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The Seldinger Technique: a Short History, and Its Applications 60 Years Later

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The Seldinger Technique: a Short History, and Its Applications 60 Years Later Reviews The Seldinger Technique: A Short History, and its Applications 60 Years Later Maxime Noel-Lamy, MD FRCPC, Fellow in Vascular and Interventional Radiology, University of Toronto University Health Network, Toronto n 1953, Sven-Ivar Seldinger described a novel technique sive as this was for the time, the procedure was quite invasive for vascular access that would have a great influence on since it required surgical exposure of the artery and arterial Imodern medicine. His work revolutionized diagnostic an- ligation for hemostasis. It was also considered limited, as it giography and contributed to the emergence of intervention- allowed access to one large vessel only. The quest to find the al radiology as a specialty. The Seldinger technique is used by solution continued throughout the 1940s. Researchers tried physicians of various specialties for a myriad of procedures in using a large hollow needle through which a smaller bore a vast array of pathologies. catheter could be fed, however, this technique could only be To realize the importance of this technique, we have to un- used in large arteries. The needle was of large caliber, which derstand the state of angiography and vascular access in the conferred a significant risk of arterial wall injury and hemor- first half of the 20th century. The first description of percuta- rhage. Furthermore, once inside the artery the catheter was neous vascular access for imaging was by dos Santos, Caldas difficult to steer. and Lamas in 1929.1 They described aortography via a direct, In 1952, Seldinger found a method to improve percutane- trans-lumbar puncture of the aorta. This was a relatively inva- ous vascular access using a flexible, polyethylene catheter de- sive technique, since it involved puncturing the aorta using veloped by Pierce in 1951.3 His innovative technique involved a large bore needle. It was also limited, as it allowed imaging the use of a metallic guide-wire as a support instead of the of the aorta only from the level of puncture. In the following needle for introduction of the catheter. First, he punctured decades, others tried to find a way to safely insert catheters in the common femoral artery with a hollow needle. He then vessels to perform angiograms at a distance from the punc- fed a metallic guide-wire through the needle and advanced ture site. The goal was to obtain arteriography of different it further into the artery. Then he removed the needle, and arteries at multiple levels. In 1940, Farinas, a Cuban radiolo- over this wire he advanced the catheter (Figure 1). gist, successfully advanced a catheter into the aorta from the This technique enabled a catheter of the same size as the common femoral artery after a surgical cut-down.2 As impres- needle to be used –larger needles and surgical exposures Figure 1. Schematic representation of the Seldinger technique for vascular access. A- A hollow needle is used to puncture the blood vessel. B- A metallic guide-wire is introduced in the needle and pushed distally in the blood vessel. C-The needle is removed and the wire left in place. Pressure is applied upstream to the puncture site to prevent bleeding (arrow). D- The catheter is introduced over the wire. E- Safe vascular access is obtained, and the wire can be removed. Corresponding Author: Maxime Noel-Lamy [email protected] 30 UTMJ • Volume 93, Number 1, December 2015 Reviews The Seldinger Technique: A Short History, and its Applications 60 Years Later of arteries were no longer necessary. Therefore, hemostasis used with Seldinger’s method. Today, micro-catheters as small could be achieved by manual compression only. Seldinger as 0.010 inches can be used to reach distal arteries anywhere published his results in 1953 in the journal Acta Radiologica.4 in the body. The Seldiner technique is still widely used today to insert a Percutaneous access is part of the daily work of inter- catheter into arteries, veins, fluid collections and hollow or- ventional and neuro-interventional radiologists, as well as gans. It remains the preferred method for access in almost all interventional cardiologists. The common femoral artery is percutaneous vascular and non-vascular interventions. most often used for arterial procedures. Radial access is fre- The discovery of a safe technique for percutaneous access quently used for coronary angioplasty and stenting. Other made selective angiographies of different vessels possible. less commonly accessed arteries include the brachial, axillary, Seldinger himself used it to perform selective renal angiogra- popliteal, and tibial arteries. Interventional radiologists also phy and to localize a para-thyroid adenoma.5,6 The advance- use the Seldinger technique for non-vascular interventions, ment of diagnostic angiography paved the way for other pio- such as percutaneous abscess