Vein
Artery
FUSIC Vascular
FUSIC Vascular
FUSIC Vascular
The aim of FUSIC vascular is to be able to use ultrasound identify vessels and use it for vascular access. This ranges from peripheral venous cannulation to arterial cannulation and central venous access.
The main vessels that need to be identified for the FUSIC vascular module are:
Central veins
• Femoral
• Internal jugular
Arteries
• Radial
• Brachial
• Femoral
Peripheral veins – appropriate for PICC or midline insertion
• Basilic vein
• Brachial vein
Arteries vs. Veins
The probe of choice for vascular access is a 5-15MHz linear array probe. This allows good detail of superficial structures and enough penetration for the vessels.
Wall
Thin
Thicker & Brighter
Pulse
Non-pulsatile
Pulsatile
Compression
Compressible
Much less compressible
Colour flow doppler
Phasic flow with respiration
Pulsatile
Comparing arteries vs. veins in the right popliteal fossa
The popliteal vein is superficial with thin walls and the popliteal artery is deep, pulsatile and has thicker walls.
Ultrasound techniques
Scanning plane
Transverse plane
There are different planes through which a vessel can be scanned. The most commonly used is the transverse plane where the vessels appear circular on the ultrasound screen.
The advantages of the transverse view is that it is helps identify structures surrounding the vessel – like other vessels and nerves.
Longitudinal plane
Another plane is the longitudinal plane where the vessel is seen passing as a straight line across the screen.
The advantages of the transverse view is that it is helps identify structures surrounding the vessel – like other vessels and nerves.
Oblique plane
This view is obtained by starting with a transverse plane view of the vessels on the ultrasound and rotating the probe half way towards the longitudinal plane view.
This maintains the view of the surrounding structures and the vessels but they will appear slightly oval/elongated.
Transverse plane view of the right internal jugular vein (caudad view). The vein is compressible and lateral to the artery.
Longitudinal view of the right internal jugular vein. The posterior wall appears to be pulsatile due to the close anatomical location of the carotid artery. Compare this with the clip of the longitudinal view of the carotid artery below.
Longitudinal view of the carotid artery. The similarity between the internal jugular vein and carotid artery in longitudinal view on ultrasound means this is not an ideal view for needling.
Needling techniques
Out-of-plane
When needling in the transverse view the most common technique is the out-of-plane technique. This is useful because the mid-point on the ultrasound probe and the mid-point on the ultrasound screen can be used to help guide your needle in the correct trajectory for the vessel.
The disadvantage of this is it is difficult to see the tip of the needle and when seen will appear as a thin line or dot. This in itself may be assumed to be the tip but could further up the shaft of the needle meaning you are deeper than you realise.
The ultrasound can be used to help measure vessel depth before starting the procedure so you know roughly how far to advance your needle.
In-plane
A longitudinal plane scan with an in-plane needling technique can be used and its advantages are that the needle tip is visualised the whole time during advancing (if done correctly).
The disadvantage is that you lose awareness of other nearby structures or vessels that may be just on either side of the ultrasound probe.
The other disadvantage is that arteries and veins look a lot similar in longitudinal than transverse plane and so inadvertent arterial puncture could occur.
Oblique in-plane
A strategy to combine the advantages of the in-plane needling technique with the advantages of the transverse view is using the in-plane oblique view.
This technique will help maintain awareness of surrounding vessels and identify the vein, whilst watching the needle-tip throughout the procedure. This is particularly useful for central venous access where you want to maintain awareness of the carotid/femoral artery whilst knowing where your needle tip is.
Central venous access
The most common sites for central lines are the internal jugular veins and the femoral veins. Each vein has its own distinct advantages and disadvantages for central venous access.
Indication
- Infusion of irritant substances/TPN
- CVP monitoring/advanced haemodynamic monitoring
- Central venous oxygen monitoring
- Inadequate peripheral access
- Extracorporeal therapies (ECMO, CRRT)
- IVC filter placement
- Venous stening
- Transvenous pacing
- Catheter guided thrombolysis
- Repeated blood sampling
Contra-indication
Relative
- Obstructed vein/thrombosis
- Stenosis of the vein
- Severe coagulopathy
- Contaminated side
- Burned site
- Uncooperative awake patient
Absolute
- No absolute contra-indications – risk/benefit balance needs to be assessed and the right line chosen for the right situation
Internal jugular vein
Anatomical location
- Midpoint between sternal notch and mastoid
- Lateral to carotid
- Needle 45 degrees to the skin aiming for ipsilateral nipple
Advantages
- Large vessel
- Easy to locate and visualise
- Lower risk pneumothorax than subclavian
- Compressible
- Short straight path into superior vena cava on the right
- Low rate of complications
Disadvantages
- Close to carotid
- Can be difficult in tracheostomised patients
- Infection
- Size of vein varies with respiration
Potential complications
- Arterial puncture
- Variable extent of nerve damage
- Pneumothorax
- Pleural effusion
- Chylothorax
Ultrasound identification
It is important to keep the carotid vein in view on the ultrasound machine when inserting an internal jugular central line.
