Vascular Access: Getting In and Out Safely
One of the most important aspects of a successful catheterization involves decision of access entry point. Several presentations covered case studies with different entry points.
Thomas M. Tu, MD, cardiologist with The Louisville Cardiology group in Louisville, Kentucky, started with a talk entitled, “Case of Difficult Radial Coronary Intervention: No Reason to Give Up.” He presented a radial access catheterization in which he met resistance. In response, he stopped and did angiography to see what was happening to the flow path. Radial anatomy is variable. Later they decided to try the other arm as an entry point and were eventually able to gain access to the coronary artery. In his opinion, you should really take advantage of ultrasound-guided entry if available. Most importantly, Dr Tu emphasized that if you encounter great resistance during the catheterization process, then you should stop, perform an angiogram to see how you are doing, then proceed.
Luis A. Guzman, MD, director of the University of Florida’s catheterization laboratory has completed many studies carefully examining catheterization procedures with respect to minimizing complications. He presented data showing that there is a real learning curve involved in mastering the transradial entry protocol. However, the advantages of transradial entry include less bleeding, more patient comfort, less radiation exposure for the operator, early discharge for the patient, and fewer complications. Dr Guzman’s study revealed that bifurcations are the most common anatomic variation observed with transradial access. In short, he prefers transradial access entry but recognizes there are challenges ahead for transitioning more cardiologists to using this method.
Next Rahul Sakhuja, MD, cardiologist with the Wellmon CVA Heart Institute in Kingsport, Tennessee, presented several case studies involving catheterizations that led to bleeding. One of the major points that he made was that if your sheath is larger than your artery, then you are going to be in trouble. He also observed that calcification clearly does matter in catheterization. You can “get stuck between a rock and a hard place” if you do not consider calcification made apparent by CTA.
Greg O. von Mering, MD, interventional cardiologist with the Munroe Regional Medical Center in Ocala, Florida, elaborated on the importance of the external diameter, not the internal diameter for which each catheterization device is designated. He pointed out how they started out with small catheters, but today we are using much larger catheters. You should take into consideration all of the information you can gather using ultrasound, CTA, and angiography. You must have an artery with adequate diameter, but not too much calcification so that you can straighten your catheter as your proceed.
In the final presentation, Bruce Gray, DO, cardiologist with the Greenville Health System in Greenville, South Carolina, discussed a wide variety of potential catheter access entries. Dr. Gray emphasized that you must perform careful patient evaluation with complete imaging. Realize that vascular access complications are common; so be prepared in advance with a plan of action. Be sure to attempt to use disease-free access points and to have a strategy in place for arteriotomy management.
Overall, the session involved the sharing of invaluable practical real world clinical experiences. It was highly appreciated by all practicing interventional cardiologists in attendance.