Seldinger angiography is a method for diagnosing the state of blood vessels. Subclavian vein puncture by Seldinger Why is it performed

A polyethylene catheter is passed along the conductor with rotational-translational movements to a depth of 5-10 cm to the superior vena cava. The conductor is removed, controlling the presence of the catheter in the vein with a syringe. The catheter is flushed and filled with heparin solution. The patient is offered to hold his breath for a short time and at this moment the syringe is disconnected from the catheter cannula and closed with a special plug. The catheter is fixed to the skin and an aseptic bandage is applied. To control the position of the end of the catheter and exclude pneumothorax, radiography is performed.

1. Puncture of the pleura and lung with the development in connection with this pneumothorax or hemothorax, cutaneous emphysema, hydrothorax, due to intrapleural infusion.

2. Puncture of the subclavian artery, formation of paravasal hematoma, mediastinal hematoma.

3. With a puncture on the left - damage to the thoracic lymphatic duct.

4. Damage to the elements of the brachial plexus, trachea, thyroid gland when using long needles and choosing the wrong direction of puncture.

5 Air embolism.

6. A through puncture of the walls of the subclavian vein with an elastic conductor during its introduction can lead to its extravascular location.

Puncture of the subclavian vein.

a - anatomical landmarks of the puncture site, points:

1 (picture below) - Ioffe point; 2-Aubaniac; 3 - Wilson;

b - the direction of the needle.

Rice. 10. Point of puncture of the subclavian vein and subclavian way the direction of the injection of the needle

Rice. 11. Puncture of the subclavian vein in the subclavian way

Subclavian vein puncture in the supraclavicular way from the Ioffe point

Puncture of the subclavian vein.

Catheterization of the subclavian vein according to Seldinger. a - passing the conductor through the needle; b - removing the needle; c - holding the catheter along the conductor; d - fixation of the catheter.

1- catheter, 2- needle, 3- "J"-shaped conductor, 4- dilator, 5- scalpel, 6- syringe - 10 ml

1. Interstitial space of the neck: borders, content. 2. Subclavian artery and its branches, brachial plexus.

The third intermuscular space is the interscalene fissure (spatium interscalenum), the space between the anterior and middle scalene muscles. Here lie the second section of the subclavian artery with the outgoing costal-cervical trunk and bundles of the brachial plexus.

Inward from the artery lies a vein, posteriorly, above and outwards 1 cm from the artery - bundles of the brachial plexus. The lateral part of the subclavian vein is located anterior and inferior to the subclavian artery. Both of these vessels cross the upper surface of the 1st rib. Behind the subclavian artery is the dome of the pleura, which rises above the sternal end of the clavicle.

Femoral vein catheterization techniques

The simplest and fast way access to enter medicines- perform catheterization. Large and central vessels are mainly used, such as the internal superior vena cava or jugular vein. If there is no access to them, then alternative options are found.

Why is it carried out

The femoral vein is located in the inguinal region and is one of the major highways that carry out the outflow of blood from lower extremities person.

Femoral vein catheterization saves lives, as it is located in an accessible place, and in 95% of cases the manipulations are successful.

The indications for this procedure are:

the impossibility of introducing drugs into the jugular, superior vena cava;
hemodialysis;
carrying out resuscitation;
vascular diagnostics (angiography);
the need for infusions;
pacing;
low blood pressure with unstable hemodynamics.

Preparation for the procedure

To puncture the femoral vein, the patient is placed on the couch in the supine position and asked to stretch and slightly spread the legs. A rubber roller or pillow is placed under the lower back. The surface of the skin is treated with an aseptic solution, if necessary, the hair is shaved off, and the injection site is limited with a sterile material. Before using the needle, a vein is found with a finger and the pulsation is checked.

The equipment of the procedure includes:

sterile gloves, bandages, wipes;
painkiller;
needles for catheterization 25 gauge, syringes;
needle size 18;
catheter, flexible conductor, dilator;
scalpel, suture material.

Items for catheterization should be sterile and be at hand of the doctor or nurse.

Technique, Seldinger catheter insertion

Seldinger is a Swedish radiologist who in 1953 developed a method for catheterization of large vessels using a guidewire and a needle. Puncture femoral artery according to his method is carried out to this day:

Gap between pubic symphysis and anterior spine ilium conditionally divided into three parts. The femoral artery is located at the junction of the medial and middle thirds of this area. The vessel should be moved laterally, as the vein runs parallel.
The puncture site is cut off on both sides, making subcutaneous anesthesia with lidocaine or other painkillers.
The needle is inserted at an angle of 45 degrees at the site of the pulsation of the vein, in the region of the inguinal ligament.
When blood of a dark cherry color appears, the puncture needle is led along the vessel by 2 mm. If blood does not appear, you must repeat the procedure from the beginning.
The needle is held motionless with the left hand. A flexible guidewire is inserted into her cannula and advanced through the cut into the vein. Nothing should interfere with advancement into the vessel, with resistance, it is necessary to slightly rotate the instrument.
After successful insertion, the needle is removed, pressing the injection site to avoid hematoma.
A dilator is put on the conductor, after excising the injection point with a scalpel, and it is inserted into the vessel.
The dilator is removed and the catheter is inserted to a depth of 5 cm.
After successful replacement of the conductor with a catheter, a syringe is attached to it and the piston is pulled towards itself. If blood enters, then an infusion with isotonic saline is connected and fixed. The free passage of the drug indicates that the procedure was correct.
After manipulation, the patient is prescribed bed rest.

Insertion of a catheter under ECG control

The use of this method reduces the number of post-manipulation complications and facilitates monitoring the state of the procedure, the sequence of which is as follows:

The catheter is cleaned with isotonic saline using a flexible guidewire. The needle is inserted through the plug, and the tube is filled with NaCl solution.
Lead “V” is brought to the cannula of the needle or fixed with a clamp. On the device, turn on the " chest lead". Another way is to connect the wire right hand to the electrode and turn on lead number 2 on the cardiograph.
When the end of the catheter is located in the right ventricle of the heart, the QRS complex on the monitor becomes higher than normal. Reduce the complex by adjusting and pulling the catheter. A high P wave indicates the location of the device in the atrium. Further direction to a length of 1 cm leads to the alignment of the tooth according to the norm and the correct location of the catheter in the vena cava.
After the performed manipulations, the tube is sutured or fixed with a bandage.

