U l t r a s o u n d - G u i d e d Va s c u l a r

Access
Peter O. Simon Jr, MDa,*, Wael E. Saad, MBBCh, FSIRb

KEYWORDS
! Ultrasound-guided venous access ! Ultrasound-guided arterial access
! Diagnostic ultrasonography ! Hemostasis

KEY POINTS
! Ultrasound-guided vascular access is the initial step in an array of medical procedures.
! The adjunct of ultrasound guidance has been shown to have numerous beneficial effects on ac-
cessing arterial and venous structures, including shortened procedure times, more precise
access, and reduced morbidity/complication rates.
! This article discusses the indications, techniques, periprocedure management, imaging modali-
ties, and outcomes related to ultrasound-guided vascular access.

BROAD INDICATIONS Subclavian Vein

! Diagnostic angiography/venography ! Long-term central venous access for im-
! Placement of indwelling reservoir/catheter/ plants (temporary, tunneled, reservoir de-
device vices [ports], and cardiac devices)
! Vascular access for the purpose of thera- ! Access for central venous interventions such
peutic intervention. as pressure measurements, venous throm-
bolysis, venoplasty, or stent placement
! IVC/SVC filter deployment.

COMMON INDICATIONS FOR VENOUS Internal Jugular Vein

ACCESS
! Long-term central venous access (tunneled,
Upper Extremity Veins
nontunneled, and reservoir devices [ports],
! Peripheral intravenous access for fluid, and cardiac devices such as temporary
medication, or blood product infusions pacers).
! Venography ! Access for central venous interventions such
! Central venous access such as peripherally as transjugular biopsy, transjugular intrahe-
inserted central catheter (PICC) lines and patic portosystemic shunt placement (TIPS),
reservoir devices (ports) pressure measurements, venous thromboly-
! Access for central venous interventions such sis, venoplasty, or stent placement.
as embolization procedures, venous throm- ! IVC/SVC filter deployment
bolysis, venoplasty, or stent placement ! Foreign-body retrieval
! Inferior vena cava (IVC)/superior vena cava ! Transvenous biopsies (such as renal,
(SVC) filter deployment. cardiac, liver)
ultrasound.theclinics.com

a
Vascular and Interventional Radiology / Special Procedures, University of Virginia Health System, 1215 Lee Street,
PO Box 800170, Charlottesville, VA 22908, USA; b Division of Vascular Interventional Radiology, Department of
Radiology and Imaging Sciences, University of Virginia Health System, Charlottesville, VA, USA
* Corresponding author.
E-mail address: [email protected]

Ultrasound Clin 7 (2012) 283–297

doi:10.1016/j.cult.2012.04.001
1556-858X/12/$ – see front matter ! 2012 Published by Elsevier Inc.
284 Simon & Saad

! Reproductive therapies such as gonadal Common Femoral Artery

vein embolization.
! Access site of choice for most diagnostic
and therapeutic catheter-based arterial
Common Femoral Vein interventions
! Access for central venous therapeutic inter- ! Angiography of virtually any vascular bed
ventions such as thrombolysis, venoplasty, to include the mesenteric circulation,
stenting, or treatment of gastric varices upper and lower extremity runoff, cardiac
(balloon-occluded retrograde transvenous arteriography, carotid arteriography, and in-
obliteration) tracranial/intraspinal arteriography
! IVC/SVC filter deployment ! Intra-arterial therapeutic intervention to virtu-
! Secondary consideration for indwelling ally any vascular bed to include embolization,
central venous catheters (tunneled cathe- angioplasty, stenting, stent-graft deploy-
ters, nontunneled catheters, ports, and ment, pressure measurement, therapeutic
cardiac devices such as temporary pacers). delivery of medication, arterial thrombolysis,
! Secondary consideration for indwelling and placement of indwelling intra-arterial
central venous catheters (tunneled cathe- devices.
ters, nontunneled catheters, ports, and
cardiac devices such as temporary pacers) VASCULAR ACCESS PRECAUTIONS AND
! Secondary consideration for intrahepatic PREPROCEDURAL EVALUATION
procedures
Guidelines for safe practices regarding coagulation
! Reproductive therapies such as gonadal
status and hemostasis risk are outlined in Table 1.
vein embolization
Each case whereby thresholds are exceeded must
! Adrenal vein or petrosal sinus sampling.
be evaluated individually, taking into account addi-
tional parameters such as patient’s condition,
Below-the-Knee (Popliteal and Tibial) Veins surgical options, and resources available in an indi-
! Access for central venous therapeutic vidual health system.
interventions
Initial Patient Evaluation
! Access for central venous interventions
such as venous thrombolysis, venoplasty, ! Review previous cross-sectional imaging/
or stent placement. laboratory studies.
! Evaluate for anomalous vessels.
INDICATIONS FOR ARTERIAL ACCESS ! Evaluate vessel patency and course. For
Radial Artery example, an occluded SVC would preclude
an internal jugular vein approach for TIPS.
! Arterial pressure monitoring/blood gas Also, check for an enlarged inguinal hernia
analysis. when planning a femoral vessel access.
! Evaluate for preexisting vascular injuries.
Brachial/Axillary Artery Avoid access where there is a vascular
injury from a prior access such as pseudoa-
! Aortography for diagnostic or therapeutic neurysms, arteriovenous fistulas, and large
purposes hematomas.
! Cardiac arteriography ! Obtain informed consent.
! Cardiac catheterization (angioplasty/stent ! Document a baseline vascular examination.
placement) The mainstay of the distal vascular exami-
! Secondary site for abdominal or peripheral nation is examination of the distal artery
intervention such as angioplasty, stenting, pulses (palpation, auscultation, Doppler
stent-graft procedures or embolization ultrasonography), skin color, temperature,
! Arterial pressure monitoring/blood gas and capillary refill.
analysis. ! A neurologic examination is required for
carotid access or whenever the catheter
Carotid Artery reaches the aortic arch.
! Rarely used; may be considered in usual
Preprocedural Imaging
cases such as the treatment of an atypical
aortic arch reconstruction or angioplasty Invasive diagnostic vascular evaluations have
procedure of the supra-aortic vessels. largely been replaced by noninvasive alternatives,
 Ultrasound-Guided Vascular Access 285

