Ultrasound-guided Arterial Cannulation: What are We Missing and Where are We Headed?

How to cite this article: Soni KD. Ultrasound-guided Arterial Cannulation: What are We Missing and Where are We Headed? Indian J Crit Care Med 2024;28(7):632-633.

Radial Arterial Cannulation by Ultrasound-Guided Dynamic Needle-Tip Positioning Using the Short-Axis Out-of-Plane Approach Versus the Long-Axis In-Plane Approach: A Randomized Controlled Study.

Introduction Radial artery cannulation is a commonly performed invasive procedure for assessing a patient's hemodynamic status and collecting blood samples. Ultrasound guidance has shown benefits in improving the success rate of first-attempt cannulation. Two main approaches, short-axis out-of-plane (SAOOP) and long-axis in-plane (LAIP), are commonly used. A modified technique called dynamic needle-tip positioning (DNTP) using the short-axis out-of-plane approach has been reported to enhance arterial catheterization. This study aims to compare the first-attempt success rates of radial artery cannulation using the two techniques, DNTP versus LAIP, along with overall success rates, cannulation time, and number of attempts. Methods This prospective, randomized, controlled, clinical study was conducted after obtaining clearance from the Institute Ethics Committee of AIIMS, Raipur. Ninety-six patients between the ages of 18 and 50 years, undergoing elective surgery under general anesthesia, and required radial arterial cannulation were randomized and equally allocated into two groups as the LAIP and DNTP approaches. The first-pass success rate, time to achieve successful cannulation, number of attempts needed, overall success rate within five minutes, and potential complications, such as thrombosis, vasospasm, and hematoma, were recorded. Results A total of 96 patients were included, with 48 in the LAIP group and 48 in the DNTP group. The DNTP group showed statistically significant advantages over the LAIP group, with a higher first-pass success rate (97.9% vs. 83.3%; p = 0.014) and shorter time to achieve successful cannulation (9.29±3.79 vs. 26.16±20.22 seconds; p = 0.001). Conclusion The ultrasound-guided short-axis DNTP technique for radial artery cannulation demonstrated a significant advantage as compared to the LAIP technique. The DNTP technique resulted in higher first-attempt cannulation success and shorter cannulation time.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial.

BACKGROUND: Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings. METHODS: In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate. RESULTS: First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W. CONCLUSION: Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

A comparison of the success rate of radial artery cannulation between the ultrasound-guided and conventional palpation techniques in elderly patients undergoing cardiothoracic surgery.

Background: Ultrasound-guided (USG) radial artery cannulation against the standard palpation technique increases the first attempt rate in both pediatric and adult patients. The objective of this study was to evaluate the benefits of USG versus the palpation technique in improving the first attempt rate in elderly patients. Methods: The patients over 65 years of age were randomized to the USG or Palpation group. The radial artery identification in the USG group was performed with the aid of the Sonimage HS 1. In the Palpation group, the radial artery was identified by manual palpation. The operators were cardiothoracic anesthesiologists. Overall success was defined as cannulation completed within 10 min. Results: Eighty patients (40 in each group) were recruited. The respective first attempt and overall success rate for the USG group were similar to the Palpation group (P > 0.999 and P = 0.732). The time to the first attempt and overall success were also similar (P = 0.075 and P = 0.636). The number of attempts, number of catheters used, and failure rates were similar between the groups (P = 0.935, P = 0.938, and P = 0.723). The number of successful cannulations within 10 min was similar for both the groups as categorized by the radial artery diameter (P = 0.169). Conclusions: The USG did not increase the first attempt or overall success rate of radial artery cannulation in the elderly patients undergoing cardiothoracic surgery. The time to first attempt and overall success were similar between both the groups. The number of attempts and number of catheters used were similar between both groups.

Comparison of Ultrasound-Guided Direct versus Ultrasound-Guided Dart Technique of Radial Artery Cannulation: A Randomized Control Study.