Possible Complications

When carrying out catheterization, it is not always possible to avoid complications:

The most common unpleasant consequence is a puncture of the posterior wall of the vein and, as a result, the formation of a hematoma. There are times when it is necessary to make an additional incision or puncture with a needle to remove blood that has accumulated between the tissues. The patient is prescribed bed rest, tight bandaging, a warm compress in the thigh area.
The formation of a thrombus in the femoral vein has a high risk of complications after the procedure. In this case, the leg is placed on an elevated surface to reduce swelling. Blood-thinning drugs are prescribed to promote the resorption of blood clots.
Post-injection phlebitis is an inflammatory process on the vein wall. The general condition of the patient worsens, a temperature of up to 39 degrees appears, the vein looks like a tourniquet, the tissues around it swell, become hot. The patient is given antibiotic therapy and treatment with non-steroidal drugs.
Air embolism - air entering the vein through a needle. The outcome of this complication can be sudden death. Symptoms of embolism are weakness, deterioration general condition, loss of consciousness or convulsions. The patient is transferred to the intensive care unit and connected to the respiratory apparatus of the lungs. With timely assistance, the person's condition returns to normal.
Infiltration - the introduction of the drug not into the venous vessel, but under the skin. May lead to tissue necrosis and surgical intervention. Symptoms are swelling and redness of the skin. If an infiltrate occurs, it is necessary to make absorbable compresses and remove the needle, stopping the flow of the drug.

Modern medicine does not stand still and is constantly evolving in order to save as much as possible. more lives. It is not always possible to provide assistance in time, but with the introduction the latest technologies mortality and complications after complex manipulations are reduced.

For catheterization of the subclavian and internal jugular vein, the patient is placed in the Trendelenburg position (the head end of the table is lowered at an angle of at least 15°) to induce swelling of the neck veins and avoid air embolism

After venous catheterization, always close the catheter to avoid air embolism.

Prepare the operating field, following the rules of asepsis

J-tipped conductor string

guide wire needle

scalpel with blade №11

catheter (with built-in dilator)

lidocaine and local anesthesia needle

suture material for fixing the catheter

The injection point is determined and treated with betadine

If the patient is conscious, anesthetize the skin and subcutaneous tissues

Draw up 0.5 ml of lidocaine into a syringe and connect it to a needle to insert a guidewire to remove a possible skin plug after passing the needle through the skin

free flow of venous blood into the syringe indicates that the needle is in the lumen of the vessel

The conductor string is inserted through the needle until there is resistance or until only 3 cm remains outside the needle.

if resistance is felt before the guidewire enters the vessel, the latter is removed, re-confirmed that the vessel is catheterized correctly, and the guidewire is reintroduced

A small incision is made with the end of the scalpel near the conductor string.

A catheter is inserted along the guide wire (with a built-in dilatator)

Grab the proximal end of the guidewire that protrudes from the proximal end of the catheter

Rotational movements advance the catheter along the conductor string through the skin into the vessel

Ensure that venous blood flows freely from the catheter

Connect the catheter to the IV tube

Fix the catheter with sutures and apply a bandage

Complications of vascular catheterization using the Seldinger method:

Rupture of the thoracic duct

Misplaced catheter

Video of central venous catheterization technique - subclavian catheter placement

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Puncture of the artery by Seldinger

Femoral artery catheterization using the Seldinger technique

N.B. If a patient is undergoing A. femoralis angiography just prior to cardiopulmonary bypass surgery, NEVER remove the catheter (sheath) through which the procedure was performed. By removing the catheter and applying a compression bandage, you expose the patient to the risk of developing unnoticed arterial bleeding (“under the sheets”) during total heparinization. Use this catheter for blood pressure monitoring.

4. Projection lines of blood vessels in the human body.

1. Upper limb. A.brachialis - projected along the line from the middle of the armpit to the middle of the elbow bend.A.radialis - from the middle of the elbow to the styloid processosradialis.A.ulnaris - from the middle of the elbow to the outer edge of the pisiform bone (on the border of the inner and middle third of the line, passed between the styloid processes.

2.Lower limb. A.femoralis - from the middle of the inguinal ligament to the internal condyle of Belra. In the popliteal fossa is divided into -A.tebialis ant. - from the middle of the popliteal fossa to the middle of the distance between the ankles on the back of the foot. A.tebialis post. - from the middle of the popliteal fossa to the middle of the distance between the inner ankle and the calcaneal tuber.

3.A.carotis communis - from the corner mandible to the sternoclavicular joint.

Practical conclusions. Vascular pulsation, vascular auscultation, finger pressure, vascular puncture.

5. Puncture of the main vessels. Seldinger method.

1958 - the Seldinger technique. It is necessary to have - a Beer needle, a guide - a fishing line, catheters equipped with a locking device, a syringe.

Stage 1 - the vessel is punctured with a Beer needle.

Stage 2 - remove the mandrel, insert the conductor.

Stage 3 - the needle is removed and a fluoroplastic tube is inserted through the conductor.

Stage 4 - the conductor is removed, the tube can be in the lumen of the vessel for up to one week, contrast agents and medicinal substances can be injected through it.

With a therapeutic purpose, P. can be used to administer medicines, blood and its components, blood substitutes, and means for parenteral nutrition into the vascular bed (venipuncture, catheterization of the subclavian vein, intra-arterial injection, regional intra-arterial infusion, perfusion); introductions medicines into various tissues (intradermal, subcutaneous, intramuscular, intraosseous administration), cavities, as well as into the pathological focus; for local anesthesia, novocaine blockades, etc., for exfusion of blood from donors, for autohemotransfusion, hemodialysis, exchange transfusions (for hemolytic jaundice of newborns); for evacuation from a cavity or focus of pus, exudate, transudate, outflow of blood, gas, etc.

There are practically no contraindications to P., a relative contraindication is the patient's categorical refusal to P. or the patient's motor excitation.

6. Topographic and anatomical substantiation of X-ray angiography.

Angiography (Greek angeion vessel + graphō to write, depict, synonymous with vasography) is an X-ray examination of vessels after the introduction of radiopaque substances into them. There are A. arteries (arteriography), veins (venography, or phlebography), lymphatic vessels (lymphography). Depending on the objectives of the study, general or selective (selective) A. is carried out. With general A., all the main vessels of the studied area are contrasted, with selective - individual vessels.