Table 1
Society of Interventional Radiology guidelines for coagulation status and hemostasis risk

Preprocedural Laboratory
Procedure Bleeding Risk Studies Management
Dialysis interventions Low risk INR, aPTT, Hct, Plt INR >2.0: treatment with
FFP or vitamin K
PICC line placement Plt <50,000/mL: transfusion
recommended
Venography
IVC filter placement
Arterial intervention Moderate risk INR INR >1.5: treatment with
up to 7F FFP or vitamin K
Venous intervention aPTT (in setting of Plt <50,000/mL: transfusion
intravenous heparin use) recommended
Chemoembolization Withhold clopidogrel for
5 days prior
Uterine fibroid
embolization
Tunneled central
venous line
Subcutaneous port
device
TIPS Significant risk INR, aPTT, Hct, Plt INR >1.5: treatment with
FFP or vitamin K
Plt <50,000/mL: transfusion
recommended
Withhold clopidogrel for
5 days prior
Withhold ASA for 5 days
prior

Abbreviations: aPTT, activated partial thromboplastin time; ASA, acetylsalicylic acid; FFP, fresh frozen plasma; Hct, hemat-
ocrit; INR, international normalized ratio; IVC, inferior vena cava; PICC, peripherally inserted central catheter; Plt, platelet
count; TIPS, transjugular intrahepatic portosystemic shunt.
Data from Malloy PC, Grassi CJ, Kundu S, et al. Consensus guidelines for periprocedural management of coagulation
status and hemostasis risk in percutaneous image-guided interventions. J Vasc Interv Radiol 2009;20:S246–7.

which include cross-sectional imaging techniques ! Infection to include cellulitis, abscess, fistula,
such as computed tomography (CT) and magnetic and bloodstream infections with subsequent
resonance imaging. Review of any available im- complications.
ages before undertaking an invasive intervention
such as ultrasound-guided vascular access is A current review of complication rates of femoral
crucial in selecting the most appropriate access arterial ultrasound-guided vascular access is pre-
route and avoiding vital structures, thus limiting sented in Table 2. Complication rates of internal
potential complications. jugular and subclavian venous access with sug-
gested thresholds is presented in Table 3. Finally,
complication rates from upper extremity venous
General Procedural Risks for Ultrasound- access are presented in Table 4.
Guided Vascular Access
! Hemorrhage Requisite Equipment
! Pain Ultrasound-related equipment
! Neuropathy
! Pseudoaneurysms ! Doppler-capable ultrasound machine
! Dissection ! Linear, high-frequency transducer (7.5 MHz
! Arteriovenous fistula or greater)
286 Simon & Saad

Table 2 Table 4
Complications of ultrasound-guided femoral Complications of upper extremity venous
arterial puncture for diagnostic or therapeutic access (PICCs and peripheral ports)
procedures
Suggested
Incidence Suggested Threshold
in Threshold Complication Incidence (%) Rate (%)
Complication FAUST Trial Rate (%)
Pneumothorax 0 0
Hematoma "5 cm 0.6% 2 Hemothorax 0 0
(3/503)
Arterial injury 0.5 1
Pseudoaneurysm 0.2% 1
Hematoma 1 2
(1/503)
Wound dehiscence 1 2
Dissection 0.4% 1
(2/503) Procedure sepsis 1 2
Blood transfusion 0.2% 1 Venous thrombosis 3 6
(1/503) Phlebitis 4 8
Hematoma with DVT 0% (0/503) 1
Data from Dariushnia SR, Wallace MJ, Siddiqi NH, et al.
Arteriovenous 0% (0/503) 1 Quality improvement guidelines for central venous access.
fistula J Vasc Interv Radiol 2010;21:978.
Any complication 1.4% <5
(7/503)
! Fenestrated drape or surgical drape mate-
Abbreviations: DVT, deep venous thrombosis; FAUST, rial. Full body drape is considered standard,
Femoral Arterial Access with Ultrasound Trial. except under conditions whereby it is not
Data from Seto AH, Abu-Fadel MS, Sparling JM, et al. practical (code situations, for example).
Real-time ultrasound guidance facilitates femoral arterial
access and reduces vascular complications: FAUST (Femoral
Local Anesthesia
Arterial Access With Ultrasound Trial). JACC Cardiovasc
Interv 2010;3(7):755. ! 21-gauge needle
! 1% lidocaine (with alternatives available in
! Sterile transducer cover the event of patient allergy)
! Transducer guides are typically not neces- ! Luer lock syringe.
sary, although sometimes preferred by Surgical Adjuncts
some practitioners.
! 11-blade scalpel
Standard Surgical Preparation and Draping ! Sterile towels as necessary.
! Chlorhexidine skin preparation solution Graduated Access Devices
! Graduated, telescopic dilation system to
Table 3 initially gain access with 21-gauge needle
Complications of internal jugular or subclavian (0.018-in wire) and to upsize to 0.035-in
venous access system. This system is typically referred to
as a micropuncture kit and usually consists
Suggested of a 2.5F to 3F inner dilator and a 4F to 5F
Threshold outer dilator.
Complication Incidence (%) Rate (%)
! Fascial dilator for the purpose of dilating
Pneumothorax 1–3 4 a soft-tissue tract to allow a catheter/sheath
Hemothorax 1 2 to enter into a blood vessel with less resis-
Hematoma 1–3 4 tance. The dilator is typically advanced
Air embolus 1 2 over a 0.035-in guide wire.
! Peel-away sheath, used for the introduction
Wound dehiscence 1 2
of a tunneled central venous line or implant-
Procedure sepsis 1–3 4 able port/reservoir catheter into a vascular
Venous thrombosis 4 8 territory.
Data from Dariushnia SR, Wallace MJ, Siddiqi NH, et al.
! Side-port vascular sheath; used for main-
Quality improvement guidelines for central venous access. taining a secure arterial or venous access
J Vasc Interv Radiol 2010;21:978. for the purposes of exchanging diagnostic
 Ultrasound-Guided Vascular Access 287