BACKGROUND: Three different types of cannulation method for radial artery are Direct technique, Seldinger technique, and modified Seldinger technique (Dart). Their comparative efficacy has been studied using palpatory method but not with ultrasound guidance. AIMS: We compared the efficacy of ultrasound-guided Direct and ultrasound-guided Dart technique of arterial cannulation. SETTINGS AND DESIGN: One hundred and sixty patients posted for elective surgeries were included in prospective randomized control, single-blind study in a tertiary care center. MATERIALS AND METHODS: The study comprised of two groups: Direct method (n = 80) and Dart method (n = 80), which were compared for the rate of successful cannulation within 5 min. The secondary objectives were time for successful cannulation, number of attempts, and rate of complications (hematoma, posterior wall puncture, and needle reinsertion) between two groups. STATISTICAL ANALYSIS: The group comparison for continuously distributed data was compared using the independent sample t-test. The Chi-square test was used for the group comparison of categorical data. Binary logistic regression was conducted to ascertain significant predictors for successful cannulation in 5 min. RESULTS: Cannulation success rate was similar in both Direct (57.5%) and Dart (55%) groups. There was no significant difference in time for successful cannulation, number of attempts, number of needle redirection, and posterior wall puncture. However, the incidence of hematoma (Direct 22.5% [18]; Dart 8% [10]) was significant. There was better success rate of cannulation (n = 90) in patients with normal pulse and bigger radial artery lumen. CONCLUSION: There was no significant difference between Dart and Direct technique with the use of ultrasound guidance.

Preferred display size and visual distance for ultrasound-guided radial artery cannulation / Tamaño preferido de la imagen en pantalla y distancia visual para la canalización de la arteria radial guiada por ecografía

Abstract Introduction: In-line positioning of an ultrasound image provides higher success rates and less time to completion for radial arterial cannulation. But preferable size and distance of ultrasound display has not been previously discussed. Objective: To assess the ideal visual distance and display size when using a smart phone or tablet as the ultrasound image display. Methods: Four smart phones or tablets were used as ultrasound displays in six different configurations in a simulated radial artery puncture. In a questionnaire, 116 anaesthesiologists working in Ibaraki Prefecture, Japan, were asked which of the six configurations was preferable for radial artery cannulation. Results: Sixty anaesthesiologists answered the questionnaire. About half (53%) preferred the smaller display (4- or 5.5-inch) fixed at a distance of 30 to 40 cm, and most of the rest (44%) preferred the larger display (7.9- or 9.7-inch) placed posterior to the probe with a visual distance of 45 to 60 cm. Conclusions: Among the anaesthesiologists, the preferable size and visual distance for ultrasound-guided radial artery cannulation varied using a smart phone or tablet for in-line display.

Resumen Introducción: El posicionamiento en línea con una imagen ecográfica permite mayores tasas de éxito y reduce el tiempo para realizar la canalización de la arteria radial. Sin embargo, no se ha hablado sobre cuál es el tamaño y la distancia preferibles para la imagen en pantalla. Objetivo: Evaluar la distancia visual y el tamaño de la imagen en pantalla cuando se utiliza un teléfono inteligente o una tableta para visualizar la imagen ecográfica. Métodos: Se utilizaron cuatro teléfonos inteligentes o tabletas como pantalla para visualizar las imágenes ecográficas en seis configuraciones distintas, en una simulación de la canalización de la arteria radial. Mediante un cuestionario se preguntó a 116 anestesiólogos que trabajan para la Prefectura de Ibaraki, Japón, cuál de las seis configuraciones era preferible para la canalización de la arteria radial. Resultados: Sesenta anestesiólogos respondieron el cuestionario. Aproximadamente la mitad (53%) prefirieron la imagen más pequeña (4 o 5,5 pulgadas), fija a una distancia de 30 a 40 cm, y la mayoría de los otros (44%) prefirieron la imagen más grande (7,9- o 9,7 pulgadas), colocada en la parte posterior al transductor, con una distancia visual de 45 a 60 cm. Conclusiones: Entre los anestesiólogos, el tamaño preferido y la distancia visual para la canalización de la arteria radial guiada por ecografía, varió utilizando un teléfono inteligente o una tableta para su visualización en línea.

Intra-arterial Foreign Body following Radial Artery Cannulation Requiring Microsurgical Removal: Case Report and Review of the Literature.

We report the case of a pediatric patient who underwent intra-arterial exploration and removal of foreign body after an arterial catheter cannula inadvertently fractured during removal and a fragment remained within the radial artery. The fragment was visualized using fluoroscopy intraoperatively and was successfully removed from the common digital artery to the index finger where it had migrated. We present the case as a rare complication of an exceedingly common procedure with a timely response to avoid further complication.

Assessment of collateral hand circulation by modified Allen's test in normal Indian subjects.

