Ultrasound guided vascular access in the electrophysiology lab: should it be a standard of care?
Ultrasound guided vascular access in the electrophysiology lab: should it be a standard of care?
Christine C Tanaka-Esposito 0
Patrick Tchou 0
0 Cleveland Clinic , Cleveland, OH , USA
Catheter directed electrophysiology (EP) studies and ablations
have emerged as common and widely accepted therapies for
various types of arrhythmia. The femoral vasculatures serve as
access sites, in the majority of instances. Despite the need for
multiple venous sheath placement within a single vein, early
reporting of vascular related bleeding complications was
naught [1, 2]. With increasing frequency of complex
procedures such as pulmonary vein antral isolation (PVAI)
performed with maintenance of peri-procedural anticoagulation
and those necessitating arterial access, vascular complication
rates rose to 1–2% [3, 4]. In spite of advancements in
catheterbased EP procedures in the past two decades leading to
improved efficacy and overall safety, the incidence of vascular
complication has remained unchanged [5, 6].
Vascular complications directly impact patient morbidity
and increase health care costs. They are usually the
consequence of inadvertent arterial puncture and cannulation,
particularly when using large diameter sheaths and/or with
aggressive anticoagulation. Baum et al. described overlap of the
femoral artery (CFA) and common femoral vein (CFV) along
some portion of their course in two-thirds of patients studied,
predisposing to simultaneous puncture of the overlapping
artery during intended venous cannulation and resulting in
arteriovenous fistula formation. High bifurcation of the CFA at the
level of the mid femoral head was also found to be not
uncommon . Such anatomic variation cannot be appreciated
without real-time imaging, and increases risk for
pseudoaneurysm formation due to accidental puncture of the
superficial femoral artery .
Real-time ultrasound guidance (US) allows direct
visualization of vascular structures, and its use has been shown to
significantly improve procedural success and/or reduce
complications. US has been endorsed in Practice Guidelines put
forth by various societies [9–11]. Yet in spite of wide
acceptance in the medical and surgical communities, US guidance
has not been routinely utilized in all EP labs. The first reported
comparative study was from our institution and included 3510
patients undergoing PVAI, requiring multiple femoral venous
accesses . US guided femoral venous access reduced total
and major vascular complications by 3-fold and 7-fold. This
result was even more significant, given that 73% of patients
undergoing US guided venipuncture had an INR ≥1.9 on the
day of the procedure. This was in comparison with the non-US
guidance group, in whom only 9% of patients had an INR
≥1.9 on the day of the procedure. This finding is a testament
to the protective effect of US, apparent even in the cohort at
greater risk for bleeding. Similar improved outcomes have
been corroborated by publications from three other
institutions, forming a robust experience that confirms the
effectiveness of US in reducing vascular complications during EP
procedures [13–15]. A summary of these four publications by
Sobolev et al., including over 4000 subjects, showed a 60%
reduction of major vascular complications and 66% reduction
of minor ones .
The article by Wiles and colleagues in the current issue
provides excellent practical description of ultrasound guided
femoral venous access in the EP lab. We applaud the authors
on their clear outline of steps for implementing this important
technique. US provides direct anatomic visualization of
vascular relationships, simplifying the process of vascular access
even in challenging situations, and ultimately minimizes
complications. We agree with the authors that this technique is
readily accessible in EP labs that already possess a
highquality echocardiography console for intracardiac echo
imaging. For those without, US imaging can be attained via a
portable and relatively inexpensive system. In our experience,
this technique is easily mastered and requires only slight
modification to the traditional approach of anatomic guided
vascular access. While the authors focus upon the use of US
guidance for femoral venous access, it is important to
recognize that the same method can facilitate femoral arterial
access. Particularly, in patients with high common femoral
artery bifurcation, US provides direct anatomic visualization,
improves arterial cannulation success, and reduces vascular
complications [17, 18]. Ultrasound guidance has been
routinely used when gaining vascular access from any site in all EP
procedures at our institution, since July 2008. The occurrence
of major vascular complications is 0.4%, among 12,680
catheter-based procedures performed in our EP labs from
when routine US use was implemented till present. Even in
spite of the high risk nature of PVAI and procedures that
require arterial access, the vascular complication rates remain
significantly lower, at 0.5%, than that reported by both
historical and contemporary studies in the literature.
Real-time ultrasound guidance for vascular access is
already recommended by some professional organization
guidelines [9–11]. The assemblage of data from multiple centers
now show a clear reduction in vascular complications when
US guidance is used for gaining femoral venous access with
EP procedures. The technique requires equipment that is
readily accessible in a standard EP lab. Moreover, it is a skill that is
easily mastered. Given this, we believe it is high time that US
guidance in gaining femoral vascular access becomes a
recommended standard of care in the EP community.
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