catheters or interventional devices (typically entering the vessel at a favorable angle

4F to 5F). that allows for sufficient subcutaneous tissue
coverage, avoids structures that may result
PROCEDURAL TECHNIQUE in morbidity, and facilitates resistance-free
advancement of the guide wire into the
For the purposes of this article, a general approach target vascular territory.
for ultrasound-guided vascular access is pre- ! During the planning scan, it is also useful to
sented initially. Considerations specific to access follow the course of the target vessel as
site are then be addressed in subsequent much as possible, to identify any features
sections. that may preclude access such as a distal
occlusive thrombus.
Intravenous Access and Medication
! Intravenous access is necessary for the
delivery of sedative medication and fluid General Anatomic Considerations
resuscitation, and should be maintained ! Under most conditions, arteries have a clearly
until the patient is discharged. In selected discernible wall and veins have an imper-
cases (such as PICC line placement), the ceptible wall on high-frequency ultrasonog-
access to be placed may serve this purpose. raphy. During the initial evaluation, the
provider should follow the target vessel
Preprocedure Ultrasonographic Evaluation distally as much possible to assess patency.
! Identify the target vessel and segment, typi- ! Veins compress with less manual pressure
cally done in the transverse plane to the than do arteries. Arteries are seen pulsating
target vessel. Be aware that some investi- under manual compression when the adja-
gators and advance practitioners also advo- cent vein is collapsed (see Fig. 1).
cate evaluation in the longitudinal plane to ! Conditions under which veins are difficult to
ensure targeting of the optimal segment compress include thrombosis, large body
and avoidance of adjacent structures. habitus, profound edema, and extremity
! Perform mild compression to characterize tenderness/lack of patient cooperation.
adjacent vascular structures such as arteries
and veins. Be aware that this examination
Standard Preparation of the Procedural Field
can be confounded under conditions of
elevated venous pressures (Fig. 1). ! Skin preparation in the target area is typical-
! Define a trajectory that avoids traversing ly performed using chlorhexidine solution,
structures that may be injured, such as achieved properly with a scrubbing motion.
adjacent arteries. Existing protocols favor the use of 2 distinct,
! It is important for the operator to consider closely spaced cleansing episodes before
not just puncturing the vessel, but rather draping the field.

Fig. 1. Normal orientation and compressibility of the internal jugular vein. (A) Normal orientation of the internal
jugular vein with respect to the carotid artery, with the vein maintaining a more superficial and lateral orienta-
tion. (B) Normal compressibility of the internal jugular vein.
288 Simon & Saad

! Place a fenestrated drape at the chosen ! Next, a 4F to 5F transitional sheath is

and prepared skin region. advanced over the wire while maintaining
! Full body drape is considered standard, countertension on the guide wire (to
except under conditions whereby it is not prevent kinking of the guide wire).
practical (code situations, for example). ! It is unnecessary to inject contrast agent to
perform a venogram unless there is difficulty
Local Anesthesia advancing the wire into the central veins.
! 1% lidocaine (or appropriate alternative) ! If venography is necessary, this is not ty-
infiltration is performed using a 21-gauge pically performed via the access needle.
or 23-gauge needle. A course should be Under such conditions, potential complica-
chosen as a rehearsal to determine the tions include losing vascular access and
optimal angle of needle entry. dissection. Instead, when necessary, venog-
raphy is performed using a 2.5F to 3F micro-
puncture sheath that can be placed over the
VASCULAR TERRITORY–SPECIFIC FEATURES
existing 0.018-in guide wire.
OF ULTRASOUND-GUIDED VASCULAR
! Fig. 2 demonstrates the preprocedure and
ACCESS
postprocedure ultrasonographic appear-
Ultrasound-Guided Vascular Access: Upper
ance of an upper extremity basilic vein
Extremity Veins
PICC line placement.
! Upper extremity veins are the most difficult
to differentiate from adjacent arteries, this
Ultrasound-Guided Vascular Access:
being particularly true in cases of low
Subclavian Vein
systemic pressures or in children. An em-
phasis should be placed on performing ! The subclavian vein is typically the most
a careful preprocedure imaging evaluation. difficult to access by ultrasound because
! The ultrasound transducer is typically posi- of the overlying bony structures that can
tioned transversely to the target vein and limit visualization.
the 21-gauge beveled tip needle is ad- ! The ideal target subclavian vein segment lies
vanced freely under ultrasound guidance. just over the lateral one-third of the first rib.
! Adjusting the angle of the ultrasound trans- ! If access is obtained in the medial segment,
ducer (often referred to as panning) allows the catheter may pass through the scalene
the provider to observe the needle and muscles and cause pain and constriction
needle tip as it is advanced to the desired of the catheter with the motion of the
target. The needle tip may then be ob- patient’s shoulder apparatus. This phenom-
served indenting the superficial wall of the enon has been referred to as pinch-off
target arm vein inward toward the lumen, syndrome. Pinch-off syndrome often results
creating a concave surface. The needle tip in compression of the catheter, leading to
has not entered the central lumen until the poor flow. Over time, this process may frac-
impaled superficial wall has rebounded ture the catheter with the possibility of
and the needle tip is observed in the central subsequent embolization of the catheter
lumen. A spontaneous return of blood may tip or extravasation of infused material.
or may not be observed. ! Adverse consequences of a far lateral
! At this point, a 0.018-in wire is carefully placement include a higher risk of infection
advanced through the needle, limiting due to placement near the axilla, as well as
movement of the needle itself. unfavorable soft-tissue relationships if the
! After the wire has been advanced carefully generation of a catheter tunnel is desired.
and without resistance, the remainder of ! The ultrasound transducer is typically posi-
the procedure is performed under fluoro- tioned transversely to the target segment of
scopic guidance. the subclavian vein, and the 21-gauge bev-
! The guide wire is advanced carefully and eled tip needle is advanced freely under
without resistance under fluoroscopic guid- ultrasound guidance.
ance into the subclavian vein. ! Adjusting the angle of the ultrasound trans-
! After the wire has been advanced into the ducer (often referred to as panning) allows
subclavian vein, a small (1–2 mm) incision the provider to observe the needle and nee-
is made using an 11-blade scalpel. The inci- dle tip as it is advanced to the desired
sion is performed over the needle body so target. The needle tip may then be ob-
as not to damage the guide wire. served indenting the superficial wall of the
 Ultrasound-Guided Vascular Access 289

