The polyethylene catheter is carried along the guide with rotational and translational movements to a depth of 5–10 cm to the superior vena cava. The guidewire is removed, controlling the location of the catheter in the vein with a syringe. The catheter is washed and filled with heparin solution. The patient is asked to hold his breath for a short time and at this moment the syringe is disconnected from the catheter cannula and closed with a special plug. The catheter is fixed to the skin and an aseptic dressing is applied. To control the position of the end of the catheter and exclude pneumothorax, radiography is performed.
1. Puncture of the pleura and lung with the development in connection with this of pneumothorax or hemothorax, subcutaneous emphysema, hydrothorax, due to intrapleural infusion.
2. Puncture of the subclavian artery, formation of paravasal hematoma, mediastinal hematoma.
3. During puncture on the left, there is damage to the thoracic lymphatic duct.
4. Damage to elements of the brachial plexus, trachea, and thyroid gland when using long needles and choosing the wrong direction for puncture.
5 Air embolism.
6. A through puncture of the walls of the subclavian vein with an elastic conductor during its insertion can lead to its extravascular location.
Puncture of the subclavian vein.
a - anatomical landmarks of the puncture site, points:
1 (picture below) - Ioffe point; 2 - Aubaniac; 3 - Wilson;
b - direction of the needle.
Rice. 10. Puncture point of the subclavian vein and subclavian direction of needle insertion
Rice. 11. Puncture of the subclavian vein using the subclavian method
Puncture of the subclavian vein using the supraclavicular method from Ioffe's point
Puncture of the subclavian vein.
Catheterization of the subclavian vein according to Seldinger. a - passing the conductor through the needle; b - removing the needle; c - passing the catheter along the guide; d - fixation of the catheter.
1- catheter, 2- needle, 3- “J”-shaped guidewire, 4- dilator, 5- scalpel, 6- syringe – 10 ml
1. Interscalene space of the neck: boundaries, contents. 2. Subclavian artery and its branches, brachial plexus.
The third intermuscular space is the interscalene gap (spatium interscalenum), the space between the anterior and middle scalene muscles. Here lie the second section of the subclavian artery with the outgoing costocervical trunk and bundles of the brachial plexus.
Inward from the artery lies a vein, posteriorly, above and outward 1 cm from the artery - the bundles of the brachial plexus. The lateral part of the subclavian vein is located anterior and inferior to the subclavian artery. Both of these vessels cross the upper surface of the 1st rib. Behind the subclavian artery there is a dome of the pleura, rising above the sternal end of the clavicle.
Femoral vein catheterization techniques
The easiest and fastest way to gain access to administer medications is to perform catheterization. Large and central vessels such as the internal superior vena cava or the jugular vein are mainly used. If there is no access to them, then alternative options are found.
Why is it carried out?
The femoral vein is located in the groin area and is one of the large highways that carries out the outflow of blood from the lower extremities of a person.
Catheterization of the femoral vein saves lives, since it is located in an accessible place, and in 95% of cases the manipulations are successful.
Indications for this procedure are:
- impossibility of administering drugs into the jugular or superior vena cava;
- hemodialysis;
- carrying out resuscitation actions;
- vascular diagnostics (angiography);
- the need for infusions;
- cardiac stimulation;
- low blood pressure with unstable hemodynamics.
Preparation for the procedure
For femoral vein puncture, the patient is placed on the couch in a supine position and asked to stretch his legs and slightly spread them. Place a rubber cushion or pillow under the lower back. The skin surface is treated with an aseptic solution, hair is shaved off if necessary, and the injection site is limited with sterile material. Before using the needle, locate the vein with your finger and check for pulsation.
The procedure includes:
- sterile gloves, bandages, napkins;
- pain reliever;
- 25 gauge catheterization needles, syringes;
- needle size 18;
- catheter, flexible guidewire, dilator;
- scalpel, suture material.
Items for catheterization must be sterile and within the reach of the doctor or nurse.
Technique, Seldinger catheter insertion
Seldinger is a Swedish radiologist who in 1953 developed a method for catheterizing large vessels using a guidewire and a needle. Puncture of the femoral artery using his method is still carried out today:
- The space 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 third of this area. The vessel should be moved laterally, since the vein runs parallel.
- The puncture site is punctured on both sides, giving subcutaneous anesthesia with lidocaine or another anesthetic.
- The needle is inserted at an angle of 45 degrees at the site of vein pulsation, in the area of the inguinal ligament.
- When dark cherry-colored blood appears, the puncture needle is moved along the vessel 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 conductor is inserted into its cannula and advanced through the cut into the vein. Nothing should interfere with the movement into the vessel; if there is resistance, it is necessary to slightly turn the instrument.
- After successful insertion, the needle is removed, pressing the injection site to avoid hematoma.
- A dilator is put on the conductor, after first excising the insertion 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 successfully replacing the guidewire with a catheter, attach a syringe to it and pull the plunger towards you. If blood flows in, an infusion with an isotonic solution is connected and fixed. Free passage of the drug indicates that the procedure was completed correctly.
- After the manipulation, the patient is prescribed bed rest.
Installation 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 an isotonic solution using a flexible guide. The needle is inserted through the plug and the tube is filled with NaCl solution.
