Antecubital vs Femoral Venous Access for Right Heart Catheterization: Benefits of a Flashback

Upper extremity versus lower extremity for secondary access during transcatheter aortic valve implantation: rationale and design of the randomised TAVI XS trial

BACKGROUND

During transcatheter aortic valve implantation (TAVI), secondary access is required for angiographic guidance and temporary pacing. The most commonly used secondary access sites are the femoral artery (angiographic guidance) and the femoral vein (temporary pacing). An upper extremity approach using the radial artery and an upper arm vein instead of the lower extremity approach using the femoral artery and femoral vein may reduce clinically relevant secondary access site-related bleeding complications, but robust evidence is lacking.

TRIAL DESIGN

The TAVI XS trial is a multicentre, randomised, open-label clinical trial with blinded evaluation of endpoints. A total of 238 patients undergoing transfemoral TAVI will be included. The primary endpoint is the incidence of clinically relevant bleeding (i.e. Bleeding Academic Research Consortium (BARC) type 2, 3 or 5 bleeding) of the randomised secondary access site (either diagnostic or pacemaker access, or both) within 30 days after TAVI. Secondary endpoints include time to mobilisation after TAVI, duration of hospitalisation, any BARC type 2, 3 or 5 bleeding, and early safety at 30 days according to Valve Academic Research Consortium‑3 criteria.

CONCLUSION

The TAVI XS trial is the first randomised trial comparing an upper extremity approach to a lower extremity approach with regard to clinically relevant secondary access site-related bleeding complications. The results of this trial will provide important insights into the safety and efficacy of an upper extremity approach in patients undergoing transfemoral TAVI.

Using Upper Arm Vein as Temporary Pacemaker Access Site: A Next Step in Minimizing the Invasiveness of Transcatheter Aortic Valve Replacement

Background The femoral vein is commonly used as a pacemaker access site during transcatheter aortic valve replacement (TAVR). Using an upper arm vein as an alternative access site potentially causes fewer bleeding complications and shorter time to mobilization. We aimed to assess the safety and efficacy of an upper arm vein as a temporary pacemaker access site during TAVR. Methods We evaluated all patients undergoing TAVR in our center between January 2020 and January 2023. Upper arm, femoral, and jugular vein pacemaker access was used in 255 (45.8%), 191 (34.3%), and 111 (19.9%) patients, respectively. Clinical outcomes were analyzed according to pacemaker access in the overall population and in a propensity-matched population involving 165 upper arm and 165 femoral vein patients. Primary endpoint was Bleeding Academic Research Consortium (BARC) type 2, 3, or 5 pacemaker access site-related bleeding. Results In the overall population, primary endpoint was lowest for upper arm, followed by femoral and jugular vein access (2.4% vs. 5.8% vs. 10.8%, p = 0.003). Time to mobilization was significantly longer (p < 0.001) in the jugular cohort compared with the other cohorts. In the propensity-matched cohort, primary endpoint showed a trend toward lower occurrence in the upper arm compared with the femoral cohort (2.4% vs. 6.1%, p = 0.10). Time to mobilization was significantly shorter (480 vs. 1140 min, p < 0.001) in the upper arm cohort, with a comparable skin-to-skin time (83 vs. 85 min, p = 0.75). Cross-over from upper arm pacemaker access was required in 17 patients (6.3% of attempted cases via an upper arm vein). Conclusions Using an upper arm vein as a temporary pacemaker access site is safe and feasible. Its use might be associated with fewer bleeding complications and shorter time to mobilization compared with the femoral vein.

