Using the Antecubital Vein as an Approach to a Developing Dilemma in Right Heart Catheterization

This article received a double-blind peer review from members of the Cath Lab Digest editorial board.

Richard Kidd, BSN, RN, CEN, CCRN, can be contacted at kiddr@musc.edu.

Right heart catheterizations (RHCs) are performed in the cardiac catheterization laboratory using balloon-tipped, thermodilution catheters. RHC is the gold standard for diagnosing and managing multiple conditions. In many cases, data from both a RHC and a left heart catheterization (LHC) are obtained simultaneously.¹ Vascular access for RHC procedures is usually obtained utilizing proximal venous access sites such as the common femoral vein or the internal jugular vein. While these routes pose relatively low risks to patients, significant complications can occur such as large hematomas, pseudoaneurysms, and arterio-venous fistula formation.¹ Additionally, the risks are increased for patients who are receiving anticoagulation therapy.¹ Performing RHCs via the antecubital vein is a prudent risk-mitigating and patient comfort strategy, particularly for patients receiving anticoagulant or antiplatelet therapy. This paper examines the purpose of RHCs, reviews the experts’ consensus on performing RHCs on anticoagulated patients, and reports the method currently being used to perform RHC from the antecubital vein.

The use of flow-directed pulmonary artery catheters or Swan-Ganz catheters became popular in the 1970’s, when the catheter was first used to guide the management of patients suffering from an acute myocardial infarction.² Since then, the utility of the Swan-Ganz catheter (or “Swan”) has grown. Today, Swans are used in the cardiac catheterization laboratory to help differentiate between different etiologies of shock, determine causes of pulmonary edema, evaluate pulmonary hypertension, diagnose pericardial tamponade, examine intra-cardiac shunts, and assess the effects of pharmacologic agents such as vasoactive drugs, inotropes, fluids, and diuretics.²

RHCs are usually performed by cannulating the femoral vein, the internal jugular vein, or the subclavian vein. Typically, these procedures have been performed on an outpatient basis and the risks are minimal. However, there is an ever-present risk of serious vascular complications. These risks all increase when a RHC is performed in patients who are taking anticoagulant or antiplatelet medications.¹ 

The risks associated with access-site complications can be reduced by briefly withholding oral anticoagulants prior to the procedure.¹ The Society of Interventional Radiology Standards of Practice committee classifies venous interventions, such as RHCs, as having a moderate risk of bleeding. Their recommendation for patients receiving warfarin is to correct any international normalized ratio (INR) above 1.5.³ Reducing the therapeutic INR of 2.0-3.0⁴ to 1.5 or less aids in reducing access-site complications. However, the risk for local and systemic thromboembolic events rises, especially in patients with poor left ventricular function, artificial heart valves, atrial dysrhythmias, and diabetes.¹ To mitigate the risks of thromboembolic events, patients are sometimes transitioned from a therapeutic INR on warfarin using subcutaneous injections or intravenous infusions of low molecular weight or unfractionated heparin.¹ Inpatient admission and monitoring is often required, increasing the costs associated with this strategy. Even with the most diligent care, however, thrombotic events and death have occurred.⁵ 

The advent of direct new oral anticoagulants adds an additional layer of complication to the dilemma of determining when it is safest to perform an invasive procedure such as a RHC. An antidote to these medications does not exist and, currently, there are insufficient data to make recommendations concerning scheduling of invasive procedures. Current proposals include monitoring of serum drug levels of patients receiving dabigatran or rivaroxaban prior to invasive procedures with high bleeding risk and considering postponement if the level is above 30 ng/mL.⁶ Unfortunately, there are limited and incomplete data for apixaban and edoxaban; therefore, no proposals have been made for these drugs.⁶

During the last decade, performing LHCs via the radial artery has gained great popularity, especially in this at-risk population.⁷ In 2003, Hildick-Smith and colleagues examined the safety and efficacy of performing LHCs on fully anticoagulated patients, defined as an INR of greater than 2, but less than 4.5. They concluded it is both safe and cost effective to perform LHCs via the radial artery.⁸ Transitioning the LHC site to the radial artery to facilitate invasive procedures on patients receiving anticoagulants has provoked providers to explore alternative venous access sites, such as the antecubital veins, when performing a RHC on patients with therapeutic levels of anticoagulants. This route helps by decreasing the need to withhold these medications or transition to different anticoagulation agents prior to the procedure.

