Access: Femoral, Radial, Brachial, Carotid

Fig. 2.1

Components of a micropuncture set. The 7 cm 21G needle (green hub) is still in a protective sheath that will be discarded when the needle is ready for use. The 40 cm 0.018″ wire is seen exiting its sheath. Once the needle is introduced into the blood vessel, the wire is advanced into the vessel through the needle hub. The needle is then retracted and removed. The micropuncture sheath (gray) is seen on the right side. The introducer can be seen extending out of its hub. The introducer is advanced fully into the sheath such that its cap securely clips on to sheath hub. The tip of introducer then extends beyond the tip of sheath. This unit is threaded over the wire into the blood vessel. Once the sheath is appropriately positioned, the introducer and wire are simultaneously removed, leaving the sheath in place

Partially pull out the 0.018″ guidewire provided in the kit from its sheath, to ensure no difficulties will be encountered in introducing it into the needle.

Keep these items on a towel spread close to the draped groin, so that they can be retrieved readily during access, without having to stretch out, or having to let go of the needle in the vessel.

After the groin region is appropriately prepped and draped, palpate the pulse for femoral artery.

Span from the anterior, superior iliac crest to the pubic symphysis with left hand to approximate the ilioinguinal ligament. Bisect the span with right hand, which indicates the location of femoral artery. Palpate for the pulsations of the femoral artery at this spot (Fig. 2.2a).

Fig. 2.2

a The pulsations of femoral artery are palpated at the point midway between anterior superior iliac spine and symphysis pubis. b The needle is stabilized with one hand as the microwire is introduced into the needle hub with the other and then advanced into the artery (c). d The microwire (curved arrow) has been introduced into the femoral artery through the micropuncture needle (arrow). e In case of any resistance, fluoroscopy can be performed to verify that the microwire is indeed intravascular. f Once the microwire has secured access to femoral artery, the needle is removed over wire. g, h, i The microsheath unit is then threaded over the wire, taking care that the wire is not inadvertently pulled out of the artery. j Following complete insertion of micropuncture sheath, the introducer hub is detached from that of the sheath. As can be seen in the figure, one hand maintains the micropuncture sheath securely in place, while the other withdraws the introducer and wire (obstructed from view by hand) simultaneously. k The introducer is almost completely out of the sheath hub, which is maintained in place. The retracting hand is holding on to the introducer hub and wire concurrently. l As soon as the wire and introducer are withdrawn, cover the hub of micropuncture sheath with thumb, to prevent unnecessary blood loss. m The J wire is inserted into the microsheath. The white introducer, obvious between the hands, enables easy insertion of the wire into microsheath by straightening out the ‘J’ shape of the tip. The same can also be done by holding the wire between index finger and thumb and then sliding the thumb back. This movement straightens out the J shape. n Advance additional wire further into the sheath, to ensure it extends into the vessel beyond sheath tip. o After insertion of the wire into the sheath, adequate length still remains outside, to ensure against inadvertent loss of wire into patient’s vasculature. p, q After removal of the smaller sheath, the sheath to be used for procedure is introduced over the wire and advanced over it into the accessed vessel (q). The sheath has its introducer in place, to enable smooth insertion. r The sheath is completely advanced into the vessel, such that its hub is right next to the skin. s, t The wire and introducer are removed from the sheath simultaneously, leaving the sheath in place (t). u The sheath is connected to a continuously running flush of heparinized saline. v It must be ensured the flush system is bubble free. To this end, the three-way stopcock at site of connection has been turned toward the saline flush. This results in back bleeding that exits through the free port. A gauze is used to soak up most of the exiting fluid, in an effort to keep the operative site clean. w The three-way stopcock is then turned toward the sheath. This results in occlusion of back bleeding while the saline flush flows out of the free port, cleaning it. The sequence of occluding the flush and then the sheath, washes out any air bubbles, clots or other particles through the free port. x The three-way stopcock is finally turned to freeport, resulting in establishment of continuous heparinized saline flow to the sheath. y The sheath is secured by suturing to the patient’s skin using the eyelet on the sheath provided for this purpose, to avoid inadvertent dislodgement. z Following completion of suturing, the operative site is cleansed. The operator should also ensure her/his gloves are clean, free of blood. Meticulous hygiene is practiced at all times to ensure there is no introduction of clots or foreign bodies into patient’s vasculature
One may also confirm the planned puncture site by placing tip of hemostat or scissors over the pulse and visualizing its relationship to the femoral head fluoroscopically. The femoral artery should be punctured at the inferomedial aspect of the femoral head.

