Femoral vein catheterization techniques. Arterial access (radial artery puncture) Femoral artery puncture

05.11.2019 -

Seldinger method(S. Seldinger; syn. puncture catheterization of arteries) - the introduction of a special catheter into a blood vessel by percutaneous puncture with a diagnostic or therapeutic purpose. Proposed by Seldinger in 1953 for arterial puncture and selective arteriography. Subsequently, S. began to use m for puncture of the veins (see Puncture vein catheterization).

Cm. apply for catheterization and contrast study atria and ventricles of the heart, the aorta and its branches, the introduction of dyes, radiopharmaceuticals, drugs, donated blood and blood substitutes into the arterial bed, as well as, if necessary, multiple studies arterial blood.

Contraindications the same as for cardiac catheterization (see).

The study is carried out in the X-ray operating room (see Operating block) using special tools included in the Seldinger kit - a trocar, a flexible conductor, a polyethylene catheter, etc. Instead of a polyethylene catheter, you can use an Edman catheter - a radiopaque elastic plastic tube of red, green or yellow color depending on diameter. The length and diameter of the catheter is selected based on the objectives of the study. The inner sharp end of the catheter is tightly adjusted to the outer diameter of the conductor, and the outer one to the adapter. The adapter is connected to a syringe or measuring device.

Usually S. m. apply for selective arteriography, for which a percutaneous puncture is performed more often than the right femoral artery. The patient is laid on his back on a special table for cardiac catheterization and his right leg is somewhat taken aside. The pre-shaven right inguinal region is disinfected and then isolated with sterile sheets. The right femoral artery is palpated with the left hand immediately below the inguinal ligament and fixed with the index and middle fingers. Anesthesia of the skin and subcutaneous tissue is performed with a 2% solution of novocaine using a thin needle so as not to lose the sensation of arterial pulsation. The scalpel cuts the skin over the artery and introduces a trocar, with the tip of which they try to feel the pulsating artery. By tilting the outer end of the trocar to the skin of the thigh at an angle of 45°, short movement forward pierce the anterior wall of the artery (Fig., a). Then the trocar is tilted even more towards the thigh, the mandrin is removed from it and a conductor is inserted towards the stream of scarlet blood, the soft end of which is advanced into the lumen of the artery under the inguinal ligament by 5 cm (Fig., b). The conductor is fixed through the skin with the index finger of the left hand in the lumen of the artery, and the trocar is removed (Fig., c). By pressing a finger, the conductor is fixed in the artery and the formation of a hematoma in the puncture area is prevented.

Schematic representation of the stages of percutaneous puncture catheterization of the artery according to the Seldinger method: a - percutaneous puncture of the artery with a trocar; b - a conductor is inserted through the trocar into the lumen of the artery; c - removal of the trocar from the artery; the conductor remaining in the lumen of the artery is pressed from the outside with a finger; d - a catheter is inserted through the conductor into the lumen of the artery; 1 - skin and subcutaneous tissue; 2 - lumen of the artery; 3 - trocar; 4 - mandrin; 5 - conductor; 6 - catheter.

A catheter with a tip pointed and tightly fitted to the diameter of the conductor is put on the outer end of the conductor, advanced to the skin of the thigh and inserted through the conductor into the lumen of the artery (Fig., d). The catheter, together with the soft tip of the conductor protruding from it, is advanced under the control of an X-ray screen, depending on the objectives of the study (general or selective arteriography), into the left heart, the aorta, or one of its branches. Then a radiopaque substance is injected and a series of radiographs is taken. If necessary, pressure recording, blood sampling, or injection medicinal substances the conductor is removed from the catheter, and the latter is washed with an isotonic solution of sodium chloride. After the study is completed and the catheter is removed, a pressure bandage is applied to the puncture site.

Complications(hematoma and thrombosis in the puncture area of the femoral artery, perforation of the walls of the arteries, aorta or heart) with technically correctly performed S. m. are rare.

Bibliography: Petrovsky B.V. and others. Abdominal aortography, Vestn. hir., t. 89, No. 10, p. 3, 1962; Seldinger S. I. Catheter replacement of the needle in percutaneous arteriography, Acta radiol. (Stockh.), v. 39, p. 368, 1953.

V. V. Zaredkiy.

percutaneous catheterization femoral artery Seldinger performed using a special set of tools, consisting of puncture needle, dilator, introducer, metallic conductor soft end and catheter, size 4-5 F ( in French).

Modern angiographic devices are designed in such a way that for puncture it is more convenient to use the right femoral artery. The patient is placed on his back on a special table for angiography and the right leg is brought to a state of maximum pronation.

The pre-shaven right inguinal region is lubricated with iodine, and then wiped with alcohol and isolated with disposable sterile sheets to prepare a large sterile area for conductor and catheter.

Given the topographic anatomy of the femoral artery, it is necessary to find the inguinal ligament and mentally divide it into three parts. The projection of the passage of the femoral artery is often located on the border of the middle and medial third of the inguinal ligament. Find her palpation, as a rule, is not difficult for its pulsation. It is important to remember that medially from the femoral artery is the femoral vein, and laterally- femoral nerve.

With the left hand, the femoral artery is palpated on the inner surface of the lower limb 2 cm below the inguinal ligament and fixed between the index and middle fingers.

The painfulness of the manipulation requires the patient, who is conscious, to undergo infiltration anesthesia with a solution of novocaine or lidocaine.

