Assessing the Feasibility of Using the Antecubital Vein to Perform Right Heart Catheterization in Children and Adults With Congenital Heart Disease: A Retrospective, Observational Single-Center Study

Background. Right heart catheterization (RHC) usually is performed via the femoral vein or the internal jugular vein. However, the antecubital fossa vein is a valid venous access, and it has become increasingly popular to perform right heart catheterization utilizing this access. Methods. A retrospective, observational study was conducted to describe use of the antecubital fossa vein for right heart catheterization in adults and children with congenital heart disease (CHD). Patients who had undergone RHC via antecubital fossa vein at the authors’ hospital between September 2019 and December 2022 were included. The outcomes studied were procedural failure and procedure-related adverse events. Results. Fifty-two patients with CHD underwent right cardiac catheterization via an upper arm vein. The upper arm vein was unable to perform the RHC in only 2 patients (3.8%). Only 1 patient developed a minor adverse event. No irreversible and/or life-threating adverse events were detected. Conclusions. The upper arm veins are safe and effective to perform a RHC in children and adults with CHD. This approach demonstrates a high percentage of technical success, and few mild complications.

Right heart catheterization (RHC) is a mainstay procedure in the diagnosis and hemodynamic assessment of pediatric and adult patients with congenital heart diseases (CHD). Transfemoral or jugular venous approaches are usually used to provide standard site access for RHC. However, obtaining vascular access via these vessels may be challenging, or even impossible, in patients with small-sized, fragile vessels and/or complex anatomy.¹ These issues are further compounded in children and adults who have undergone multiple cardiac surgeries; the repeated catheterizations predispose the patient to long-term vessel injury, thrombosis, and chronic total occlusion of these access sites.¹ On the other hand, preservation of adequate vascular access is mandatory for a growing population reaching adulthood age and requiring future cardiac interventions through these traditional venous routes.

In recent years, RHC utilizing the antecubital veins has regained attention in selected populations for which the feasibility and safety of this technique has been proven.^1-4 However, data are limited regarding its use in the CHD population.^5,6 Therefore, the authors sought to investigate whether antecubital venous access could be used for RHC in the CHD population and to compare the success rate (ie, the ability to complete RHC via the primary chosen site) of this technique in simple and complex cardiac lesions.

This was a retrospective, observational, single-center study that included all children and adults with CHD who underwent RHC via an upper arm superficial venous approach (cephalic vein, basilic vein, or antecubital vein) at the Paediatric Cardiology Unit and Adult Congenital Heart Disease (ACHD) Unit, Monaldi Hospital, Naples, Italy, between September 2019 and August 2023. Data were assessed by analyzing the archive of ACHD and Pediatric Cardiology Departments of Monaldi Hospital. As this was an observational retrospective study, ethical approval was not required.

Patients were divided into 2 groups: the simple CHD group (group I), which included biventricular anatomy patients, and the complex CHD group (group II), which included patients with univentricular anomalies and patients with atrioventricular and/or ventriculoarterial discordance. Demographics (age, weight, cardiac surgical history, simple vs complex anatomy), procedural information (right vs left upper arm venous vascular access, sheath size, angiography, procedural failure, concomitant coronary angiography, fluoroscopy time), and vascular complications were recorded. Procedural success was defined by the ability to complete RHC via the primary chosen site. Crossover to other venous access sites was recorded. Vascular complications were defined as arterial-venous fistula, pseudoaneurysm, hematoma or haemorrhage, arterial puncture, or thrombosis.

Written informed consent for patient information and images to be published was provided by the patient or their legally authorized representative.

Vascular access. Nurses obtained upper-extremity venous access using an 18- gauge cannula.  Ultrasound guidance was used at the discretion of the operator. Due to its large size, the basilic vein was the preferred vein for vascular access, followed by cephalic and ante-cubital vein. The site was prepped and draped in the cardiac catheterization laboratory. After local anaesthesia was administered, the cannula was exchanged with a 4 to 6 French (Fr) sheath over a 0.025-inch guidewire using a modified Seldinger technique (Figure 1). Because the vein does not have a muscle layer, antispasm medications were not routinely used. Intravenous unfractionated heparin 75 IU/kg was administered at the beginning of the diagnostic RHC. At the conclusion of the procedure, hemostasis was obtained using a local compressive bandage and by elevating the arm.

