1. Echo guided puncture Ch.Bachvarov “St. Marina” University Hospital, Varna

2. Introduction Procedures Vascular/ nonvascular Arterial / venous interventions Approaches: – transfemoral-radial – transbrachial- transpopliteal-transpedal Direct puncturing of common carotid - ???? Charles Dotter was a North American radiologist born in Boston, Massachussetts (1920 - 1985). Dr. Dotter first described transluminal angioplasty in 1964 Imaging guidance

3. Ultrasound machines New standarts – mobile equipment New transducers Techniques – free hand / needle guidance

4. Venous interventions It is estimated that approximately 5 million central venous catheters (CVCs) are inserted annually in the United States / more than 500 per year There are three major sites for accomplishing CVC access: IJ, subclavian, and femoral Hemoports in all age groups – the youngest patient is 10 months old! Angiojet thrombaspiration procedures Cava filters

5. Venous interventions- landmark method

6. Venous interventions-US exam

7. Short-Axis (Out-of-Plane) Versus Long-Axis (In-Plane) Visualization

8. Venous interventions-US exam

9. Patency of jugular and subclavian veins Patency of jugular and subclavian veins Neck or axillar lymphadenomegaly Neck or axillar lymphadenomegaly Pathologic findings in area of intervention – skin lesions, tumors of soft tissues and bones, Meta, cysts, haematomas Pathologic findings in area of intervention – skin lesions, tumors of soft tissues and bones, Meta, cysts, haematomas Thyroid / parathyroid glands pathology Thyroid / parathyroid glands pathology Assessement of common carotids, bulbs and posterior circulation Assessement of common carotids, bulbs and posterior circulation

10. Venous interventions-US exam Right IJV

11. Venous interventions-US exam Right IJV

12. Venous interventions-US exam

13. TRIALS

14. SOAP – 3 Trial Successful Cannulation First-Attempt Cannulation Success Cannulation Attempt Time to Cannulation - “needle to skin to J-wire in”, measured in seconds Arterial Puncture Rescue - After 5 attempts or 5 mins of attempting cannulation, the patient was rescued by the dynamic technique

15. SOAP – 3 Trial

16. S and D better than LM, D is better than S D required more training and extra person Static:  Easy  Identifies thrombosed, small (uni or bilateral) IJ  Close to D in improvement

17. SOAP – 3 Trial Suggests:  US assist for all central line placements  Protocol based on vein size:  5 mm or less - relative contraindication, go to other site where may be compensatory enlargement  5-10 mm - may benefit from dynamic US  10 mm or more – attempt static( max 3 passes)

18. Advantages of ultrasound techniques over landmark insertion methods Clearly demonstrates vein presence, diameter,patency, direction, and relation to surrounding structures Puncture site and angle of approach of needle to target can be optimized to minimize the risk of complications Using real-time ultrasound can guide needle tip into vessel or can observe vessel compression Guidewire placement within the correct vessel can be confirmed Some immediate complications can be diagnosed or excluded (haematoma /carotid puncture /pneumothorax / haemothorax / pericardial effusion) with appropriate training

19. Disadvantages of ultrasound techniques over landmark insertion methods More complex technique and need for good hand-eye coordination. Poor technique may lead to failure to visualize the needle tip. If the shaft of the needle is mistaken for the tip or if tissue deformation only is seen, then a false impression of the needle position may be given Limitations of ultrasound physics can cause errors, for example, reverberation artefact may give a false impression that the needle tip is deeper than it actually is In small infants, the physical size of the probe may be limiting Cost and maintenance of ultrasound equipment

20. US in arterial interventions – transfemoral approach Antegrade/retrograde High bifurcation of CFA Stature of the patient Placement of wire/introducer in SFA Inguinal limphadenomegaly Defects of the abdominal wall - hernias Previous surgical interventions on CFA – arteriotomy, bypasses, patch plasty repair

21. Transfemoral approach- prefered option in lower limb interventions External Iliac artery External Iliac vein

22. Transfemoral approach- prefered option in lower limb interventions

23. Bad puncturing cases

24. US in arterial interventions – transfemoral approach

25. US in arterial interventions – transpopliteal approach 75 y o

26. US in arterial interventions – transpopliteal approach fabella

27. Popliteal vessels position  Compressing the pop. vein - patency  The most suitable puncture site - where the PA is visualized without superimposition of the vein  Usually this point is proximal and medial to the knee joint and caudal to the semimembranous muscle  Dislocate the pop. vein by injection of local anesthetic US in arterial interventions – transpopliteal approach

28. US in arterial interventions – transpedal approach Anatomical variations – number/diameter of tibial arteries Kinking in distal segments Severity of PAD below the knee – number of visible arteries on previous Dg exams,calcifications Flow by Doppler mode – site of puncturing

29. US in arterial interventions – upper limb Less pathology More difficult terrain in patients on chronic dialysis Have to think about anatomical variants Have to avoid complications during puncturing and inserting the introducers – hematomas,dissections of the arterial wall,spasms

30. US in arterial interventions – upper limb Antegrade /retrograde –transaxillar and transbrachial approaches AV fistulas, interventions on subclavian artery, carotids, main branches of abdominal aorta and peripheral territories Transradial approach

31. US in arterial interventions – upper limb Sonography cross-section view at mid-arm level. MACN, medial antebrachial cutaneous nerve of the forearm; BCm, biceps muscle; Tm, triceps muscle; Br, brachial artery; Mn, median nerve mki

32. Some remarks for home Puncturing under US in venous access is recommended / obligatory in children Puncturing under US in arterial access is questionable / can decrease radiation exposure Appropriate Equipment /Training is required US guidance reduces the risk of complications US guidance save time in most cases

33. Thank you for your attention!