Tips and Tricks for Venous Access: Lessons Learned from 3,000 Procedures
By Dr. J. Gordon Wright, MD, FACS, RVT
After performing over 3,000 Endovenous Ablations, first let me say this is nothing magic here. I don’t have comprehensive knowledge of what has and has not been published on this topic, but I am sure many articles and textbook chapters have been written on the technical aspects of obtaining access for endovenous ablation. I offer these tips and tricks in the hope that some diligent person out there who is just beginning to perform endovenous ablations will benefit (1).
The Right Tools
There are a few choices you can make regarding the equipment and supplies you own that will impact the ease or difficulty with which you will gain access. This is not intended to be a comprehensive list of what you must have, but reflects my thoughts on the common options you will have available.
Ultrasound (US) Machine –There are several makes and models which fit the bill and are reasonable choices, and the choice depends on floor space, portability, cost, and ease of use. The choice of which US machine would be the best choice for you and your particular practice is a complex decision with too many variables to address here.
Room Lighting –A darkened room with a variable intensity operating room light that is directed to your operative field and keeps the monitor in the dark is the best choice.
Micropuncture Kit – If the vein is small, a micropuncture kit is very useful. Some phlebologists use the micropuncture kits for all their access, although I use it selectively. I like the kit sold by Merit Medical. The twenty-one gauge needle is chemically etched and I find it to be noticeably more echogenic than mechanically etched needles. Also, the mechanically etched needles will stick to the adventitia so if you “tansfix” the vein and get the front and back walls of the vein shish-ka-bobbed on your micropuncture needle, you will never be able to recover from this.
Optional Adjunctive equipment – I highly recommend that you have the following adjunctive items on-hand in case you need them. How and when you would these adjuncts is described in the next section, on prevention of venospasm.
- A Sterile Tourniquet.
- Nitroglycerine Ointment, 2%.
- Stand-Off Pads or a Permanent Stand- Off attachment to your US probe.
- Space Heater.
- Bean bag warmer.
- Blankets warmed in a microwave oven.
- Ultrasound Gel Warmer.
Spasm is your enemy – prevention is your goal For the first two hundred cases, consider using all of the following tips and tricks to minimize spasm. For the next ten thousand cases, consider using some of these as needed:
Keep the patient calm - it’s always a good idea in general, but you will quickly learn that the more nervous the patient, the more easily they will spasm down. A reassuring and pleasant demeanor is your best bet when calming the patient. Another tip is to minimize the time between the patient walking in your door and the procedure actually beginning. During that time, do not let the patient sit alone, because if left alone all they will think is: I am going to get a needle shot! I am going to get a needle shot! I am going to get a needle shot! . . . . and as their anxiety level goes through the roof, their veins all shrink. Another way to help prevent spasm is to use ten to fifteen degrees of reverse Trendelenberg position to slightly distend the lower extremity veins. This does not make a big difference, but it helps a little and costs nothing.
You should also pick easy targets. For the Greater Saphenous Vein (GSV), the “sweet spot” is about five centimeters below the knee joint, where the GSV courses a little more anteriorly as it runs over the flat anterior-medial part of the medial tibial condyle. If your target is small, then open a sterile tourniquet in the field and apply it about fifteen to twenty centimeters proximal to your intended venipuncture site target vein. This is only effective with some reverse Trendelenberg, and should be done before any attempt is made at venipuncture.
Keep the patient warm by making the room a little warmer than it otherwise needs to be. If your patient complains of being cold, or looks cold, offer them a blanket warmed in a microwave. For local agents, a warm bean bag will assist in warming the skin. You can also warm up your preparation solutions. I put Hibiclens® in an ultrasound gel dispenser and then warm it in a gel warmer. Nitroglycerine ointment (2%) applied to the skin near the likely target venipuncture site about ten minutes before the skin puncture has been shown to dilate subcutaneous veins. Nevertheless, DO NOT allow the application of the nitro to delay your treatment of the patient because the effect of the Nitro is small and the effect of anxiety is large. Remember: spasm is your enemy.
The Right Technique
Good technique comes with experience. As your technique improves, you will find that the incidence of spasm drops off precipitously. If you can get access with one slow single deliberate pass, you will RARELY cause problematic spasm. Discipline yourself to get comfortable, get steady, pick an easy target, get good direct and ultrasound visualization, and go slowly but confidently. Even in the absence of spasm, good technique is a key factor to a successful procedure.