After performing local anesthesia of the skin and subcutaneous tissue with 1% lidocaine solution or 2% novocaine solution, puncture femoral artery. Puncture needle entered in the direction ripple, at an angle not exceeding 45 degrees, which reduces the subsequent likelihood of excessive kink catheter.

Tilting the outer end needles to the skin, pierce the anterior wall of the vessel. But more often needle passes both walls at once, and then the tip needles enters the lumen of the vessel only when moving it in the opposite direction.

igloo tilt even more to the thigh, remove from it mandrin and insert a metal conductor, the tip of which is advanced into the lumen of the artery by 10-15 cm in the central direction under pupart ligament. Carefully advancing the tool, it is necessary to assess the presence of resistance. In the correct position needles in the vessel, there should be no resistance.

Further promotion conductor, especially in persons over 50 years of age, it is necessary to carry out only under X-ray control to the level of the twelfth thoracic vertebra (Th-12).

Through the skin with the index finger of the left hand is fixed conductor in the lumen of the artery, and needle are pulled out. Finger pressure prevents removal from the artery conductor and leakage past it under the skin of arterial blood.

To the outer end conductor put on dilator, corresponding in diameter to the input catheter. dilator enter by moving along conductor 2-3 cm into the lumen of the femoral artery.

After removal dilator put on the conductor introducer, which is entered by conductor into the femoral artery.

At the next stage catheterization required at the outer end conductor put on catheter and promoting it distally, enter into introducer and then into the femoral artery.

From the femoral artery catheter (from the Greek kathet?r - a surgical instrument for emptying the cavity) - a tubular instrument designed for the introduction of drugs and X-ray contrast agents into the natural channels and cavities of the body, blood and lymphatic vessels, as well as to extract their contents for diagnostic or therapeutic purposes. carried out along the vascular bed under X-ray control until aorta, then conductor removed and further advancement of the catheter up to target vessel carried out without it.

It should be remembered that after the end of the procedure, the place puncture must be firmly pressed against the bone base to avoid hematoma.

External iliac artery (arteria iliaca external, femoral artery (arteria temoralis) and their branches. Front view.

1-common iliac artery;

2-internal iliac artery;

3-external iliac artery;

4-lower epigastric artery;

5-femoral vein;

6-external genital arteries;

7-medial circumflex artery femur;

8-femoral artery;

9-subcutaneous nerve;

10-lateral artery, envelope of the femur;

11-deep femoral artery;

12-superficial artery, envelope of the ilium;

13-inguinal ligament;

14-deep artery enveloping the ilium;

15-femoral nerve.

As with venous access, arterial access used for various purposes:
for intra-arterial blood transfusion;
during arterial catheterization.

For intra-arterial infusion use the vessels closest to the heart. Intra-arterial blood transfusion is technically more difficult than intravenous. In addition, complications are possible in the form of damage and thrombosis of the arterial trunks. For this reason, currently this method practically not applied.

Indications:
clinical death due to massive unreplenished blood loss;
terminal state with shocks of any etiology (BP is 60 mm Hg and below);
no access to veins.

Advantages. This access allows you to transfuse a sufficient amount of transfusion medium into the vascular bed in the shortest possible time. direct blood supply to cerebral vessels coronary vessels. Reflex stimulation of cardiac activity. In addition, it should be noted that the diameter of the needles in arterial access is much smaller than in venous access.

Arterial puncture

The need for this manipulation occurs when:
obtaining arterial blood samples;
direct registration blood pressure;
the introduction of contrast agents in cases of certain examination methods.
The most commonly used puncture of the radial and femoral arteries.

Puncture of the radial artery

It is used most often, since in this case, even with a violation of blood circulation in the radial artery, the blood supply to the hand usually does not change. Before puncture, it is necessary to make sure that the ulnar artery and its anastomoses with the palmar arch are functioning normally - Allen's test for the adequacy of collateral circulation: they pinch the ulnar and radial arteries with their fingers so that the blood flows out of the veins from the hand and it turns pale. The patient is asked to squeeze and unclench his hand several times. In this case, the palm acquires a deathly pale hue. The ulnar artery is released, and with sufficient collateral circulation, despite the clamped radial artery, normal color the skin is restored after 5-10 s. If the color of the hand does not return to its original color during this time, the Allen test is considered negative, which indicates occlusion of the radial artery.

Anatomy. The radial and ulnar arteries are branches of the brachial artery and supply blood to the hand through the superficial and deep palmar arch. The radial artery is located along the lateral edge of the forearm, palpated on the wrist at the distal end of the radius. Here it is covered only by fascia and skin.

Puncture progress. The hand is unbent at the wrist joint, placed on a roller, and the pulsation of the arteries is determined. The skin and subcutaneous tissue are infiltrated with an anesthetic solution, since arterial puncture is a painful procedure for the patient. Anesthesia also eliminates arterial spasm. The vessel is fixed between the index and middle fingers, the needle is inserted in the proximal direction at an angle of 45° to the horizontal plane. With a slow approach to the artery, there is a feeling of transmission pulsation. The needle is advanced until blood appears. A more experienced physician can puncture the artery at a right angle, which minimizes trauma to the artery. The presence of the needle in the artery is indicated by the entry of scarlet pulsating blood into the syringe.

Puncture of the femoral artery

Anatomy. The femoral artery is a continuation of the trunk of the external iliac artery. The artery crosses the middle of the line drawn from the anterior superior iliac spine to the pubic joint. Medial to the artery lies the femoral vein, both vessels pass together in the Scarpov triangle.