Right Heart Catheterization: An Antecubital Vein Approach to Reduce Fluoroscopy Time, Radiation Dose, and Guidewires Need

Antecubital access for right heart catheterization (RHC) is a widespread technique, even though there is a need to clarify if there are differences and significant advantages compared to proximal vein access. To pursue this issue, we retrospectively identified patients who underwent RHC in our clinic over a 7 year period (between January 2015 and December 2022). We revised demographic, anthropometric, and procedural data, including the fluoroscopy time, the radiation exposure, and the use of guidewires. The presence of any complications was also assessed. In patients with antecubital access, the fluoroscopy time and the radiation exposure were lower compared to proximal vein access (6 vs. 3 min, mean difference of 2 min, CI 95% 1-4 min, p < 0.001 and 61 vs. 30 cGy/m2, mean difference 64 cGy/m2, CI 95% 50-77, p < 0.001). The number of patients requiring the use of at least one guidewire was lower in the group undergoing RHC through antecubital access compared to proximal vein access (55% vs. 43%, p = 0.01). The feasibility was optimal, as just 0.9% of procedures switched from antecubital to femoral access, with a negligible rate of complications. The choice of the antecubital site exhibits advantages, e.g., a shorter fluoroscopy time, a reduced radiation dose, and a lower average number of guidewires used compared to proximal vein access.

Endocavitary electrophysiological study by percutaneous antecubital vein and without X-ray for risk stratification of asymptomatic ventricular pre-excitation in young athletes

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Evaluation of AP is usually performed by transesophageal and intracardiac studies.

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In young athletes with AVP, our standard of care is to perform ESnoXR.

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ESnoXR may considered a less invasive alternative for risk stratification of AP.

Athletes with asymptomatic ventricular pre-excitation (VP) should undergo electrophysiological study for risk stratification. We aimed to evaluate the feasibility, efficacy, safety and tolerability of an electrophysiological study using a percutaneous antecubital vein access and without the use of X-ray (ESnoXr). Methods: We collected data from all young athletes < 18 year-old with AVP, who underwent ESnoXr from January 2000 to September 2020 for evaluation of accessory pathway refractoriness and arrhythmia inducibility using an antecubital percutaneous venous access. Endocavitary signals were used to advance the catheter in the right atrium and ventricle. Results: We included 63 consecutive young athletes (mean age 14.6 ± 1.9 years, 46% male). Feasibility of the ESnoXr technique was 87% while in 13% fluoroscopy and/or a femoral approach were needed. Specifically, fluoroscopy was used in 7 cases to position the catheter inside the heart cavities with an average exposure of 43 ± 38 s while in 2 femoral venous access was needed. The mean procedural time was 35 ± 11 min. The exam was diagnostic in all patients, there were no procedural complications and tolerability was excellent. 53% of the patients had an accessory pathway with high refractoriness and no inducible atrio-ventricular reentry tachycardia: this subgroup was considered eligible to competitive sports and no event was observed during long-term follow-up (13.6 ± 5.2 years) without drug use. The others underwent catheter ablation. Conclusion. ESnoXr has been shown to be a feasible, effective, safe and well-tolerated procedure for the assessment of arrhythmic risk in a population of young athletes with asymptomatic VP.

The Transbrachial Venous Approach for Pelvic Congestion Syndrome Embolization: An Easy Way to Outpatient Procedure

BACKGROUND

Pelvic congestion syndrome (PCS) is a frequent finding in adult women and transcatheter embolization of dilated and refluxing veins is the treatment of choice. The procedure can be performed through different venous accesses such as the transfemoral, transjugular, and the transbrachial access. The aim of this study was to demonstrate the feasibility and safety of the transbrachial approach for transcatheter embolization in this pathology in 201 women. Advantages and disadvantages of this access were discussed.

METHODS

Between January 2007 and October 2020, female patients who underwent transcatheter embolization for PCS were selected. Embolization procedural details such as venous access sites and embolized veins were collected.

RESULTS

Two hundred and one patients were selected for pelvic vein embolization due to PCS. The basilic vein was punctured in 103 patients (51.2%), the cephalic vein was chosen in 76 patients (37.8%) and deep brachial veins in 19 (9.6%). Technical success was observed in 198 (98.5%) cases. Only one major adverse effect was registered; one patient presented with hematoma of the arm that could be managed conservatively.

CONCLUSION

The transbrachial venous approach for PCS embolization is safe, effective and minimal invasive. It provides a significant patient comfort, has a low complication rate and can be performed on an outpatient basis.

