"I get a great flash, but can't advance the wire."

"I can feel a great pulse, but I can't even get a flash."

"I can't even get a flash when I'm using ultrasound and I can SEE the needle pass right through the artery."

Sound familiar? The biggest reason a lines are hard is because most of the patients that need them are so sick. They're on pressors, have no blood pressure or are have varying degrees of vascular disease. Odds are, the problem does not lie with you.

So let's pick each problem apart and see if it's any easier.

Problem #1 Atherosclerosis. A general term meaning disruption and hardening of either the intima, media or adventitia or all three.

Imagine taking a needle/catheter and trying to slowly pierce a drinking straw. Under your advancing needle, the fore wall indents to meet the back wall and at that point you have enough purchase on the tissue to go thru and thru, never seeing a flash and being greatly confused because there is a great pulse that you went dead center on.

Assuming you did something wrong, you withdraw too quickly for a flash and go again, and again, never realizing you were right on target.

Always assume you're on target when you don't get a flash. Backing out at an absurdly slow rate will give a flash most of the time. Removing the needle and just backing out the catheter is a good way to hedge your bets, but it's not necessary.

Threading the wire is a different story.

So you have your flash, now what?

You may have created a flap of the adventitia, media and/or an intimal plaque that will make passing a wire difficult if not impossible. Softer, more forgiving wires are of some use here because they're less likely to make a disruption worse. The Arrow aline built in wire is pretty stiff and might not be so forgiving. It may feel as though it's advancing when it's just going through the artery. Softer wires, not so much.

A common mistake when advancing any wire is going too steep. Drop your angle and try to guess the direction the vessel takes as you gently advance your wire. Any resistance at all means your failing.

Lastly, for these rock hard arteries, Arrow makes a free needle, seldinger technique kit with a longer 20 ga catheter and nice soft wire. The needle is pointed and very sharp and is less likely to indent the vessel as much as the more blunt arrow catheter/needle/wire advancement kit.

Free needle to wire, remove needle over the wire, load catheter onto the wire and advance catheter into the artery, remove wire. Nice kit.

Problem #2 later...