Fig. 2. Preprocedure and postprocedure appearance of the upper extremity basilic vein before and after peripher-
ally inserted central catheter (PICC) line placement. (A) Normal gray-scale ultrasonographic appearance of the ba-
silic vein. (B) Normal compressibility of a patent basilic vein. (C) Postprocedure appearance of the basilic vein after
PICC line placement. The interval-placed catheter is clearly within the targeted vein without associated thrombus.

target vein inward toward the lumen, circumstances when the 0.018-in wire does
creating a concave surface. The needle tip not immediately course toward the SVC,
has not entered the central lumen until the rotating the guide wire as well as advancing
impaled superficial wall has rebounded the wire during deep inspiration may affect
and the needle tip is observed in the central successful placement into the SVC.
lumen. A spontaneous return of blood may ! After the wire has been advanced into the
or not be observed. SVC, a small (1–2 mm) incision is made
! Unique to this approach, the needle may using an 11-blade scalpel. The incision is
contact the surface of the first rib or clav- performed over the needle body so as not
icle. Particular attention should be directed to damage the guide wire.
to avoiding a pathway that crosses the ! Next, a 4F to 5F transitional sheath is
pleural surface. It is this access approach advanced over the wire while maintaining
that results in the highest incidence of countertension on the guide wire (to prevent
pneumothorax. kinking of the guide wire). This action is typi-
! It is advised that this vessel be aspirated cally followed by the placement of a more
before the placement of the 0.018-in guide robust wire such as a 0.035-in guide wire.
wire. Because of a close relationship with ! A venogram is not routinely performed
the subclavian artery and the inability to except under conditions whereby there is
compress the vessel beneath the rib cage, difficulty advancing the guide wire into the
an inadvertent arterial puncture is possible. SVC.
Under most conditions, the puncture nee- ! Postaccess imaging is typically obtained
dle may be withdrawn and the patient can (either by fluoroscopic spot film or formal
be observed for complications before reat- chest radiograph), as this site carries a high-
tempts at access. er risk for pneumothorax. If a pneumothorax
! At this point, a 0.018-in wire is carefully is not detected but the patient develops
advanced through the needle, limiting respiratory symptoms in the recovery area,
movement of the needle itself. the patient should be evaluated and repeat
! After the wire has been advanced carefully imaging should be promptly performed.
and without resistance, the remainder of
the procedure is performed under fluoro-
scopic guidance.
Ultrasound-Guided Vascular Access: Internal
! Several attempts may be necessary to
Jugular Vein
advance the guide wire into the SVC. The
ability to access the SVC may be affected ! The ultrasound transducer is typically posi-
by the curve at the tip of the wire as well tioned transversely to the internal jugular
as the patient’s phase on respiration. Under vein and the 21-gauge beveled tip needle
290 Simon & Saad