Puncture progress. The femoral vein is punctured at the pupart ligament (inguinal). Use a large needle with a diameter of 1.2 mm.

For comfort manipulation the needle is placed on the syringe. The middle and index fingers of the left hand probe the pulsation of the vessel wall. The needle is inserted between the fingers with a cut down to avoid puncture of the opposite wall and directed at a slight angle to the skin. As soon as the needle penetrates the lumen of the artery, blood under strong pressure enters the syringe. After that, the syringe is disconnected and further necessary measures (transfusion, catheterization) are started.

I. Indications. Puncture of the radial artery is performed to: 1) determine blood gases or 2) obtain a blood sample if it is impossible to take it from a vein or capillaries.

II. Equipment. Butterfly needles 23 or 25 gauge, 1- or 3-gram syringe, swabs soaked in alcohol and povidone-iodine (povidone-iodine complex), gauze pads 4x4, a sufficient amount of diluted heparin solution 1:1000.

III. Execution technique

A. Flush with a small amount of heparin solution (1:1000 dilution) into the syringe in which the blood sample will be delivered to the laboratory for blood gas determination. A small amount of heparin coating the walls of the syringe is sufficient to prevent blood coagulation. Too much heparin can interfere with results laboratory research. When taking blood to determine biochemical parameters with heparin, the syringe is not washed.

B. The most widely used puncture of the radial artery, which will be described below. Alternative option- puncture of the posterior tibial artery. The femoral arteries are best preserved for emergencies. The brachial arteries should not be punctured due to the lack of collateral circulation in them.

B. Check the condition of the collateral circulation and the patency of the ulnar artery using the Allen test. Press the radial and ulnar arteries on your wrist at the same time, then rub your palm so that it turns white. Reduce pressure on the ulnar artery. If the palm turns pink in less than 10 seconds, there is adequate collateral circulation through the ulnar artery. If the normal color of the palm is not restored within 15 seconds or more or does not appear at all, this means that the collateral circulation is poorly developed and it is better not to puncture the radial artery on this hand. Then it is necessary to check the state of collateral circulation on the other hand.

D. To obtain a blood sample, hold the patient's hand in left hand and straighten it at the wrist. With the index finger of the left hand, palpate the radial artery (Fig. 19). Some help can be provided by marking the puncture site with a fingernail.

E. Wipe the puncture site first with a povidone-iodine swab, then with an alcohol swab.

E. Puncture the skin at an angle of approximately 30° and slowly advance the needle with the bevel upward until blood appears in the connecting tube (see Fig. 19). When taking blood from an artery, it is not necessary to create a strong vacuum in the syringe to fill it.

G. Draw the required amount of blood (the minimum required) into the syringe. The volume of blood taken should not exceed 3-5% of the total circulating blood volume (the volume of circulating blood in a newborn child is approximately 80 ml/kg). Therefore, if 4 ml of blood is taken from a newborn with a body weight of 1 kg, this is 5% of the total circulating blood volume.

3. After removing the needle, to ensure adequate hemostasis, apply a pressure bandage with gauze pad 4x4 to the wrist for at least 5 minutes, but so that there is no complete occlusion of the arteries.

I. Before determining blood gases in the obtained sample, it is necessary to remove air bubbles from it and hermetically close the syringe. Failure to do so may result in errors in the analysis results.

K. The syringe is then placed on ice and immediately sent to the laboratory. On the laboratory form, the time of blood sampling, the temperature of the patient and the level of hemoglobin are noted.

IV. Complications

A. Infection. The risk of infectious complications can be minimized by strictly observing sterility during the procedure. The infection is usually caused by Gram-positive bacteria such as Staphylococcus epidermidis. They should be treated with nafcillin or vancomycin and gentamicin. Each hospital should determine the sensitivity of the pathogen to antibiotics.

B. Hematoma. To reduce the risk of hematoma formation, use the smallest possible gauge of the needle and immediately after its removal, apply a pressure bandage for approximately 5 minutes. Hematomas usually resolve on their own.

B. Arteriospasm, thrombosis and embolism. The risk of these complications can be reduced by using the smallest possible needle gauge. With thrombosis, recanalization of the vessel usually occurs after a certain period of time. Arteriospasm, as a rule, is eliminated on its own.

D. Inaccuracy of the results of determining the lawn of blood. Too much heparin in the syringe can lead to erroneously low pH and PCO2 values. Before drawing blood, remove the heparin solution from the syringe. The presence of air bubbles in the blood sample, due to a leaky syringe, can lead to falsely high PO2 readings and falsely low PCO2 readings.

Why is it carried out

The femoral vein is located in the inguinal region and is one of the major highways that carry out the outflow of blood from lower extremities person.

catheterization femoral vein saves lives, as it is located in an accessible place, and in 95% of cases, manipulations are successful.

The indications for this procedure are:

the impossibility of introducing drugs into the jugular, superior vena cava;
hemodialysis;
carrying out resuscitation;
vascular diagnostics (angiography);
the need for infusions;
pacing;
low blood pressure with unstable hemodynamics.

Preparation for the procedure

To puncture the femoral vein, the patient is placed on the couch in the supine position and asked to stretch and slightly spread their legs. A rubber roller or pillow is placed under the lower back. The surface of the skin is treated with an aseptic solution, if necessary, the hair is shaved off, and the injection site is limited with a sterile material. Before using the needle, a vein is found with a finger and the pulsation is checked.

