Right Heart Catheterization

Transcription

1 Right Heart Catheterization Ian C Gilchrist, MD, FSCAI Professor of Medicine Heart & Vascular Institute Penn State/Hershey Medical Center Hershey, PA DUKE 2010 Presenter Disclosure Information Ian C. Gilchrist, MD, FSCAI Following relationships exist related to this presentation: Honorarium for Educational Lectures Terumo Medical Corporation Research Grants to Penn State Angel Medical Systems, AstraZeneca Boston Scientific, Bristol-Myers Squibb Merck, Osiris Therapeutics Portola Pharmaceuticals, Roche Evolution of Technique Brachial Artery Cutdown Percutaneous Femoral Access Transradial Arterial Access Complete Forearm Vascular Access Transradial Cutdown 1

2 One Less Excuse To Avoid Transradial Great invention and I d love to invest, but I need to do a right heart catheterization, I m just sticking with the femoral approach Right & Left Heart Catheterization From the Wrist Left Heart Catheter (blue) Right Heart Catheter (white) Gilchrist IC. Cathet Cardiovasc Intervent 2002;55: Forearm Venous System Extreme anatomic variability Collaterals Redundant passages Veins relatively distensible Low pressure vs arterial Venous spasm Less likely with soft catheters Not usually a problem Use nitrates, not Ca ++ blocker 2

3 General Rules of the Road Expect variability, but Radial (lateral) veins tend to form Cephalic vein (50%) Ulnar (medial) veins continue as Basilic vein (100%) Cephalic vein joins with the Axillary vein at a T-Junction. Defines start of the subclavian and central venous system 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 Exchange Heparin Lock for Vascular Sheath Heparin Lock 3

4 Heparin Locks, Needles & Wires Trouble Shooting Access Nurses unable to get access? Try in cath lab ± tourniquet Inspect arm carefully, try other arm Ultrasound for deep vessels (next to arteries) No blood return on sheath aspiration? Veins collapse easily, not a concern if flush flows easily 5F Right Heart Catheters 4

5 Passing Catheter to Central System Do not inflate balloon tips before subclavian Passage should be without resistance X-ray at shoulder to confirm approach to T Junction If resistance, take limited venogram Hydrophilic wire may be helpful Once in subclavian system, rest is like any other upper body venous approach Venogram of Left Upper Arm Passing Smoothly Up the Arm 5

6 Trouble Shoot at the T Junction Trouble Shoot at the T Junction Do not push! Do not inflate balloon in cephalic Inspiration may change angle & enhance central flow Hydrophilic or other small wire may be useful Confirm with venogram Finishing the Procedure Remove right heart catheter with balloon Remove sheath Use local compression (elastic) & elevation for hemostasis Right heart catheter can potentially be left in place, although historical experience suggests a hazard of thrombosis. 6

7 Central Venous Obstruction Obstruction Central Venous Obstruction Devices, s/p trauma, cancer therapy (lines/radiation) risk Venogram if obstruction to catheter Try hydrophilic wire or other small wire May be able to recannulate, but also may perforate catheter solution obstruction icg2009 Obstruction at Shoulder Repair 7

8 Obstruction at Shoulder Repair Prior shoulder fracture Catheter not tracking over hydrophilic wire Venogram shows problem Unable to track course Finished in left arm catheter collaterals solution wire icg2009 Left/Right Heart Procedures Femoral vs Radial Procedural Time Arterial Time Time (minutes) Less radiation time p<.001 Femoral (n=175) Radial (n=105) Femoral (n=175) Radial (n=105) What else from the Arm? Endomyocardial Biopsy Temporary Pacing Caval Filters Moyer CD, Gilchrist IC. Cathet Cardiovas Intervent 2005;64:

9 Forearm Approach Cephalic/Axillary Junction Cephalic vein makes 90 turn Ulnar side access straightest course Right Heart Catheterization Balloon-tip, 120 cm catheter Temporary Pacing Endomyocardial Biopsy Caval Filters Radial Artery Access 4-6 F Micropuncture Sheath Nicardipine vasodilator Systemic heparin Venous Access Heparin lock placed by nurses Exchanged for 5F sheath NTG used for veno-spasm Cautions Obstruction to drainage Radial breast surgery Trauma SVC disease Prior brachial cutdown No visible veins Ref (July 2006): Summary 9