is advanced freely under ultrasound ! After the wire has been advanced carefully
guidance. and without resistance, the remainder of
! Adjusting the angle of the ultrasound trans- the procedure is performed under fluoro-
ducer (often referred to as panning) allows scopic guidance.
the provider to observe the needle and ! After the wire has been advanced into the
needle tip as it is advanced to the desired SVC, a small (1–2 mm) incision is made
target. The needle tip may then be ob- using an 11-blade scalpel. The incision is
served indenting the superficial wall of the performed over the needle body so as not
target vein inward toward the lumen, to damage the guide wire.
creating a concave surface. The needle tip ! Next, a 4F to 5F transitional sheath is
has not entered the central lumen until the advanced over the wire while maintaining
impaled superficial wall has rebounded countertension on the guide wire (to
and the needle tip is observed in the central prevent kinking of the guide wire). This
lumen. action is typically followed by the place-
! Some operators choose to alternatively ment of a more robust wire such as
access the vein with the transducer placed a 0.035-in guide wire.
transversely to the vessel, but the needle ! After the transition has been completed,
inserted along the long access of the trans- preparations can be made for catheter
ducer, approaching from the lateral plane. placement such as tunnel generation and/
This technique is favored by some practi- or peel-away sheath placement.
tioners for the purposes of placing a tunneled ! Fig. 3 demonstrates the typical sequence of
line, especially in obese patients. This ap- maneuvers performed during access of the
proach may facilitate passing the needle internal jugular vein using ultrasonography.
access as close to the clavicle as possible, The maneuvers shown here form the basis
which allows for the formation of a smooth for obtaining vascular access at other
curve and limited movement of the catheter anatomic locations.
when the patient’s soft tissues change posi-
tion (when elevated from supine back to
Ultrasound-Guided Vascular Access: Femoral
upright). An adverse consequence of this
Vein
approach is the tendency for the wire to
migrate in the cranial direction. ! Fluoroscopy is used for the purposes of
! At this point, a 0.018-in wire is carefully localizing the mid-segment of the femoral
advanced through the needle, limiting head. This site is chosen because it allows
movement of the needle itself. If it is not for manual compression of the vessel
clear by ultrasonography that the vessel against this structure to obtain hemostasis.
has been entered, aspiration of the needle This site also provides a favorable relation-
can be performed. The potential downside ship, as the femoral artery and vein are
to this maneuver is the additional move- adjacent to one another in the transverse
ment may cause dislodgment of the needle plane at this level (Figs. 4 and 5).
from the vessel. ! Another consideration when evaluating the
vessel during preoperative ultrasonography

Fig. 3. Ultrasonographic appearance of the internal jugular vein during puncture. (A) Normal orientation of the
carotid artery and internal jugular vein. (B) Typical compressible nature of the more lateral internal jugular vein.
In (C) the arrow marks the appearance of the access needle as it is directed toward the internal jugular vein. In (D)
the access needle is seen “tenting” the internal jugular vein, just before entry (arrow). In (E) the successful punc-
ture with the needle tip within the center of the vein lumen is indicated (arrow).
 Ultrasound-Guided Vascular Access 291

! Adjusting the angle of the ultrasound trans-

ducer (often referred to as panning) allows
the provider to observe the needle and nee-
dle tip as it is advanced to the desired
target. The needle tip may then be ob-
served indenting the superficial wall of the
target vein inward toward the lumen,
creating a concave surface. The needle tip
has not entered the central lumen until the
impaled superficial wall has rebounded
and the needle tip is observed in the central
lumen.
! The angle of entry is important for the intro-
duction of therapeutic devices or large
Fig. 4. Normal anatomic relationships of the femoral sheaths. Any angle too steep may result in
vessels. Contrast-enhanced magnetic resonance imaging kinking of an introducer sheath and should
through the pelvis displays the normal anatomic relation- be avoided.
ships of the common femoral artery (CFA) and common
! Once the vein has been entered, a 0.018-in
femoral vein (CFV) at the level of the femoral head.
guide wire is carefully advanced through
the needle, limiting movement of the needle
is the relationship of the profunda femoris. If itself. If it is not clear by ultrasonography
fluoroscopy is unavailable, a useful ultra- that the vessel has been entered, aspiration
sound landmark is the common femoral of the needle can be performed. The poten-
vein caudal to its bifurcation. tial downside to this maneuver is the addi-
! The ultrasound transducer is typically posi- tional movement may cause dislodgment
tioned transversely to the common femoral of the needle from the vessel.
vein, and the 21-gauge beveled tip needle is ! After the wire has been advanced carefully
advanced freely under ultrasound guidance. and without resistance, the remainder of

Fig. 5. Ultrasonographic appearance of the common femoral vessels. (A) Normal ultrasonographic appearance of
the common femoral artery and vein. (B) The compressible nature of the common femoral vein is evident, allow-
ing for clear identification for the purposes of planning vascular access. Calipers represent the compressed medial
and lateral margins of the common femoral vein.
292 Simon & Saad

