VASCULAR ACCESS

Techniques of arterial access

John D Mitchell
Ian J Welsby

Indications
The only absolute indication for the placement of an arterial line is
during cardiopulmonary bypass, when the lack of pulsatile blood
flow makes the measurement of blood pressure impossible. How-
ever, arterial lines are useful whenever beat-to-beat blood pressure
monitoring or frequent sampling of arterial blood is indicated.
This includes situations such as sepsis, shock, hypertensive crisis,
respiratory compromise, prolonged ventilator weans, and other
conditions where the use of vasoactive drugs is required. Arterial
lines may also aid in the assessment of cardiac contractility by
examination of the shape of the waveform and upstroke of the
tracing, or as a requisite portion of some techniques for the mini-
mally invasive assessment of cardiac output.

Contraindications
The only absolute contraindication to arterial line placement is
infection at the insertion site. Relative contraindications include the
presence of systemic anticoagulation or bleeding disorder, which
increases the risk for haematoma formation and haemorrhage. A
history of severe arterial occlusive disease should be excluded prior
to cannulation. A local infection or prior surgery with implantation
of foreign materials such as a dialysis graft or an arteriovenous
fistula near the site make that specific site unsuitable.

Patient assessment and preparation

A brief history should be obtained, focusing on indications and
contraindications. A modified Allen’s test prior to planned radial
cannulation to establish adequate collateral flow has been advo-
cated by some. In this technique, pressure is applied to the radial
and ulnar arteries simultaneously and maintained while the hand
is elevated until it is exsanguinated. Pressure over the ulnar artery
is then released while the radial artery is kept compressed. If colour
does not return within 5 seconds, the Allen’s test is positive.
Controversy exists as to whether Allen’s test is reliable; safe
cannulation has been documented in the presence of a positive test.
Some experts advocate using this test only when other evidence
of vascular compromise is present; others suggest that a Doppler
evaluation of the collateral flow be completed prior to cannulation
in high-risk patients.
It is useful to have an assistant to aid in maintaining position
and aseptic technique. Supplies include a cap, mask, sterile gloves,

John D Mitchell is a Clinical Associate in General and Cardiothoracic

Anesthesia at Duke University Medical Center, North Carolina, USA.

Ian J Welsby is Assistant Professor of Anesthesiology at Duke University

Medical Center, North Carolina, USA.