Statistical analysis. All statistical analyses were performed using Statistical Package for Social Sciences for Windows, version 20 (SPSS). Continuous variables (such as age and weight) were expressed as mean ± standard deviation. Categorical data (such as the side of vascular access—ie, right or left) were expressed as frequency (percentage). Continuous and categorical variables were analyzed by Z-test and chi-square test or Fisher exact test, respectively. Data analysis was considered statistically significant at P <0.01.

During the study timeframe, 52 patients (11 children and 41 adults) with CHD underwent right cardiac catheterization via an upper arm vein (basilic, cephalic, or antecubital vein). The mean age and weight were 43.1±22.3 years (range, 8.4–81.3 years) and 67±22.2 kg (range, 27–150 kg), respectively. Thirty-nine (75%) patients had “simple CHD (group I), and 13 (25%) patients had complex CHD (group II); among the latter, 6 patients had an “univentricular anatomy” and/or had undergone partial or total cavopulmonary anastomosis.

The RHC was successfully performed via upper arm vein in all patients but two: a male adult with ventricular septal defect and a history of bilateral thrombosis of upper-arm superficial veins (patient 5), and a female adult with right isomerism and double outlet right ventricle, wherein both the basilic vein as well as the femoral vein were inadequate to reach the pulmonary artery due to ventricular-arterial discordance and the pulmonary stenosis (the right cardiac catheterization was performed using the femoral artery as vascular access) (patient 23).

In the other 50 (96.2%) cases in which RHC was successfully performed, the right arm was preferred to the left arm: 45 (90%) vs 5 (10%). The sheath used was 4 Fr in 1 case (2%), 5 Fr in 17 cases (34%), and 6 Fr in 32 cases (64%). The indirect Fick method was used to calculate the cardiac outputs in 36 patients (72%), and the thermodilution technique was utilized in 14 patients (28%). In 9 patients (18%), a contemporary angiography of the superior vena cava and/or the pulmonary artery was performed with a pigtail catheter. In 10 patients (20%), a concomitant coronary angiography was performed via the radial artery.

The mean fluoroscopic time was 4.09 minutes (range, 1.04–45.13 minutes) with no significant differences between group I and group II (7.3 vs 12.5 minutes; P= 0.09). In 1 case (patient 17), a switch of the upper arm vascular access to the femoral vein was necessary because the detection a significant stenosis of an extracardiac Fontan conduit was detected, requiring a larger sheath (10 Fr) for stenting. Only 1 patient (patient 43) developed a minor adverse event related to antecubital vein vascular access (cephalic vein thrombosis), which resolved after 24 hours of sodic heparin infusion. No irreversible and/or life-threating adverse events were detected. The patients’ features are summarized in the Table.

Upper extremity venous access has emerged as a valid alternative to conventional access in the highly heterogeneous RHC population due to its safety profile and comparable success rate.^2-4 In this regard, previous studies showed that RHC performed via arm venous access, regardless of access point, is also associated with greater patient comfort, lower vascular site complications, and shorter procedure time and thereby lower radiation exposure.^2-5

Similarly, anecdotical experiences and small case series advocated this approach for diagnostic and interventional procedures for the CHD population.^6-8 To the authors’ knowledge, the current study is one of the largest to report the safety and feasibility of RHC via upper extremity venous access in children and adults with CHDs. 

Benefits. For this particular population, several potential advantages of this technique over conventional venous access have been identified. In general, the upper arm venous access provides a more favorable angulation via the superior vena cava to cross the tricuspid valve and enter in pulmonary artery as compared to via the inferior vena cava. Thus, this approach is more feasible in patients with CHD showing enlarged right atrium or ventricle or severe tricuspid regurgitation. The wire and catheter manipulation via superior vena cava should be easier, especially when using the veins on the medial side of the forearm that present a straighter course compared to those on the lateral side.

The upper arm venous approach may be used to perform an RHC in the setting of congenital anomalies of the inferior vena cava and its tributaries, instead of the superior vena cava. These anomalies account for 0.6% to 2% of patients with CHD. Usually, the vascular variations do not have clinical implications, but they may make it challenging—or even impossible—to complete RHC using the femoral approach through the azygos or hemiazygos venous connection. In fact, the manipulation of the catheters is more difficult due to the longer course, the multiple curves, and the acute angulation of the azygos vein entering the superior vena cava compared to a more linear upper arm venous approach.

