Ulnar Art lines

[Radar26]

I’ve comes across situations where the radial artery is pinpoint (and calcified) on both side when looking with ultrasound, but there is a big ulnar artery that looks easy to cannulate.

Anyone have experience placing ulnar art lines? Is there more risk for hand ischemia when placing an ulnar art line vs a radial one as long as the other artery is left unpunctured? I was taught in training “just don’t do it” but with no good explanation as to why not to...

If this has been addressed in old posts, point me in that direction- I couldn’t find anything during my search.

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[BLADEMDA]

Given the low rates of forearm artery occlusion with patent hemostasis techniques, ipsilateral ulnar access after failed radial access appears to be safe. Dahal and colleagues4 compared outcomes of radial vs ulnar artery access with a meta-analysis of the five randomized, controlled trials. Among the 2744 patients (29% female), there was no difference in major adverse cardiac events (3.1% vs 3.5%, P=NS) or access-related complications (14.9% vs 15.4%, P=NS) including the individual events of arterial spasm, stenosis, occlusion, or bleeding. Only one case of nerve injury was noted in the ulnar artery arm, which resolved with conservative therapy. There was no difference in fluoroscopy parameters, time to access, or contrast volume, but the ulnar artery was consistently more difficult to access, with a larger number of punctures required and higher rate of access site crossover (14% vs 3.8%, P=0.003). These studies suggest that use of the ulnar artery is as safe as radial (given the cautionary notes). However, given a slight increase in difficulty, there is little reason to start with an ulnar approach for the typical patient, but ulnar catheterization is an excellent alternative for the difficult radial access, and almost certainly superior to femoral access.

Radial Access Failure: When Should We Go Ulnar?

Dr. Seto hypothesized that a small, tortuous radial artery might be associated with a larger ulnar artery, providing a straighter and more negotiable course for catheter passage.

www.cathlabdigest.com

 

[BLADEMDA]

Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study - PubMed

The success rate of an arterial cannulation in a patient with a strong ulnar pulse is the same as for radial artery cannulation.

pubmed.ncbi.nlm.nih.gov

 

[BLADEMDA]

I have NEVER cannulated the Ulnar artery in all my years. This old dog may indeed learn new tricks. Before i would consider using the ulnar artery I would make certain the radial artery on that same arm/wrist/hand was not MUCKED with or disturbed in any way prior to sticking the ulnar artery. I would also check the size/diameter of each artery in both hands. Since my N=0 vs a N of over 10,000 for radial a-lines I would be hesitant at first. I have had good success placing axillary arterial lines by using a pediatric central line kit for access.

Arterial Line Placement: Safety First

ARTERIAL lines are regularly inserted in patients in the perioperative and critical care setting to measure hemodynamic variables, such as beat-to-beat blood pressure and cardiac output, and to regularly obtain blood gas values and other measurements from plasma. In the research setting...

pubs.asahq.org

 

[MirrorTodd]

It's probably just not necessary when you have a brachial artery just up the way.

 

[Gaseous Clay]

I totally respect you Blade, but 10k seems awfully high. If you’ve been in practice for 25 years, that’s 400 a year which is almost 1.5-2/day every day you’ve worked. In residency we put in a lines for just about every case it seemed. In PP we put them in much, much less frequently.

Admittedly I put in an ulnar art line as a resident when someone called me for help since they were struggling. That attending was pretty chill but don’t think he was all too happy with that. Patient did fine post op.

 

[IMGASMD]

Why not brachial or axillary a-line first?

 

[MirrorTodd]

I have NEVER cannulated the Ulnar artery in all my years. This old dog may indeed learn new tricks. Before i would consider using the ulnar artery I would make certain the radial artery on that same arm/wrist/hand was not MUCKED with or disturbed in any way prior to sticking the ulnar artery. I would also check the size/diameter of each artery in both hands. Since my N=0 vs a N of over 10,000 for radial a-lines I would be hesitant at first. I have had good success placing axillary arterial lines by using a pediatric central line kit for access.