- Lead “V” is attached to the needle cannula or secured with a clamp. The device switches on the “thoracic abduction” mode. Another method suggests connecting the wire of the right hand to the electrode and turning 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. The complex is reduced by adjusting and pulling the catheter. A tall 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 prong according to the norm and the correct location of the catheter in the vena cava.
- After the manipulations are completed, the tube is sutured or secured with a bandage.
Possible complications
When performing catheterization, it is not always possible to avoid complications:
- The most common unpleasant consequence is a puncture of the posterior wall of the vein and, as a consequence, the formation of a hematoma. There are times 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, and a warm compress to the thigh area.
- Blood clot formation 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. Medicines that thin the blood and help resolve blood clots are prescribed.
- Post-injection phlebitis is an inflammatory process on the vein wall. The patient's general condition worsens, a temperature of up to 39 degrees appears, the vein looks like a tourniquet, the tissue around it swells and becomes hot. The patient is given antibacterial therapy and treatment with non-steroidal drugs.
- Air embolism is the entry of air into a venous vessel through a needle. The outcome of this complication can be sudden death. Symptoms of embolism include weakness, deterioration of general condition, loss of consciousness or convulsions. The patient is transferred to intensive care and connected to a breathing apparatus. With timely assistance, the person’s condition returns to normal.
- Infiltration is the introduction of the drug not into a venous vessel, but under the skin. May lead to tissue necrosis and surgical intervention. Symptoms include 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 to save as many lives as possible. It is not always possible to provide assistance on time, but with the introduction of new technologies, mortality and complications after complex manipulations are decreasing.
For subclavian and internal jugular vein cannulation, place the patient in the Trendelenburg position (the head of the table is lowered at an angle of at least 15°) to induce distention of the neck veins and avoid air embolism
After vein catheterization, the catheter is always closed to avoid air embolism
Prepare the surgical field, observing the rules of asepsis
J-end conductor string
needle for inserting a conductor string
scalpel with blade No. 11
catheter (with built-in dilator)
lidocaine and needle for local anesthesia
suture material for catheter fixation
The injection point is determined and treated with betadine.
If the patient is conscious, numb the skin and subcutaneous tissues
Draw 0.5 ml of lidocaine into a syringe and connect it to a needle to insert a guide wire to remove a possible skin plug after passing the needle through the skin
the free flow of venous blood into the syringe indicates that the needle is in the lumen of the vessel
Insert the conductor string through the needle until resistance occurs or until only 3 cm remains outside the needle
if resistance is felt before the guide wire enters the vessel, remove the latter, re-check that the vessel is catheterized correctly, and re-insert the guide wire
The end of the scalpel makes a small incision near the conductor string
A catheter (with a built-in dilatator) is inserted along the conductor string.
Grasp the proximal end of the guide wire, which protrudes from the proximal end of the catheter
Rotational movements move the catheter along the guide string through the skin into the vessel
Make sure that venous blood flows freely from the catheter
Connect the catheter to the tube for intravenous administration
The catheter is secured with sutures and a bandage is applied.
Complications of vascular catheterization using the Seldinger method:
Rupture of the thoracic duct
Incorrect catheter placement
Video of central vein catheterization technique - installation of a subclavian catheter
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Seldinger artery puncture
Catheterization of the femoral artery using the Seldinger technique
N.B. If a patient undergoes A. femoralis angiography immediately prior to bypass surgery, NEVER remove the catheter through which the procedure was performed. By removing the catheter and applying a compression bandage, you expose the patient to the risk of developing undetected arterial bleeding (“under the sheets”) due to total heparinization. Use this catheter to monitor your blood pressure.
Copyright (c) 2006, Cardiac Surgical ICU at Leningrad Regional Hospital, all rights reserved.
4.Projection lines of blood vessels in the human body.
1. Upper limb. A.brachialis – projected along a line from the middle of the armpit to the middle of the elbow. A.radialis – from the middle of the elbow to the styloid process osradialis. A.ulnaris – from the middle of the elbow to the outer edge of the pisiform bone (on the border of the inner and middle third of the line, carried out between the styloid processes.
2. Lower limb. A.femoralis – from the middle of the inguinal ligament to the internal condyle of the belrus. In the popliteal fossa it is divided into –A.tebialis ant.– from the middle of the popliteal fossa to the middle of the distance between the ankles on the back of the foot. A.tebialis post.– from the middle of the popliteal fossa to the middle of the distance between the inner malleolus and the calcaneal tubercle.
3.A.carotis communis – from the angle of the lower jaw to the sternoclavicular joint.
Practical conclusions. Pulsation of blood vessels, auscultation of blood vessels, finger pressure, puncture of blood vessels.
5.Puncture of the great vessels. Seldinger technique.
1958 – Seldinger technique. You need to have a Beer needle, a guide – a fishing line, catheters equipped with a locking device, a syringe.
Stage 1 – the vessel is punctured using a Beer needle.
Stage 2 – the mandrin is removed and the conductor is inserted.
Stage 3 – the needle is removed and a fluoroplastic tube is inserted through the guidewire.
Stage 4 – the conductor is removed, the tube can remain in the lumen of the vessel for up to one week, through which contrast agents and medications can be administered.
