A Novel Use of an Arterial Catheter for Extended Peripheral Venous Access in Postoperative Liver Transplant Recipients: A Case Series

Introduction

Reliable and sustained intravenous access is fundamental to postoperative management following liver transplantation.^[1]

Recipients typically require prolonged administration of immunosuppressive agents, broad-spectrum antibiotics, antifungals, blood products, albumin, electrolyte infusions, and occasionally vasoactive medications. Frequent laboratory monitoring further increases the need for dependable vascular access. However, establishing and maintaining peripheral venous access in this population is often challenging.

Several factors contribute to difficult venous access in postoperative liver transplant recipients. Generalised oedema secondary to large intraoperative fluid shifts, hypoalbuminemia, and capillary leak may obscure peripheral veins. Vasodilation associated with cirrhosis and reperfusion physiology further complicates venous visualisation and cannulation. Repeated intraoperative and postoperative cannulations may result in thrombosed or fragile veins. Additionally, coagulopathy may limit repeated puncture attempts. Multiple failed attempts increase patient discomfort, delay therapy, and heighten infection risk.

Central venous catheters (CVCs) and peripherally inserted central catheters (PICCs) provide reliable long-term access but carry risks including catheter-related bloodstream infection, thrombosis, mechanical complications, and bleeding.^[2,3]

These risks are particularly significant in liver transplant recipients who are immunosuppressed and vulnerable to infectious complications.

Ultrasound guidance has transformed vascular access practice by improving first-pass success rates and reducing complications.^[4]

Extended peripheral or midline catheters represent an intermediate option; however, their availability may be limited, and cost considerations may restrict routine use in resource-constrained settings.^[5]

Real-time visualisation allows identification of deeper, larger calibre peripheral veins such as the basilic and brachial veins. We hypothesised that a standard arterial catheter, typically used for invasive blood pressure monitoring and inserted via the Seldinger technique, could function as an extended peripheral venous catheter when placed into upper arm veins under ultrasound guidance.

We describe our experience using a 20-G arterial catheter as an extended peripheral venous access device in postoperative liver transplant recipients with difficult peripheral access.

Case Series

This case series was conducted in the liver transplant intensive care unit of a tertiary teaching hospital after obtaining informed consent from patients or their legal representatives.

Fifteen adult patients who underwent orthotopic liver transplantation were included in the study period. Patients ranged in age from 38 to 65 years. All had anticipated a need for intravenous therapy exceeding five days and demonstrated difficulty with conventional peripheral venous access, defined as either two failed attempts by experienced nursing staff or poor visualisation/palpation of suitable peripheral veins.

Patients were excluded if they required ongoing invasive arterial blood pressure monitoring, had evidence of local infection at the proposed insertion site, or had severe uncorrected coagulopathy (international normalised ratio > 2.5).

All patients were receiving standard postoperative immunosuppressive regimens and broad-spectrum antimicrobial therapy as per institutional transplant protocols.

Catheter and Insertion Technique

A 20-G Leadercath arterial catheter (Vygon, UK) was used in all cases. This catheter, commonly used for arterial cannulation, has adequate length and flexibility and is inserted using the Seldinger technique, features that make it potentially suitable for extended peripheral venous access.

All insertions were performed by anesthesiologists experienced in ultrasound-guided vascular access.

OPEN IN VIEWER Figure 1.

Venous Puncture Using Ultrasound

The patient’s upper arm was positioned comfortably with mild external rotation.

A high-frequency linear ultrasound probe (6-13 MHz) was used to identify a suitable peripheral vein, preferably the basilic vein due to its larger calibre and distance from major neurovascular structures [Figure 1]. The brachial vein was selected if the basilic vein was unsuitable.

Vein patency, diameter, and compressibility were assessed.

Strict aseptic precautions were maintained, including full barrier precautions and sterile probe cover.

Local anaesthesia was administered using 1% lignocaine.

Under real-time ultrasound guidance, venipuncture was performed.

Upon confirmation of non-pulsatile blood return, a guidewire was advanced [Figure 2].

The arterial catheter was introduced over the guidewire using the Seldinger technique [Figure 3].

Venous placement was confirmed by easy aspiration of dark, non-pulsatile blood and smooth saline flush without resistance or swelling.

OPEN IN VIEWER Figure 2.

Guidewire Insertion

OPEN IN VIEWER Figure 3.

Catheter Insertion

The catheter was secured using sutures and covered with a sterile transparent dressing. Catheters were flushed intermittently with heparinised saline (10 U/mL) every six hours to maintain patency. Insertion sites were inspected twice daily for erythema, swelling, discharge, tenderness, or infiltration.

Discussion

Difficult venous access is a common and frustrating problem in postoperative liver transplant recipients.^[1]

Oedema, altered hemodynamics, and repeated prior cannulations contribute to poor peripheral vein quality. Repeated failed attempts at cannulation may lead to patient discomfort, anxiety, delays in therapy, and increased risk of local complications.

CVCs, though reliable, carry well-recognised risks including catheter-related bloodstream infections, thrombosis, pneumothorax, and bleeding.^[2,3]

These complications may be particularly consequential in immunocompromised transplant recipients. While central access is often necessary in the immediate perioperative period, minimising unnecessary central line exposure during recovery is desirable.

Midline catheters offer a longer peripheral option, but may not always be readily available and can increase the cost burden.^[5]

The arterial catheter used in this series possesses several characteristics that make it suitable for venous use, including Seldinger-based insertion and greater length than standard peripheral cannulas.

Ultrasound guidance enhances safety by allowing real-time visualisation, confirmation of venous entry, and avoidance of adjacent structures.^[4]

In our series, the first attempt success rate was 100%, and the mean dwell time exceeded seven days, suggesting adequate durability for extended intravenous therapy in the early postoperative period.

The absence of infectious or thrombotic complications in this small cohort is encouraging. Strict aseptic technique, careful site selection, regular monitoring, and avoidance of vesicant or hyperosmolar infusions likely contributed to the favourable outcomes.

The limitations of this case series include its small sample size, single-centre design, and absence of a comparator group. We did not perform routine Doppler screening for asymptomatic thrombosis. Therefore, subclinical events cannot be excluded.

Future larger prospective studies comparing arterial catheter-based extended peripheral access with midline and PICC lines in transplant populations would help define its safety profile and cost-effectiveness more clearly.

Conclusion

This case series demonstrates that ultrasound-guided placement of a 20-G arterial catheter into upper arm peripheral veins can provide safe and durable extended venous access in postoperative liver transplant recipients with difficult peripheral veins. The technique achieved consistent first attempt success, satisfactory dwell time, and absence of clinically evident complications in our cohort. It may serve as a practical bridge between short peripheral cannulas and CVCs, potentially reducing central line exposure and improving patient comfort in the early post-transplant period. Further studies are warranted to validate these findings and establish standardised practice guidelines.

Supplementary material