If you consider yourself to be in the beginning stages of your learning, consider purchasing a Blue Phantom to practice your ultrasound probe-eye-hand-brain-monitor-
It is my strong bias that only one pair of hands should be gaining access. The operator who is advancing the needle with one hand should be holding the US probe in their other hand. Otherwise, your right hand will NOT get the kinetic feedback you need from your left hand, and your access will be ten times more difficult. If you are not ready to do the intraoperative US on your own, you need to practice with a Blue Phantom until you are ready.
Take time to understand how and why a “standoff” works. Get comfortable with creating one from gel, or purchase a permanent ($200) or disposable ($10) standoff pad. A standoff should be used whenever your access target is in those difficult-to-visualize near-field zones, just one1 or two mm below the skin.
Unless you are very ambidextrous, position the patient, yourself, and your ultrasound monitor the same way every time. For most right-handed operators, this means you should stand (or sit) near the patient’s right leg, with the US monitor near the patient’s left leg. You need to orient your US probe and the Left/Right orientation of your monitor so that when you hold the probe in a longitudinal direction and move it to the left, the image on your monitor moves to the right. The opposite is true for lefties. Most operators find that the longitudinal view is easier to use than the transverse view. Once you have identified your target in a longitudinal view, then:
- Check to make sure you are resting the US probe and your left hand lightly on the skin so as not to compress any veins, then position yourself so you are facing the distal most edge of the US probe and your line of vision is aligned with the imaging plane of the US probe.
- Next, create a “tripod” on the skin by positioning your probe, your left hand, fingers, wrist, elbow, shoulder and back to form a very stable structure. The three legs of the “tripod” are: (1) the distal most edge of the US probe, (2) the tip of your extended left 5th finger resting on the patient’s skin, and (3) your left pisiform bone, also resting on the patient’s skin. (see figure 1)
- Raise a skin wheal, using lidocaine WITHOUT epinephrine. IMPORTANT: Take extra care to evacuate all the air from the syringe, hub, and needle before attempting to raise your skin wheal. Even a small bubble of air in the hub will diffuse through the skin and subcutaneous tissue, creating a huge acoustic shadow right where you don’t want it.
- Make a dermotomy with a #11 scalpel held in the same plane as the imaging plane of the US probe and at the same angle of attack with which you want your needle to approach the vein.
- If your target is in the near-field zone (just 1-2 millimeters subdermal) then put the tip of your access needle just a few mm into the dermotomy, bevel up, temporarily lift the probe off the skin, and create a 1 centimeter “standoff” with some gel, then hold the US probe in the gel but off the skin and regain your image.
- Approach the vein slowly but with determination. It is surprising how far you can invaginate the adventitia into the lumen of the vein, especially if the vein is in a loose, fatty portion of the thigh (one of the advantages to the relatively skinny flat portion of the medial tibial condyle). So don’t give up until you feel a “pop” as the needle penetrates the vein wall. Do not be fooled by the “pop” of the saphenous envelope, which is sometimes within ½ millimeter of the adventitia.
- When advancing the needle for access, an assistant in the room should watch the hub of your access needle and let you know when they see the “flash” of a blood return. In this way, the operator can keep his eyes on the monitor and does not have to look up and down repeatedly looking for a blood return. My assistants simply say “OK” when they see a flash, but more importantly, they tell me “I can’t see” if they cannot clearly see the hub. If they cannot see the hub and say nothing, it is possible for the operator to unknowingly advance the needle too far and lose what could have been an easy access.
- Once you get a flash, it is useful to advance the needle tip an additional 1 or 2 mm within the lumen to get a little more “purchase” on the vein, so that if you let go of the needle it will not get pulled distally by the recoil of the compressed vein, skin and subcutaneous tissue, and back itself out of the vein.
Although venous access is the most challenging part of the procedure, the skills needed to minimize difficulty with access are easily acquired with experience. Hopefully, some of these pearls will accelerate your journey to being the best you can be at providing this rewarding treatment modality to your patients.
1 Disclaimer: The Author has no commercial interest in any of the drugs, devices or supplies mentioned in this article.
Dr. Wright received a BS in Electrical Engineering and BA in Biology from Washington University and culminated his formal training with a two year fellowship in Vascular Surgery under the late Robert Hobson II, MD, FACS at Boston University. He practices Phlebology full time and is the founder of the Midwest Vein Center which has three offices in the Chicagoland area.