For therapeutic purposes, P. can be used to administer drugs, blood and its components, blood substitutes, and means for parenteral nutrition into the vascular bed (venipuncture, catheterization of the subclavian vein, intra-arterial administration, regional intra-arterial infusion, perfusion); administration of drugs into various tissues (intradermal, subcutaneous, intramuscular, intraosseous administration), cavities, as well as into the pathological focus; for local anesthesia, novocaine blockades etc., for exfusion of blood from donors, during autohemotransfusion, hemodialysis, exchange transfusions (for hemolytic jaundice of newborns); for evacuation of pus, exudate, transudate, spilled blood, gas, etc. from a cavity or focus.
There are practically no contraindications to performing P.; a relative contraindication is the patient’s categorical refusal to perform P. or the patient’s motor agitation.
6.Topographic-anatomical rationale for X-ray angiography.
Angiography (Greek angeion vessel + graphō write, depict, synonym vasography) - radiographic examination of vessels after the introduction of radiopaque substances into them. There are A. arteries (arteriography), veins (venography, or phlebography), lymphatic vessels (lymphography). Depending on the purposes of the study, general or selective (selective) A. is carried out. With general A. all the main vessels of the studied area are contrasted, with selective - individual vessels.
To introduce a radiopaque substance into the vessel under study, it is punctured or catheterization . In A. of the vessels of the arterial system, the radiopaque substance passes through the arteries, capillaries and enters the foam of the area under study. Accordingly, the phases of A. are distinguished - arterial, capillary (parenchymal), and venous. Based on the duration of the phases of A. and the rate of disappearance of the radiopaque substance from the vessels, regional hemodynamics in the organ under study are judged.
Cerebral angiography allows us to identify, in particular, aneurysms , hematomas, tumors in the cranial cavity, vascular stenosis and thrombosis. A. internal carotid artery (carotid angiography) is used in the diagnosis of pathological processes in the cerebral hemispheres. To recognize pathological processes in the area of the posterior cranial fossa, the vessels of the vertebrobasilar system are examined (vertebral angiography) by catheterization of the vertebral artery.
Selective total cerebral A. is carried out using the catheterization method, in turn all the vessels involved in the blood supply to the brain are contrasted. The method is usually indicated in patients who have suffered subarachnoid hemorrhage to detect the source of bleeding (usually an arterial or arteriovenous aneurysm), as well as to study collateral circulation during cerebral ischemia.
Superselective cerebral angiography (catheterization of individual branches of the middle, posterior or anterior cerebral arteries) is usually used to identify vascular lesions and to perform endovascular interventions (for example, installing an occlusion balloon in the afferent vessel of the aneurysm to exclude it from the circulation).
Thoracic aortography(A. thoracic aorta and its branches) is indicated for recognizing thoracic aortic aneurysm, coarctation of the aorta and other anomalies of its development, as well as aortic valve insufficiency.
Angiocardiography(examination of the great vessels and cavities of the heart) is used to diagnose malformations of the great vessels, congenital and acquired heart defects, to clarify the location of the defect, which allows choosing a more rational method of surgical intervention.
Angiopulmonography(A. pulmonary trunk and its branches) is used for suspected developmental defects and tumors of the lungs, thromboembolism of the pulmonary arteries.
Bronchial arteriography, in which an image of the arteries supplying the lung is obtained, is indicated for pulmonary hemorrhages of unknown etiology and localization, enlarged lymph nodes of unknown origin, congenital defects hearts (tetrad Fallot), malformations of the lungs, is carried out for differential diagnosis malignant and benign tumors and inflammatory processes in the lungs).
Abdominal aortography(A. abdominal aorta and its branches) is used for lesions of parenchymal organs and retroperitoneal space, bleeding in abdominal cavity or gastrointestinal tract. Abdominal aortography makes it possible to detect hypervascular kidney tumors; at the same time, metastases to the liver, another kidney, lymph nodes, and tumor invasion into neighboring organs and tissues can be detected.
Celiacography(A. celiac trunk) is performed to clarify the diagnosis of tumors, injuries and other lesions of the liver and its vessels, spleen, pancreas, stomach, gall bladder and bile ducts, greater omentum.
Upper mesentericography(A. superior mesenteric artery and its branches) is indicated in the differential diagnosis of focal and diffuse lesions of the small and large intestines, their mesentery, pancreas, retroperitoneal tissue, as well as in order to identify sources of intestinal bleeding.
Renal arteriography(A. renal artery) is indicated in the diagnosis of various kidney lesions: injuries, tumors. hydronephrosis, urolithiasis.
Peripheral arteriography, in which an image of the peripheral arteries of the upper or lower extremity is obtained, is used for acute and chronic occlusive lesions of the peripheral arteries, diseases and injuries of the extremities.
Upper cavography(A. superior vena cava) is carried out in order to clarify the localization and extent of a blood clot or compression of the vein, in particular with tumors of the lungs or mediastinum, to determine the degree of tumor growth into the superior vena cava.
Lower Cavography(A. inferior vena cava) is indicated for kidney tumors, mainly the right one, and is also used to recognize ileofemoral thrombosis, identify the causes of edema of the lower extremities, and ascites of unknown origin.
Portography(A. portal vein) is indicated for diagnosis portal hypertension, lesions of the liver, pancreas, spleen.
Renal venography(A. renal vein and its branches) is carried out for the purpose of diagnosing kidney diseases: tumors, stones, hydronephrosis, etc. The study allows us to identify thrombosis of the renal vein, determine the location and size of the blood clot.
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Seldinger artery puncture
SELDINGER METHOD (S. Seldinger; syn. puncture catheterization of arteries) - insertion 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. m. began to be used for venous puncture (see Catheterization of veins, puncture).