The equipment of the procedure includes:

sterile gloves, bandages, wipes;
painkiller;
needles for catheterization 25 gauge, syringes;
needle size 18;
catheter, flexible conductor, dilator;
scalpel, suture material.

Items for catheterization should be sterile and be at hand of the doctor or nurse.

Technique, Seldinger catheter insertion

Seldinger is a Swedish radiologist who in 1953 developed a method for catheterization of large vessels using a guidewire and a needle. Puncture of the femoral artery according to his method is carried out to this day:

The gap between the symphysis pubis and the anterior iliac spine is conventionally divided into three parts. The femoral artery is located at the junction of the medial and middle thirds of this area. The vessel should be moved laterally, as the vein runs parallel.
The puncture site is cut off on both sides, making subcutaneous anesthesia with lidocaine or other painkillers.
The needle is inserted at an angle of 45 degrees at the site of the pulsation of the vein, in the region of the inguinal ligament.
When blood of a dark cherry color appears, the puncture needle is led along the vessel by 2 mm. If blood does not appear, you must repeat the procedure from the beginning.
The needle is held motionless with the left hand. A flexible guidewire is inserted into her cannula and advanced through the cut into the vein. Nothing should interfere with advancement into the vessel, with resistance, it is necessary to slightly rotate the instrument.
After successful insertion, the needle is removed, pressing the injection site to avoid hematoma.
A dilator is put on the conductor, after excising the injection point with a scalpel, and it is inserted into the vessel.
The dilator is removed and the catheter is inserted to a depth of 5 cm.
After successful replacement of the conductor with a catheter, a syringe is attached to it and the piston is pulled towards itself. If blood enters, then an infusion with isotonic saline is connected and fixed. The free passage of the drug indicates that the procedure was correct.
After manipulation, the patient is prescribed bed rest.

Insertion of a catheter under ECG control

The use of this method reduces the number of post-manipulation complications and facilitates monitoring the state of the procedure, the sequence of which is as follows:

The catheter is cleaned with isotonic saline using a flexible guidewire. The needle is inserted through the plug, and the tube is filled with NaCl solution.
Lead “V” is brought to the cannula of the needle or fixed with a clamp. On the device include the mode "chest assignment". Another way is to connect the wire right hand to the electrode and turn on lead number 2 on the cardiograph.
When the end of the catheter is located in the right ventricle of the heart, the QRS complex on the monitor becomes higher than normal. Reduce the complex by adjusting and pulling the catheter. A high P wave indicates the location of the device in the atrium. Further direction to a length of 1 cm leads to the alignment of the tooth according to the norm and the correct location of the catheter in the vena cava.
After the performed manipulations, the tube is sutured or fixed with a bandage.

Possible Complications

When carrying out catheterization, it is not always possible to avoid complications:

The most common unpleasant consequence is the puncture of the posterior wall of the vein and, as a result, the formation of a hematoma. There are cases when it is necessary to make an additional incision or puncture with a needle to remove blood that has accumulated between the tissues. The patient is prescribed bed rest, tight bandaging, warm compress in the thigh area.
The formation of a thrombus in the femoral vein has a high risk of complications after the procedure. In this case, the leg is placed on an elevated surface to reduce swelling. Blood-thinning drugs are prescribed to promote the resorption of blood clots.
Post-injection phlebitis - inflammatory process on the wall of the vein. The general condition of the patient worsens, the temperature appears up to 39 degrees, the vein looks like a tourniquet, the tissues around it swell, become hot. The patient is given antibiotic therapy and treatment with non-steroidal drugs.
Air embolism - air entering the vein through a needle. This complication may result in sudden death. Symptoms of embolism are weakness, deterioration in general condition, loss of consciousness or convulsions. The patient is transferred to the intensive care unit and connected to the respiratory apparatus of the lungs. With timely assistance, the person's condition returns to normal.
Infiltration - the introduction of the drug not into the venous vessel, but under the skin. May lead to tissue necrosis and surgical intervention. Symptoms are swelling and redness of the skin. If an infiltrate occurs, it is necessary to make absorbable compresses and remove the needle, stopping the flow of the drug.

Modern medicine does not stand still and is constantly evolving in order to save as much as possible. more lives. It is not always possible to provide assistance in time, but with the introduction the latest technologies mortality and complications after complex manipulations are reduced.

Angiography according to Seldinger - a method for diagnosing the state of blood vessels

Angiography c refers to the X-ray contrast study of blood vessels. This technique is used in computed tomography, fluoroscopy and radiography, the main goal is to assess the roundabout blood flow, the state of the vessels, as well as the extent of the pathological process.

This study should be carried out only in special X-ray angiographic rooms based on specialized medical institutions that have modern angiographic equipment, as well as appropriate computer equipment that can record and process the obtained images.

Hagiography is one of the most accurate medical examinations.

This diagnostic method can be used in the diagnosis coronary disease hearts, kidney failure, and to detect various kinds of cerebrovascular accidents.

Types of aortography

In order to contrast the aorta and its branches in the case of preservation of the pulsation of the femoral artery, the method of percutaneous aortic catheterization (Seldinger angiography) is most often used, in order to visually differentiate the abdominal aorta, translumbar puncture of the aorta is used.

It is important! The technique involves the introduction of an iodine-containing water-soluble contrast agent by direct puncture of the vessel, most often through a catheter that is inserted into the femoral artery.

