Journal of Clinical Apheresis 30:380–381 (2015)
Letter to the Editor Deep Vein Puncture Under Ultrasonographic Guidance—An Alternative Approach for Vascular Access of Apheresis Therapies Norio Hanafusa,1,2* Toshihiro Torato,1 Daisuke Katagiri,1 Tomoko Usui,1 Akihiko Matsumoto,1 Eisei Noiri,1 and Masaomi Nangauku1 1
Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan 2 Division of Total Renal Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
To the Editor: Granulocyte monocyte apheresis (GMA) is one of the modalities in apheresis that is reported to be clinically effective for inflammatory bowel diseases (IBD) [1]. Those who suffer from IBD often experience dehydration and for whom the vascular access is difficult to be placed due to collapse of superficial veins. When we consider the blood flow of upper limbs, blood flow from the brachial artery must enter into either superficial or deep veins. Even if superficial veins do not accept sufficient blood flow, it can be considered that blood is drained through deep veins. Ultrasonography (US) guided central vein puncture has been reportedly related to improving success rate and to reduce complications [2,3]. The procedure was also used for deep veins in emergency department for intravenous access [4]. We have developed and reported the procedure of US-guided vascular access puncture on hemodialysis patients [5]. We also have applied this method to GMA patients who have difficult vascular accesses. In order to elucidate usefulness of US-guided deep vein puncture, we retrospectively evaluated the medical charts of the patients who required such access puncture methods. From June 2013 to January 2015, we investigated the patients: (1) who received GMA therapy, (2) for whom we could not draw sufficient blood flow from superficial veins, and (3) whose deep veins were punctured under US guidance. The effectiveness and adverse events were assessed from the medical chart of such patients. Actual procedures were reported previously [5]. We describe them here in brief. We used a portable US device, Nanomaxx (Covidien Japan, Tokyo, Japan) with linear probe (6–13 MHz) for the current procedure. We investigate the direction of the deep vein under longitudinal view. Next, we place the probe perpendicular to the vein. At this time, the positions of vital structures such as brachial arteries and C 2015 Wiley Periodicals, Inc. V
median veins nerves are identified in relation to the target deep vein, so that we should not damage them during the procedure (Fig. 1). Thereafter, we puncture the vein under US guidance. Once the tip of the needle is observed on the screen, we gradually thrust the needle little by little. After we place the needle in proper place, we remove the inner needle and complete the puncture. In total, we applied this method to four patients with ulcerative colitis. Their ages range from 26 to 63 years old. The reasons why we selected the deep veins as vascular access are as follows: (1) damaged superficial veins due to repeated cannulation in one patient, (2) small sized superficial veins probably by nature in two, and (3) dehydration due to discontinuation of fluid therapy after amelioration of IBD in one. In total 33 sessions of GMA were performed on them with Adacolumn (JIMRO, Takasaki, Japan). Blood flow rate was kept as 30 mL/min and session length was set as 60 min. Needle size was uniformly set as 17 Gauge. All of the sessions were completed without interruption, although most of the sessions (23 sessions) required tourniquet. No adverse events such as injury of the arteries or nerves, or bleeding complications were experienced. We demonstrated that deep vein puncture under US guidance can be a useful strategy for GMA procedure on those whose superficial veins accept only inadequate blood flow for the therapy. Deep veins as the *Correspondence to: Norio Hanafusa, MD, PhD 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: [email protected] Received 5 February 2015; Accepted 9 February 2015 Published online 5 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21389
Alternative Vascular Access of Apheresis
381
Fig. 1. General appearance and the screen of the ultrasonographic device during the actual procedure is indicated in this figure. Deep accompanying vein(s) can be observed as well as brachial artery and median nerve on the screen. We target and puncture the deep vein without injuring the artery or nerve.
vascular access of GMA have advantages over other two major types of blood vessels. The first type of the vessel is central veins, which are often used in apheresis therapy with use of catheters. However, GMA treatments are often performed on the basis of outpatients, on whom it is not practical to use a catheter. Moreover, the procedure itself needs more preparation than this method. It might cause anxieties on the patients themselves, because the puncture site is either neck or inguinal regions. Although arteries, usually a brachial artery, can be used, puncture of them can cause much more complications compared to puncture of veins. Therefore, we consider this method is superior to one using such accesses. However, there are several problems in applying this procedure; the most important is the procedure requires some skills. We should emphasize that it is indispensable to closely observe vital structures such as artery or nerves, as well as the very tip of the needle while thrusting. One must firstly become familiar with the procedure itself in applying it to superficial veins.
Another point is obviously that it requires US devices. Nonetheless, we believe in this method when we perform GMA on IBD patients. Moreover, the same methods might be applicable also for other modalities of apheresis. REFERENCES 1. Habermalz B, Sauerl S. Clinical effectiveness of selective granulocyte, monocyte adsorptive apheresis with the adacolumn device in ulcerative colitis. Dig Dis Sci 2010;55:1421–1428. 2. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a metaanalysis of the literature. Crit Care Med 1996;24:2053–2058. 3. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361. [PMC][10.1136/bmj.327.7411.361 ] [12919984] 4. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med 1999;34:711–714. 5. Hanafusa N, Noiri E, Nangaku M. Vascular access puncture under ultrasound guidance. Ther Apher Dial 2014;18:213–214.