To introduce a radiopaque substance into the vessel under study, it is punctured or catheterization . With A. of the vessels of the arterial system, the radiopaque substance passes through the arteries, capillaries and enters the foam of the area under study. Accordingly, the A. phases are distinguished - arterial, capillary (parenchymal), venous. According to the duration of the A. phases and the rate of disappearance of the radiopaque substance from the vessels, regional hemodynamics in the organ under study is judged.

Cerebral angiography allows you to identify, in particular, aneurysms , hematomas, tumors in the cranial cavity, stenosis and thrombosis of blood vessels. A. internal carotid artery (carotid angiography) is used in the diagnosis of pathological processes in the cerebral hemispheres. To recognize pathological processes in the region of the posterior cranial fossa, the vessels of the vertebrobasilar system (vertebral angiography) are examined by catheterization of the vertebral artery.

Selective total cerebral A. is carried out by the catheterization method, all the vessels involved in the blood supply to the brain are alternately contrasted. The method is usually indicated in patients who have had a subarachnoid hemorrhage to detect the source of bleeding (usually arterial or arteriovenous aneurysm), as well as to study the collateral circulation during cerebral ischemia.

Superselective cerebral angiography (catheterization of individual branches of the middle, posterior or anterior cerebral arteries) is usually used to detect vascular lesions and to perform endovascular interventions (for example, the installation of an occlusive balloon in the afferent vessel of the aneurysm to turn it off from the circulation).

Thoracic aortography(A. thoracic aorta and its branches) is indicated for the recognition of thoracic aortic aneurysm, aortic coarctation and other anomalies of its development, as well as aortic valve insufficiency.

Angiocardiography(examination of the main vessels and cavities of the heart) is used to diagnose malformations of the main vessels, congenital and acquired heart defects, clarify the localization of the defect, which allows you to choose a more rational method of surgical intervention.

Angiopulmonography(A. pulmonary trunk and its branches) is used for suspected malformations and tumors of the lungs, thromboembolism of the pulmonary arteries.

Bronchial arteriography, in which an image of the arteries supplying the lung is obtained, is indicated for pulmonary hemorrhages of unclear etiology and localization, swollen lymph nodes of an unclear nature, congenital heart defects (tetrad fallo), malformations of the lungs, is carried out with differential diagnosis malignant and benign tumors and inflammatory processes in the lungs).

Abdominal aortography(A. abdominal aorta and its branches) is used for lesions of parenchymal organs and retroperitoneal space, bleeding in abdominal cavity or the gastrointestinal tract. Abdominal aortography makes it possible to detect hypervascular tumors of the kidneys, while metastases to the liver, another kidney, lymph nodes, tumor growth into neighboring organs and tissues can be detected at the same time.

celiacography(A. celiac trunk) is performed to clarify the diagnosis of tumors, injuries and other lesions of the liver and its vessels, spleen, pancreas, stomach, gallbladder and bile ducts, big omentum.

Upper mesentericography(A. superior mesenteric artery and its branches) is indicated in the differential diagnosis of focal and diffuse lesions of the small and large intestines, their mesentery, pancreas, retroperitoneal tissue, and also in order to identify sources of intestinal bleeding.

Renal arteriography(A. renal artery) is indicated in the diagnosis of various kidney lesions: injuries, tumors. hydronephrosis, urolithiasis.

Peripheral arteriography, in which an image of the peripheral arteries of the upper or lower extremity is obtained, is used for acute and chronic occlusive lesions of peripheral arteries, diseases and injuries of the extremities.

Upper cavography(A. superior vena cava) is carried out in order to clarify the localization and extent of a thrombus or compression of a vein, in particular with tumors of the lungs or mediastinum, to determine the degree of tumor invasion into the superior vena cava.

Lower cavography(A. inferior vena cava) is indicated for tumors of the kidneys, mainly the right one, it is also used to recognize ileofemoral thrombosis, identify the causes of edema of the lower extremities, ascites of unknown origin.

Portography(A. portal vein) is indicated for the diagnosis of portal hypertension, lesions of the liver, pancreas, spleen.

Renal phlebography(A. renal vein and its branches) is carried out in order to diagnose kidney diseases: tumors, stones, hydronephrosis, etc. The study allows you to identify thrombosis of the renal vein, determine the location and size of the thrombus.

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Puncture of the artery by Seldinger

SELDINGER METHOD (S. Seldinger; syn. puncture catheterization of arteries) - the introduction of a special catheter into a blood vessel by percutaneous puncture for diagnostic or therapeutic purposes. Proposed by Seldinger in 1953 for arterial puncture and selective arteriography. Subsequently, S. began to use m for puncture of the veins (see Puncture vein catheterization).

S. m is used for the purpose of catheterization and contrast studies of the atria and ventricles of the heart, the aorta and its branches, the introduction of dyes, radiopharmaceuticals, drugs, donor blood and blood substitutes into the arterial bed, as well as, if necessary, multiple studies of arterial blood.

Contraindications are the same as for cardiac catheterization (see).

The study is carried out in the X-ray operating room (see Operating block) using special tools included in the Seldinger kit - a trocar, a flexible conductor, a polyethylene catheter, etc. Instead of a polyethylene catheter, you can use an Edman catheter - a radiopaque elastic plastic tube of red, green or yellow color depending on diameter. The length and diameter of the catheter is selected based on the objectives of the study. The inner sharp end of the catheter is tightly adjusted to the outer diameter of the conductor, and the outer one to the adapter. The adapter is connected to a syringe or measuring device.

Usually S. m is used for selective arteriography, for which a percutaneous puncture is performed more often than the right femoral artery. The patient is placed on his back on a special table for cardiac catheterization and is somewhat taken aside. right leg. The pre-shaven right inguinal region is disinfected and then isolated with sterile sheets. The right femoral artery is palpated with the left hand immediately below the inguinal ligament and fixed with the index and middle fingers. Anesthesia of the skin and subcutaneous tissue is performed with a 2% solution of novocaine using a thin needle so as not to lose the sensation of arterial pulsation. The scalpel cuts the skin over the artery and introduces a trocar, with the tip of which they try to feel the pulsating artery. Having tilted the outer end of the trocar to the skin of the thigh at an angle of 45°, the anterior wall of the artery is pierced with a quick short forward movement (Fig., a). Then the trocar is tilted even more towards the thigh, the mandrin is removed from it and a conductor is inserted towards the stream of scarlet blood, the soft end of which is advanced into the lumen of the artery under the inguinal ligament by 5 cm (Fig., b). The conductor is fixed through the skin with the index finger of the left hand in the lumen of the artery, and the trocar is removed (Fig., c). By pressing a finger, the conductor is fixed in the artery and the formation of a hematoma in the puncture area is prevented.