Arterial Line Placement: Safety First

ARTERIAL lines are regularly inserted in patients in the perioperative and critical care setting to measure hemodynamic variables, such as beat-to-beat blood pressure and cardiac output, and to regularly obtain blood gas values and other measurements from plasma. In the research setting...

pubs.asahq.org

We have had a couple residents over the years accidentally place ulnar artery catheters. Lol they've worked just fine.

 

[IMGASMD]

I totally respect you Blade, but 10k seems awfully high. If you’ve been in practice for 25 years, that’s 400 a year which is almost 1.5-2/day every day you’ve worked. In residency we put in a lines for just about every case it seemed. In PP we put them in much, much less frequently.

Admittedly I put in an ulnar art line as a resident when someone called me for help since they were struggling. That attending was pretty chill but don’t think he was all too happy with that. Patient did fine post op.

Maybe 4 hearts a day, then you can get 10k much sooner...?

 

[GassYous]

I totally respect you Blade, but 10k seems awfully high. If you’ve been in practice for 25 years, that’s 400 a year which is almost 1.5-2/day every day you’ve worked. In residency we put in a lines for just about every case it seemed. In PP we put them in much, much less frequently.

Admittedly I put in an ulnar art line as a resident when someone called me for help since they were struggling. That attending was pretty chill but don’t think he was all too happy with that. Patient did fine post op.

I was thinking that. I rarely place them now because our surgeons are efficient and good. But if you're supervising 1:4 I can see it.

 

[NICMAN]

I have only been out to in practice a few years but as the QI, Clinical case/peer review guy for our group I have seen two ischemic hands because of ulnar art lines. That is an N = 2 in three years... so I would recommend that ulnar lines never be placed (which is now our policy). Even if the radial is patent there is no way of knowing e.g., that some RT might not to a radial stick and have it vasoconstrict. Brachial and axillary lines are usually much easier and almost always successful unless major vascular work has been done. I use an ultrasound to keep from mucking around and just bullseye it, thread, and hook it up--done!

 

[deleted126335]

I have only been out to in practice a few years but as the QI, Clinical case/peer review guy for our group I have seen two ischemic hands because of ulnar art lines. That is an N = 2 in three years... so I would recommend that ulnar lines never be placed (which is now our policy). Even if the radial is patent there is no way of knowing e.g., that some RT might not to a radial stick and have it vasoconstrict. Brachial and axillary lines are usually much easier and almost always successful unless major vascular work has been done. I use an ultrasound to keep from mucking around and just bullseye it, thread, and hook it up--done!

N=1, but I saw a colleague fail to place a radial aline- he did hit the artery. Subsequently put in an ulnar on the same side. Hand became ischemic. I won't place one

 

[Gaseous Clay]

Maybe 4 hearts a day, then you can get 10k much sooner...?

He’s also quoted thousands, maybe even tens of thousands, of blocks so also doing lots of outpatient stuff. He’s a busy man!

 

[ToKingdomCome]

Why not brachial or axillary a-line first?

Any tips for placing brachial ? I I assume the artery is fat and juicy under ultrasound and you just want to be careful with median and radial nerve damage?

 

[abolt18]

Any tips for placing brachial ? I I assume the artery is fat and juicy under ultrasound and you just want to be careful with median and radial nerve damage?

Above the AC is less prone to kinking the catheter. But yes just watch out for the median nerve. It's quite nice on ultrasound.

 

[anaesthetic]

.

 

[BLADEMDA]

I totally respect you Blade, but 10k seems awfully high. If you’ve been in practice for 25 years, that’s 400 a year which is almost 1.5-2/day every day you’ve worked. In residency we put in a lines for just about every case it seemed. In PP we put them in much, much less frequently.

Admittedly I put in an ulnar art line as a resident when someone called me for help since they were struggling. That attending was pretty chill but don’t think he was all too happy with that. Patient did fine post op.