Seldinger catheterization technique

Percutaneous catheterization of the femoral artery according to Seldinger is performed using a special set of instruments, which includes:

puncture needle;
dilator;
introducer;
metal conductor with a soft end;
catheter (French size 4-5 F).

A needle is used to puncture the femoral artery to pass a metal conductor in the form of a string. Then the needle is removed, and a special catheter is inserted through the conductor in the lumen of the artery - this is called aortography.

Due to the painful manipulation, the conscious patient needs infiltration anesthesia with a solution of lidocaine and novocaine.

It is important! Percutaneous catheterization of the aorta according to Seldinger can also be performed through the axillary and brachial arteries. Passing a catheter through these arteries is more often performed in cases where there is obstruction of the femoral arteries.

Seldinger angiography is considered universal in many ways, which is why it is used most often.

Translumbar puncture of the aorta

In order to visually differentiate the abdominal aorta or arteries of the lower extremities, for example, when they are affected by aorto-arteritis or atherosclerosis, preference is given to such a method as direct translumbar puncture of the aorta. The aorta is punctured with a special needle from the back.

If it is necessary to obtain contrasting branches of the abdominal aorta, then high translumbar aortography with aortic puncture is performed at the level of the 12th thoracic vertebra. If the task includes the process of contrasting the bifurcation of the artery of the lower extremities or the abdominal aorta, then the translumbar puncture of the aorta is performed at the level of the lower edge of the 2nd lumbar vertebra.

During this translumbar puncture, it is very important to pay special attention to the research methodology, in particular, a two-stage removal of the needle is carried out: first it must be removed from the aorta and only after a few minutes - from the para-aortic space. Thanks to this, it is possible to avoid and prevent the formation of large para-aortic hematomas.

It is important! Techniques such as translumbar puncture of the aorta and Seldinger angiography are the most widely used procedures for contrasting the arteries, the aorta and its branches, which makes it possible to obtain an image of almost any part of the arterial bed.

The use of these techniques in special conditions medical institutions allows to achieve a minimal risk of complications and at the same time is an affordable and highly informative diagnostic method.

SELDINGER METHOD (S. Seldinger; syn. puncture catheterization of arteries) - the introduction of a special catheter into a blood vessel by percutaneous puncture for diagnostic or therapeutic purposes. Proposed by Seldinger in 1953 for arterial puncture and selective arteriography. Subsequently, S. began to use m for puncture of the veins (see Puncture vein catheterization).

S. m is used for the purpose of catheterization and contrast study of the atria and ventricles of the heart, the aorta and its branches, the introduction of dyes, radiopharmaceuticals, drugs, donor blood and blood substitutes into the arterial bed, as well as, if necessary, multiple studies of arterial blood.

Contraindications are the same as for cardiac catheterization (see).

Usually S. m is used for selective arteriography, for which a percutaneous puncture is performed more often than the right femoral artery. The patient is laid on his back on a special table for cardiac catheterization and his right leg is somewhat taken aside. The pre-shaven right inguinal region is disinfected and then isolated with sterile sheets. The right femoral artery is palpated with the left hand immediately below the inguinal ligament and fixed with the index and middle fingers. Anesthesia of the skin and subcutaneous tissue is performed with a 2% solution of novocaine using a thin needle so as not to lose the sensation of arterial pulsation. The scalpel cuts the skin over the artery and introduces a trocar, with the tip of which they try to feel the pulsating artery. Having tilted the outer end of the trocar to the skin of the thigh at an angle of 45°, the anterior wall of the artery is pierced with a quick short forward movement (Fig., a). Then the trocar is tilted even more towards the thigh, the mandrin is removed from it and a conductor is inserted towards the stream of scarlet blood, the soft end of which is advanced into the lumen of the artery under the inguinal ligament by 5 cm (Fig., b). The conductor is fixed through the skin with the index finger of the left hand in the lumen of the artery, and the trocar is removed (Fig., c). By pressing a finger, the conductor is fixed in the artery and the formation of a hematoma in the puncture area is prevented.

A catheter with a tip pointed and tightly fitted to the diameter of the conductor is put on the outer end of the conductor, advanced to the skin of the thigh and inserted through the conductor into the lumen of the artery (Fig., d). The catheter, together with the soft tip of the conductor protruding from it, is advanced under the control of an X-ray screen, depending on the objectives of the study (general or selective arteriography), into the left heart, the aorta, or one of its branches. Then a radiopaque substance is injected and a series of radiographs is taken. If it is necessary to register pressure, take blood samples or administer medicinal substances, the conductor is removed from the catheter, and the latter is washed with an isotonic solution of sodium chloride. After the study is completed and the catheter is removed, a pressure bandage is applied to the puncture site.

Complications (hematoma and thrombosis in the puncture area of the femoral artery, perforation of the walls of the arteries, aorta or heart) with technically correctly performed S. m are rare.

Bibliography: Petrovsky BV, etc. Abdominal aortography, Vestn. hir., t. 89, No. 10, p. 3, 1962; S e 1 d i n-g e g S. I. Catheter replacement of the needle in percutaneous arteriography, Acta radiol. (Stockh.), v. 39, p. 368, 1953.

Puncture of the femoral artery by Seldinger

The Seldinger puncture is carried out with the aim of introducing a catheter into the aorta and its branches, through which it is possible to contrast the vessels, to probe the heart cavities. A needle with an inner diameter of 1.5 mm is injected immediately below the inguinal ligament along the projection of the femoral artery. A conductor is first inserted through the lumen of the needle inserted into the artery, then the needle is removed and a polyethylene catheter with an outer diameter of 1.2-1.5 mm is put on the conductor instead.