A catheter with a tip pointed and tightly fitted to the diameter of the conductor is put on the outer end of the conductor, advanced to the skin of the thigh and inserted through the conductor into the lumen of the artery (Fig., d). The catheter, together with the soft tip of the conductor protruding from it, is advanced under the control of an X-ray screen, depending on the objectives of the study (general or selective arteriography), into the left heart, the aorta, or one of its branches. Then a radiopaque substance is injected and a series of radiographs is taken. If it is necessary to register pressure, take blood samples or administer medicinal substances, the conductor is removed from the catheter, and the latter is washed with an isotonic solution of sodium chloride. After the study is completed and the catheter is removed, a pressure bandage is applied to the puncture site.

Complications (hematoma and thrombosis in the area of the femoral artery puncture, perforation of the walls of the arteries, aorta or heart) with technically correctly performed S. m. are rare.

Bibliography: Petrovsky BV, etc. Abdominal aortography, Vestn. hir., t. 89, No. 10, p. 3, 1962; S e 1 d i n-g e g S. I. Catheter replacement of the needle in percutaneous arteriography, Acta radiol. (Stockh.), v. 39, p. 368, 1953.

Angiography according to Seldinger - a method for diagnosing the state of blood vessels

Angiography c refers to the X-ray contrast study of blood vessels. This technique is used in computed tomography, fluoroscopy and radiography, the main purpose is to assess the roundabout blood flow, the state of the vessels, as well as the extent of the pathological process.

This study should be carried out only in special X-ray angiographic rooms based on specialized medical institutions that have modern angiographic equipment, as well as appropriate computer equipment that can record and process the obtained images.

Hagiography is one of the most accurate medical examinations.

This diagnostic method can be used in the diagnosis of coronary heart disease, kidney failure, and to detect various kinds of cerebrovascular accidents.

Types of aortography

In order to contrast the aorta and its branches in the case of preservation of the pulsation of the femoral artery, the method of percutaneous aortic catheterization (Seldinger angiography) is most often used, for the purpose of visual differentiation of the abdominal aorta, translumbar puncture of the aorta is used.

It is important! The technique involves the introduction of an iodine-containing water-soluble contrast agent by direct puncture of the vessel, most often through a catheter that is inserted into the femoral artery.

Seldinger catheterization technique

Percutaneous catheterization of the femoral artery according to Seldinger is performed using a special set of instruments, which includes:

puncture needle;
dilator;
introducer;
metal conductor with a soft end;
catheter (French size 4-5 F).

A needle is used to puncture the femoral artery to pass a metal conductor in the form of a string. Then the needle is removed, and a special catheter is inserted through the conductor in the lumen of the artery - this is called aortography.

Due to the painful manipulation, the conscious patient needs infiltration anesthesia with a solution of lidocaine and novocaine.

It is important! Percutaneous catheterization of the aorta according to Seldinger can also be performed through the axillary and brachial arteries. Passing a catheter through these arteries is more often performed in cases where there is obstruction of the femoral arteries.

Seldinger angiography is considered universal in many ways, which is why it is used most often.

Translumbar puncture of the aorta

In order to visually differentiate the abdominal aorta or arteries of the lower extremities, for example, when they are affected by aorto-arteritis or atherosclerosis, preference is given to such a method as direct translumbar puncture of the aorta. The aorta is punctured with a special needle from the back.

If it is necessary to obtain contrasting branches of the abdominal aorta, then high translumbar aortography with aortic puncture is performed at the level of the 12th thoracic vertebra. If the task includes the process of contrasting the bifurcation of the artery of the lower extremities or the abdominal aorta, then the translumbar puncture of the aorta is performed at the level of the lower edge of the 2nd lumbar vertebra.

During this translumbar puncture, it is very important to pay special attention to the research methodology, in particular, a two-stage removal of the needle is carried out: first it must be removed from the aorta and only after a few minutes - from the para-aortic space. Thanks to this, it is possible to avoid and prevent the formation of large para-aortic hematomas.

It is important! Techniques such as translumbar puncture of the aorta and Seldinger angiography are the most widely used procedures for contrasting the arteries, the aorta and its branches, which makes it possible to obtain an image of almost any part of the arterial bed.

The use of these techniques in special conditions medical institutions allows to achieve a minimal risk of complications and at the same time is an affordable and highly informative diagnostic method.

Info-Farm.RU

Pharmaceutics, medicine, biology

Seldinger method

The Seldinger method (Seldinger catheterization) is used to gain safe access to blood vessels and other hollow organs. It is used for angiography, catheterization of the central veins (subclavian, internal jugular, femoral) or arterial catheterization, gastrostomy using the method of percutaneous endoscopic gastrostomy of some conicostomy techniques, electrode placement of artificial pacemakers and cardioverter-defibrillators, and other interventional medical procedures.

Invention history

The method was proposed by Sven Ivar Seldinger) - a Swedish radiologist, an inventor in the field of angiography.

Angiographic examinations are based on the technique, a catheter is inserted into the vessel with a needle for dosed administration of a contrast agent. The problem was that, on the one hand, it is necessary to deliver the substance to the required place, but at the same time minimally damage the vessels, especially at the study site. Before the invention of Sven Seldinger, two techniques were used: a catheter on a needle and a catheter through a needle. In the first case, the catheter may be damaged when passing through the tissues. In the second case, a large needle is needed, which causes much more damage to the vessel at the catheterization site. Sven Seldingera, born into a family of mechanics, tried to find a way to improve angiographic technique by placing the largest catheter with the smallest needle. The technique essentially consists in the fact that first a needle is inserted, a guidewire is inserted through it, then the needle is removed, and the catheter is inserted through the guidewire. Thus, the hole is no larger than the catheter itself. The results were presented at a conference in Helsinki in June 1952, and then Seldinger published these results.

The Seldinger method reduced the number of complications in angiography, which contributed to the greater spread of the latter. This also meant that the catheter could be more easily oriented to the desired location in the body. The invention laid the foundation for the subsequent development of interventional radiology.