the procedure is performed under fluoro- incidence of kinking of the vascular sheath
scopic guidance. after insertion.
! After the wire has been advanced into the ! Once the vein has been entered, a 0.018-in
IVC, a small (1–2 mm) incision is made using guide wire is carefully advanced through
an 11-blade scalpel. The incision is per- the needle, limiting movement of the needle
formed over the needle body so as not to itself. If it is not clear by ultrasonography
damage the guide wire. Under most circum- that the vessel has been entered, aspiration
stances, the IVC lies to the right of the spine. of the needle can be performed. The poten-
! Next, a 4F to 5F transitional sheath is ad- tial downside to this maneuver is the addi-
vanced over the wire while maintaining tional movement may cause dislodgment
countertension on the guide wire (to prevent of the needle from the vessel.
kinking of the guide wire). This action is typi- ! After the wire has been advanced carefully
cally followed by the placement of a more and without resistance, the remainder of
robust wire such as a 0.035-in guide wire. the procedure is performed under fluoro-
! A venogram is not routinely performed scopic guidance.
except under conditions whereby there is ! After the wire has been advanced more
difficulty advancing the guide wire into the centrally, a small (1–2 mm) incision is
IVC. made using an 11-blade scalpel. The inci-
! After the transition has been completed, sion is performed over the needle body so
preparations can be made for catheter or as not to damage the guide wire.
device placement. ! Next, a 4F to 5F transitional sheath is
advanced over the wire while maintaining
countertension on the guide wire (to prevent
Ultrasound-Guided Vascular Access: Lower
kinking of the guide wire). This action is typi-
Extremity Veins (Popliteal or Tibial Veins)
cally followed by the placement of a more
! Lower extremity veins are infrequently ac- robust wire such as a 0.035-in guide wire.
cessed. If access is necessary, this is ! At this point, a venogram is routinely per-
most frequently for the treatment of acute formed to evaluate the extent of existing
or chronic deep venous thrombosis, often thrombus and to characterize the venous
for the purposes of venous thrombolysis. access/vascular territory.
Additional interventions after thrombolysis
may include therapy for an outflow stenosis
or chronic thrombus using balloon veno-
Ultrasound-Guided Vascular Access: Upper
plasty followed by stent placement.
Extremity (Radial, Brachial, and Axillary)
! The ultrasound transducer is typically posi-
Arteries
tioned transversely to the target vein, and
the 21-gauge beveled tip needle is ad- ! Upper extremity arteries are the most diffi-
vanced freely under ultrasound guidance. cult to differentiate from adjacent veins,
! Adjusting the angle of the ultrasound trans- and this is particularly true in cases of low
ducer (often referred to as panning) allows systemic pressures or in children. An em-
the provider to observe the needle and nee- phasis should be placed on performing
dle tip as it is advanced to the desired a careful preprocedure imaging evaluation.
target. The needle tip may then be ob- ! The ultrasound transducer is typically posi-
served indenting the superficial wall of tioned transversely to the target artery,
the target vein inward toward the lumen, and the 21-gauge beveled tip needle is
creating a concave surface. The needle tip advanced freely under ultrasound guidance.
has not entered the central lumen until the ! Adjusting the angle of the ultrasound trans-
impaled superficial wall has rebounded ducer (often referred to as panning) allows
and the needle tip is observed in the central the provider to observe the needle and nee-
lumen. dle tip as it is advanced to the desired
! For interventions such as thrombectomy/ target.
thrombolysis, large vascular sheaths are ! On entry into the arterial lumen, pulsatile
typically necessary. In addition, because blood return typically occurs.
these sheaths are commonly indwelling for ! Once the artery has been entered, a 0.018-
periods of 24 to 72 hours, an obtuse (rather in guide wire is carefully advanced through
than steep) angle is favored. Such planning the needle, limiting movement of the needle
of skin and vessel entry sites can limit the itself.
 Ultrasound-Guided Vascular Access 293

! After the wire has been advanced carefully and a skin entry site is selected that will
and without resistance into the artery, the allow the needle to enter the skin and artery
remainder of the procedure is performed at an approximate 45# angle (entering the
under fluoroscopic guidance. vessel at the level of the mid-portion of
! After the wire has been advanced into the the femoral head).
subclavian artery, a small (1–2 mm) incision ! Using ultrasound guidance, a 21-gauge or
is made using an 11-blade scalpel. The inci- 18-gauge beveled tip needle is typically
sion is performed over the needle body so advanced into the artery using a single-
as not to damage the guide wire. The inci- wall technique (puncturing the superficial
sion should also be superficial as not to wall and then advancing the wire through
damage the underlying artery. the needle).
! Next, a 4F to 5F transitional sheath is ! Adjusting the angle of the ultrasound trans-
advanced over the wire while maintaining ducer (often referred to as panning) allows
countertension on the guide wire (to prevent the provider to observe the needle and nee-
kinking of the guide wire). This action is typi- dle tip as it is advanced to the desired
cally followed by the placement of a more target.
robust wire such as a 0.035-in guide wire. ! On entry into the arterial lumen, pulsatile
! After the transition has been completed, blood return typically occurs.
preparations can be made for subsequent ! Once the artery has been entered, an ap-
diagnostic or therapeutic intervention. propriately sized guide wire is carefully
! Fig. 6 demonstrates imaging features that advanced through the needle, limiting move-
allow for differentiation of the brachial artery ment of the needle itself.
and veins. ! After the wire has been advanced carefully
and without resistance into the artery, the
remainder of the procedure is performed
Ultrasound-Guided Vascular Access: Common
under fluoroscopic guidance.
Femoral Artery
! An alternative technique is referred to as the
! The typical cross-sectional and ultrasono- double-wall method. This approach is
graphic appearance of the common femoral unique in that the puncture needle is ad-
vessels are demonstrated in Figs. 4 and 5. vanced through both the superficial and
! Entry into the femoral artery at the level of deep walls of the artery until it contacts
the mid-portion of the femoral head is the femoral head. After the needle has con-
desired, because of the ability to compress tacted the femoral head, the wire can be
the vessel against the bony landmark after safely handled with the opposite hand and
catheter removal as well as its favorable the needle can be carefully withdrawn,
orientation (side-to-side) with the femoral and the guide wire inserted after blood re-
vein. turn is seen. The primary advantage to this
! The site of entry into the vessel is estimated approach is that the ultrasound transducer
using a metallic marker and fluoroscopy, is not needed after initial vessel puncture
and a skin mark is made. After the desired and can therefore be placed away from
arterial entry site is selected, the ultrasound the field, freeing an extra hand for additional
probe is placed transversely over the vessel stability.

Fig. 6. Differentiation of brachial arteries and veins. (A) Typical ultrasonographic appearance of the brachial
vessels, superficial to the humerus. (B) The compressibility of the brachial veins is seen, allowing the brachial
artery to be clearly differentiated. In cases where compression is difficult to achieve, color Doppler (C) is a useful
adjunct, allowing for the differentiation of the brachial vessels based on differential direction of blood flow.
294 Simon & Saad

