Vascular Access: Anatomical Routes, Clinical Considerations, and Patient Considerations PDF

# Vascular Access - Anatomical Routes, Clinical Considerations, and Patient Considerations ## Vein ### Saphenous, cont. - Anatomical route: foot, Greater Saphenous ascends along the inner (medial) side of the leg and behind the knee. Terminates in the femoral vein. - Clinical considerations:...

# Vascular Access - Anatomical Routes, Clinical Considerations, and Patient Considerations ## Vein ### Saphenous, cont. - Anatomical route: foot, Greater Saphenous ascends along the inner (medial) side of the leg and behind the knee. Terminates in the femoral vein. - Clinical considerations: - CVAD: preferably do not insert in a lower extremity of a crawling or ambulatory patient. - Numerous valves in the legs may cause threading difficulties making it difficult to advance the catheter. ### Popliteal - Anatomical route: Formed by the confluence of the anterior and posterior tibial vessels; ascends through the popliteal space where it becomes the femoral vein. - Clinical considerations: - May be palpated or visualized by the knee. - Vein can also be assessed/visualized using US. - Considerations for lower-extremity CVAD: preferably do not insert in lower extremity of a crawling or ambulatory patient ### Umbilical - Anatomical route: Patent vein in the umbilical cord available for up to 1 week post-birth for vascular access. Patent artery in the umbilical cord available up to 4 days post-birth for vascular access. - Clinical considerations: - Single or dual lumen catheters may be inserted into the umbilical vein up to one week after birth for critically ill infants and neonates. - Catheter tip is placed above the level of the diaphragm for all infusates and CVP monitoring. ## B. Arterial Access - Choice of artery is dependent on the ability to palpate a pulse or to locate it by Doppler flow or ultrasound guidance. ### Table 4. Arteries | Artery | Anatomical Route | Clinical Considerations | |---|---|---| | Radial | The radial artery begins at the bifurcation of the brachial artery, just below the bend of the elbow, and passes along the radial side of the forearm to the wrist. | The use of ultrasound during insertion allows for more proximal positioning of Insertion site. Most common site for arterial line placement in both adults and children because of its superficial nature and ease of maintenance. Perform Allen’s Test prior to radial artery access to ensure collateral blood flow. | | Brachial | The brachial artery may be palpated as it courses medial to the bicep muscle and tendon into the antecubital fossa, with the arm extended and the palm facing up. | Several centimeters above the antecubital fossa, cannulation of the brachial artery requires ultrasound guidance as it courses deeper up the arm. Use with caution due to the absence of collateral blood flow. | | Brachial, cont. | | The brachial artery is not recommended for pediatric patients due to the absence of collateral blood flow. | | Femoral | The femoral artery lies at the mid-inguinal point, which lies midway between pubic symphysis and the anterior superior iliac spine. | The femoral artery may be best palpated below the inguinal ligament, midway between the anterior superior spine of the ilium and the pubic symphysis. AVA recommends the use of ultrasound for all insertions. | ## Review History for allergies or sensitivities to catheter material, latex sensitivity or allergy, adhesive/tape, lidocaine, IV contrast, chlorhexidine. ### Table 5. Vascular Pathology (Disease Process and Comorbidity Impact on Vascular Access) | Condition | History and Assessment | Best Practice | Rationale | |---|---|---|---| | Chronic Kidney Disease | eGFR of less than 60 mL/min/1.73 m2 CKD Stage 3 or higher ESRD Presence of AV Fistula | Consultation of Vascular Access Specialist Consultation with Nephrologist for comprehensive documented plan of care prior to any midline, PICC, or CVAD insertion Avoid VAD insertion in arm, axillary, or subclavian veins of potential future AV fistula Avoid placement on ipsilateral side of an AVF; possible exception in hospice patients, nephrologist consultation Internal Jugular CVAD insertion | Reduction of complications and improved patient outcomes Stenosis of flow pathway for hemodialysis through an AVF The venous and arterial vasculature has been surgically altered and damage to any vessels distal or proximal to the fistula can result in serious complications and may compromise the use of the fistula | | Mastectomy with Axillary Lymph Node Dissection | | Contralateral arm for any WAD insertion Axillary or U insertion | Lymphedema can occur years or decades after original lymph node dissection surgery Risk of lymphedema is increased when 1 or more lymph nodes are removed This risk also exists with breast/node conserving surgery | ## C. Considerations for Vascular Access Related to Patient History and Assessment - Review patient's history of previous VAD type, site, dwell, and any associated complications. - Comorbidities: - Affect device selection, insertion, and wound healing (i.e., diabetes mellitus, steroid therapy, edema, and lymphedema) - Consider additional measures to promote wound healing in these patients