Classification of catheterization methods

At the moment, there are at least three methods of catheterization:

needle catheter;
ear catheter;
catheterization according to Seldinger;

The technique of "catheter on a needle" is widely used for catheterization of peripheral vessels. To date, many different peripheral venous catheters have been developed. The vessel is punctured with a needle with a catheter on it, the needle is held in one position, and the catheter is advanced. The needle is removed completely. When used for puncture of deeply located organs (in particular, central veins), the catheter may be damaged when passing through the tissues.

The "catheter in the needle" technique is used to catheterize the epidural space during epidural anesthesia (surgery) and analgesia (childbirth, acute pancreatitis, certain cases intestinal obstruction, anesthesia in postoperative period and cancer patients), for extended spinal anesthesia. It consists in the fact that first the organ is punctured with a needle, and a catheter is inserted inside it. Later, the needle is removed. The needle is much thicker than the catheter. If large diameter catheters are used, tissue injury occurs when using this technique.

Actually Seldinger catheterization.

Method technique

Seldinger catheterization is performed in the following order:

a. The organ is punctured with a needle.
b. A flexible metal or plastic conductor is passed into the needle, advanced further into the organ.
c. The needle is taken out.
d. A catheter is put on the conductor. The catheter is advanced along the conductor into the organ.
e. The conductor is taken out.

Figure 3 Removing the needle

Figure 4 Insertion of the catheter

Figure 5 Removing a conductor

The thinner the needle, the less tissue damage. If the catheter is significantly thicker than the needle, before putting it on the conductor, a dilator is passed through the conductor, which increases the diameter of the passage in the tissues. The expander is taken away, and then the catheter itself is inserted through the conductor.

Figure 1 organ puncture with a needle

Figure 2 Insertion of the guidewire into the needle

Figure 3 Removing the needle

Figure 4 Using an expander

Figure 5 Insertion of the catheter

Figure 6 Removing the conductor

Especially often, the dilator is used when setting up central venous catheters with several lumens. Each lumen of the catheter ends with a port for the introduction of drugs. One of the lumens starts at the tip of the catheter (usually its port is marked in red), and the other / other sides (its port is usually marked in blue or other color than red). Double-lumen catheters are used for the introduction of various drugs (their mixing is prevented as much as possible) and for extracorporeal therapy methods (for example, hemodialysis).

Possible Complications

Depending on the conditions, Seldinger catheterization can be performed both without additional imaging methods, and under ultrasound or radiological control. In any case, with different frequency, the following complications may develop:

Damage by a needle, conductor, dilator or catheter to the wall of the corresponding organ.
Damage by a needle, conductor, dilator or catheter to surrounding structures (depending on the place of catheterization, these can be arteries, nerves, lungs, lymphatic duct, etc.) with the subsequent development of appropriate complications.
The introduction of a catheter outside the desired organ, followed by the introduction of the appropriate substance.
infectious complications.
Loss of parts of a damaged guidewire or catheter in an organ, for example. parts of a central venous catheter.
Other complications due to the already long stay of catheters in vessels and organs.

Puncture of the artery by Seldinger

The Seldinger puncture is carried out with the aim of introducing a catheter into the aorta and its branches, through which it is possible to contrast the vessels, to probe the heart cavities. A needle with an inner diameter of 1.5 mm is injected immediately below the inguinal ligament along the projection of the femoral artery. A conductor is first inserted through the lumen of the needle inserted into the artery, then the needle is removed and a polyethylene catheter with an outer diameter of 1.2-1.5 mm is put on the conductor instead.

The catheter, together with the conductor, is advanced along the femoral artery, iliac arteries into the aorta to the desired level. Then the conductor is removed, and a syringe with a contrast agent is attached to the catheter.

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2.4. Angiographic diagnostics

Angiographic studies largely ensured the rapid development of vascular surgery. However, today it is no longer possible to say unequivocally that angiography is currently the “gold standard” for diagnosing diseases of the aorta and peripheral vessels. The latest non-invasive imaging methods: ultrasound duplex scanning, computed tomography, magnetic resonance angiography - not only reduce the risk of diagnostic studies, but also have a higher resolution in some cases. The global trend in the development of radiation diagnostics is the ever wider use of non-invasive techniques for the choice of tactics and method. surgical treatment. At the present stage of development of medical technologies, angiography is becoming more and more medical procedure and is used in the course of X-ray surgery, endovascular interventions.

Nevertheless, the relative high cost of such diagnostic equipment as X-ray, computer, electron emission or magnetic resonance tomographs limits the widespread use of these methods. At the same time, due to the development of computer technologies for processing and saving images, the synthesis of new low-toxic radiopaque preparations, angiography continues to be one of the main diagnostic methods, which, at relatively low cost, makes it possible to obtain an integral image of any part of the vascular bed, serve as a method for verifying data obtained by other methods of radiation visualization. The introduction of digital subtraction angiography (DSA) has contributed to an increase in the information content of angiographic data. This has made complex invasive procedures faster and less risky, and with their help, the amount of contrast agents introduced into the vascular bed for diagnostic and interventional procedures has been significantly reduced.

Indications and contraindications for diagnostic angiography. Patient preparation. Stages of angiographic examination:

Definition of indications and contraindications;

Preparation of the patient for the study;

Puncture or exposure of the vessel;

The introduction of a contrast agent;

X-ray filming of the angiographic image;

Removing the catheter, stopping bleeding;

General indications for diagnostic angiography are the need to determine the nature, localization of the pathological process and assess the state of the arterial or venous bed in the lesion, study the compensatory possibilities of collateral blood flow, determine the surgical tactics of treatment in each specific case and promote the choice of a rational method of surgery. Particular indications for angiographic examination are congenital anomalies of blood vessels and organs, traumatic injuries, occlusive and stenosing processes, aneurysms, inflammatory, specific, tumor vascular diseases.

There are no absolute contraindications to angiographic examination. Relative contraindications are acute insufficiency liver and kidneys, active tuberculosis in the open form and other specific diseases in the acute stage of the course, acute infectious diseases, individual intolerance to iodine preparations.

Preparation of the patient for the study. Angiographic examination is a surgical manipulation associated with the invasion of needles, conductors, catheters and other instruments into the vascular bed, accompanied by the introduction of a radiopaque iodine-containing substance. In this regard, it should be carried out after a thorough general clinical and instrumental examination, including ultrasound and, if necessary, computed tomography, magnetic resonance.