! Once the wire has been advanced, an inci- coagulopathy or distal venous obstruction,
sion is made using an 11-blade scalpel at which may require longer periods of manual
a depth of 3 mm. The blade incision is compression.
made over the needle so as not to damage ! Bleeding risk at the internal jugular site can
the wire. be increased by coughing.
! A 4F to 5F transitional sheath (micropunc- ! Purse-string sutures may be used in select
ture dilator) is passed over the wire while circumstances to control bleeding from
holding countertension on the wire so as venous access sites, but should be used
not to kink the wire, thus allowing the oper- with caution.
ator to pass a more robust wire.
! A side-port sheath is then placed and flush Axillary Artery Access Site
lines are connected in standard fashion.
! Manual pressure can be exerted on the
! Fig. 7 shows the ideal imaging features of
axillary artery access site. Manual pressure
appropriate placement in the femoral
is maintained while the arm is in mid-
artery. Of note, puncture of the vessel is
abduction and is exerted against the
performed below the level of the inguinal
humeral head for a period of 10 to 15
ligament in most cases.
minutes in the absence of coagulopathy.
! The arm should be maintained overnight in
SITE-SPECIFIC POSTACCESS HEMOSTASIS a sling to support a neutral position. Distal
Venous Access Sites pulses should be monitored and referenced
with the initial baseline pulse examination.
! Manual compression for 5 minutes is
performed except under conditions of Femoral Artery Access Site
! Manual pressure is maintained on the
femoral artery access site to obtain hemo-
stasis. Manual pressure is adjusted to
occlude the access site, but not enough to
occlude the femoral artery and compromise
distal flow. A Doppler probe is a useful
adjunct for monitoring of the artery and esti-
mating the degree of manual pressure
required.
! Manual pressure is maintained with the
patient in a supine position. Manual pres-
sure is maintained against the underlying
femoral head for a period of 15 to 20
minutes in the absence of coagulopathy. A
useful guideline is 3 minutes of manual
compression for each 1F size of the access
device.
! A thorough pulse examination before, during,
and after access/hemostasis is crucial for the
purposes of identifying changes (such as
Fig. 7. Satisfactory fluoroscopic appearance of ultra- thrombosis/embolic phenomena).
sound-guided arterial sheath placement. This single ! Numerous percutaneous closure devices
fluoroscopic image taken after hand injection of intra- are available, which reduce the period of
arterial contrast agent through the side port of a vascular manual compression necessary to achieve
sheath placed using ultrasound guidance shows the hemostasis and reduce the bed-rest
ideal imaging features of appropriate placement in the period, thus allowing earlier discharge of
femoral artery. Specifically, the common femoral artery
the patient. Refer to the product insert for
is entered at the mid-portion of the femoral head, allow-
device-specific recommendations.
ing for compression against this structure to control
hemorrhage. The bifurcation of the profunda femoris
! At the authors’ institution and in the absence
is also clearly seen, anatomically allowing for the deploy- of a closure device, for the purposes of
ment of a vascular closure device, if clinically indicated. diagnostic arteriography, the patient must
The dashed line represents the approximate anatomic be flat for 2 hours and then may have the
course of the inguinal ligament. head elevated for an additional 2 hours, after
 Ultrasound-Guided Vascular Access 295

which ambulation is permitted. When an ! At the authors’ institution, patients under-

intervention is performed, the head may be going diagnostic arteriography and treated
elevated at 6 hours, and the patient is on with a closure device may have the head
strict bed rest until the next morning. elevated to 30# immediately, with ambula-
tion at 2 hours and discharge at 4 hours.
POST-ACCESS PROCEDURAL EVALUATION In the absence of a closure device, patients
AND MANAGEMENT must lie flat for 2 hours and may ambulate at
Postprocedural Observation Period 4 hours. Patients undergoing therapeutic
arterial interventions without a closure
! In the absence of conscious sedation, device may elevate the head of the bed at
patients receiving a basic venous access 6 hours and are maintained on strict bed
procedure such as a PICC line may be dis- rest overnight.
charged immediately. ! For closure devices, refer to device-specific
! When sedative medications are used, instructions for further details.
patients undergoing tunneled line place- ! The accessed extremity is maintained
ment, port placement, or IVC filter removal straight for the bed-rest period.
may be discharged to the care of a respon- ! Strict bed rest includes no bathroom privi-
sible adult within 1 hour of full recovery from leges. In these cases, the patient must use
sedative medication. a bedpan or other method of collection.
! In cases when more extensive procedures
are performed, patients are typically ob-
served overnight in the hospital. Ultimately, Analgesia and Medications
the length of stay is determined by ! Pain after routine ultrasound-guided vas-
the patient’s existing medical problems cular access is typically minimal and is clas-
and the most extensive portion of the sified as mild to moderate (for the first
procedure. 24 hours). More severe pain should raise
! Patients undergoing diagnostic arterial suspicion for a complication, and warrants
angiography may be discharged 6 to 8 direct evaluation.
hours after the procedure in the absence ! In the setting of tunnel or port placement,
of a closure device. With the use of an arte- a patient may require short-term narcotic
rial closure device this period can be pain medication for control of analgesia.
reduced to 4 hours. Combinations of acetaminophen and hy-
! In the case of femoral arterial puncture, the drocodone are commonly used for this
patient should not travel by car (hip flexed) purpose. Intravenous analgesic medication
for longer than 1 hour on the day of the is uncommon for the purpose of routine
procedure. ultrasound-guided vascular access.
! When the vascular access is performed as
Managment of Fluids, Diet, and Activity
part of a more extensive procedure such
! Intravenous access should be maintained as embolization of a mass (eg, uterine
until the patient is ready for discharge. fibroid embolization), patients may require
! After the patient has recovered from seda- intravenous narcotic medications for ade-
tion (if administered), a clear liquid diet quate treatment of analgesia. Commonly
should be tolerated before discharge. used analgesics include fentanyl, morphine,
! Intravenous fluids, in the appropriate clin- or hydromorphone patient-controlled anal-
ical setting, should be administered until gesia, commonly used for 12 to 48 hours
the patient has tolerated a clear liquid diet. depending on the nature of the procedure
! At the authors’ institution, for PICC lines and the patient.
and venography performed with peripheral ! Antiemetics such as ondansetron may be
intravenous access, the patient may ambu- helpful in the setting of embolization proce-
late immediately. For more advanced diag- dures, conscious sedation, or in the event
nostic and therapeutic venous procedures of an adverse reaction resulting in nausea.
the head may be elevated immediately, ! For the sole purposes of ultrasound-guided
but the patient must remain on bed rest vascular access, systemic antibiotics are
for 2 hours. typically unnecessary. The use of antibi-
! In the event the patient coughs, sneezes, otics is typically determined by the main
strains, or laughs, the patient must apply procedure performed (port implantation,
manual pressure to the puncture site. embolization, and so forth).
296 Simon & Saad