S. m. is used for the purpose of catheterization and contrast examination of the atria and ventricles of the heart, the aorta and its branches, the introduction of dyes, radiopharmaceuticals, medicines, donor blood and blood substitutes into the arterial bed, as well as, if necessary, multiple examinations of arterial blood.
Contraindications are the same as for cardiac catheterization (see).
The study is carried out in the X-ray operating room (see Operating unit) using special instruments included in the Seldinger set - a trocar, a flexible conductor, a polyethylene catheter, etc. Instead of a polyethylene catheter, an Edman catheter can be used - a radiopaque elastic plastic tube of red, green or yellow color depending on diameter. The length and diameter of the catheter are 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 end is tightly adjusted to the adapter. The adapter is connected to a syringe or measuring device.
Usually S. m. is used for selective arteriography, for which percutaneous puncture is performed, most often of the right femoral artery. The patient is placed on his back on a special table for cardiac catheterization and slightly taken to the side right leg. The pre-shaved right groin area is disinfected and then isolated with sterile drapes. With the left hand, the right femoral artery is probed immediately below the inguinal ligament and fixed with the index and middle fingers. Anesthesia of the skin and subcutaneous tissue is performed with 2% novocaine solution using a thin needle so as not to lose the sensation of artery pulsation. Using a scalpel, an incision is made in the skin above the artery and a trocar is inserted, 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 movement forward (Fig., a). Then the trocar is tilted even more towards the thigh, the mandrel 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 pointed tip tightly adjusted to the diameter of the conductor is put on the outer end of the conductor, advanced to the skin of the thigh and inserted into the lumen of the artery along the conductor (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 purpose of the study (general or selective arteriography) into the left chambers of the heart, the aorta or one of its branches. A radiopaque contrast agent is then injected and a series of radiographs are taken. If it is necessary to record pressure, take blood samples or administer medications, the guidewire is removed from the catheter, and the latter is washed with isotonic sodium chloride solution. After completing the examination and removing the catheter, a pressure bandage is applied to the puncture site.
Complications (hematoma and thrombosis in the area of puncture 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. et al. Abdominal aortography, Vestn. chir., t. 89, no. 10, p. 3, 1962; S e 1 d i p-g e g S. I. Catheter replacement of the needle in percutaneous arteriography, Acta radiol. (Stockh.), v. 39, p. 368, 1953.
Angiography according to Seldinger - a method for diagnosing the condition of blood vessels
Angiography refers to an X-ray contrast study of blood vessels. This technique is used in computed tomography, fluoroscopy and radiography, the main purpose is to assess the circumferential blood flow, the condition 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 in specialized medical institutions that have modern angiographic equipment, as well as appropriate computer technology, which can register and process received images.
Hagiography is one of the most accurate medical studies.
The diagnostic method can be used in diagnostics coronary disease hearts, renal failure, and for detecting various kinds of cerebral circulation disorders.
Types of aortography
In order to contrast the aorta and its branches in the case of persistent pulsation of the femoral artery, the method of percutaneous catheterization of the aorta (Seldinger angiography) is most often used; for the purpose of visual differentiation of 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;
- a 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 wire in the form of a string. Then the needle is removed, and a special catheter is inserted through the guidewire into the lumen of the artery; this is called aortography.
Due to the painfulness of the manipulation, the conscious patient needs infiltration anesthesia using 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 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 aortoarteritis or atherosclerosis, preference is given to a method such as direct translumbar puncture of the aorta. The aorta is punctured using a special needle from the back.
If it is necessary to obtain contrast of the branches of the abdominal aorta, 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 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 be especially careful about the research methodology; in particular, a two-stage needle removal 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 image almost any part of the arterial bed.
The use of these techniques in special medical institutions allows to achieve a minimal risk of complications and at the same time is an accessible and highly informative diagnostic method.
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Seldinger method
The Seldinger method (Seldinger catheterization) is used to obtain safe access to blood vessels and other hollow organs. It is used for angiography, catheterization of central veins (subclavian, internal jugular, femoral) or catheterization of arteries, placement of a gastrostomy using the method of percutaneous endoscopic gastrostomy of some conicostomy techniques, placement of electrodes artificial drivers rhythm and cardioverter defibrillators, other interventional medical procedures.
History of invention
The method was proposed by Sven Ivar Seldinger, a Swedish radiologist and inventor in the field of angiography.
Angiographic examinations are based on a technique in which a catheter is inserted into the vessel using a needle for dosed administration of a contrast agent. The problem was that, on the one hand, it was necessary to deliver the substance to the required place, but at the same time minimally damage the vessels, especially at the site of study. Before the invention of Sven Seldinger, two techniques were used: a catheter on a needle and a catheter through a needle. In the first case, the catheter may be damaged when passing through tissue. In the second case, a larger needle is required, which causes much more damage to the vessel at the catheterization site. Sven Seldinger, born into a family of mechanics, tried to find a way to improve angiographic technique by placing the largest catheter with the smallest needle. The technique essentially means that a needle is first installed, a guidewire is inserted through it, then the needle is removed and the catheter is inserted over the guidewire. Thus, the hole is no larger than the catheter itself. The results were presented at a conference in Helsinki in June 1952, and Seldinger subsequently published these results.
