By: Sridevi Pitta, MD, MBA, FSCAI and Jayant Bagai, MD, FSCAI

Contributors: Rajesh V. Swaminathan, MD, and Faisal Latif, MD, FACC, FSCAI       

While transradial access is being increasingly adopted and used for coronary angiography and percutaneous coronary intervention (PCI) as part of a “radial-first” strategy in cardiac catheterizations laboratories worldwide, transfemoral access is still required in several situations, including failure of radial access and need for larger bore sheaths. The risk of major bleeding with femoral access for PCI is 1–3 percent and results in a significantly higher blood transfusion rate, length of stay, and 30-day mortality.1,2 While several patient and procedural factors increase the risk of major femoral bleeding, operator technique resulting in puncture outside the optimal location more than quadruples the risk of vascular complications.1,3,4 In this Tip of the Month, we provide a concise summary of techniques and tools to puncture the femoral artery in the optimal location, with the intention of improving safety of femoral access.

 

Optimal Technique and Location of Femoral Puncture

Figure 1 provides examples of optimal, low, and high puncture with attendant complications of suboptimal access, noted in the figure’s legend. If a low or high puncture is identified, there should be a low threshold to remove the needle: Apply manual pressure for two minutes and repuncture. Table 1 provides a summary of traditional and more contemporary techniques of femoral access. Ultrasound (US) guidance resulted in a similar rate of optimal cannulation of the common femoral artery (CFA) compared with fluoroscopic guidance, but it lowered the incidence of punctures below the femoral bifurcation, median time to access, number of attempts, and rate of vascular complications (1.4 percent vs. 3.4 percent, p=0.004). It was significantly superior to fluoroscopic guidance (82.6 percent vs. 69.8 percent) in patients with a high femoral bifurcation.5  

 

Table 1 – Summary of the different techniques of femoral access.

Technique Procedural Steps Advantages Disadvantages
Palpation and use of landmarks

1. Determine the location of the inguinal ligament by palpation of the anterior superior iliac spine and pubic tubercle or by using the inguinal crease.

2. Enter skin at 3 cm below the inferior trajectory of the inguinal ligament.

3. Aim needle at the site of the strongest pulse. (Figure 2)

4. Intend to puncture the common femoral artery (CFA) 1–2 cm below the inguinal ligament.

It is familiar to most operators based on traditional teaching.

It allows for rapid access.

The inguinal crease is notoriously unreliable in marking the location of the inguinal ligament. (Figure 3)

It is difficult to appreciate the location of the inguinal ligament with palpation, especially in obese patients.

There is a risk of suboptimal access due to the variable trajectory of needle.

There is an inability to control for anatomic variants or pathology such as high bifurcation, plaque, and calcification.

Fluoroscopic

1. Under fluoroscopy, position the tip of the hemostat at the inferior border of the femoral head. (Figure 4)

2. Enter the skin with a needle at this site.

3. Aim to puncture the CFA overlying the middle third of the femoral head.

It is familiar to most operators based on traditional teaching.

It allows for rapid access, especially in the presence of a weak pulse.

The presence and extent of vessel calcification can be noted.

It can be misleading in patients with large pannus.

The location of the skin entry site may be different from the location of the inferior border of the femoral head after infiltration with local anesthetic.

It cannot account for a high CFA bifurcation (superior to the inferior border of the femoral head but inferior to the midpoint of the femoral head) or a very high bifurcation (superior to the midpoint of the femoral head). (Figure 5)

Ultrasound (US) guided7

1. Image the CFA in the long and short axis to identify the bifurcation. (Figure 6)

2. While imaging the bifurcation in the short axis, slide the US just above the bifurcation.

3. While holding US probe with the non-dominant hand, advance needle with dominant hand, starting 1–3 cm below the US probe depending on the needle trajectory (1 cm for steep and 2–3 cm for shallow trajectory). (Figure 7)

4. Look for the needle tip tenting vessel in the short axis (out-of-plane) view.

5. Advance the needle until the needle tip appears in the center of the vessel and look for blood return.

It allows the operator to determine and avoid plaque, calcification, and a pulsatile femoral vein.

It avoids back-wall and side-wall puncture.

Operator training and experience is required.

There’s a learning curve (though with substantial reduction in time after 10 cases).5

There’s a risk of high puncture if the US probe slides cranially or the needle trajectory is very shallow and close to the US probe.

Needle tip depth may be underestimated if the US beam intersects the proximal needle shaft instead of the tip.

 

Combined or Hybrid Femoral Artery Access Technique

There is substantial evidence supporting the use of US to improve the efficiency and safety of femoral access.5,8 The combination of fluoroscopy with US adds confirmation of the puncture at the optimal location and may decrease the likelihood of a high puncture if the US probe inadvertently slides cranially. Generally, determining the transition of the CFA into the external iliac artery by US is difficult, unless there is a substantial increase in vessel diameter. Use of a micropuncture needle is recommended. While a randomized trial did not show a lower incidence of femoral bleeding with routine use of a micropuncture needle compared with a standard 18G Cook needle, it is worthwhile to know that the puncture size made by the former is 56 percent smaller than that made by the latter.9,10 This is of value in the event of inadvertent high or low puncture, in which case the needle can be removed and manual pressure held.

The following steps are recommended for a contemporary combined approach with minor variations based on individual experience and preference. A portable US unit with a variable 5–10 MHz linear array transducer capable of imaging to a depth of up to 6 cm, and ideally a large screen, is recommended. 

