda femoris, common femoral vein (B-mode, short axis)

Fig. 60.14

Superficial femoral artery , profunda femoris, common femoral vein (color flow Doppler, short axis view)

Fig. 60.15

Common femoral artery bifurcation (color flow, long axis view)

Fig. 60.16

Common femoral artery in longitudinal plane with needle insertion

The literature supporting the use of ultrasound, as compared to the fluoroscopic-guided technique, is limited. A recent prospective trial randomized 1,004 patients into receiving either fluoroscopic-guided puncture or ultrasound-guided puncture of the femoral artery. The overall cannulation rate was similar between the two groups; however, the ultrasound-guided cohort was more successful at first pass access (83% vs 46%) and median time to puncture (136 s vs 148 s). The study also demonstrated a lower complication rate with ultrasound-guided femoral access (1.4% vs 3.4%), with the major difference in regard to hematomas >5 cm [16].

In the past 2 years, our group has solely used ultrasound-guided techniques to perform percutaneous endovascular aneurysm repair. The need for accurate access with >20 French sheaths is crucial, and we have relied on ultrasound-guided punctures of the common femoral artery to allow safe placement of these larger sheaths. Recently, in 2008, Arthurs et al. examined 88 patients who underwent total percutaneous closure for aortic aneurysm repair. Although retrospective, their group identified a significant benefit of ultrasound-guided common femoral access. It not only decreased operative time but also had a higher technical success rate as well as a lower conversion to open repair [17].

Popliteal Artery

The popliteal artery is predominantly cannulated for retrograde access, and it can be used for peripheral arterial interventions. Our group does not prefer this site due to the fear of complications; however, with ultrasonic imaging these can be minimized. The ultrasound probe is placed in a transverse plane, similar to the technique for accessing the popliteal vein, but a slight cranial angle is added for better visualization.

In 2005, Yilmaz et al. retrospectively looked at 174 patients who underwent retrograde popliteal artery access for both claudication and critical limb ischemia. In a total of 234 procedures, the overall complication rate was 6.4%, with only 4.3% being related to arterial puncture. It is clearly a safe method with sonographic guidance, and although it is not our preference, it is still a valid option for access [18].

Brachial Artery

The brachial artery is the second most common arterial site accessed in peripheral intervention. The brachial artery is found in the groove just underneath the bicipital aponeurosis, with the median nerve coursing medial to it. Typically, there are paired brachial veins on each side, as is seen in the popliteal and tibial arteries of the lower extremity. Higher complication rates, including thrombosis, have been reported here and are primarily related to the small diameter of the vessel.

Many vascular specialists use this site for visceral and renal angiography and intervention. Percutaneous techniques rely on either palpation of the artery, use of a Doppler needle, or ultrasound guidance. It is our preference to use ultrasound guidance with transverse and longitudinal imaging similar to that employed in the common femoral artery. It allows for visual identification of the artery and reduces the number of unsuccessful punctures.

Radial Artery

The radial artery has traditionally only been used for inpatient arterial access in blood pressure monitoring. However, it has recently gained significant interest as a site for percutaneous cannulation. This artery is being used in both diagnostic and therapeutic cardiac catheterization, and cannulation rests mostly on palpable pulsation of the vessel. Ultrasound imaging has proven a useful adjunct, and a recent meta-analysis reported a definite benefit. An improved first-pass success rate of 71% was seen, and even though most trials did not use uniform criteria for their outcome measurements, a trend toward a reduced number of attempts and a faster time to catheterization was seen [19]. Our group has not utilized the radial artery for any peripheral procedures, but it is a viable option for use and its acceptance is growing.

Reimbursement

Reimbursement is available when ultrasound is used to gain vessel access. It is dependent on three primary components during the dictation of each procedure. The first is that the operator must document the patency of the selected vessel (i.e., widely patent, patent but with area of stenosis, etc.). Second, the operator must document the real-time visualization of the needle entry using ultrasound as a guide. Third, the operator must have documentation of permanent recording and reporting. Please see Table 60.1 for the reported physician reimbursement in 2010 (CPT + 76937).

Table 60.1 2010 Reimbursement for ultrasound-assisted access

Conclusion

In conclusion, ultrasound imaging provides a safe, effective way to visualize a vessel while achieving access. It provides both gray-scale imaging and Doppler flow to better assess the vessel for stenosis or thrombosis, with color flow helping to delineate arteries from veins in cases with difficult anatomy. It provides significantly more information than both anatomic landmarks and fluoroscopy can provide. All clinicians engaging in peripheral percutaneous intervention should have a thorough knowledge of how to image each of the vessels discussed in this chapter, and the ability to interpret the image seen, using it as a guide to effectively access the vessel lumen with a needle (Table 60.2).

Table 60.2 Major randomized controlled trials for ultrasound-guided arterial and venous access

Recent evidence has also shown that the orientation of the probe can help provide a better view of all aspects of access. Whereas the transverse orientation of a probe can provide a good image, a longitudinal view has its benefits as well. These device positions are known as short-axis out-of-plane and long-axis in-plane views. The short-axis out-of-plane view provides a good cross section of a vessel, allows for compressibility, and provides a good view of the lumen. The long-axis in-plane view allows complete visualization of the length of the needle as it penetrates the anterior wall at an angle, which can provide the operator with better ability not to traverse the posterior wall. Gao et al. reviewed 470 patients in a meta-analysis of saphenous vein punctures, and although there were no statistically significant differences in the first-pass success rate, mean attempts to success, and complications, each view clearly offers its advantages [23]. It is our practice to identify most vessels, pre-insertion, in each view with both gray scale and color Doppler to gain as much information about the anatomy of the patient as possible prior to inserting the needle. Typically our group employs a short-axis out-of-plane view for puncturing the anterior wall; however, switching to a long-axis in-plane view is often used to ensure that no penetration of the posterior wall occurs. This is especially important in situations where the vessel of importance is small in caliber or has an abundance of channels surrounding it. Both views are important, and determining which view to use is often patient specific.

Review Questions

• 1. A 67-year-old male presents to the emergency room in diabetic ketoacidosis and has no discernable veins in either upper extremity. Central venous access is needed. What is the best way to attain good access?

  • a. Femoral venous access, palpating for the femoral artery

  • b. Jugular venous access, palpating the carotid artery for landmarks

  • c. Jugular venous access using anatomic landmarks

  • d. Jugular venous access using both short-axis out-of-plane and long-axis in-plane views with duplex ultrasound

• 2. A 72-year-old female presents to the ER in severe sepsis with hypotension. No peripheral IV access is attainable, and the patient has a longstanding history of tunneled catheters before. Upon viewing the neck with duplex ultrasound, it is difficult to ascertain which vessel is the jugular vein. What is the next best step?

  • a. Attempt palpating the artery and stick away from it

  • b. Abandon ultrasound and use traditional landmarks to stick the vein

  • c. Switch to color flow to delineate which vessel is the artery and which is the vein

  • d. Attempt to stick one and attach transducer to catheter to attain a pressure measurement

• 3. While attempting femoral arterial access using ultrasound in a transverse view, you have pulsatile blood return; however, you lose it shortly after and are uncertain whether or not you have lost access or traversed through the posterior wall of the vessel. What is the next best step?

  • a. Pull the needle out and hold pressure

  • b. Attempt to shoot dye through the needle and assess where you are

  • c. Try to pass a guidewire through what you have in place

  • d. Turn the probe to a long-axis in-plane view to see if you are able to see the length of the needle and if it has passed through the posterior wall of the vessel

Answer Key

• 1. d

• 2. c

• 3. d