I put in a lot of arterial lines and I have been in practice more than 25 years. I also cover CRNAs in a ratio of 1:4 for many, many years. For anyone doing cardiac, vascular or high risk cases in a busy private practice they too will likely exceed 10,000 arterial lines. I really don't hesitate to place an a-line if I think I may need it. I view it as additional security/safety in ASA3/ASA4 cases. In fact, as I get older I should be placing more a-lines because the CRNAs are less experienced and less knowledgeable than the former groups of the past.

 

[BLADEMDA]

I prefer the axillary artery over the brachial artery for arterial line placement. IMHO, it is a safer site. When I can't get the radial under u/s (which is rare) I obtain a pediatric central line kit and use the axillary artery. Remember, in my day we did thousands of transarterial axillary blocks as our "standard" brachial plexus block. So, sticking the axillary artery isn't an issue for many of the older practitioners out there.

I also respect others who choose the Femoral approach on certain patients if he/she can't access the radial artery.

Avoiding the brachial plexus when placing axillary a-lines

Recently I've been doing more axillary arterial lines in the ICU. They are much easier to place than radials, have more collateral circulation than brachials, and last way longer than either so it means torturing your patients less. However, one thing that still bugs me about them is that I...

forums.studentdoctor.net

 

[Arch Guillotti]

He’s also quoted thousands, maybe even tens of thousands, of blocks so also doing lots of outpatient stuff. He’s a busy man!

10,000 central lines also while running 4 rooms.

 

[Justice4all]

I did not place any ulnar prior to fellowship(peds) but with pediatric patients and those with syndromes, ulnar might be the only chance. I ve place 3 so far. I usually check both upper extremities and usually verify (US)that radial is patent but usually small and unable to cannula the with a 24g. No issues or complications. All these patients were above 2 years of age. Will attempt a posterior tibial before ulnar over that age.
Axillary is in back pocket but never had the pleasure to do one yet.

 

[Gaseous Clay]

10,000 central lines also while running 4 rooms.

I hate to make fun of Blade but someone needs to keep a running tally of his procedures. I believe he’s also done >10,000 ISB half of which were with exparel 😉.

All kidding aside it is certainly feasible to hit that many procedures, usually not with 10k+ other procedures like lines, epidurals, and PNBs. If so, hopefully you make $1M/year.

 

[Airway]

We have had a couple residents over the years accidentally place ulnar artery catheters. Lol they've worked just fine.

I did that as a resident... ICU blah blah crashing patient, nurse talking at me, non standard positioning and then oops ulnar arterial line

 

[Wolverines83]

Peds fellowship we routinely did ulnar lines as sometimes it’s just bigger than the radial. Did them on neonates in the heart room. No complications. No hesitation from any of the attendings either.

 

[okayplayer]

Doing it in a kid is way different than an old vasculopath...spoken by someone peripherally involved in a devastating ischemic complication from an ulnar line.

Don’t place them in an adult. Definitely don’t place them in an adult after mucking around with the ipsilateral radial artery.

 

[vector2]

I do not place them in adults. I've done it a couple times before but it makes me a bit uncomfortable. If I fail on a distal radial (which is exceedingly rare in the age of U/S), I will just stick the radial more proximally. If that doesn't work I'll stick the radial in the other arm. If the other arm isn't free, I'll just do an axillary.

 

[Angus Avagadro]

We have had a couple residents over the years accidentally place ulnar artery catheters. Lol they've worked just fine.

Accidently? How did it happen? Must be a good story!

 

[deleted126335]

Accidently? How did it happen? Must be a good story!

Dyslexia or Stupidity.

 

[Volatile]

I did not place any ulnar prior to fellowship(peds) but with pediatric patients and those with syndromes, ulnar might be the only chance. I ve place 3 so far. I usually check both upper extremities and usually verify (US)that radial is patent but usually small and unable to cannula the with a 24g. No issues or complications. All these patients were above 2 years of age. Will attempt a posterior tibial before ulnar over that age.
Axillary is in back pocket but never had the pleasure to do one yet.