  1. Localize the inferior border of the femoral head with a hemostat and mark the location on the skin with a pen.
  2. Place the US on the femoral head; image the bifurcation with the US in the long-axis and then rotate the probe 90 degrees to visualize the bifurcation in the short-axis.
  3. Slide the probe to image CFA just above the bifurcation and choose the site with lesser plaque; avoid dense anterior calcification.
  4. Inject a local anesthetic guided by the US.
  5. Reposition and stabilize the US with your nondominant hand; place the vessel in the center of the screen and ensure the depth is optimal.
  6. Using your dominant hand, advance the micropuncture needle at a relatively steep trajectory just underneath the marker on the US probe until close proximity or tenting of the anterior vessel wall is noted, but do not puncture the vessel.
  7. Confirm the needle position is at or below the middle of the femoral head by fluoroscopy (unless a very high bifurcation is confirmed by the US).
  8. Puncture the vessel under US guidance.
     
  9. Once there is free blood flow, advance a 0.018-inch wire through the needle and confirm entry into the common iliac (away from the deep circumflex iliac branch) before advancing the 4F or 5F micropuncture sheath. (Figure 8) 
  10. Note that angiography can be performed via the micropuncture sheath or its inner dilator to ensure an optimal puncture location before PCI, and especially prior to large bore access. (Figure 9) Care must be taken to ensure the micropuncture sheath tip is withdrawn slightly with free aspiration of blood to avoid injecting the contrast forcefully into the side wall of the artery and causing a dissection or perforation. This video shows US-guided CFA access and examples of optimal, low, and high access.

 

Conclusions

The routine use of US with fluoroscopy can increase the success rate of first-pass CFA puncture, which can lower access-site-related bleeding and vascular complications. Meticulous attention to the technique and use of adjunctive tools for femoral access with the routine use of US for access should be considered best practice.

 

References

  1. Doyle BJ, Ting HH, Bell MR, et al. Major femoral bleeding complications after percutaneous coronary intervention: incidence, predictors, and impact on long-term survival among 17,901 patients treated at the Mayo Clinic from 1994 to 2005. JACC Cardiovasc Interv. 2008 Apr;1(2):202–9.
  2. Valgimigli M, Gagnor A, Calabró P, et al. Radial versus femoral access in patients with acute coronary syndromes undergoing invasive management: a randomised multicentre trial. Lancet. 2015 Jun 20; 385(9986):2465–76.
  3. Pitta SR, Prasad A, Kumar G, Lennon R, Rihal CS, Holmes DR. Location of femoral artery access and correlation with vascular complications. Catheter Cardiovasc Interv. 2011 Aug 1;78(2):294–9.
  4. Sherev DA, Shaw RE, Brent BN. Angiographic predictors of femoral access site complications: implication for planned percutaneous coronary intervention. Catheter Cardiovasc Interv 2005 Jun; 65(2):196–202. 
  5. Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC Cardiovasc Interv. 2010 Jul;3(7):751–8.
  6. Sandoval Y, Burke MN, Lobo AS, et al. Contemporary Arterial Access in the Cardiac Catheterization Laboratory. JACC Cardiovasc Interv. 2017 Nov 27;10(22):2233–41.
  7. Pitta SR, Gulati R, Mathew V. “Ultrasound Guided Vascular Access: A New Tool in the Cath Lab.” SCAI. Published June 2, 2016, http://www.scai.org/QITTip/ultrasound-guided-vascular-access-new-tool-in-cath.
  8. Sobolev M, Slovut DP, Lee Chang A, et al. Ultrasound-Guided Catheterization of the Femoral Artery: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Invasive Cardiol. 2015 Jul; 27(7):318–23.
  9. Ambrose JA, Lardizabal J, Mouanoutoua M, et al. Femoral micropuncture or routine introducer study (FEMORIS). Cardiology. 2014; 129(1):39–43.10. Baker NC, Ansel GM, Rao SV, et al. The choice of arterial access for percutaneous coronary intervention and its impact on outcome: An expert opinion perspective. Am Heart J. 2015 Jul;170(1):13–22. 

 

 

Figure 1
Figure 1 – Optimal access allows for effective manual compression and increases the likelihood of being able to use a vascular closure device (VCD). Low access increases the risk of pseudoaneurysm, arteriovenous fistula, and compartment syndrome (in the event of uncontrolled bleeding from the profunda femoris) and the inability to use most VCDs. High access increases the risk of retroperitoneal bleeding.

Figure 2
Figure 2 – Conventional access guided by palpation; aiming the needle at the site of the maximal femoral impulse.

Figure 3
Figure 3 – An illustration of unreliability of the inguinal crease in determining the site of optimal needle entry.

Figure 4
Figure 4 – The correct location of skin entry based on the location of the inferior border of the femoral head; note the marked distance from the inguinal crease.

Figure 5
Figure 5 – Examples of normal, high, and very high femoral artery bifurcations.

Figure 6
Figure 6 – Clockwise from upper left: ultrasound (US) images of the common femoral artery (CFA) and vein, a CFA bifurcation in the short-axis, a needle tip with reverberation artifact in the lumen of the CFA, and a long-axis image of CFA bifurcation.

Figure 7
Figure 7 – A two-hand approach of holding an ultrasound probe (US) in the left hand and the micropuncture needle just underneath the US probe in the right hand for real-time US-guided access.

Figure 8
Figure 8 – A fluoroscopic image of a 0.018 inch wire traversing the correct path to the common iliac artery. In this case, the needle entry site appears to be high and unless there’s a known high bifurcation, high access should be excluded by angiography via a micropuncture dilator.

Figure 9
Figure 9 – Examples of low and high access, both suboptimal.

 

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