How to achieve ultrasound-guided femoral venous access: the new standard of care in the electrophysiology laboratory

Ultrasound-guided versus anatomic landmark-guided vascular access in cardiac electrophysiology procedures: A systematic review and meta-analysis

INTRODUCTION

Electrophysiology (EP) procedures are nowadays the gold-standard method for tachyarrhythmia treatment with impressive success rates, but also with a considerable risk of complications, mainly vascular. A systematic review and meta-analysis was performed to evaluate the safety of ultrasound (US)-guided femoral vein access in EP procedures compared to the traditional anatomic landmark-guided method.

METHODS

We searched Pubmed (MEDLINE), Embase, Web of Science, and Cochrane electronic databases for relevant entries, dated from January 1st, 2000 to June 30th, 2021. Only observational studies and randomized controlled trials were included in this analysis. Data extraction included study details, patient characteristics, procedure details, and all types of vascular complications. Complications were classified as major if any intervention, prolongation of hospitalization, or readmission was required.

RESULTS

9 studies (1 randomized controlled trial and 8 observational), with 7858 participants (3743 in the US-guided group, 4115 in the control group), were included in the meta-analysis. Overall vascular complication rates were significantly decreased in the US-guided group compared to the control group (1.2 versus 3.2%, RR = 0.38, 95% CI, 0.27-0.53), in all EP procedures. Sub-group analysis of AF ablation procedures yielded similar results (RR 0.41, 95% CI, 0.29-0.58, p < 0.00001). The event reduction effect was significant for both major and minor vascular complications.

CONCLUSION

US-guided vascular access in EP procedures is associated with significantly reduced vascular complications, compared to the standard anatomic landmark-guided approach, regardless of procedure complexity.

Transesophageal Echocardiography-Guided Transseptal Left Atrial Access to Improve Safety in Patients Undergoing Pulmonary Vein Isolation

Background: Endovascular pulmonary vein isolation (PVI) has become an important strategy for rhythm control in patients with symptomatic atrial fibrillation (AF). Transseptal access is a critical step of this procedure and can result in potentially life-threatening complications. This retrospective study evaluates the safety of standardized, transesophageal echocardiography (TEE)-guided transseptal access to the left atrium in consecutive patients who underwent PVI. Methods: After the implementation of a standardized, TEE-guided procedure for transseptal access, the data of 404 consecutive PVI procedures using radiofrequency ablation and 3D-mapping were prospectively collected over 5 years. TEE-guided transseptal punctures were performed on 375 patients undergoing one to three PVIs. The patient cohort was retrospectively analyzed for major and minor complications, fluoroscopy time, fluoroscopy dose and ablation outcomes. Results: No single complication related to transseptal access occurred, affirming the safety of the TEE-guided approach. Fluoroscopy time and fluoroscopy dose decreased significantly after 152 procedures. PVI-related minor complications occurred in 11 procedures (2.6%) and included 10 vascular-access-related complications (2.4%) and 1 TEE-related esophageal hematoma (0.2%), which healed spontaneously. Conclusion: Our single-center study shows that TEE guidance may allow safe transseptal access to the left atrium in patients undergoing PVI.

Ultrasound guidance for femoral venous access in electrophysiology procedures-systematic review and meta-analysis

PURPOSE

The most common complications of electrophysiology (EP) procedures are related to vascular access. Our study aims to conduct a meta-analysis comparing ultrasound (US)-guided vs. palpation-based technique for femoral venous access in EP procedures.

METHODS

Electronic databases were searched and systematically reviewed for studies comparing femoral vein puncture with/without US in EP procedures. The primary outcome was the rate of major vascular complications; secondary outcomes were minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time. Predefined subgroup analysis was conducted separately for patients undergoing pulmonary vein isolation procedure (PVI). A random-effects model was used to derive risk ratios (RR) with 95% confidence interval (CI).

RESULTS

Nine studies involving 8232 patients met our inclusion criteria. Compared with the standard technique, the use of US reduced major vascular complications (from 2.01 to 0.71%, p < 0.0001). The rate of minor vascular complications (RR = 0.30, 95% CI, 0.14-0.62, p = 0.001) and inadvertent artery puncture were lower with US-guided puncture (RR = 0.31, 95% CI, 0.17-0.58, p = 0.0003). Puncture time was shorter (mean difference = - 92.1 s, 95% CI, - 142.12 - - 42.07 s, p = 0.0003) and postprocedural groin pain was less frequent (RR = 0.57, 95% CI, 0.41-0.79, p = 0.0008) in the US group. Subgroup analysis of patients undergoing PVI also showed significant reduction of major vascular complications (RR = 0.27, 95% CI, 0.12-0.64, p = 0.003) and inadvertent artery puncture (RR = 0.35, 95% CI, 0.21-0.59, p < 0.0001).

CONCLUSION

Real-time US-guidance of femoral vein puncture in EP procedures is beneficial: it reduces major and minor vascular complications, inadvertent artery puncture, postprocedural groin pain, and puncture time.

A Review of Central Venous Access Using Ultrasound Guidance Technology

More than 5 million central lines are placed in the United States each year. Advanced practice providers place central lines and must understand the importance of ultrasound guidance technology. The use of anatomic landmarks to place central lines has been employed in the past and in some instances is still used. This method may make accessing the target vessel difficult in the patient with anomalous anatomy or in the obese patient. These characteristics decrease successful placement and increase complications. Different organizations have agreed that the use of ultrasound during central venous access has decreased rates of complication and cost. In addition to cannulating and accessing a central vein, ultrasound can be used to rapidly confirm placement and to rule out complications such as pneumothorax. Utilizing ultrasound to assist in performance of procedures, and in assessment of patients, is a skill that should be optimized by nurse practitioners.

Bilateral renal forniceal rupture due to retroperitoneal hematoma after femoral venous access

Retroperitoneal hematoma is a potential complication of femoral venous access that rarely leads to bilateral ureteral obstruction. We present the case of a 73-year-old woman who underwent an ablation procedure for atrial fibrillation complicated by laceration of an aberrant obturator artery during femoral venous cannulation, leading to a compressive retroperitoneal hematoma, bilateral ureteral obstruction, acute renal failure, and renal forniceal rupture. The patient was successfully treated with embolization of the inferior epigastric artery and aberrant obturator artery, hematoma evacuation, and ureteral stent placement. This case illustrates a rare complication of arterial laceration during femoral venous access without ultrasound guidance.