The Seldinger method has reduced the number of complications with angiography, which has contributed to the increased prevalence of the latter. This also meant that the catheter could be more easily oriented to the desired location in the body. The invention laid the foundation for the subsequent development of interventional radiology.
Classification of catheterization methods
On this moment There are at least three catheterization techniques:
- catheter on a needle;
- catheter ears;
- Seldinger catheterization;
The catheter-on-a-needle technique is widely used for catheterization of peripheral vessels. Currently, many different peripheral venous catheters have been developed. The vessel is punctured with a needle with a catheter on it, the needle is held in one position, and the catheter is advanced. The needle is completely removed. When used for puncture of deeply located organs (in particular, central veins), the catheter may be damaged when passing through the tissue.
The “catheter in a needle” technique is used to catheterize the epidural space during epidural anesthesia ( surgical interventions) and analgesia (childbirth, acute pancreatitis, certain cases of intestinal obstruction, pain relief in postoperative period and cancer patients), for prolonged spinal anesthesia. It consists in the fact that first the organ is punctured with a needle, and a catheter is inserted inside it. The needle is later removed. In this case, the needle is significantly thicker than the catheter. If large diameter catheters are used, tissue injury occurs when using this technique.
Actually Catheterization according to Seldinger.
Method technique
Seldinger catheterization proceeds in the following order:
- a. The organ is punctured with a needle.
- b. A flexible metal or plastic conductor is inserted into the needle and advanced further into the organ.
- c. The needle is removed.
- d. A catheter is placed over the guidewire. The catheter is advanced along the guide into the organ.
- e. The conductor is removed.
- Damage to the wall of the corresponding organ by a needle, guidewire, dilator or catheter.
- Damage to surrounding structures by a needle, guidewire, dilator or catheter (depending on the site of catheterization, these can be arteries, nerves, lungs, lymphatic ducts, etc.) with the subsequent development of corresponding complications.
- Inserting a catheter beyond the desired organ and then injecting the appropriate substance there.
- Infectious complications.
- Loss of parts of a damaged guidewire or catheter in an organ, for example. parts of the central venous catheter.
- Other complications caused by the long stay of catheters in vessels and organs.
Figure 3 Removing the needle
Figure 4 Catheter insertion
Figure 5 Removing a conductor
The thinner the needle, the less tissue damage. If the catheter is significantly thicker than the needle, before putting it on the guidewire, an expander is passed along the guidewire, which increases the diameter of the passage in the tissues. The dilator is removed, and then the catheter itself is inserted through the guidewire.
Figure 1 organ puncture with a needle
Figure 2 Inserting the guidewire into the needle
Figure 3 Removing the needle
Figure 4 Using the expander
Figure 5 Catheter insertion
Figure 6 Removing a conductor
The dilator is especially often used when installing central venous catheters with several lumens. Each lumen of the catheter ends with a port for drug administration. One of the lumens begins at the tip of the catheter (usually its port is marked in red), and the other / other sides (usually its port is marked in blue or another color other than red). Double-lumen catheters are used for administering various drugs (to prevent their mixing as much as possible) and for carrying out extracorporeal therapy methods (for example, hemodialysis).
Possible complications
Depending on the conditions, Seldinger catheterization can be performed either without additional imaging methods or under ultrasound or radiological control. In any case, the following complications may develop with varying frequency:
Seldinger artery puncture
Seldinger puncture is carried out to insert a catheter into the aorta and its branches, through which it is possible to contrast the vessels and probe the cavities of the heart. A needle with an internal diameter of 1.5 mm is inserted immediately below the inguinal ligament along the projection of the femoral artery. A guidewire 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 placed on the guidewire instead.
The catheter together with the guide is advanced along the femoral artery, iliac arteries and into the aorta to the desired level. The guidewire is then removed and a syringe with contrast agent is attached to the catheter.
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2.4. Angiographic diagnostics
Angiographic studies have largely contributed to the rapid development of vascular surgery. However, today it is no longer possible to say unequivocally that even now angiography is the “gold standard” for diagnosing diseases of the aorta and peripheral vessels. The latest non-invasive imaging methods: duplex ultrasound scanning, computed tomography, magnetic resonance angiography - not only reduce the risk diagnostic studies, but also have, in some cases, greater resolution. The global trend in the development of radiation diagnostics is the increasingly widespread use of non-invasive techniques for choosing tactics and methods of surgical treatment. At the present stage of development of medical technologies, angiography is becoming increasingly medical procedure and is used during X-ray surgery and endovascular interventions.
However, the relative high cost of such diagnostic equipment, such as X-ray, computed tomography, electron emission or magnetic resonance imaging scanners, limits wide application these methods. At the same time, thanks to the development of computer technologies for image processing and storage, the synthesis of new low-toxic radiopaque agents, angiography continues to be one of the main diagnostic methods, which, at a relatively low cost, allows one to obtain an integral image of any part of the vascular bed and serve as a method for verifying data obtained by other methods of radiation visualization. The introduction of digital subtraction angiography (DSA) contributed to increasing the information content of angiographic data. It made it difficult invasive procedures faster and less dangerous, with their help the amount of contrast media injected into the vascular bed for diagnostic and interventional procedures was significantly reduced.