Similar considerations may be applied in cases of an acquired vascular injury that causes interruption of inferior vena cava. Unfortunately, this circumstance is not infrequent in children and adults with CHD who have undergone multiple cardiac surgeries and repeated catheterizations, resulting in thrombosis or chronic occlusion of the vessel.  In this setting, the upper arm venous approach may be an alternative route for subsequent cardiac procedures.

The RHC approach may also be used in patients with a functional single ventricle who have experienced Glenn anastomosis in order to assess anatomic and hemodynamic suitability for Fontan completion, as well as to perform catheter-based interventions before surgery. In these cases, the superior venous access is mandatory to access pulmonary arteries. Thus, the upper arm venous access may be considered in order to avoid severe complications related to jugular approach, such as carotid artery puncture, hemothorax, or pneumothorax. In addition, this technique allows the operator to work in a wider area and more distant from the image intensifier, facilitating more comfort and less radiation exposure compared to the traditional approach (Figure 2).

In the CHD population, the upper venous arm approach offers the benefit of being able to perform RHC using local anaesthesia or conscious sedation, subsequently minimizing the effects of anaesthetic agents on hemodynamic evaluation and reducing anaesthesia-related complications, including avoiding tracheal intubation.^2-5 These aspects are important in patients with CHD who show severe cyanosis, heart failure, arterial pulmonary hypertension, and other conditions for which RHC may become a high-risk procedure.^6-7

Similar to other studies, this study did not report bleeding complications.^2-7 Given the superficial nature of these vessels, bleeding control using upper arm venous access is rapid and may be obtained with only manual compression.

The authors believe the upper arm approach is advantageous, particularly in children and infants for whom the immobilization of the neck and the leg after the procedure is not often tolerated, which increases the risk of large hematomas. In addition, the faster mobilization after the procedure results in more comfort for the patient.^5-6 Furthermore, the benefit of the upper arm venous access may be considered for patients with CHD undergoing RHC without anticoagulant discontinuation.

All patients in the current study requiring a left catheterization underwent a “full forearm approach” via upper arm vein and radial artery. Similar to previous studies,^2-6 these findings may support the cost-effectiveness of the venous arm approach compared with traditional vascular access because of associated enhanced resource utilization and shorter hospital stay.

Finally, multiple RHCs may increase the risk of venous thrombosis of the venous access. The facilitation of vascular access with this technique may be a valid strategy to preserve central access in view of future and more complex interventions requiring traditional routes.

The authors believe that arm venous access may be used not only for RHC, but may also have potential applications in procedures such as endomyocardial biopsy, interventional cardiac catheterization requiring a “small” sheath, and percutaneous mechanical thrombectomy.⁸

Risks/contraindications. Potential causes of failure to complete a RHC by upper venous access may include tortuous and/or calcified venous anatomy, chronic thrombotic vein occlusion due to prior catheter lines, rare congenital anomalies, or simply the inability to adequately torque a catheter into position. In these cases, ultrasound-guided venous access may be helpful before the RHC to evaluate vessel health, viability, size, and patency, and to choose the most suitable side of the puncture.

Results of this retrospective, observational, single-center study demonstrate that the upper arm veins provide safe and effective access points, whether using the basilic, cephalic, or antecubital vein, to perform an RHC in children and adult patients with CHD. The procedure was shown to generate few clinical concerns and was accompanied by few mild complications.

From the ¹Pediatric Cardiology Division, University of Campania “Luigi Vanvitelli”, AORN “Ospedali dei Colli”, Monaldi Hospital, Naples, Italy; ²Invasive Cardiology Unit, University of Campania “Luigi Vanvitelli”, AORN “Ospedali dei Colli”, Monaldi Hospital, Naples, Italy; ³Adult Congenital Heart Disease Unit, AORN “Ospedali dei Colli”, Monaldi Hospital, Naples, Italy

Note: The first two authors contributed equally to the development of the manuscript

Funding. This work was not supported by foundations.

Competing interests. None declared.

Address for Correspondence: Mario Giordano, MD, AORN “Ospedali dei Colli”, Monaldi Hospital, Via Leonardo Bianchi 1, Naples, Italy. Email: giordanomario1123@gmail.com

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