10 Thank you 10

11 Arm Venous Access And Right Heart Catheterization Ian C Gilchrist, MD July 2010 References Cheng NJ, Ho WJ, Ko YS, et al. Percutaneous Cardiac Catheterization Combining Direct Venipuncture Of Superficial Forearm Veins And Transradial Arterial Approach: A Feasibility Approach. Acta Cardiol Sin. 2003;19: Gilchrist IC. Right Heart Catheterization Via the Radial Route: Transradial Access To The Central Venous System. Cardiac Interventions Today Apr; Gilchrist IC. Radial Approach to Right Heart Catheterization and Intervention. Indian Heart Journal 2010; 62(3): Gilchrist IC, Moyer CD, Gascho JA. Transradial Right And Left Heart Catheterizations: A Comparison To Traditional Femoral Approach. Catheter Cardiovasc Interv. 2006;67(4): Gilchrist IC, Kharabsheh S, Nickolaus MJ, Reddy R. Radial Approach To Right Heart Catheterization: Early Experience With A Promising Technique. Catheter Cardiovasc Interv Jan;55(1):20-2. Lo TS, Buch AN, Hall IR, Hildick-Smith DJ, Nolan J. Percutaneous Left And Right Heart Catheterization In Fully Anticoagulated Patients Utilizing The Radial Artery And Forearm Vein: A Two-Center Experience. J Interv Cardiol. 2006;19(3): Moyer CD, Gilchrist IC. Transradial Bilateral Cardiac Catheterization And Endomyocardial Biopsy: A Feasibility Study. Catheter Cardiovasc Interv. 2005;64(2): Yang CH, Guo GB, Yip HK, Hsieh K, Fang CY, Chen SM, Cheng CI, Hang CL, Chen MC, Wu CJ. Bilateral Cardiac Catheterizations: The Safety And Feasibility Of A Superficial Forearm Venous And Transradial Arterial Approach. International Heart J. 2006;47(1):21-7.

12 Antithrombotic Options For Transradial Angiography And PCI Ian C Gilchrist, MD July 2010 References Ahmed I, Gertner E, Nelson WB, House CM, Dahiya R, Anderson CP, Benditt DG, Zhu DWX. Continuing Warfarin Therapy Is Superior To Interrupting Warfarin With Or Without Bridging Anticoagulation Therapy In Patients Undergoing Pacemaker And Defibrillator Implantation. Heart Rhythm 2010;7: Bertrand OF, Rodés-Cabau J, Rinfret S, Larose E, Bagur R, Proulx G, Gleeton O, Costerousse O, De Larochellière R, Roy L. Impact Of Final Activated Clotting Time After Transradial Coronary Stenting With Maximal Antiplatelet Therapy. Am J Cardiol. 2009;104(9): Feray H, Izgi C, Cetiner D, Men EE, Saltan Y, Baltay A, Kahraman R. Effectiveness Of Enoxaparin For Prevention Of Radial Artery Occlusion After Transradial Cardiac Catheterization. J Thromb Thrombolysis. 2010;29(3): Hamon M, Rasmussen LH, Manoukian SV, Cequier A, Lincoff MA, Rupprecht HJ, Gersh BJ, Mann T, Bertrand ME, Mehran R, Stone GW. Choice Of Arterial Access Site And Outcomes In Patients With Acute Coronary Syndromes Managed With An Early Invasive Strategy: The ACUITY Trial. EuroIntervention 2009;5: Pancholy SB. Comparison Of The Effect Of Intra-Arterial Versus Intravenous Heparin On Radial Artery Occlusion After Transradial Catheterization. Am J Cardiol. 2009;104(8): Plante S, Cantor WJ, Goldman L, Miner S, Quesnelle A, Ganapathy A, Popel A, Bertrand OF. Comparison of bivalirudin versus heparin on radial artery occlusion after transradial catheterization. Catheter Cardiovasc Interv Apr 29. [Epub ahead of print] Spaulding C, Lefèvre T, Funck F, Thébault B, Chauveau M, Ben Hamda K, Chalet Y, Monségu H, Tsocanakis O, Py A, Guillard N, Weber S. Left Radial Approach For Coronary Angiography: Results Of A Prospective Study. Cathet Cardiovasc Diag 1996;39: Venkatesh K, Mann T. Transitioning From Heparin To Bivalirudin In Patients Undergoing Ad Hoc Transradial Interventional Procedures: A Pilot Study. J Invasive Cardiol. 2006;18(3):120-4.