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series

BACKGROUND

Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.

METHODS

An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.

RESULTS

One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).

CONCLUSIONS

UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.

Safety and feasibility of upper limb vascular access for cardiac catheterization in anticoagulated and non-anticoagulated patients

BACKGROUND

The upper limb approach utilizing transradial access for combined left and right heart catheterization (CLRHC) and ultrasound-guided antecubital venous access for isolated right heart catheterization (IRHC) are strategies that may reduce risks, especially in anticoagulated patients. combined left and right heart catheterization.

OBJECTIVES

To assess safety and feasibility of upper limb approach for IRHC or CLRHC in anticoagulated versus non-anticoagulated patients.

METHODS

Ninety-three patients who underwent IRHC or CLRHC with ultrasound-guided antecubital venous access and transradial arterial access were prospectively enrolled. The primary outcome was a composite of procedure failure and incidence of immediate vascular complications.

RESULTS

Of the 93 patients, 44 (47%) were on anticoagulation and 49 (53%) were not. Mean age was 54 ± 17 and 53 ± 15 years, respectively. Atrial fibrillation (39% vs 15%) and chronic kidney disease (21% vs 6%) were more common in anticoagulated patients. The main indication for anticoagulation was deep vein thrombosis/pulmonary thromboembolism in 22 patients (50%). The primary outcome occurred in 4 (8%) patients in the non-anticoagulated group as compared with 0 in the anticoagulated group (p = 0.12). Procedure failure occurred in two patients (4%) and immediate vascular complications in two patients (4%) in the non-anticoagulated group (p = 0.3 for all). There was no difference between groups regarding duration of the procedure, radiation dose, fluoroscopy time, post-procedure recovery room time and median time to venous or arterial hemostasis.

CONCLUSIONS

The upper limb approach for heart catheterization had similar rates of procedure failure and immediate vascular complications in anticoagulated patients when compared to non-anticoagulated patients.

Ultrasound-guided antecubital vein approach for right heart catheterisation in a Brazilian tertiary centre

Objective

As a parallel to the radial approach for left heart catheterisation, forearm veins may be considered for the performance of right heart catheterisation. However, data regarding the application of this technique under ultrasound guidance are scarce. The current study aims to demonstrate the feasibility of right heart catheterisation through ultrasound-guided antecubital venous approach in the highly heterogeneous population usually referred for right heart catheterisation.

Methods

Data from consecutive right heart catheterisations performed at an academic centre in Brazil, between January 2016 and March 2017 were prospectively collected.

Results

Among 152 performed right heart catheterisations, ultrasound-guided antecubital venous approach was attempted in 127 (84%) cases and it was made feasible in 92.1% of those. Yet, there was no immediate vascular complication with the antecubital venous approach in this prospective series.

Conclusions

Ultrasound-guided antecubital venous approach for the performance of right heart catheterisation was feasible in the vast majority of cases in our study, without occurrence of vascular complications.

Feasibility and safety of the antecubital venous access for right heart catheterization in patients with pulmonary hypertension

Background

The diagnosis of pulmonary arterial hypertension requires right heart catheterization (RHC) which is typically performed via proximal venous access (PVA). Antecubital venous access (AVA) is an alternative approach for RHC that can minimize complications, decrease procedural duration and allow for immediate patient recovery. A direct comparison between the two procedures in patients with pulmonary hypertension (PH) is lacking.

Objectives

To determine the feasibility, safety, and adoption rates of AVA-RHC as compared with ultrasound-guided PVA in a subpopulation of patients with PH.

Methods

All patients who underwent RHC for evaluation of PH between December 2014 and March 2017 at a single large academic medical center were included in this study. Demographic, procedural and outcomes data were retrieved from the medical records.