Indications and contraindications for diagnostic angiography. Preparing the patient. Stages of angiographic examination:
Determination of indications and contraindications;
Preparing the patient for the study;
Puncture or exposure of the vessel;
Introduction of a contrast agent;
X-ray angiographic image;
Removing the catheter, stopping bleeding;
General indications for diagnostic angiography are the need to determine the nature, localization of the pathological process and assess the state of the arterial or venous bed in the lesion, study the compensatory capabilities of collateral blood flow, determine surgical treatment tactics in each specific case and promote the choice of a rational method of operation. Particular indications for angiographic examination are congenital anomalies of blood vessels and organs, traumatic injuries, occlusive and stenotic processes, aneurysms, inflammatory, specific, and tumor vascular diseases.
There are no absolute contraindications to angiographic examination. Relative contraindications are acute liver and kidney failure, active tuberculosis in open form and other specific diseases in the acute stage of their course, acute infectious diseases, individual intolerance to iodine drugs.
Preparing the patient for the study. An angiographic examination is a surgical procedure associated with the invasion of needles, guidewires, catheters and other instruments into the vascular bed, accompanied by the introduction of a radiopaque iodine-containing substance. In this regard, it should be carried out after a thorough general clinical and instrumental examination, including ultrasound and, if necessary, computed tomography, magnetic resonance imaging.
Patient preparation first of all includes explaining to the patient the need for an x-ray angiographic examination. Next, you should find out in detail the patient's medical history to determine indications of possible past manifestations of allergies to novocaine and iodine-containing drugs. If individual intolerance is suspected and the patient’s sensitivity to iodine is determined, a Demyanenko test should be performed. If the test is positive, the test should be abandoned, desensitizing therapy should be performed, and the test should be repeated again.
On the eve of the study, a cleansing enema is performed, and tranquilizers are prescribed at night. On the day of the study, the patient does not eat; the hair in the area of the puncture of the vessel is carefully shaved. Immediately before the study (30 minutes), premedication is started. The examination is usually performed under local anesthesia. At hypersensitivity Intubation anesthesia can be used for iodine preparations for angiographic examination.
Rice. 2.22. Overview aortogram.
After completing the study, the catheter is removed from the vessel and careful hemostasis is performed by pressing the puncture hole. The direction of pressing should correspond to the direction of the previous puncture of the vessel. Then apply an aseptic pressure bandage with a rubber inflatable cuff for 2 hours (small instruments) or a tight gauze roll (large instruments).
During translumbar aortography and removal of the catheter from the aorta, blood is removed from the para-ortic tissue with a syringe and an aseptic bandage or sticker is applied. The patient requires strict bed rest in the supine position for 24 hours, blood pressure monitoring and observation by the doctor on duty.
Angiography methods. Access to the vascular bed. Based on the site of administration of the contrast agent and subsequent recording of angiograms, the following are distinguished:
Direct - injected directly into the vessel being examined;
Indirect - injected into the arterial system to obtain the venous or parenchymal phase of organ contrast. With the development of digital subtraction angiography, indirect arteriography with the introduction of a contrast agent into the venous bed was often used.
Based on the method of administering the contrast agent, the following methods are distinguished:
▲ puncture - insertion directly through a puncture needle;
Survey aortography - a contrast agent is injected through a catheter into the abdominal or thoracic aorta. Often this method of contrast is called “survey aortography”, since it is followed by a more detailed - selective angiographic study of any individual arterial basin (Fig. 2.22).
Semi-selective angiography - a contrast agent is injected into the main vessel in order to obtain a contrast image of both this artery and its nearby branches (Fig. 2.23).
Rice. 2.23. Semi-selective angiogram.
Selective angiography corresponds to the main principle approach to angiography - targeted application of a contrast agent as close as possible to the site of pathology (Fig. 2.24).
Types of vascular catheterization. Antegrade catheterization is a method of selective approach to vessels: percutaneous catheterization of the femoral, popliteal or common carotid artery and insertion of a simulated catheter into the vessels on the affected side.
Retrograde catheterization - holding a catheter against the blood flow during angiography by puncture of the femoral, popliteal, axillary, ulnar or radial arteries according to Seldinger.
Angiography of the arterial system. Technique of translumbar puncture of the abdominal aorta. The patient's position is lying on his stomach, arms bent at the elbows and placed under the head. The 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 place where the needle is inserted. 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). Along the needle, infiltration anesthesia is administered with a solution of novocaine.
Rice. 2.24. Selective angiogram (right renal artery).
Upon reaching the para-aortic tissue, transmission vibrations of the aortic wall are clearly felt, confirming the correctness of the puncture. A “cushion” 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 stream of blood from the needle. The movement of the needle is constantly monitored by fluoroscopy. A guidewire is inserted through the lumen of the needle into the aorta and the needle is removed. More often, a middle puncture of the aorta at the L2 level is used. If occlusion or aneurysmal dilatation of the infrarenal aorta is suspected, a high puncture of the suprarenal abdominal aorta at the level of Th 12 -Lj is indicated (Fig. 2.25).
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 administration on conventional angiographic equipment (50-70 ml at a rate of 25-30 ml/s) can only be administered through catheters of a fairly large diameter - 7-8 F (2.3-2.64 mm). Attempts to use these catheters for transaxillary or cubital arterial access are accompanied by various complications. However, with the development of digital subtraction angiography, when it became possible to enhance the radiopaque image of blood vessels using computer methods after the introduction of a relatively small amount of contrast agent, catheters of small diameters 4-6 F or 1.32-1.98 mm began to be increasingly used. Such catheters allow safe and expedient access through the arteries of the upper extremities: axillary, brachial, ulnar, radial. Method of puncture of the common femoral artery according to Seldinger.