drainage, nephrostomy, biliary neers of interventional radiology, such as Charles Dotter, who drainage, and gastrostomy. In these procedures, a drainage described the first percutaneous balloon-angioplasty of arte- catheter with side-holes is inserted over the wire and a distal rial atherosclerotic stenosis in 1964.7 As imaging technology cope-loop is formed to lock the catheter in place. The Seld- evolved with the arrival of ultrasound, CT-scan, and digital inger technique is also commonly used by internists, intensiv- angiography, Seldinger’s eponym technique could be used ists and anesthesiologists to insert central venous and arterial for new applications. For instance, ultrasound is commonly lines. The table below is a non-exhaustive list of minimally used today to guide the puncture, allowing for safer access. invasive procedures in modern medicine that would not be Additionally, CT-guidance can be used to access percutane- possible without the Seldinger technique (Table 1). ously deep fluid collections or vessels that cannot be seen un- der ultrasound. Innumerable types of guide-wires, catheters, Short Biography of Sven-Ivar Seldinger (1921-1988)8 balloons, stents and other devices were created and are now Sven-Ivar Seldinger was born in the small town of Mora, Swe- den in 1921. He studied medicine at the Karolinska Institute in Table 1. Current applications of the Seldinger technique Stockholm (1940-1948). He took an early interest in radiology and chose this field as his specialty. His training in radiology Field Procedure started in 1950 at the Karolinska Sjukhuset. He was working at Vascular Access Central venous lines the university clinic at this center when he developed the novel Dialysis catheters Implanted ports catheterization technique named after him. After publishing Peripherally-inserted central catheters (PICCs) his innovation in 1953, he applied his new technique to per- Oncology Chemo and radio-embolization form selective angiographies of the kidney and other arteries. Bland embolization of vascular tumors/me- In addition, he used it to puncture bile ducts for cholangiogra- tastasis phy. He defended his thesis on the topic in 1966. He qualified Portal vein embolization for the title of Docent of Radiology in 1967. He subsequently Arterial Interventions Angioplasty and stenting for atherosclerosis Endovascular aneurysm repair returned to his hometown of Mora and became Head of the Embolization of bleeds (trauma, gastro-intesti- Diagnostic Radiology Department at the local hospital. This is nal, iatrogenic, etc.) where he worked for most of his career. He is considered one Vascular malformations embolization of the pioneers of interventional radiology. He was awarded Venous Interventions Catheter-directed thrombolysis of acute ve- the Valentine award from the New York Academy of Medicine nous thrombosis/pulmonary embolism Vein recanalization/angioplasty in 1975. He passed away in his home in the province of Dalar- Inferior vena cava filter insertion for thrombo- na, Sweden, in 1998, at the age of 77. embolic protection Varicose veins ablations References Uro-genital Percutaneous nephrostomy and percutaneous 1. Dos Santos R, Pereira Caldas J and Lamas A. Arterografia da aorta e dos stone treatments vasos abdominais. A Medicina Contemporanea. 1929; 11: 93-96. Dilatation of ureteric strictures 2. Farinas PL. A new technique for the arteriographic examination of the ab- Uterine fibroid embolization dominal aorta and its branches. Am J Roentgenol 1941; 46: 641. Varicocele embolization 3. Pierce EC. Percutaneous femoral artery catheterisation in man with special reference to aortography. Surg Gynaecol Obstet 1951; 93: 56. Gastrointestinal - Percutaneous abscess drainage 4. Seldinger SI. Catheter replacement of the needle in percutaneous arteriog- Hepatobilliary Percutaneous cholecystostomy raphy; a new technique. Acta Radiol. 1953; 39: 368-76. Trans-hepatic biliary drainage/stone extraction 5. Seldinger SI. Localization of parathyroid adenomata by arteriography. Acta Trans-jugular porto-systemic shunts (TIPS Radiol 1954; 42: 353-366. Percutaneous gastrostomy 6. Seldinger SI, Lindblom K. Renal arteriography, as compared with renal Neuro-intervention Cerebral aneurysms embolization puncture in the diagnosis of cysts and tumours. Athens: Société Internatio- Brain and spine vascular malformations nale d’Urologie. 1955; 45: 15-20. embolization 7. Dotter CT, Judkins MP. Transluminal treatment of arteriosclerotic obstruc- Stroke intervention tion. Description of a new technique and a preliminary report of its applica- Carotid arteries stenting tion. Circulation. 1964; 30: 654-670. 8. Sven-Ivar Seldinger: biography and bibliography. AJR Am J Roentgenol. Cardiology Coronary angioplasty and stenting 1984;142(1):4. Percutaneous closure of atrial and ventricular 9. Higgs ZC, Macafee DA, Braithwaite BD, Maxwell-armstrong CA. The Seld- septum defects inger technique: 50 years on. Lancet. 2005;366(9494):1407-9. Trans-catheter aortic valve implantation (TAVI) UTMJ • Volume 93, Number 1, December 2015 31.
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