I’ve never placed a posterior tibial art line, actually had never even considered it an option. Anyone done this on an adult?
I can recall a particular case while deployed, dude had b/l arms blown to pieces and struggling to cannulate the damn dorsalis forever

 

[vector2]

I’ve never placed a posterior tibial art line, actually had never even considered it an option. Anyone done this on an adult?
I can recall a particular case while deployed, dude had b/l arms blown to pieces and struggling to cannulate the damn dorsalis forever

What's I've done for mangled arms or burns when the femoral is unavailable is an axillary, and instead of a dressing just suture it really well and have the surgeon prep the line into the field / ioban over it. Now obviously if they're working in the axilla it's not gonna work, but mid-humerus or lower you should be good

 

[abolt18]

I’ve never placed a posterior tibial art line, actually had never even considered it an option. Anyone done this on an adult?
I can recall a particular case while deployed, dude had b/l arms blown to pieces and struggling to cannulate the damn dorsalis forever

Done it in a peds heart once before.

Kid had no identifiable radial artery in either side. Placed pulse-ox on each hand and compressed the ulnar artery, pulse-ox went flat. Went to the foot and did posterior tibial artery. Worked well, but was very different from central pressure after bypass so I ended up scrubbing in and placing a fem line. Those peds cardiac people do things a little different.

 

[sevoflurane]

we used to use fem a-lines for all pedi bypass cases.

 

[sevoflurane]

As per ulnar lines... I’ll go brachial then axillary. Never had to put an ulnar aline.

 

[Bones411]

I gotta admit it, I was one of those residents that did it by accident as a CA 1. We had small blue drapes for all radial arterial lines, put the drape on, got distracted, threaded the catheter, took the drape off and thought, huh something looks different, usually the the line is on the thumb side...

 

[yerhuckleberry]

Do them all the time. Syndromic children often have a significant size discrepancy between their radial and ulnar arteries, for whatever reason...one way or the other. Never had an issue by using the smallest possible French size of appropriate length.

 

[CavGas]

Just a 2nd year resident here.. we had a young pt come up from ICU on low dose norepi for evolving dead bowel, no a line.. radials look butchered on both sides. Old school attending immediately places ulnar and after 15-20 mins i check the hand and the three medial fingers look kinda dusky- black.. it immediately resolved after we pulled it and placed a femoral.

I wouldn’t put one since femoral or brachial is usually available!

 

[vector2]

Just a 2nd year resident here.. we had a young pt come up from ICU on low dose norepi for evolving dead bowel, no a line.. radials look butchered on both sides. Old school attending immediately places ulnar and after 15-20 mins i check the hand and the three medial fingers look kinda dusky- black.. it immediately resolved after we pulled it and placed a femoral.

I wouldn’t put one since femoral or brachial is usually available!

Ulnar is already (theoretically) risky, so doing that in a pt with a mangled radial, in shock, and on pressors is for all intents and purposes malpractice.

 

[Hoya11]

As per ulnar lines... I’ll go brachial then axillary. Never had to put an ulnar aline.

To the people doing brachial lines, do people give you a hard time about them?

I also do radial -> Brachial --> axillary, fem, but often I have run into folks afraid of complications of brachial. I have never seen one and seen plenty of data supporting there safety, why wont they catch on as the next step after radial failure?

 

[FiO2@21]

My limited experience with ulnar is that it tends to take a sudden turn. So it might look attractive proximally but be a pain to actually cannulate.

I’ve done a dorsalis pedis/anterior tibial artery line on an adult once... my ICU attending wanted me to mix it up. It wasn’t bad at all. Used a longer catheter.

 

[26B]

If distal radial doesn't work, I've had good success with going a a few inches proximal and using a micropuncture kit if necessary.