BACKGROUND: Allen's test (AT) and Modified Allen's Test (MAT) are used as screening methods for assessment of the hand circulation. Few people lack the dual blood supply of hand and are at risk of hand ischemia after any intervention on radial artery. The Purpose of the study was to assess the collateral circulation of hand using MAT in normal Indian subjects and in elderly population to know the prevalence of positivity of Allen's test. METHODS: 900 participants (1800 hands) were divided in two groups. Group I had participants with age <50 years and group II had participants with age ≥50 years. MAT was performed in all participants and results were compared between the two groups. RESULTS: In group I (n = 450, 900 hands), 313 were males and 137 were females, with mean age of 35.04 years. The relative percentages of a normal, equivocal, borderline and abnormal MAT were 77.8%, 16.6%, 3.7% and 1.6%, respectively. In group II (n = 450, 900 hands), 248 were males and 202 were females, with mean age of 60.4 years. The relative percentages of a normal, equivocal, borderline and abnormal MAT were 69.0%, 18.6%, 6.60% and 5.66%, respectively. A positive/abnormal test was significantly more common (5.66% Vs 1.66%, P < 0.00001) in older group. CONCLUSION: MAT is simple, time tested and non invasive test to assess collateral circulation of the hand. A negative MAT safely selects patients for radial artery harvest; however, if the test is positive and in older patients then a second objective test may be needed.

The Use of Topical Nitroglycerin to Facilitate Radial Arterial Catheter Insertion in Children: A Randomized Controlled Trial.

OBJECTIVES: To determine whether the use of topical nitroglycerin patch increases radial artery diameter and facilitate cannulation in children. DESIGN: Randomized controlled trial. SETTING: Cairo University Hospital. PARTICIPANTS: Children aged 2 to 8 years old scheduled for cardiac surgery. INTERVENTION: In the nitroglycerin group (n = 20), a gauze-covered, half-sized nitroglycerin patch (5 mg) was applied at the site of radial pulsation 1 hour before induction of anesthesia. In the control group (n = 20), a gauze pad was applied to the bare skin at the site of radial pulsation with no intervention. MEASUREMENTS AND MAIN RESULTS: The primary outcome was the diameter of the radial artery in both limbs using ultrasonography. Other outcomes included the degree of arterial palpability, number of arterial punctures, and incidence of successful first puncture cannulation. The radial artery diameter increased after 30 minutes and 60 minutes compared with the baseline value in the nitroglycerin group in both limbs, whereas no change was reported in the radial artery diameter in the control group. The nitroglycerin group showed a greater incidence of successful first cannulation trial, a fewer number of trials, and a shorter cannulation time compared with the control group. There were no significant hypotensive episodes in any patient. CONCLUSION: Local application of a half-sized, 5 mg nitroglycerin patch for 60 minutes in children increased the radial artery diameter bilaterally, increased the rate of first trial success, and decreased the time needed for arterial cannulation without significant hypotensive episodes.

Comparison between ultrasound guided technique and digital palpation technique for radial artery cannulation in adult patients: An updated meta-analysis of randomized controlled trials.

STUDY OBJECTIVE: Possible advantages and risks associated with ultrasound guided radial artery cannulation in-comparison to digital palpation guided method in adult patients are not fully known. We have compared ultrasound guided radial artery cannulation with digital palpation technique in this meta-analysis. DESIGN: Meta-analysis of randomized controlled trials. SETTING: Trials conducted in operating room, emergency department, cardiac catheterization laboratory. PATIENTS: PubMed and Cochrane Central Register of Controlled Trials (CENTRAL) were searched (from 1946 to 20th November 2017) to identify prospective randomized controlled trials in adult patients. INTERVENTION: Two-dimensional ultrasound guided radial artery catheterization versus digital palpation guided radial artery cannulation. MEASUREMENTS: Overall cannulation success rate, first attempt success rate, time to cannulation and mean number of attempts to successful cannulation. Odds ratio (OR) and standardized mean difference (SMD) or mean difference (MD) with 95% confidence interval (CI) were calculated for categorical and continuous variables respectively. RESULTS: Data of 1895 patients from 10 studies have been included in this meta- analysis. Overall cannulation success rate was similar between ultrasound guided technique and digital palpation [OR (95% CI) 2.01 (1.00, 4.06); p = 0.05]. Ultrasound guided radial artery cannulation is associated with higher first attempt success rate of radial artery cannulation in comparison to digital palpation [OR (95% CI) 2.76 (186, 4.10); p < 0.001]. No difference was seen in time to cannulate [SMD (95% CI) -0.31 (-0.65, 0.04); p = 0.30] and mean number of attempt [MD (95% CI) -0.65 (-1.32, 0.02); p = 0.06] between USG guided technique with palpation technique. CONCLUSION: Radial artery cannulation by ultrasound guidance may increase the first attempt success rate but not the overall cannulation success when compared to digital palpation technique. However, results of this meta-analysis should be interpreted with caution due presence of heterogeneity.