Rice. 2.25. Puncture levels for performing translumbar aortography. a - high, b - medium, c - low; 1 - celiac trunk; 2 - superior mesenteric artery; 3 - renal arteries; 4 - inferior mesenteric artery.
Puncture of the femoral artery is performed 1.5-2 cm below the Pupart ligament, in the place of the clearest 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 infiltration of the skin and subcutaneous tissue on the right and left from the artery to the periosteum of the pubic bone. It is important to try to lift the artery from the bone bed on the bone, which makes puncture easier, as it brings the artery wall closer to the surface of the skin. After completion of anesthesia, a small skin incision (2-3 mm) is made to facilitate insertion 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 puncture of the right femoral artery). When its end comes into contact with the anterior wall of the artery, pulse impulses can be felt. The artery should be punctured 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 stream of blood appears or until the needle exits the puncture canal. Then you should try the puncture again.
Rice. 2.26. Vessel puncture according to Seldinger. a: 1 - puncture of the vessel with a needle; 2 - a conductor is retrogradely inserted into the vessel; 3 - the needle is removed, the bougie and introducer are inserted; 4 - introducer in the artery; b: 1 - correct puncture site of the femoral artery; 2 - undesirable puncture site.
The artery is pierced with a thin needle with an outer diameter of 1 - 1.2 mm without a central mandrel with oblique sharpening in both the antegrade and retrograde directions, depending on the purpose of the study. When a stream of blood appears, the needle is tilted towards 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. The guidewire is then fixed in the artery and the needle is removed. A catheter or introducer is installed along the guide into the lumen of the artery during long-term interventions with catheter changes (Fig. 2.26).
In cases where the femoral arteries cannot be punctured, for example after bypass surgery or in occlusive diseases, when the lumen of the femoral artery, pelvic arteries or distal aorta is closed, an alternative approach should be used.
Such accesses can be axillary or brachial arteries, translumbar puncture of the abdominal aorta.
Rice. 2.27. Contralateral femoral approach.
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 technique is preferred; in addition, it allows intervention for multi-level stenoses of the femoral-popliteal and iliofemoral zone. To pass through the aortic bifurcation, Cobra, Hook, and Sheperd-Hook catheters are usually used. Contralateral access for stenting and arterial replacement can be difficult when using relatively rigid balloon-expandable stents. In these cases, a long introducer should be used on a rigid conductor “Amplatz syper stiff”, etc. (Fig. 2.27).
The contralateral approach technique has some advantages over the antegrade approach for interventions in the femoropopliteal area. First, retrograde placement of the catheter makes it possible to perform an intervention on the proximal portion of the femoral artery, which would be inaccessible with an antegrade puncture. The second aspect is pressing the artery to achieve hemostasis and applying a pressure aseptic dressing after the intervention occurs on the opposite side of the operation, which ultimately reduces the incidence of early postoperative complications.
Antegrade femoral approach. The antegrade approach technique is used by many authors. This type of 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 allows for more precise control of instruments. However, in addition to the potential advantages, the antegrade technique also has disadvantages. To accurately target the superficial femoral artery, a higher puncture of the common femoral artery is required. Puncture of the artery above the inguinal ligament can lead to a serious 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 bifurcation angle (Fig. 2.28).
Rice. 2.28. Antegrade femoral approach. A - angle and direction of the needle with antegrade access; LU - inguinal ligament; R - retrograde access; 1 - place of correct puncture of the femoral artery; 2 - undesirable puncture site.
Popliteal access. In approximately 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. A safe puncture of the popliteal artery can be carried out only 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 introducers 8-9 F, since the diameter of the artery in this place 6 mm. The technique of puncture of the popliteal artery is similar to the technique of the punctures described above. The popliteal artery, together with the nerve and vein, passes 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 side. Manipulations are performed under local anesthesia (Fig. 2.29).
Access through the brachial artery. The brachial approach is an alternative technique for inserting instruments into the aorta and its branches, often used for diagnostic procedures when it is impossible to perform femoral artery puncture or translumbar puncture of the aorta. In addition, this approach may be an alternative approach to endovascular interventions on the 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 cerebral vessels when passing instruments through the aortic arch. The puncture of the brachial artery should be performed in its distal part above the cubital fossa. At this point the artery lies most superficially; hemostasis can be facilitated by pressing the artery against the humerus (Fig. 2.30).
Radial access through the radial artery is accompanied by injury to a smaller vessel than the femoral artery, which makes it possible to avoid the necessary long-term hemostasis, a period of rest and bed rest after endovascular intervention.
Indications for radial access: good pulsation radial artery with adequate collateral circulation from the ulnar artery through the palmar arterial arch. For this purpose, the “Allen test” is used, which must be performed on all patients who are candidates for radial access. The examination is carried out as follows:
The radial and ulnar arteries are pressed;
6-7 flexion-extension movements of the fingers;
With the fingers extended, simultaneous compression of the ulnar and radial arteries is continued. The skin of the hand turns pale;
Relieve compression of the ulnar artery;
Continuing to press the radial artery, control the color of the skin of the hand.
Within 10 s, the color of the skin of the hand should return to normal, which indicates sufficient development of collaterals. In this case, the Allen test is considered positive, and radial access is acceptable.