The catheter, together with the conductor, is advanced along the femoral artery, iliac arteries into the aorta to the desired level. Then the conductor is removed, and a syringe with a contrast agent is attached to the catheter.

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Puncture of the femoral artery by Seldinger

Femoral artery catheterization using the Seldinger technique

N.B. If a patient is undergoing an A. femoralis angiography just prior to cardiopulmonary bypass surgery, NEVER remove the catheter (sheath) through which the procedure was performed. By removing the catheter and applying a compression bandage, you will expose the patient to the risk of developing an unnoticed arterial bleeding("under the sheets") against the background of total heparinization. Use this catheter for blood pressure monitoring.

Angiography of the arterial system. Types of access to the arteries.

Technique of translumbar puncture of the abdominal aorta.

The position of the patient - lying on his stomach, arms bent at the elbows and placed under the head. Reference points for puncture are the outer edge of the left m.erector spinae and the lower edge of the XII rib, the intersection point of which is the point of needle injection. After anesthetizing the skin with a 0.25-0.5% novocaine solution, a small skin incision (2-3 mm) is made and the needle is directed forward, deep and medially at an angle of 45 ° to the surface of the patient's body (approximate direction to the right shoulder). In the course of the needle, infiltration anesthesia is performed with a solution of novocaine. Upon reaching the para-aortic tissue, transmission vibrations of the aortic wall are clearly felt, confirming the correctness of the puncture. A "pillow" of novocaine (40-50 ml) is created in the para-aortic tissue, after which the aortic wall is pierced with a short sharp movement. Evidence that the needle is in the lumen of the aorta is the appearance of a pulsating jet of blood from the needle. The movement of the needle is constantly monitored by fluoroscopy. A conductor is inserted through the lumen of the needle into the aorta and the needle is removed. The average aortic puncture at the level of L2 is more commonly used. If occlusion or aneurysmal expansion of the infrarenal aorta is suspected, a high puncture of the suprarenal abdominal aorta at the level of Th12-L1 is indicated. The translumbar puncture technique for angiography of the abdominal aorta is almost always a necessary measure, since the required volume and speed of contrast agent injection on conventional angiographic equipment (50-70 ml at a rate of 25-30 ml / s) can only be introduced through catheters of a rather large diameter - 7-8 F (2.3-2.64 mm). Attempts to use these catheters for transaxillary or cubital arterial approaches are accompanied by various complications. However, with the development of digital subtraction angiography, when it became possible to enhance the radiopaque image of vessels by computer methods after the introduction of a relatively small amount of contrast agent, catheters of small diameters 4-6 F or 1.32 have become increasingly used. These catheters allow safe and reasonable access through the arteries. upper limbs: axillary, humeral, ulnar, radial.

Puncture technique of the common femoral artery according to Seldinger.

Femoral artery puncture is performed 1.5-2 cm below the pupart ligament, in the place of the most distinct pulsation. Having determined the pulsation of the common femoral artery, local infiltration anesthesia is performed with a solution of novocaine 0.25-0.5%, but so as not to lose the pulsation of the artery; layer-by-layer infiltrate the skin and subcutaneous tissue to the right and left of the artery to the periosteum of the pubic bone. It is important to try to elevate the artery from the bone bed to the bone, which facilitates puncture, as it brings the wall of the artery closer to the surface of the skin. After completion of anesthesia, a small skin incision (2-3 mm) is made to facilitate the passage of the needle. The needle is passed at an angle of 45°, fixing the artery with the middle and index fingers of the left hand (during the puncture of the right femoral artery). When its end comes into contact with the anterior wall of the artery, pulse shocks can be felt. The puncture of the artery should be carried out with a sharp short movement of the needle, trying to puncture only its anterior wall. Then a stream of blood enters immediately through the lumen of the needle. If this does not happen, the needle is slowly pulled back until a blood stream appears or until the needle exits the puncture canal. Then you should repeat the puncture attempt. The artery is pierced with a thin needle with an outer diameter of 1-1.2 mm without a central mandrel with an oblique sharpening, both in the antegrade and retrograde directions, depending on the purpose of the study. When a jet of blood appears, the needle is tilted to the patient's thigh and a conductor is inserted through the channel into the lumen of the artery. The position of the latter is controlled by fluoroscopy. Then the conductor is fixed in the artery, and the needle is removed. A catheter or introducer is installed along the conductor into the lumen of the artery during long-term interventions with a change of catheters. In cases where the femoral arteries cannot be punctured, such as after bypass surgery or occlusive disease, when the lumen of the femoral artery, pelvic arteries, or distal aorta is obstructed, an alternative approach should be used.

Such accesses can be axillary or brachial arteries, translumbar puncture of the abdominal aorta.

Contralateral femoral approach.