Journal of Clinical Apheresis DOI 10.1002/jca
Letter to the Editor Deep Vein Puncture Under Ultrasonographic Guidance—An Alternative Approach for Vascular Access of Apheresis Therapies Norio Hanafusa,1,2* Toshihiro Torato,1 Daisuke Katagiri,1 Tomoko Usui,1 Akihiko Matsumoto,1 Eisei Noiri,1 and Masaomi Nangauku1 1
Department of Hemodialysis and Apheresis, The University of Tokyo Hospital, Tokyo, Japan 2 Division of Total Renal Care Medicine, The University of Tokyo Hospital, Tokyo, Japan
To the Editor: Granulocyte monocyte apheresis (GMA) is one of the modalities in apheresis that is reported to be clinically effective for inflammatory bowel diseases (IBD) [1]. Those who suffer from IBD often experience dehydration and for whom the vascular access is difficult to be placed due to collapse of superficial veins. When we consider the blood flow of upper limbs, blood flow from the brachial artery must enter into either superficial or deep veins. Even if superficial veins do not accept sufficient blood flow, it can be considered that blood is drained through deep veins. Ultrasonography (US) guided central vein puncture has been reportedly related to improving success rate and to reduce complications [2,3]. The procedure was also used for deep veins in emergency department for intravenous access [4]. We have developed and reported the procedure of US-guided vascular access puncture on hemodialysis patients [5]. We also have applied this method to GMA patients who have difficult vascular accesses. In order to elucidate usefulness of US-guided deep vein puncture, we retrospectively evaluated the medical charts of the patients who required such access puncture methods. From June 2013 to January 2015, we investigated the patients: (1) who received GMA therapy, (2) for whom we could not draw sufficient blood flow from superficial veins, and (3) whose deep veins were punctured under US guidance. The effectiveness and adverse events were assessed from the medical chart of such patients. Actual procedures were reported previously [5]. We describe them here in brief. We used a portable US device, Nanomaxx (Covidien Japan, Tokyo, Japan) with linear probe (6–13 MHz) for the current procedure. We investigate the direction of the deep vein under longitudinal view. Next, we place the probe perpendicular to the vein. At this time, the positions of vital structures such as brachial arteries and C 2015 Wiley Periodicals, Inc. V
median veins nerves are identified in relation to the target deep vein, so that we should not damage them during the procedure (Fig. 1). Thereafter, we puncture the vein under US guidance. Once the tip of the needle is observed on the screen, we gradually thrust the needle little by little. After we place the needle in proper place, we remove the inner needle and complete the puncture. In total, we applied this method to four patients with ulcerative colitis. Their ages range from 26 to 63 years old. The reasons why we selected the deep veins as vascular access are as follows: (1) damaged superficial veins due to repeated cannulation in one patient, (2) small sized superficial veins probably by nature in two, and (3) dehydration due to discontinuation of fluid therapy after amelioration of IBD in one. In total 33 sessions of GMA were performed on them with Adacolumn (JIMRO, Takasaki, Japan). Blood flow rate was kept as 30 mL/min and session length was set as 60 min. Needle size was uniformly set as 17 Gauge. All of the sessions were completed without interruption, although most of the sessions (23 sessions) required tourniquet. No adverse events such as injury of the arteries or nerves, or bleeding complications were experienced. We demonstrated that deep vein puncture under US guidance can be a useful strategy for GMA procedure on those whose superficial veins accept only inadequate blood flow for the therapy. Deep veins as the *Correspondence to: Norio Hanafusa, MD, PhD 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail: [email protected] Received 5 February 2015; Accepted 9 February 2015 Published online 5 March 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/jca.21389
Alternative Vascular Access of Apheresis
381
Fig. 1. General appearance and the screen of the ultrasonographic device during the actual procedure is indicated in this figure. Deep accompanying vein(s) can be observed as well as brachial artery and median nerve on the screen. We target and puncture the deep vein without injuring the artery or nerve.
vascular access of GMA have advantages over other two major types of blood vessels. The first type of the vessel is central veins, which are often used in apheresis therapy with use of catheters. However, GMA treatments are often performed on the basis of outpatients, on whom it is not practical to use a catheter. Moreover, the procedure itself needs more preparation than this method. It might cause anxieties on the patients themselves, because the puncture site is either neck or inguinal regions. Although arteries, usually a brachial artery, can be used, puncture of them can cause much more complications compared to puncture of veins. Therefore, we consider this method is superior to one using such accesses. However, there are several problems in applying this procedure; the most important is the procedure requires some skills. We should emphasize that it is indispensable to closely observe vital structures such as artery or nerves, as well as the very tip of the needle while thrusting. One must firstly become familiar with the procedure itself in applying it to superficial veins.
Another point is obviously that it requires US devices. Nonetheless, we believe in this method when we perform GMA on IBD patients. Moreover, the same methods might be applicable also for other modalities of apheresis. REFERENCES 1. Habermalz B, Sauerl S. Clinical effectiveness of selective granulocyte, monocyte adsorptive apheresis with the adacolumn device in ulcerative colitis. Dig Dis Sci 2010;55:1421–1428. 2. Randolph AG, Cook DJ, Gonzales CA, Pribble CG. Ultrasound guidance for placement of central venous catheters: a metaanalysis of the literature. Crit Care Med 1996;24:2053–2058. 3. Hind D, Calvert N, McWilliams R, Davidson A, Paisley S, Beverley C, Thomas S. Ultrasonic locating devices for central venous cannulation: meta-analysis. BMJ 2003;327:361. [PMC][10.1136/bmj.327.7411.361 ] [12919984] 4. Keyes LE, Frazee BW, Snoey ER, Simon BC, Christy D. Ultrasound-guided brachial and basilic vein cannulation in emergency department patients with difficult intravenous access. Ann Emerg Med 1999;34:711–714. 5. Hanafusa N, Noiri E, Nangaku M. Vascular access puncture under ultrasound guidance. Ther Apher Dial 2014;18:213–214.
Journal of Clinical Apheresis DOI 10.1002/jca