 

[IMGASMD]

If distal radial doesn't work, I've had good success with going a a few inches proximal and using a micropuncture kit if necessary.

I never was trained with micropuncture kits. Can someone enlighten me, what’s so different about this than let’s say arrow a-line? I’ve seen vascular surgeon struggle even with the kit...

Isn’t it just get into the vessel, thread the wire, thread the catheter?

 

[vector2]

I never was trained with micropuncture kits. Can someone enlighten me, what’s so different about this than let’s say arrow a-line? I’ve seen vascular surgeon struggle even with the kit...

Isn’t it just get into the vessel, thread the wire, thread the catheter?

The advantage of the micro puncture kit (we have Cook medical) is a very sharp, lightweight needle (that will usually stay in situ after flash even if you take your hand off of it), soft tip wire that can make it into a lot of wonky vessels, and the fact that the catheter is actually a long, small bore (4-5 fr) introducer sheath that can be placed into deep vessels without a scalpel and separate dilator.

 

[abolt18]

The advantage of the micro puncture kit (we have Cook medical) is a very sharp, lightweight needle (that will usually stay in situ after flash even if you take your hand off of it), soft tip wire that can make it into a lot of wonky vessels, and the fact that the catheter is actually a long, small bore (4-5 fr) introducer sheath that can be placed into deep vessels without a scalpel and separate dilator.

View attachment 328333

Agreed, great for those heavily calcified arteries that are hard to break into. And that tiny wire is gentle, I think much less likely to dissect an artery as you thread it. And I always let go of the needle after I get in (using my right hand), then grab it with my left hand to stabilize while threading the wire. I think an important thing also with the thin wire is to not force it because you can distort it very easily.

Edit: my only beef with it is that there's no great way to suture it in. It's tapered all the way down so sutures on it don't do you any good. I just end up suturing the tubing down and taping the catheter thoroughly with steri-strips.

 

[Shimmy8]

That catheter is also longer so more stable for higher radial lines, brachial, and even axillary. My go to for tough lines and deep venous access using ultrasound.

 

[sevoflurane]

Micropunctures are great for big patients that need access for a few days. I like them in particular for venous access above the elbow. Extremely reliable, can run pressors through them, easy blood draws and are also super comfortable for patients.

 

[epidural man]

You guys are good, going up the arm.
Here is my algorithm -

1. radial ((multiple attemps),
2. (Me muttering under my breath)...I guess we don’t really need an A-line

 

[GassYous]

You guys are good, going up the arm.
Here is my algorithm -

1. radial ((multiple attemps),
2. (Me muttering under my breath)...I guess we don’t really need an A-line

Been there!

 

[IMGASMD]

You guys are good, going up the arm.
Here is my algorithm -

1. radial ((multiple attemps),
2. (Me muttering under my breath)...I guess we don’t really need an A-line

I almost aborted one today....

You skipped one step I took today. Get a blood pressure.... it was 110/70. Can’t even blame the bp!

 

[sevoflurane]

To the people doing brachial lines, do people give you a hard time about them?

Nope. If I do, I kindly explain to them that it is perfectly fine to use a brachial.

 

[Hoya11]

Nope. If I do, I kindly explain to them that it is perfectly fine to use a brachial.

The idea that they are somehow not safe is really deeply seeded, I had a vascular surgeon give me a horrified look when I said I was going to place one... is everyone just uneducated about them?

They are so easy and reliable. And my arrow catheter is certainly not going to obstruct flow in that big artery . I dont get the risk..

 

[vector2]

The idea that they are somehow not safe is really deeply seeded, I had a vascular surgeon give me a horrified look when I said I was going to place one... is everyone just uneducated about them?

They are so easy and reliable. And my arrow catheter is certainly not going to obstruct flow in that big artery . I dont get the risk..

I think they get called a couple times a year for a brachial pseudoaneurysm and then by sheer recall bias just assume that the complication rate must be super high.