There is anatomical variation for the relative relationship between the carotid artery and internal jugular vein. Most commonly the internal jugular lies anterior and laterally to the carotid in the transverse view. If the internal jugular vein is anterior to the carotid artery then there is a risk that you could go through the posterior wall of the internal jugular and into the carotid.
If this is the case sometimes it is best to scan slightly up/down or slide the probe slightly medially/laterally to see if there is a better view where the artery and vein are side by side, therefore reducing the risk of going through the vein and into the artery.
Anatomical variation of the internal jugular vein (IJV) around the carotid artery. Dark blue is most common, light blue is uncommon.
Note: this is a transverse section looking up from the the patients feet towards the head (cephalad). During US guided IJV access the images are taken from the head end looking down at the patients feet (caudad) as the US image below demonstrates.
Transverse view of the right internal jugular vein (caudad view).
Femoral vein
Anatomical location
- 2-3cm below the midpoint of the inguinal ligament is the femoral artery
- The femoral vein lies 1cm medial to the artery.
Advantages
- Large vein
- Free of other devices (e.g. tracheostomy, endotracheal tube ties etc.)
- No risk of haemo/pneumothorax
Disadvantages
- High infection risk
- Thrombus risk
- Close to femoral artery
- Difficulty dressing and accessing device
- Post-removal bleeding – difficult to compress/higher pressure in femoral vein than internal jugular vein when head-up
Potential complications
- Infection
- Thrombosis
- Haemoatoma
- Nerve injury
- Pseudo-aneurysm
- Bowel penetration (more likely if femoral hernia)
- Bladder puncture (more likely if distended)
- Psoas abscess.
Ultrasound identification
The probe is placed just below the inguinal ligament to identify the femoral vein. In the transverse view from lateral to medial lies the femoral nerve, then femoral artery, then femoral vein. Compress these with you probe to help identify the compressible femoral vein and the pulsatile femoral artery.
Original
Labelled
Right common femoral vein giving the characteristic 'Mickey Mouse' appearance on ultrasound. This is at the level of the inguinal crease (cephalad view).
PICC/Midlines
Anatomical location
These are usually inserted into the brachial/basilic veins in the mid-upper arm. The brachial vein is a deep vein whereas the basilic and cephalic veins are large superficial veins. The cephalic is large for a superficial vein but is usually too small for PICC/midline insertion, so either the catheter does not fit or if it does the flow rate around the line is too low and there is an increased risk of deep vein thrombosis.
Upper limb vein anatomy
Advantages
- Low risk of serious complications
- Suitable for prolonged use
- No need to position patient supine
Disadvantages
- Higher risk of thrombosis
- More difficult to assure correct tip position
- Unsuitable for high-volume or very viscous infusions
- Usually unsuitable for CVP monitoring or central venous blood sampling (high risk of lumen obstruction and poor waveform fidelity).
Ultrasound identification
Using the ultrasound scan 2-5cm proximal to the antecubital fossa. From medially to laterally the veins are the basillic, then the brachial, then the cephalic. The brachial vein often sits deeper near the brachial artery and median nerve and it may have more than one lumen.
Ultrasound left arm proximal to antecubital fossa (cephalad view). The deep brachial veins are seen compressible between the median nerve and the brachial artery.
Original
Labelled
Ultrasound of the left arm scanning 2cm proximal to the antecubital fossa.
Scanning medially from the brachial vein the basilic vein comes into view. This can be seen as larger and more superficial than the brachial vein. There is also fewer surrounding structures (such as arteries and nerves) making it a more ideal location for vascular access (PICC/midline) in this case.
Arterial line insertion
Arterial line insertion can be difficult in certain patients and ultrasound can be used to help with this.
The main arteries that are used for arterial line insertion are the radial, brachial and femoral.
The most common technique for arterial cannulation is the out-of-plane transverse view.
It is important to maintain sterility during arterial line insertion with an ultrasound probe – so sterile ultrasound gel with a sterile probe cover should be used.
Peripheral venous access
In some patients where peripheral venous cannulation is difficult then ultrasound guided vascular access may be used. This is a safe way to help identify a vein and increase success rate in the difficult patients. Either an in-plane or out of plane technique for needling can be used.
Content created by Ben Stoney
Design by Max Broadbent
The ultrasound images and clips used on this website have be reproduced following the local clinical governance guidance.