Results

In total, 159 RHC were included (124 AVA, 35 PVA). The duration of RHC was significantly shorter in the AVA compared with PVA group (53 (IQR 38–70) vs. 80 (IQR 56–95) min, respectively, p < 0.001). 19% of AVA (24/124) procedures were switched to PVA. Failed attempts at AVA were more common in scleroderma (50% failure rate). Success rate of AVA increased from 81.2% to 93.3% from the first to last quartile. Fluoroscopy time was similar in both groups, the difference between the groups in the radiation dose are not statistically significant (54.5 (IQR 25–110) vs. 84.5 (IQR 30–134)).

Conclusion

AVA-RHC is a feasible and safe alternative to PVA in patients with PH who are evaluated for pulmonary arterial hypertension diagnosis. Our experience and rapid adoption rate support the use of AVA as the preferred access site for RHC in uncomplicated PH patients.

RadialFirst in CHIP and Cardiogenic Shock

This article highlights the advantages and disadvantages of transradial arterial (TRA) access for a variety of presentations including acute coronary syndromes; cardiogenic shock; unprotected left main, heavily calcified coronaries; bifurcations; and chronic total occlusions. It includes techniques for overcoming challenges of using TRA access, including spasm and the need for larger bore guides. In addition, the authors review the use of ultrasound for access, percutaneous hemodynamic support via axillary approach, and tips and tricks to performing right heart catheterizations from the antecubital vein.

Right heart catheterization procedures in patients with suspicion of pulmonary hypertension - experiences of a tertiary center

INTRODUCTION

Right heart catheterization (RHC) is an invasive procedure providing direct and accurate measurements of hemodynamics of the cardiovascular system. Acute pulmonary vasoreactivity testing (APVT) following basal RHC in some patients is an established tool evaluating the reversibility of hypertension in the pulmonary vasculature.

AIM

We sought to assess the most common indications, vascular approaches and complications during RHC in a single high-volume center.

MATERIAL AND METHODS

A total of 534 RHC procedures in 348 patients (64% male) were performed. The prospective registry was carried out for 28 months. Collected data included indications for RHC, vascular approaches, hemodynamic and clinical data, complications and response of pulmonary vessels in APVT.

RESULTS

In 401 (75%) procedures pulmonary hypertension (mean pulmonary artery pressure (mPAP) ≥ 25 mm Hg) was confirmed. Left heart failure was the most common indication (55.8%), mainly ischemic (26%) or dilated cardiomyopathy (19.9%). Other indications included a suspicion of arterial (21.7%), or chronic thromboembolic pulmonary hypertension (14.6%). The right internal jugular vein approach was used in 89.1% of procedures. Acute pulmonary vasoreactivity testing was performed in 143 patients, and it was positive in 67 (46.9%) cases. Complications occurred in 21 (3.9%) procedures and included pulmonary edema (0.2%), pneumothorax (0.2%) and puncture of the artery followed by the insertion of a vascular sheath (0.4%), atrial arrhythmia (0.2%), superior vena cava dissection (0.2%), incidental artery puncture (1.1%) and local hematoma (2.2%).

CONCLUSIONS

The most frequent indication for RHC was left heart failure, and the most common approach was the right internal jugular vein. RHC is safe procedure with a low rate of major complications.

Brachial Approach As an Alternative Technique of Fibrin Sheath Removal for Implanted Venous Access Devices

Implanted venous access device (IVAD) late dysfunction is commonly caused by fibrin sheath formation. The standard method of endovascular fibrin sheath removal is performed via the femoral vein. However, it is not always technically feasible and sometimes contraindicated. Moreover, approximately 4–6 h of bed rest is necessary after the procedure. In this article, we describe an alternative method of fibrin sheath removal using the brachial vein approach in a young woman receiving chemotherapy for breast cancer. The right basilic vein was punctured, and a long 6°F introducer sheath was advanced into the right subclavian vein. Endovascular maneuvers consisted on advancing Atrieve™ Vascular Snare 15–9 mm after catheter insertion in the superior vena cava through a 5.2°F Judkins left catheter. IVAD patency was restored without any complication, and the patient was discharged immediately after the procedure. In conclusion, fibrin sheath removal from an obstructed IVAD could be performed via the right brachial vein. Further research is necessary in order to prove efficacy of this technique.