Preparation of the patient primarily includes explaining to the patient the need for an X-ray angiographic study. Next, you should find out in detail the patient's history to determine indications of possible past manifestations of allergy to novocaine and iodine-containing drugs. If individual intolerance is suspected and the patient's sensitivity to iodine is determined, a Demyanenko test should be performed. If the test is positive, the study should be abandoned, desensitizing therapy should be carried out and the test should be repeated again.

On the eve of the study, a cleansing enema is performed, and tranquilizers are prescribed at night. On the day of the study, the patient does not eat, his hair is carefully shaved in the area of the vessel puncture. Immediately before the study (30 minutes) premedication is started. The study is usually carried out local anesthesia. At hypersensitivity to iodine preparations for angiographic examination, intubation anesthesia can be used.

Rice. 2.22. Survey aorto-gram.

After the end of the study, the catheter is removed from the vessel and careful hemostasis is performed by pressing the puncture hole. The direction of pressing should correspond to the direction of the previous puncture of the vessel. Then apply an aseptic pressure bandage with a rubber inflatable cuff for 2 hours (small instruments) or a tight gauze roller (large instruments).

During translumbar aortography and removal of the catheter from the aorta, blood is removed from the para-ortal tissue with a syringe and an aseptic bandage or sticker is applied. The patient needs strict bed rest in the supine position for 24 hours, control of blood pressure and observation of the doctor on duty.

angiography methods. Access to the vascular bed. At the site of injection of a contrast agent and subsequent registration of angiograms, the following are distinguished:

Direct - injected directly into the test vessel;

Indirect - is introduced into the arterial system to obtain a venous or parenchymal phase of organ contrast. With the development of digital subtraction angiography, indirect arteriography with the introduction of a contrast agent into the venous bed has often been used.

According to the method of introducing a contrast agent, the following methods are distinguished:

▲ puncture - introduction directly through the puncture needle;

Plain aortography - a contrast agent is injected through a catheter into the abdominal or thoracic aorta. Often this method of contrasting is called "survey aortography", since it is followed by a more detailed - selective angiographic study of any individual arterial basin (Fig. 2.22).

Semi-selective angiography - a contrast agent is injected into main vessel in order to obtain a contrast image of both this artery and its nearby branches (Fig. 2.23).

Rice. 2.23. Semiselective angiogram.

Selective angiography corresponds to the basic fundamental approach to angiography - the targeted supply of a contrast agent as close as possible to the pathology site (Fig. 2.24).

Types of vascular catheterization. Antegrade catheterization is a method of a selective approach to vessels: percutaneous catheterization of the femoral, popliteal or common carotid artery and insertion of a simulated catheter into the vessels on the side of the lesion.

Retrograde catheterization - holding a catheter against blood flow during angiography by puncture of the femoral, popliteal, axillary, ulnar or radial arteries according to Seldinger.

Angiography of the arterial system. Technique of translumbar puncture of the abdominal aorta. The position of the patient - lying on his stomach, arms bent at the elbows and placed under the head. Reference points for puncture are the outer edge of the left m.erector spinae and the lower edge of the XII rib, the intersection point of which is the point of injection of the needle. After anesthetizing the skin with a 0.25-0.5% novocaine solution, a small skin incision (2-3 mm) is made and the needle is directed forward, deep and medially at an angle of 45 ° to the surface of the patient's body (approximate direction to the right shoulder). In the course of the needle, infiltration anesthesia is performed with a solution of novocaine.

Rice. 2.24. Selective angiogram (right renal artery).

Upon reaching the para-aortic tissue, transmission vibrations of the aortic wall are clearly felt, confirming the correctness of the puncture. A "pillow" of novocaine (40-50 ml) is created in the para-aortic tissue, after which the aortic wall is pierced with a short sharp movement. Evidence that the needle is in the lumen of the aorta is the appearance of a pulsating jet of blood from the needle. The movement of the needle is constantly monitored by fluoroscopy. A conductor is inserted through the lumen of the needle into the aorta and the needle is removed. More often use the average puncture of the aorta at the level of L 2 . If occlusion or aneurysmal expansion of the infrarenal aorta is suspected, a high puncture of the suprarenal abdominal aorta at the level of Th 12 -Lj is indicated (Fig. 2.25).

The translumbar puncture technique for angiography of the abdominal aorta is almost always a necessary measure, since the required volume and speed of contrast agent injection on conventional angiographic equipment (50-70 ml at a rate of 25-30 ml / s) can only be introduced through catheters of a rather large diameter - 7-8 F (2.3-2.64 mm). Attempts to use these catheters for transaxillary or cubital arterial approaches are accompanied by various complications. However, with the development of digital subtraction angiography, when it became possible to enhance the radiopaque image of vessels by computer methods after the introduction of a relatively small amount of contrast agent, catheters of small diameters 4-6 F or 1.32-1.98 mm began to be increasingly used. Such catheters allow safe and expedient access through the arteries of the upper extremities: axillary, brachial, ulnar, radial. Puncture technique of the common femoral artery according to Seldinger.

Rice. 2.25. Puncture levels for translumbar aortography. a - high, b - medium, c - low; 1 - celiac trunk; 2 - superior mesenteric artery; 3 - renal arteries; 4 - inferior mesenteric artery.

Femoral artery puncture is performed 1.5-2 cm below the pupart ligament, in the place of the most distinct pulsation. Having determined the pulsation of the common femoral artery, local infiltration anesthesia is performed with a solution of novocaine 0.25-0.5%, but so as not to lose the pulsation of the artery; layer-by-layer infiltrate the skin and subcutaneous tissue right and left from the artery to the periosteum of the pubic bone. It is important to try to elevate the artery from the bone bed to the bone, which facilitates puncture, as it brings the wall of the artery closer to the surface of the skin. After completion of anesthesia, a small skin incision (2-3 mm) is made to facilitate the passage of the needle. The needle is passed at an angle of 45°, fixing the artery with the middle and index fingers of the left hand (during the puncture of the right femoral artery). When its end comes into contact with the anterior wall of the artery, pulse shocks can be felt. The puncture of the artery should be carried out with a sharp short movement of the needle, trying to puncture only its anterior wall. Then a stream of blood enters immediately through the lumen of the needle. If this does not happen, the needle is slowly pulled back until a blood stream appears or until the needle exits the puncture canal. Then you should repeat the puncture attempt.