Ultrasound Versus Traditional Palpation to Guide Radial Artery Cannulation in Critically Ill Children: A Randomized Trial.

OBJECTIVES: To identify success rates for radial artery cannulation in a pediatric critical care unit using either palpation or ultrasound guidance to cannulate the radial artery. METHODS: A prospective randomized comparative study of critically ill children who required invasive monitoring in a tertiary referral center was conducted. All patients were randomized by a stratified block of 4 to either ultrasound-guided or traditional palpation radial artery cannulation. The primary outcomes were the first attempt and total success rates. RESULTS: Eighty-four children were enrolled, with 43 randomized to the palpation technique and 41 to the ultrasound-guided technique. Demographic data between the groups were not significantly different. The total success and first attempt rates for the ultrasound-guided group were significantly higher than those for the palpation group (success ratio, 2.03; 95% confidence interval, 1.13-3.64; P = .018; and success ratio, 4.18; 95% confidence interval, 1.57-11.14; P = .004, respectively). The median time to success for the ultrasound-guided group was significantly shorter than that for the palpation group (3.3 versus 10.4 minutes; P < .001). Cannulation complications were lower in the ultrasound-guided group than the palpation group (12.5% versus 53.3%; P < .001). CONCLUSIONS: The ultrasound-guided technique could improve the success rate and allow for faster cannulation of radial artery catheterization in critically ill children.

Radial Artery Occlusion - Incidence, Predictors and Long-term outcome after TRAnsradial Catheterization: clinico-Doppler ultrasound-based study (RAIL-TRAC study).

Background and aim The purpose of this study was to assess incidence, predictors and outcome of radial artery occlusion (RAO) after transradial catheterization (TRC) based on clinical and Doppler ultrasound study. Methods A total of 1,945 consecutive patients undergoing transradial catheterization for diagnostic evaluation or intervention were included. Radial artery examination was based on palpation and colour Doppler study on the day before, 1 day (D1), 1 month (D30) and 6 months (D180) following the procedure. RAO was defined as absence of pulse on palpation and forward flow on Doppler study. Predictors of RAO were found by logistic regression analysis. Results Baseline demographic and procedural data were recorded. The mean radial arterial diameter was 2.56 ± 0.29 mm. On D1, radial artery Doppler examination revealed RAO in 339 patients (17.4%) but pulse was still palpable in 115 (34%) of them. At D30, these were 221 (11.4%) and 114 (52%), respectively, as no new RAO were noted. Interestingly, 118 (34.8%) patients had spontaneous recanalization of their radial artery as shown by catch-up in patency rate. At D180, these were 99 (5.1%) and 68 (69%), respectively, meaning further new catch-up implying further recanalization. Patients with persistent RAO remained asymptomatic. On multivariate analysis, female sex, diabetes, lower BMI, radial artery diameter ≤2.2 mm and radial artery-to-sheath ratio (AS ratio) < 1 were predictors of RAO. Conclusion TRC for coronary angiography, ad hoc and staged angioplasty can be performed with similar efficacy and safety though RAO occurs more frequently in patients with prior radial artery cannulation and with larger sheath size. Persistent RAO remains asymptomatic.

Review of Ultrasound-Guided Radial Artery Catheter Placement.

Radial artery catheters are commonly placed for continuous blood pressure monitoring, frequent arterial blood gas analysis, or frequent blood sampling for diagnostic testing. Radial artery cannulation can be challenging and ultrasound guidance has emerged as a valuable adjunct for the placement of radial artery catheters. The advantages of ultrasound guidance include: real-time visualization of landmarks, improved pre-procedure planning, reduction in complications, less time spent at the bedside, and improved first-attempt success rates. Disadvantages of ultrasound guidance include: equipment cost, equipment availability, limited availability of experts to train providers, and the cost of training providers. Ultrasound machines are readily available and widely utilized in many emergency departments, operating rooms, and ICUs. We will summarize the use of ultrasound guidance for the placement of radial artery catheters and describe the techniques used during ultrasound-guided arterial catheter placement. Training on the use of ultrasound should be encouraged for all practitioners who place radial artery catheters.

