Percutaneous Approach, Including Transseptal and Apical Puncture

In contrast with the direct brachial technique (see Chapter 5), the percutaneous approach to left and right heart catheterization achieves vascular access by needle puncture , and thus obviates surgical isolation of the vessel during either the insertion or the subsequent withdrawal of the cardiac catheter. Once the needle has been positioned within the vessel lumen, a flexible guidewire is advanced through the needle and well into the vessel being accessed . This guidewire remains in an intravascular position as the needle is withdrawn and provides the means for introducing the desired catheter. Although most operators once inserted end-hole catheters directly over the guidewire, current practice is to first place an introducing sheath over the guidewire, and then to advance the catheter through this sheath , . This modification reduces patient discomfort and eliminates repetitive local arterial trauma during catheter exchanges, although it does increase the size of the puncture slightly (the outer diameter of the sheath is 1F size or 0.33 mm larger than the corresponding bare catheter). At the termination of the percutaneous catheterization procedure, the catheters and introducing sheaths are withdrawn, and bleeding from the puncture sites is controlled by the application of direct pressure. (1)