Figura 1. Placement of a 7-Fr introducer in the right basilic vein (orange color) and a 6-Fr introdu...

Figura 2. Fluoroscopy images showing the advancement (panel A) of the Swan-Ganz catheter through ant...

Figura 3. Pulmonary arteriography. Digital subtraction images (panels A and B) and non-subtracted i...

Introduction

Right-heart catheterization (RHC) is the method of choice for the accurate measurement of pulmonary artery pressure, cardiac output, and pulmonary vascular resistance1. In cases of suspected chronic thromboembolic pulmonary hypertension (CTEPH, group 4), a pulmonary arteriography is also conducted. This is a diagnostic method that remains the gold standard for confirming or ruling out this condition1, which has an incidence of 2.3% among patients who have survived an acute pulmonary embolism2.

RHC is performed through a peripheral venous access, traditionally the femoral or the internal jugular vein. Peripheral venous access from the arm is an older alternative that, in recent years and with the growing use of transradial arterial access, has once again been considered in diagnostic and therapeutic cardiovascular interventional procedures3. This is mainly because it offers better patient ergonomics, lower rates of puncture site complications, and the possibility of performing the procedure under anticoagulation3, 4. However, to date, there are no recommendations in current clinical practice guidelines regarding which access route to choose1.

Inferior vena cava filters (IVCFs) are usually placed in the inferior vena cava below the renal veins to prevent the migration of thrombi from the lower limbs to the pulmonary vascular bed. Despite their mechanical effectiveness, clinical guidelines provide few indications for their implantation, reserving them for patients with pulmonary embolism (PE) who also have a contraindication to anticoagulant treatment4. In patients with suspected CTEPH who need to undergo right-heart catheterization and pulmonary arteriography, the presence of an IVCF could be an obstacle for transfemoral access, as catheters would have to be advanced through it. Thus, in this patient subgroup, antebrachial vascular access is an alternative for performing right-heart catheterization, since the materials would not need to pass through the IVCF, thus presenting as an alternative to jugular vascular access.

We present a clinical case of a patient with suspected CTEPH and a history of IVCF implantation. A decision was made to use the right antebrachial vascular access through the basilic vein to perform right-heart catheterization and pulmonary arteriography without the need to discontinue anticoagulation.

Clinical case

The patient was a 73-year-old man, former smoker, who in 2017 experienced an intermediate-risk pulmonary embolism (PE), for which he successfully completed a full course of oral anticoagulant therapy. In 2018, after having completed anticoagulant treatment, he experienced a new episode of PE that required prolonged hospitalization and was again treated with oral anticoagulants. Following hospital discharge, he had an episode of upper gastrointestinal bleeding, which required esophageal variceal ligation and was subsequently diagnosed with de novo liver cirrhosis of unknown etiology. Due to the bleeding event, anticoagulant therapy was discontinued and an inferior vena cava filter (IVCF) (Gunther-Tulip, Cook, United States) was placed at the infrarenal level. The filter was never removed, and residual deep vein thrombosis was confirmed bilaterally at the femoropopliteal level.

He had his first consultation at our center in 2023 due to exertional dyspnea. A transthoracic color Doppler echocardiogram showed pulmonary hypertension (pulmonary artery systolic pressure [PASP] = 64 mmHg), and a ventilation/perfusion scan evidenced multiple perfusion defects in the lateral and medial segments of the right upper lobe, with preserved ventilation. Due to suspected CTEPH, right- and left-heart catheterization and pulmonary arteriography were requested. Left-heart catheterization was requested in anticipation of a possible pulmonary endarterectomy, which is the treatment of choice1.

Given the IVCF, femoral access was avoided, and right-heart catheterization and pulmonary arteriography were performed using antebrachial venous access through the right basilic vein. Left-heart catheterization was performed via right transradial arterial access. The patient had resumed oral anticoagulant therapy (rivaroxaban 20 mg/day), which was not discontinued throughout the procedure.

Access preparation

After sterile field placement, the right basilic vein was punctured using an 18-G Teflon (Abbocath) intravenous catheter under ultrasound guidance, followed by the advancement of a 0.035” J-tip guidewire and the insertion of a 13-cm long 7-Fr introducer sheath (Terumo, Japan) (Figure 1).

Right-heart catheterization and selective pulmonary arteriography

Subsequently, a 7-Fr Swan-Ganz (Edwards Lifesciences, United States) catheter—the standard catheter size available at our center—was advanced and the corresponding measurements were taken, confirming the diagnosis of precapillary pulmonary hypertension with elevated pulmonary vascular resistance (Figure 2, Video 1 in the Supplementary material). The Swan-Ganz catheter was then removed, and a 6-Fr angled (45°) pigtail catheter was advanced over a 0.035” Teflon-coated J-tip guidewire, positioned selectively in the right pulmonary artery (Figure 2, Video 2 in the Supplementary material).