Analysis of radial artery catheter placement by respiratory therapists using ultrasound guidance.

BACKGROUND: The use of ultrasound (US) guidance for radial artery cannulation has been shown to improve first attempt success rate, reduce time to successful cannulation, and reduce complications. We sought to determine whether properly trained respiratory therapists (RTs) could utilize US guidance for the placement of radial artery catheters. Primary outcome measurements were successful cannulation and first attempt success rate. Secondary outcomes included the effect of systolic blood pressure, prior attempts, palpable pulse strength, and gender in relation to US-guided radial artery cannulation success rates. METHODS: RTs certified in arterial catheter insertion were trained in radial artery catheterization using US by emergency medicine physicians. Subjects were enrolled based on the need for an arterial catheter placement. The catheters and US devices used were standardized. Data recorded included pulse strength, systolic and diastolic blood pressure, number of attempts, and successful/unsuccessful artery cannulation. All catheterization attempts were performed according to institutional policy and procedure. RESULTS: One hundred twenty-two radial artery catheter insertion attempts were made between December of 2008 and October of 2011, in patients in whom the treating physician requested RT radial artery cannulation. The overall success rate was 86.1%, whereas the first attempt success rate was 63.1%. There was no difference found between the overall mean success rate for weak or absent pulses, age, systolic blood pressure, gender, or prior attempts. CONCLUSION: RTs can effectively utilize US technology to place radial artery catheters. Systolic blood pressure, prior attempts, and gender are not reliable predictors of success for US-guided radial artery cannulation. Training on the use of US should be strongly encouraged for all practitioners who place radial artery catheters.

The Clinical Application of SpO_2-Allen's Test in Radial Artery Cannulation for Invasive Blood Monitor / 医学研究杂志

Objective To observe the safety and efficiency of SpO_2 -Allen's test in peri -puncture radial artery cannulation for invasive blood monitor. Methods 50 patients were selected for the radial artery cannulation in surgical intensive care unit(SICU). All of them were still sober. All of the patients were examined by SpO_2 -Allen's test and Allen's test before radial artery cannulation, 3 days after puncture and after pulling out the cannula. Resluts The results of Allen's test of 42 patients were negative,while those of 49 patients were negative in SpO_2 - Allen's test. Statistics difference existed between group of SpO_2 - Allen's text and group of Allen's text(P

Unusual complication of radial artery cannulation.

Currently, radial artery cannulation is the preferred method for continuous hemodynamic monitoring in critically ill patients. Reported complications of radial artery cannulation include infection, digital gangrene, thrombosis, pseudoaneurysm, skin necrosis and median nerve palsy. Radial artery catheter fracture is a very rare complication. A review of the English language literature revealed only one reported case. We present an additional case of spontaneous radial artery catheter fracture.

La canulation artérielle radiale est à l'heure actuelle le meilleur moyen de surveillance continue de l'hémodynamie chez les patients gravement atteints. Parmi les complications signalées, mentionnons les infections, la gangrène des 2doigts, les thromboses, les pseudo-anévrismes, la nécrose de la peau et la paralysie du nerf médian. Toutefois, la cassure du cathéter artériel radial s'avère une complication très rare. Un examen de la documentation en anglais a permis de relever un seul cas déclaré. Il sera question ici d'un autre cas de cassure spontanée du cathéter artériel.

Post-cannulation Radial Artery Aneurysm in a Patient Undergoing Mitral Valvular Replacement: A case report / 대한마취과학회지

Radial artery is the most common site which is chosen for the continuous monitoring of arterial blood pressure and blood sampling in the critically ill patients. This method is regarded as a safe one though there are various complications. In most complications, the clinical sequelae do not have much significances. However, serious complications have been reported including cerebral embolism, or ischemic necrosis of hand or forearm requiring amputation although the incidences are rare. Post-cannulation radial artery aneurysm is not common in clinical practices. We report a case of post-cannulation radial artery aneurysm in a 23-year-old female patient undergoing mitral valvular replacement. Radial artery cathteter was indwelt for 14 days at the same site. It should be kept in mind that aseptic and atraumatic technique must be used and the catheter must not be indwelt at one point for a long time in arterial cannulation.