! For the purposes of routine vascular access, ! Management of significant bleeding should
home prescription–strength analgesic me- be initially managed by maintaining ade-
dications are typically not prescribed. If the quate vascular access, obtaining a type,
vascular access is performed as part of cross and coagulation parameters (pro-
a more extensive procedure, that portion di- thrombin time, international normalized
ctates the need for discharge analgesic ratio, partial thromboplastin time), cessa-
medications. tion or reversal of anticoagulation (such as
heparin), and administering isotonic resus-
Post Procedure Monitoring citation fluid. Further management may
include critical care or surgical consultation.
! Routine monitoring should include heart ! In the setting of active hemorrhage, blood
rate, blood pressure, and oxygen saturation. transfusion should be considered to maintain
! These parameters should occur at 15- a hematocrit greater than 30%. Guidelines
minute intervals. for higher transfusion thresholds are not in-
! In the setting of conscious sedation, labile tended for the actively hemorrhaging patient.
blood pressure should be anticipated, ! Imaging evaluation may include chest
which may be due to vasodilatory effects radiograph to evaluate for hemothorax
of medication, hypovolemia, or hemor- and noncontrast CT to evaluate for retro-
rhage. Initial therapy should include volume peritoneal bleeding.
resuscitation and a heightened awareness,
warranting intervention if the patient does Management of Thoracic Complications
not respond appropriately.
! If the patient does not respond appropri- ! If postprocedure chest pain occurs, chest
ately, a source of hemodynamic instability radiography should be performed to eval-
should be sought and appropriate re- uate for pneumothorax or hemothorax.
suscitative measures should be initiated. ! Clinically meaningful pneumothorax or he-
Appropriate management is addressed mothorax is typically treated with a thoracos-
below. Imaging evaluation often is per- tomy tube, supplemental oxygenation, and
formed using CT. resuscitation (in the case of hemothorax).
! Particularly in the case of arterial interven- ! If a small, asymptomatic pneumothorax
tions, a baseline vascular examination is occurs, tube thoracostomy may not be
essential in monitoring the success of required. Repeat imaging is performed in
a procedure as well as complications. A 1 hour. A thoracostomy tube is indicated if
change in pulse can alert the practitioner the patient is symptomatic or there is
to the presence of emboli, compressive expansion of the pneumothorax.
hematoma, or dissection.
Management of Infectious Complications
! In the case of aortic arch or cerebrovascular
circulation, a baseline neurologic examina- ! Abscess at the vascular access site, like
tion is useful in detecting stroke. abscesses elsewhere, are treated with
surgery.
! Local infections related to implants, such as
catheters and ports, should prompt re-
COMPLICATIONS AND MANAGEMENT moval of the foreign body with possible
Management of Postprocedure Hemorrhage open drainage of the access site.
! Intravenous access should be maintained ! Broad-spectrum antibiotics that cover the
until the patient is ready for discharge in likely offending organism may be used, nar-
the event that fluid resuscitation or intrave- rowed to appropriate culture results.
nous medication is required.
Management of Vascular Injuries
! Several types of postprocedure hemor-
rhage may occur: ! Include arterial dissection, arteriovenous
# Skin hemorrhage fistula, or pseudoaneurysms.
# Target-vessel hemorrhage ! Dissection should be identified at the time
# Site hematomas (which may result in of the procedure. In the event of a flow-
a secondary neuropathy in the case of limiting injury, a stent should be deployed.
upper arterial punctures) If the injury is not flow limiting, observation
# Retroperitoneal hematoma with imaging follow-up with or without anti-
# Hemothorax. coagulation is a treatment option.
 Ultrasound-Guided Vascular Access 297

! Arteriovenous fistulas are rarely recognized Denys BG, Uretsky BF, Reddy PS, et al. An ultrasound
during the inciting procedure. Such an injury method for safe and rapid central venous access.
typically is noted on follow-up clinical or N Engl J Med 1991;324(8):566.
imaging examination. The initial treatment Dogra V, Saad WE. Ultrasound-guided procedures. New
of choice for a physiologically meaningful Yark: Thieme Medical Publisher; 2009.
fistula is endovascular therapy. Surgical con- Malloy PC, Grassi CJ, Kundu S, et al. Consensus guide-
sultation may be necessary in some cases. lines for periprocedural management of coagulation
! Pseudoaneurysms are often treated with status and hemostasis risk in percutaneous image-
thrombin injection. guided interventions. J Vasc Interv Radiol 2009;20:
S240–9.
FURTHER READINGS Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time
ultrasound guidance facilitates femoral arterial
Dariushnia SR, Wallace MJ, Siddiqi NH, et al. Quality access and reduces vascular complications: FAUST
improvement guidelines for central venous access. (Femoral Arterial Access With Ultrasound Trial).
J Vasc Interv Radiol 2010;21:976–81. JACC Cardiovasc Interv 2010;3(7):751–8.