Rice. 2.26. Vessel puncture according to Seldinger. a: 1 - puncture of the vessel with a needle; 2 - a conductor is retrogradely introduced into the vessel; 3 - the needle is removed, the bougie and introducer are inserted; 4 - introducer in the artery; b: 1 - correct puncture site of the femoral artery; 2 - unwanted puncture site.

The artery is pierced with a thin needle with an outer diameter of 1-1.2 mm without a central mandrel with an oblique sharpening, both in the antegrade and retrograde directions, depending on the purpose of the study. When a jet of blood appears, the needle is tilted to the patient's thigh and a conductor is inserted through the channel into the lumen of the artery. The position of the latter is controlled by fluoroscopy. Then the conductor is fixed in the artery, and the needle is removed. A catheter or introducer is installed along the conductor into the lumen of the artery during long-term interventions with a change of catheters (Fig. 2.26).

In cases where the femoral arteries cannot be punctured, such as after bypass surgery or occlusive disease, when the lumen of the femoral artery, pelvic arteries, or distal aorta is obstructed, an alternative approach should be used.

Such accesses can be axillary or brachial arteries, translumbar puncture of the abdominal aorta.

Rice. 2.27. Contralateral femoral approach.

Contralateral femoral approach. Most endovascular interventions on the iliac arteries can be performed using the ipsilateral femoral artery. However, some lesions, including stenoses of the distal external iliac artery, are not accessible from the ipsilateral common femoral artery. In these cases, the contralateral approach is preferred; in addition, it allows performing interventions in case of multilevel stenoses of the femoral-popliteal and ilio-femoral zone. Cobra, Hook, Sheperd-Hook catheters are commonly used to pass through the aortic bifurcation. Contralateral access for stenting and arterial arthroplasty can be difficult when using balloon-expandable stents with a relatively rigid design. In these cases, a long introducer on a rigid conductor "Amplatz syper stiff" and others should be used (Fig. 2.27).

The contralateral approach technique has some advantages over the antegrade approach for interventions in the femoropopliteal area. First, retrograde insertion of the catheter allows intervention on the proximal portion of the femoral artery, which would be inaccessible with antegrade puncture. The second aspect is the pressure of the artery for hemostasis and the application of a pressure aseptic bandage after the intervention occurs on the opposite side of the operation, which ultimately reduces the incidence of early postoperative complications.

Antegrade femoral approach. The antegrade access technique is used by many authors. This type intervention provides more direct access to many lesions in the middle and distal part of the femoropopliteal segment of the artery. The closest approach to stenoses and occlusions in the arteries of the leg provides more precise instrument control. However, in addition to potential advantages, antegrade technique also has disadvantages. A higher puncture of the common femoral artery is required to accurately hit the superficial femoral artery. Puncture of an artery above the inguinal ligament can lead to a formidable complication - retroperitoneal hematoma. Techniques such as injection of a contrast agent through a puncture needle help identify the anatomy of the bifurcation of the common femoral artery. For its best display, an oblique projection is used to open the bifurcation angle (Fig. 2.28).

Rice. 2.28. Antegrade femoral approach. A - angle and direction of the needle during antegrade access; LU - inguinal ligament; R - retrograde access; 1 - the place of the correct puncture of the femoral artery; 2 - unwanted puncture site.

Popliteal access. Approximately in 20-30% of standard cases, the technique of antegrade and contralateral approaches to the femoral artery is not able to ensure the delivery of instruments to the occluded areas of the superficial femoral arteries. In these cases, the popliteal approach technique is indicated, which is used only in patients with patent distal segments of the superficial femoral artery and proximal segments of the popliteal artery. A safe puncture of the popliteal artery can only be carried out with thinner instruments with a diameter of no more than 4-6 F. When using instruments such as drills, dilatation balloons with stents, it is permissible to use introducers 8-9 F, since the diameter of the artery in this place 6 mm. The technique of popliteal artery puncture is similar to the technique described above. The popliteal artery, together with the nerve and vein, runs from above along the diagonal of the popliteal triangle. The superficial location of the artery in this place allows its retrograde puncture, which is performed exactly above the joint. In this case, the patient lies on his stomach or on his side. Manipulations are performed under local anesthesia (Fig. 2.29).

Access through the brachial artery. Shoulder access is an alternative technique for inserting instruments into the aorta and its branches, often used for diagnostic procedures when femoral artery puncture or translumbar puncture of the aorta is not possible. In addition, this access may be an alternative approach to endovascular interventions on the renal arteries. It is preferable to use the left brachial artery. This is dictated by the fact that catheterization of the right brachial artery significantly increases the risk of cerebral vessel embolization when passing instruments through the aortic arch. The brachial artery should be punctured in its distal part above the cubital fossa. In this place, the artery lies most superficially, hemostasis can be facilitated by pressing the artery against the humerus (Fig. 2.30).

Radial access through the radial artery is accompanied by injury to a vessel smaller than the femoral artery, which makes it possible to do without indispensable long-term hemostasis, a period of rest and bed rest after endovascular intervention.

Indications for radial approach: good pulsation of the radial artery with adequate collateral circulation from the ulnar artery through the palmar arterial arch. To do this, use the "Allen-test", which must be carried out in all patients - candidates for radial access. The examination is carried out as follows:

Press down the radial and ulnar arteries;

6-7 flexion-extensor movements of the fingers;

With unbent fingers, simultaneous compression of the ulnar and radial arteries is continued. The skin of the hand turns pale;

Remove compression of the ulnar artery;

Continuing the pressing of the radial artery, control the color of the skin of the hand.

Within 10 s, the skin color of the hand should return to normal, which indicates sufficient development of collaterals. In this case, the "Allen test" is considered positive, radial access is acceptable.

If the skin color of the hand remains pale, the Allen test is considered negative and radial access is not allowed.

Rice. 2.29. Popliteal access.

Contraindications to this access are the absence of a radial artery pulse, a negative Allen test, the presence of an arteriovenous shunt for hemodialysis, a very small radial artery, the presence of pathology in the c. proximal arteries, instruments larger than 7 F are required.

Rice. 2.30. Access through the brachial artery.

Rice. 2.31. Access through the radial artery.

Technique of radial arterial access. Before performing a puncture, the direction of the radial artery is determined. The puncture of the artery is carried out 3-4 cm proximal to the styloid process of the radius. Before the puncture, local anesthesia is performed with a solution of novocaine or lidocaine through a needle held parallel to the skin so as to exclude arterial puncture. The skin incision must also be made with great care to avoid injury to the artery. The puncture is made with an open needle at an angle of 30-60 ° to the skin in the direction of the artery (Fig. 2.31).