Most endovascular interventions on the iliac arteries can be performed using the ipsilateral femoral artery. However, some lesions, including stenoses of the distal external iliac artery, are not accessible from the ipsilateral common femoral artery. In these cases, the contralateral approach is preferred; in addition, it allows performing intervention in case of multilevel stenoses of the femoral-popliteal and ilio-femoral zone. Cobra, Hook, Sheperd-Hook catheters are commonly used to pass through the aortic bifurcation. Contralateral access for stenting and arterial arthroplasty can be difficult when using balloon-expandable stents with a relatively rigid design. In these cases, a long introducer on a rigid conductor "Amplatz syper stiff", etc., should be used. The contralateral approach technique has some advantages compared to the antegrade approach for interventions in the femoral-popliteal zone. First, retrograde insertion of the catheter allows intervention on the proximal portion of the femoral artery, which would be inaccessible with antegrade puncture. The second aspect is the pressure of the artery for hemostasis and the application of a pressure aseptic bandage after the intervention occurs on the opposite side of the operation, which ultimately reduces the frequency of early postoperative complications. Antegrade femoral approach. The antegrade access technique is used by many authors. This type intervention provides more direct access to many lesions in the middle and distal part of the femoropopliteal segment of the artery. The closest approach to stenoses and occlusions in the arteries of the leg provides more precise instrument control. However, in addition to potential advantages, antegrade technique also has disadvantages. A higher puncture of the common femoral artery is required to accurately hit the superficial femoral artery. Puncture of an artery above the inguinal ligament can lead to a formidable complication - retroperitoneal hematoma. Techniques such as injection of a contrast agent through a puncture needle help identify the anatomy of the bifurcation of the common femoral artery. To better display it, an oblique projection is used to open the angle of the bifurcation.

Approximately in 20-30% of standard cases, the technique of antegrade and contralateral approaches to the femoral artery is not able to ensure the delivery of instruments to the occluded areas of the superficial femoral arteries. In these cases, the popliteal approach technique is indicated, which is used only in patients with patent distal segments of the superficial femoral artery and proximal segments of the popliteal artery. Safe puncture of the popliteal artery can only be carried out with thinner instruments with a diameter of no more than 4-6 F. When using instruments such as drills, dilatation balloons with stents, it is permissible to use sheaths 8-9 F, since the diameter of the artery in this place is 6 mm . The technique of popliteal artery puncture is similar to the technique described above. The popliteal artery, together with the nerve and vein, runs from above along the diagonal of the popliteal triangle. The superficial location of the artery in this place allows its retrograde puncture, which is performed exactly above the joint. In this case, the patient lies on his stomach or on his side. Manipulations are performed under local anesthesia.

Access through the brachial artery.

Shoulder access is an alternative technique for inserting instruments into the aorta and its branches, often used for diagnostic procedures when femoral artery puncture or translumbar puncture of the aorta is not possible. In addition, this access may be an alternative approach to endovascular interventions on renal arteries. It is preferable to use the left brachial artery. This is dictated by the fact that catheterization of the right brachial artery significantly increases the risk of embolization of cerebral vessels when passing instruments through the aortic arch. The brachial artery should be punctured in its distal part above the cubital fossa. In this place the artery lies most superficially, hemostasis can be facilitated by pressing the artery against the humerus.

Radial access through the radial artery is accompanied by injury to a vessel smaller than the femoral artery, which makes it possible to do without the indispensable long-term hemostasis, rest period and bed rest after endovascular intervention. Indications for radial access: good pulsation of the radial artery with adequate collateral circulation from the ulnar artery through the palmar arterial arch.

To do this, use the "Allen-test", which must be carried out in all patients - candidates for radial access.

The examination is carried out as follows:

Press down the radial and ulnar arteries;

6-7 flexion-extensor movements of the fingers;

With unbent fingers, simultaneous compression of the ulnar and radial arteries is continued. The skin of the hand turns pale;

Remove compression of the ulnar artery;

Continuing the pressing of the radial artery, control the color of the skin of the hand. Within 10 s, the skin color of the hand should return to normal, which indicates sufficient development of collaterals. In this case, the "Allen test" is considered positive, radial access is acceptable. If the skin color of the hand remains pale, the Allen test is considered negative and radial access is not allowed.

Contraindications to this access are the absence of a radial artery pulse, a negative Allentest, the presence of an arteriovenous shunt for hemodialysis, a very small radial artery, the presence of pathology in. proximal arteries, instruments larger than 7 F are required.

Technique of radial arterial access. Before performing a puncture, the direction of the radial artery is determined. The puncture of the artery is carried out 3-4 cm proximal to the styloid process of the radius. Perform before puncture local anesthesia a solution of novocaine or lidocaine through a needle held parallel to the skin, so as to exclude the puncture of the artery. The skin incision must also be made with great care to avoid injury to the artery. The puncture is made with an open needle at an angle of 30-60° to the skin in the direction of the artery.

Technique of direct catheterization of the carotid arteries. Puncture of the common carotid artery is used for selective studies of the carotid arteries and arteries of the brain. Landmarks are m.sternocleidomastoideus, the upper edge of the thyroid cartilage, the pulsation of the common carotid artery. The superior border of the thyroid cartilage indicates the location of the bifurcation of the common carotid artery. After anesthesia, the skin is punctured with the tip of a scalpel, m.sternocleidomastoideus is pushed outwards and the needle is advanced forward in the direction of the pulsation of the common carotid artery. It is very important that pulse shocks are not felt to the side of the needle tip, but directly in front of it, which indicates the orientation of the needle to the center of the artery. This avoids tangential wounds to the artery wall and the formation of hematomas. The artery is punctured with a short dosed movement. When a jet of blood appears through the lumen of the needle, a conductor is inserted into the artery and the needle is removed. A catheter is installed along the conductor into the lumen of the artery, the type of which depends on the purpose of the study.