To study transitioning RHCs from proximal venous access to antecubital venous access, Shah and colleagues⁷ performed a retrospective study of 272 patients who underwent a RHC. When the study began in 2008, 100% of RHCs were performed via proximal venous access. At the conclusion in 2012, 85% were performed via antecubital venous access. Overall success rates for the proximal venous access route were 96%, while the antecubital venous access route was 91%. The 5 French (Fr) sheath used with the antecubital venous access group was significantly smaller than the 8 Fr used in the proximal venous access group. Fluoroscopy times were significantly shorter in the antecubital venous access group; however, there was no statistical difference in dosage of radiation exposure. The antecubital venous access group had a 0% complication rate, while the proximal venous access group had a 3% complication rate that included inadvertent arterial puncture and hematoma formation. 

Rogers and Lederman⁹ report that a RHC via the forearm or antecubital veins is both simple and achievable. Veins on the medial side of the arm are more desirable, as they are the best, most direct route to the heart. Accessing the cephalic vein on the radial side of the arm is also acceptable; however, that process presents a greater challenge because the cephalic vein enters the axillary vein at a sharp angle, making passage of the catheter somewhat more difficult. 

Access for this procedure can begin prior to the patient’s entering the cath suite by establishing a 20ga or larger peripheral IV in the antecubital vein. The access site is dressed according to organizational policy. Once in the catheterization laboratory, the dressing is removed, the site again prepped, and the patient is draped in the usual sterile fashion. The area around the IV catheter is infiltrated with a local anesthetic. Once adequate local anesthesia has been achieved, a 0.018- to 0.021-inch guide wire is inserted into the IV catheter. The IV catheter is then removed and a 5 Fr sheath is inserted over the guide wire into the vein. A hydrophilic sheath with a tapered dilator, such as the Glidesheath (Terumo), is recommended for ease of insertion. Under normal circumstances, there is no need to administer anticoagulants such as heparin for this procedure.⁷

A balloon-tipped thermodilution catheter, the Baxter-Edwards 5 Fr thermodilution catheter model 132F5, for example, or a similar catheter, is inserted through the sheath in the antecubital vein. A hydrophilic wire such as a 0.018-inch Glidewire (Terumo) or a 0.014-inch Mailman interventional guide wire (Boston Scientific) can be used, if needed, to help navigate tortuous vessels. Once the catheter enters the subclavian vein, the balloon is inflated, and the RHC is performed as usual, including pressure measurements, blood sampling for mixed venous oxygen saturation, and performance of thermodilution cardiac output determinations. At the conclusion of the procedure, all catheters and wires are removed from the sheath. The sheath is flushed and removed from the antecubital vein. Manual pressure is held until hemostasis is achieved, usually within 2-5 minutes.⁷  

Patients with complex medical conditions, particularly those receiving anticoagulant drugs, frequently undergo RHC procedures. Balancing the risk of bleeding and access-site complications against the risks associated with withholding anticoagulants requires clinicians to seek alternate means of performing RHCs. Performing RHCs via the easily compressible antecubital veins is a safe and feasible alternative to the riskier proximal venous access sites.

Moving forward, additional studies evaluating the antecubital approach to RHCs are needed. Research to support a shorter duration in the catheterization suite will be of interest to clinicians and management personnel alike, as shorter procedures can equate to more efficient room utilization and possibly lower overall cost. Additional studies to support decreased fluoroscopy time would be beneficial, especially if these studies were able to demonstrate a decrease in radiation exposure. Another realm to further explore is patient perceptions of comfort for the antecubital route. The antecubital venous access route could perhaps provide the patient with an easier and more comfortable experience. Finally, research is needed to determine if this route is amenable to leave-in Swan procedures for patients who require ongoing hemodynamic monitoring in the intensive care unit.

The author wishes to acknowledge and thank Eric R. Powers, MD, and Jennie C. Ariail, PhD, for their assistance in reviewing and editing this manuscript.

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