Selective arteriography of the right pulmonary vascular bed was performed in anteroposterior and contralateral oblique projections using an injector pump. The pigtail catheter was then advanced into the left pulmonary artery, and the same sequence was repeated (Figure 3). The patient showed poor cooperation in maintaining sustained apnea, so selective injections were also applied in the pulmonary segments without digital subtraction. Finally, left-heart catheterization was conducted through the right radial arterial access. The procedure involved 10 minutes of fluoroscopy and a radiation dose (Air Kerma) of 750 mGy (the patient was obese).

Results

Pulmonary manometry confirmed the presence of precapillary pulmonary hypertension (mean pulmonary pressure 41 mmHg; pulmonary resistance 391 dyn/s/cm-5; 5 Wood units), and pulmonary arteriography revealed, in the right lung, web-like lesions in the upper lobe and subocclusive lesions in the middle lobe, and in the left lung, occlusion of the interlobar artery—findings suggestive of chronic thromboembolic disease (Figure 3). Left-heart catheterization did not show angiographically significant coronary lesions.

Discussion

Brachial venous access for right-heart catheterization was first reported almost 100 years ago by Dr. Werner Forssmann. That was a historic event, as it is considered the first documented cardiac catheterization in history, performed in 19295. Nevertheless, this practice has lost favor largely due to the use of larger and more direct venous access routes such as the femoral and internal jugular veins7. Numerous studies from other countries have assessed the technical feasibility of antebrachial access for right-heart catheterization4. However, on the one hand, most of these studies used 5-Fr catheters and, on the other hand, there are no data from the Latin American region.

In this case, we report on a patient for whom transfemoral access was not ideal due to the presence of an IVCF, and who required both right-heart catheterization and pulmonary arteriography. Jugular access was considered more uncomfortable for the patient and less ergonomic for both the team and the operator, in addition to the risk associated with central venous puncture in an anticoagulated patient. Nevertheless, it would be an appropriate alternative to transfemoral access.

In this case, both procedures were successfully performed through the basilic vein under ultrasound guidance using a 7-Fr introducer. This access, performed with ultrasound-guided puncture, is the most widely accepted technique to improve efficacy and safety. Unlike the jugular route, the basilic vein provides comfort for the operator, maintaining radiation protection standards, and can be used simultaneously with transradial arterial access. Antebrachial access facilitates early ambulation—unlike transfemoral access—and reduces the rate of complications associated with central venous access, such as puncture site hematoma. It even reduces fluoroscopy time and associated radiation dose8.

However, it is important to emphasize the significance of catheterizing the basilic vein and not the cephalic vein, as the latter has a more angled junction with the axillary vein (“T-shaped”), which can hinder catheter advancement. This is the reason why ultrasound-guided puncture selection and vessel selection are recommended. Identifying the vascular anatomy of the arm for this method requires experience, which is associated with a learning curve necessary to achieve satisfactory outcomes.

Conclusion

We present a case of right-heart catheterization and pulmonary arteriography via the right basilic vein using a 7-Fr introducer, in a patient with an IVCF. Antebrachial access via the basilic vein using ultrasound guidance for right-heart catheterization and pulmonary arteriography is an alternative to femoral or jugular access that could be associated with a better safety profile in terms of complications. Future research will be necessary to confirm the safety and efficacy of this ultrasound-guided technique in our region, with the aim of reducing procedure-related complications.

1. Humbert M, Kovacs G, Hoeper MM, et al. 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension. Vol. 43, European Heart Journal. Oxford University Press; 2022. p. 3618-731.

2. Ikeda N, Yamashita Y, Morimoto T, et al. Incidence of Chronic Thromboembolic Pulmonary Hypertension After Pulmonary Embolism in the Era of Direct Oral Anticoagulants: From the COMMAND VTE Registry-2. Journal of the American Heart Association 2024;13(21):e035997.

3. Gilchrist IC, Moyer CD, Gascho JA. Transradial right and left heart catheterizations: A comparison to traditional femoral approach. Catheterization and Cardiovascular Interventions 2006 Apr 1;67(4):585-8.

4. Harwani N, Chukwu E, Alvarez M, Thohan V. Comparison of Brachial Vein Versus Internal Jugular Vein Approach for Access to the Right Side of the Heart with or Without Myocardial Biopsy. American Journal of Cardiology 2015;116(5):740-3.

5. Himes E. Society of Interventional Radiology Clinical Practice Guideline for Inferior Vena Cava Filters in the Treatment of Patients with Venous Thromboembolic Disease. Journal of Vascular and Interventional Radiology 2020;31:1529-44.

6. Meyer JA. Werner Forssmann and catheterization of the heart, 1929. Ann Thorac Surg 1990 Mar;49(3):497-9.

7. Hoffman RB, Wilson G. A new approach to pulmonary angiography. AJR 1968;102:328-35.

8. Roule V, Ailem S, Legallois D, et. al. Antecubital vs Femoral Venous Access for Right Heart Catheterization: Benefits of a Flashback. Canadian Journal of Cardiology 2015;31:12:1497.e1-1497.e6.

Para descargar el PDF del artículo
Right heart catheterization and pulmonary arteriography via basilic vein in a patient with an inferior vena cava filter

Haga click aquí