Technique of direct catheterization of the carotid arteries. Puncture of the common carotid artery is used for selective studies of the carotid arteries and arteries of the brain.

Landmarks are m.ster-nocleidomastoideus, the upper edge of the thyroid cartilage, the pulsation of the common carotid artery. The superior border of the thyroid cartilage indicates the location of the bifurcation of the common carotid artery. After anesthesia, the skin is punctured with the tip of a scalpel, m. sternocleidomastoideus is pushed outwards and the needle is advanced forward in the direction of the pulsation of the common carotid artery. It is very important that pulse shocks are not felt to the side of the needle tip, but directly in front of it, which indicates the orientation of the needle to the center of the artery. This avoids tangential wounds to the artery wall and the formation of hematomas. The artery is punctured with a short dosed movement. When a jet of blood appears through the lumen of the needle, a conductor is inserted into the artery and the needle is removed. A catheter is installed along the conductor into the lumen of the artery, the type of which depends on the purpose of the study (Fig. 2.32).

Open Access. Large-diameter instruments are not used due to the risk of damage to the artery; open access to the vessels is carried out by arteriotomy.

Instrumentation, doses and rate of administration of the contrast agent.

For thoracic and abdominal aortography, catheters of caliber 7-8 F 100-110 cm long are needed, which provide a contrast agent injection rate of up to 30 ml/s; and for peripheral and selective angiography, 4-6 F catheters 60-110 cm long. Usually, catheters with a pig tail configuration and multiple lateral holes are used for contrast agent injections into the aorta. The contrast medium is usually administered by an automatic injector. For selective angiography, catheters of other configurations are used, each of which provides selective catheterization of the mouth of any one artery or group of aortic branches - coronary, brachiocephalic, visceral, etc. In this case, to obtain angiograms, a manual injection of a contrast agent is often quite sufficient.

Rice. 2.32. Puncture access through the common carotid arteries, a - general access; b - antegrade and retrograde punctures.

Currently, non-ionic water-soluble contrast agents containing from 300 to 400 mg of iodine per 1 ml (Ultravist-370, Omnipack 300-350, Visipak-320, Xenetics-350, etc.) are more often used for angiography. ). In rare cases, the previously widely used water-soluble ionic contrast agent 60-76% Urografin is used, which, due to the pronounced pain, nephro- and neurotoxic effects, should be limited to the diagnosis of distal lesions of the arterial bed or used in intraoperative angiography under intubation anesthesia.

The rate of administration of the contrast agent should be commensurate with the imaging technique and with the blood flow velocity. For injections into the thoracic aorta, a rate of 25 to 30 ml/s is adequate; for the abdominal aorta - from 18 to 25 ml/s; for peripheral arteries (pelvic, femoral) - the rate is from 8 to 12 ml / s when using from 80 to 100 ml of a contrast agent. This provides visualization of the arteries of the lower extremities down to the feet. The imaging speed for thoracic aortography is typically 2 to 4 fps; for abdominal aortography - 2 frames/s; for limbs in accordance with the speed of blood flow - 1-2 frames/s; for the pelvis - 2-3 frames / s and for the vessels of the legs - from 1 to 1 frame / 3 s.

Digital subtraction angiography requires a smaller volume and slower injection rate of the contrast agent. Thus, for abdominal aortography, it is sufficient to introduce 20–25 ml of an X-ray contrast agent at a rate of 12–15 ml/s. And in some cases, it is possible to obtain aortograms with the introduction of a radiopaque agent into the venous bed. It should be noted that this requires a sufficiently large volume of contrast agent - up to 50-70 ml, and the resulting angiograms will correspond to the quality of survey - general angiograms. The highest resolution of DSA is achieved with direct selective injection of a contrast agent into the vessel under study with the so-called post-process computer image processing - mask subtraction (skeleton and soft tissues), image summation, amplification and underlining of the vascular pattern of angiograms, longitudinal or volumetric reconstruction of images of several anatomical regions into one. An important advantage of modern angiographic devices is the possibility of direct intraoperative measurement of the diameter of blood vessels, parameters of stenosis or aneurysm of the artery. This allows you to quickly determine the tactics of X-ray surgical intervention, accurately select the necessary instruments and implantable devices.

Complications. Any radiopaque studies are not absolutely safe and are associated with a certain risk. Possible complications include external and internal bleeding, thrombosis, arterial embolism, perforation of a non-punctured vessel wall with a conductor or catheter, extravasal or intramural injection of a contrast agent, breakage of the conductor or catheter, reactions associated with the toxic effect of contrast agents. The frequency and type of complications encountered during arterial puncture vary depending on the site of catheterization. The frequency of complications is different: for example, with femoral access - 1.7%; with translumbar - 2.9%; with shoulder access - 3.3%.

bleeding can be external and internal (hidden) with the formation of a pulsating hematoma and further pseudoaneurysm;

thrombosis occurs with prolonged occlusion of the vessel or its dissection; however, its frequency has decreased significantly with the use of smaller diameter catheters and guidewires, a decrease in the time of operation, and the improvement of anticoagulant drugs;

embolism develops with the destruction of atherosclerotic plaques or separation of blood clots from the arterial wall. The nature of the complication depends on the size of the embolus and the specific vessel supplying this arterial pool;

arteriovenous fistulas can form as a result of simultaneous puncture of an artery and a vein, most often with a femoral approach.

The conditions for the safety of aorto-arteriography are strict adherence to indications, contraindications and a rational choice of research methodology, a number of preventive measures aimed at combating potential complications (washing needles, catheters and connecting tubes with isotonic sodium chloride solution with heparin, a thorough check of instruments). Manipulations with the conductor and catheter should be short and less traumatic. During the entire diagnostic study or therapeutic X-ray surgical intervention, it is necessary to control the ECG, blood pressure, and blood clotting time. Anticoagulants, antispasmodics, desensitizing drugs also contribute to the prevention of complications and are the key to reducing the risk of angiography.

Rice. 2.33. Puncture of the internal jugular vein, a-first method; b - the second way.

With proper puncture and catheter handling technique, and the use of non-ionic or low-osmolar contrast agents, the complication rate for angiography is less than 1.8%.