Open Access. Due to the risk of damage to the artery, large-diameter instruments are not used; open access to the vessels is carried out by arteriotomy. Instrumentation, doses and rate of administration of the contrast medium. For thoracic and abdominal aortography, catheters of caliber 7-8 F, 100-110 cm long, are required, which provide a contrast agent injection rate of up to 30 ml / s; and for peripheral and selective angiography, 4-6 F catheters 60-110 cm long. Typically, catheters with a pig tail configuration and multiple side holes are used for injection of contrast agent into the aorta. The contrast medium is usually administered by an automatic injector. For selective angiography, catheters of other configurations are used, each of which provides selective catheterization of the mouth of any one artery or group of aortic branches - coronary, brachiocephalic, visceral, etc. In this case, to obtain angiograms, a manual injection of a contrast agent is often quite sufficient. Currently, non-ionic water-soluble contrast agents containing from 300 to 400 mg of iodine per 1 ml (Ultravist-370, Omnipack 300-350, Visipak 320, Xenetics-350, etc.) are more often used for angiography. In rare cases, the previously widely used water-soluble ionic contrast agent 60-76% Urografin is used, which, due to the pronounced pain, nephro and neurotoxic effects, should be limited to the diagnosis of distal lesions of the arterial bed or used in intraoperative angiography under intubation anesthesia. The rate of administration of the contrast agent should be commensurate with the imaging technique and with the blood flow velocity. For injections into the thoracic aorta, a rate of 25 to 30 ml/s is adequate; for the abdominal aorta - from 18 to 25 ml/s; for peripheral arteries (pelvic, femoral) - the rate is from 8 to 12 ml / s when using from 80 to 100 ml of a contrast agent. This provides visualization of the arteries of the lower extremities down to the feet. The imaging speed for thoracic aortography is typically 2 to 4 fps; for abdominal aortography - 2 frames/s; for limbs in accordance with the speed of blood flow - 1-2 frames/s; for the pelvis - 2-3 frames / s and for the vessels of the legs - from 1 to 1 frame / 3 s. Digital subtraction angiography requires a smaller volume and a lower rate of contrast agent injection. Thus, for abdominal aortography, it is sufficient to administer 20-25 ml of X-ray contrast agent at a rate of 12-15 ml/s. And in some cases, it is possible to obtain aortograms with the introduction of a radiopaque agent into the venous bed. It should be noted that this requires a sufficiently large volume of contrast agent - up to 50-70 ml, and the resulting angiograms will correspond to the quality of the overview - general angiograms. The highest resolution of DSA is achieved with direct selective injection of a contrast agent into the vessel under study with the so-called post-process computer image processing - subtraction of the mask (skeleton and soft tissues), image summation, amplification and underlining of the vascular pattern of angiograms, longitudinal or volumetric reconstruction of images of several anatomical regions into one.

An important advantage of modern angiographic devices is the possibility of direct intraoperative measurement of the diameter of blood vessels, parameters of stenosis or aneurysm of the artery. This allows you to quickly determine the tactics of X-ray surgical intervention, accurately select the necessary instruments and implantable devices. Complications. Any radiopaque studies are not absolutely safe and are associated with a certain risk. To possible complications include external and internal bleeding, thrombosis, arterial embolism, perforation of a non-punctured vessel wall with a conductor or catheter, extravasal or intramural administration of a contrast agent, breakage of the conductor or catheter, reactions associated with toxic effect contrast agents. The frequency and type of complications encountered during arterial puncture vary depending on the site of catheterization. The frequency of complications is different: for example, with femoral access - 1.7%; with translumbar - 2.9%; with shoulder access - 3.3%. Main complications: bleeding can be external and internal (hidden) with the formation of a pulsating hematoma and further pseudoaneurysm; thrombosis occurs with prolonged occlusion of the vessel or its dissection; however, its frequency has decreased significantly with the use of smaller diameter catheters and guidewires, a decrease in the time of operation, and the improvement of anticoagulant drugs; embolism develops with the destruction of atherosclerotic plaques or separation of blood clots from the arterial wall. The nature of the complication depends on the size of the embolus and the specific vessel supplying this arterial pool; arteriovenous fistulas can form as a result of simultaneous puncture of an artery and a vein, most often with a femoral approach. The safety conditions of aortoarteriography are strict adherence to indications, contraindications and a rational choice of research methodology, a number of preventive measures aimed at combating potential complications (washing needles, catheters and connecting tubes with isotonic sodium chloride solution with heparin, a thorough check of instruments). Manipulations with the conductor and catheter should be short and less traumatic. During the entire diagnostic study or therapeutic X-ray surgical intervention, it is necessary to control the ECG, blood pressure, blood clotting time. Anticoagulants, antispasmodics, desensitizing drugs190 Fig. 2.33. Puncture of the internal jugular vein, a - the first method; b - the second way. rats also contribute to the prevention of complications and are the key to reducing the risk of angiography. With proper puncture and catheter handling techniques, and the use of non-ionic or low-osmolar contrast media, the complication rate for angiography is less than 1.8%.

Femoral vein catheterization techniques. Arterial access (radial artery puncture) Femoral artery puncture

Arterial puncture

Puncture of the radial artery

Puncture of the femoral artery

Why is it carried out

Preparation for the procedure

Technique, Seldinger catheter insertion

Insertion of a catheter under ECG control

Possible Complications

Angiography according to Seldinger - a method for diagnosing the state of blood vessels

Types of aortography

Seldinger catheterization technique

Translumbar puncture of the aorta

Puncture of the femoral artery by Seldinger

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Puncture of the femoral artery by Seldinger

Angiography of the arterial system. Types of access to the arteries.

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