If the skin color of the hand remains pale, the Allen test is considered negative and radial access is unacceptable.
Rice. 2.29. Popliteal access.
Contraindications to this access are the absence of a radial artery pulse, a negative Allen test, 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.
Rice. 2.30. Access through the brachial artery.
Rice. 2.31. Access through the radial artery.
Radial arterial access technique. Before performing the puncture, the direction of the radial artery is determined. The artery is punctured 3-4 cm proximal to the styloid process of the radius. Before puncture, local anesthesia is performed with a solution of novocaine or lidocaine through a needle drawn parallel to the skin, so as to prevent 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 (Fig. 2.31).
Technique of direct catheterization of the carotid arteries. Puncture of the common carotid artery is used for selective studies of the carotid arteries and cerebral arteries.
Landmarks are the m.sternocleidomastoideus, the upper edge of the thyroid cartilage, and the pulsation of the common carotid artery. The superior edge of the thyroid cartilage indicates the location of the bifurcation of the common carotid artery. After anesthesia, a skin puncture is made with the tip of a scalpel, m. sternocleidomastoideus is pushed outward and the needle is moved forward in the direction of the pulsation of the common carotid artery. It is very important that the pulse impulses are felt not to the side of the needle tip, but directly in front of it, which indicates the orientation of the needle towards the center of the artery. This allows you to avoid tangential wounds to the artery wall and the formation of hematomas. The artery is punctured with a short, measured movement. When a stream 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 guide into the lumen of the artery, the type of which depends on the purpose of the study (Fig. 2.32).
Open access. Large-diameter instruments are not used due to the risk of damage to the artery; open access to the vessels is carried out by arteriotomy.
Instrumentation, doses and speed of contrast agent administration.
For thoracic and abdominal aortography, catheters with a caliber of 7-8 F and a length of 100-110 cm are required, which provide a contrast agent injection rate of up to 30 ml/s; and for peripheral and selective angiography - catheters 4-6 F with a length of 60-110 cm. Typically, catheters with a “Pig tail” configuration and multiple side holes are used for injections of a contrast agent into the aorta. The contrast agent is usually administered using 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. However, to obtain angiograms, manual injection of a contrast agent is often sufficient.
Rice. 2.32. Puncture access through the common carotid arteries, and - general access; b - antegrade and retrograde punctures.
Currently, for angiography, non-ionic water-soluble contrast agents containing from 300 to 400 mg of iodine per ml are more often used (Ultravist-370, Omnipaque 300-350, Vizipak-320, Xenetics-350, etc. ). In rare cases, the previously widely used water-soluble ionic contrast drug 60-76% "Urografin" is used, which, due to its 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 the speed of blood flow. 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) - speed from 8 to 12 ml/s when using from 80 to 100 ml of contrast agent. This provides visualization of the arteries of the lower extremities down to the feet. The acquisition 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 slower injection rate of contrast agent. 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 radiocontrast agent into the venous bed. It should be noted that this requires a fairly large volume of contrast agent - up to 50-70 ml, and the resulting angiograms will correspond to the quality of survey - 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 - mask subtraction (skeleton and soft tissues), image summation, intensification and emphasis of the vascular pattern of angiograms, longitudinal or volumetric reconstruction of images of several anatomical areas into one whole. An important advantage of modern angiographic devices is the possibility of direct intraoperative measurement of vessel diameter, parameters of arterial stenosis or aneurysm. This allows you to quickly determine the tactics of X-ray surgery and accurately select the necessary instruments and implantable devices.
Complications. Any X-ray contrast studies are not absolutely safe and are associated with certain risks. 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 a conductor or catheter, reactions associated with the toxic effect of contrast agents. The frequency and type of complications encountered during arterial puncture vary depending on the site of catheterization. The frequency of complications varies: for example, with femoral access - 1.7%; with translumbar - 2.9%; with shoulder access - 3.3%.
bleeding can be external and internal (hidden) with the formation of a pulsating hematoma and subsequently a pseudoaneurysm;
thrombosis occurs during prolonged occlusion of a vessel or its dissection; however, its incidence has decreased significantly with the use of smaller diameter catheters and guidewires, decreased operative time, and improved anticoagulant medications;
embolism develops when atherosclerotic plaques are destroyed or blood clots detach from the arterial wall. The nature of the complication depends on the size of the embolus and the specific vessel supplying blood to this arterial basin;
arteriovenous fistulas can form as a result of simultaneous puncture of an artery and vein, most often with femoral access.
The safety conditions for aorto-arteriography are strict adherence to indications, contraindications and rational choice research methods, carrying out a number of preventive measures aimed at combating potential complications (washing needles, catheters and connecting tubes with isotonic sodium chloride solution with heparin, careful checking of instruments). Manipulations with the guidewire and catheter should be short and low-traumatic. During the entire diagnostic study or therapeutic X-ray surgery, monitoring of ECG, blood pressure, and blood clotting time is necessary. Anticoagulants, antispasmodics, and desensitizing drugs also help prevent complications and are the key to reducing the risk of angiography.
Rice. 2.33. Puncture of the internal jugular vein, a-first method; b - second method.
With proper puncture and catheter handling techniques, as well as the use of non-ionic or low-osmolar contrast agents, the incidence of complications during angiography is less than 1.8%)