SURGERY 3 © 2004 The Medicine Publishing Company Ltd

VASCULAR ACCESS
eye protection, towels, povidone iodine (in water or alcohol), ster-
ile gauze, tape or suture, 1% lignocaine, a 20 gauge (G) catheter
without an injection port, and a pressure transduction kit.
Techniques of cannulation
Percutaneous: following local anaesthesia, a 20 G cannula is
inserted at a 30–45° angle through the skin along the course of
the artery. There are no circumstances in which a wider cannula
is needed. A 22 G cannula (or smaller) should be used in children.
From this point, there are several variations, each of which can
result in successful cannulation. Free return of arterial blood and a
characteristic arterial waveform on pressure transduction confirm
correct placement of an arterial line.
Direct cannulation – the catheter is advanced until arterial
blood flows back freely. The catheter is lowered to an angle of
15º, then advanced 2–3 mm into the artery to ensure that the
catheter, not just the needle, is within the artery prior to cannula
advancement.
Transfixation – after arterial blood is seen in the needle hub,
or if direct cannulation fails, the needle is advanced until it passes
through the posterior wall and blood flow ceases. At this point,
the needle is removed, and the catheter is withdrawn until blood
flows freely and then advanced into the artery.
‘Liquid stylet’ technique – in order to aid threading once the
cannula is within the artery, a syringe of normal saline attached
to the catheter is slowly injected while the catheter is advanced.
The Modified Seldinger technique involves threading a
guidewire into the artery to facilitate passage of the catheter fol-
lowing placement of the needle within the artery. If resistance
is appreciated, the needle should be advanced or withdrawn to
optimize flow and threading repeated. If still unsuccessful, the
needle should be rotated 90–180° in order to eliminate the possi-
bility of an intimal flap interfering with passage of the wire. Some
commercially available catheters have an integral wire.
Surgical cutdown is used only as a last resort.
Sites of access and placement
The femoral artery can be identified at the midpoint of the
inguinal ligament between the anterior superior iliac spine and the
pubic symphysis. It lies medial to the femoral nerve and lateral to
the femoral vein. A modified Seldinger technique should be used.
The angle of entry should be between 30º and 45º, and below the
ligament to avoid the risk of inadvertently entering the peritoneum
or causing a retroperitoneal haematoma.
The radial artery is most easily identified in the wrist at the
distal end of the radius, where it is most superficial. Here, it lies
between the brachioradialis and flexor carpi radialis tendons. A
point for insertion is 1–2 cm above the skin crease at the wrist,
directly over the pulse. Hyperextension of the wrist with a rolled-up
towel or roll of gauze will decrease arterial tortuosity and facilitate
cannulation. It is the most popular site for arterial cannulation,
because of the superficial nature of the pulse and ease of place-
ment and maintenance at this location,
The ulnar artery is most easily palpable on the medial aspect
of the wrist as it passes anterior to the flexor retinaculum, pisiform
to distal. The ulnar nerve courses between the artery and pisiform
bone, putting it at risk of injury during attempts at cannulation.
Hyperextension of the wrist may aid in placement.
SURGERY
The brachial artery is easily identified on the medial side of the
arm in the antecubital fossa at the lateral border of the brachialis
muscle, medial to the biceps tendon. Entry at this site is associ-
ated with a high rate of thrombosis; distal ischaemia and embolic
events occur more often here than at other sites. For these reasons,
cannulation at this site should be avoided unless necessary.
The axillary artery arises from the subclavian artery beyond
the first rib and courses through the axilla entwined in the bra-
chial plexus, continuing into the arm to give rise to the brachial
artery. It is most easily palpated with the arm abducted at least
90º. In order to avoid injury to the brachial plexus, cannulate the
axillary artery high in its course, when the plexus is posterior,
avoiding transfixation. Neurological and vascular integrity should
be monitored while the catheter is in place, although risk is lower
than with brachial approaches due to excellent collateral flow at
this level.
The dorsalis pedis artery is located on the dorsal surface of the
foot, just lateral to the extensor hallucis longus. It is usually most
easily palpated at the level of the joint between the cuneiform and
the first metatarsal bone. The foot should be placed in the neutral
position for cannulation attempts. This artery may be small and
difficult to cannulate.
Adjuncts to aid placement
Ultrasound devices allow visualization of the artery, whereas
a Doppler signal will provide audible evidence. Both may be
employed either to identify the vessel or as real-time aid provid-
ing direct feedback during cannulation.
Complications
Vascular injury – haematomas can easily occur during
attempted cannulation or catheter removal and are usually effec-
tively treated with application of pressure to the site for at least
10 minutes. Pseudoaneurysms and arteriovenous fistulas can also
occur, particularly with traumatic cannulation of the femoral artery
with larger cannulas, or in the presence of a coagulopathy. Surgi-
cal repair may be required, particularly in cases where vascular
compromise or distal ischaemia results.
Thrombosis and embolism – thrombosis is the most common
complication affecting indwelling arterial lines, occurring in up to
30% of cases in the USA, sometimes after the catheter is removed.
The rate of thrombosis increases with the duration of cannulation
and tends to extend proximally from the cannulation site. Most
arteries recannalize within 30 days. Thrombosis is asymptomatic
in most cases, but complications (skin necrosis, distal ischaemia,
retrograde embolization of thrombus) may occur.
Nerve trauma occurs rarely and may be the result of haematoma
formation around the nerve sheath. Nerve trauma is associated
with large-bore axillary catheterization (brachial plexus injury),
and multiple attempts at brachial artery catheterization (median
nerve injury). The risk is higher in anticoagulated patients.
Infection rates increase in proportion to the duration of can-
nulation. While most are local infection with Staphylococcus
epidermidis, systemic infections may result. Cutdown for access
increases the infection rate substantially.
Other: accidental disconnection of arterial lines may result in
substantial haemorrhage if not discovered promptly. Accidental
injection of drugs may result in severe vasospasm, ischaemia, and
skin necrosis if not treated immediately. 
4 © 2004 The Medicine Publishing Company Ltd