Immobilize a segment of the artery between the index and middle fingers of left hand.

Infiltrate the skin overlying the immobilized segment with local anesthesia, using 1% lidocaine with epinephrine.

Also infiltrate the tissues overlying the artery, aspirating prior to injecting, to ensure the lidocaine is not administered into the arterial lumen. If the artery lumen is entered, blood will be aspirated into the syringe, indicating that the needle needs to be withdrawn.

Make a small, superficial stab incision in the skin overlying the immobilized segment.

The needle used for puncturing the artery may be from 21 to 23G.

Using the free right hand, hold the needle with the thumb, index, and middle fingers, with the bevel leading and the opening pointing upwards. Enter through the stab at 45° over the site where arterial pulsations are felt. An indentation in the hub (aligned with the bevel, which should be positioned superiorly) of the needle also assists in correct positioning of the needle tip.

When the artery is punctured and needle is in its lumen, blood will emanate from the needle hub.

Stop advancing the needle once within the lumen and avoid going through the facing arterial wall, resulting in a double wall puncture.

Without moving the needle any further, gently cover the hub with your thumb.

Use your free hand to pick the provided wire and advance it into the needle hub, introducing it into the arterial lumen (Fig. 2.2b, c, d).

If any resistance is sensed, fluoroscopically confirm the location and correct intravascular trajectory of the wire (Fig. 2.2e).

Make sure to have control of some segment of the wire at all times, a part of which should always extend out of the needle hub.

Once the wire is 5–10 cm into the arterial lumen, retract the needle over the wire (Fig. 2.2f). Make sure to have control of some segment of the wire at all times.

Introduce the pre-assembled micropuncture sheath with dilator over the wire into the artery (Fig. 2.2g, h). Again, ensure a hold of some segment of the wire at all times and advance the microsheath completely (Fig. 2.2i).

Withdraw the wire and introducer, leaving the sheath in the artery (Fig. 2.2j, k).

Cover the hub of the sheath with your thumb to prevent unnecessary blood loss (Fig. 2.2l).

Introduce a J wire (60–70 cm) into the sheath, until it is in the artery well beyond the sheath (Fig. 2.2m, n). Again, ensure that access is available to some segment of the wire at all times (Fig. 2.2o).

Maintaining control of wire at all times, retract, and completely withdraw the small sheath over the wire.

Compress the artery with the same (left) hand which is holding onto the wire to prevent bleeding from the enlarged entrance wound.

Introduce the 5 Fr or larger sheath over the wire into the arterial lumen (Fig. 2.2p, q, r).

Retract and remove the wire and sheath introducer, when the sheath has been positioned in the artery (Fig. 2.2s, t).

Connect the sheath to previously prepared tubing with a neonatal transducer to ensure the continuously running heparinized saline solution is at a rate of 30 ml/hr (Fig. 2.2u).

Prior to even beginning the procedure, the heparinized saline flush systems for the sheath and at least one catheter should be prepared. It should be ensured that the entire tubing system is free of air bubbles, or any other foreign material (see Chap. 1).

Make a wet connection so that no air bubbles enter the vascular system (Fig. 2.2v, w, x; also see Chap. 1).

Secure the sheath by suturing it to the skin using 2-0 silk, or covering it with Tegaderm adhesive to the skin (Fig. 2.2y, z).