Defining the common femoral artery: Insights from the femoral arterial access with ultrasound trial

Randomized trial of an oblique versus standard fluoroscopic-guided micropuncture technique for femoral arterial access: The Micropuncture-CFA trial

BACKGROUND

The anterior-posterior fluoroscopic guidance (the AP technique) is a standard method for common femoral artery (CFA) access, but the rate of CFA access with ultrasound vs. the AP technique was not significantly different. We have shown an oblique fluoroscopic guidance (the oblique technique) with a micropuncture needle (MPN) resulted in CFA access in 100 % of patients. The outcome of the oblique vs. AP technique is unknown. We compared the utilities of the oblique vs. AP technique for CFA access with a MPN in patients undergoing coronary procedures.

METHODS

A total of 200 patients were randomized to the oblique vs. AP technique. Using the oblique technique, a MPN was advanced to the mid pubis in the 20° ipsilateral right-or left anterior oblique view with fluoroscopic guidance and the CFA was punctured. In the AP technique, a MPN was advanced to the mid femoral head in the AP view with fluoroscopic guidance and the CFA was punctured. The primary endpoint was the rate of successful access to the CFA.

RESULTS

The rates of first pass and CFA access were higher with the oblique vs. AP technique (82 % vs. 61 %, and 94 % vs. 81 %, respectively; P < 0.01). The number of needle punctures was lower with the oblique vs. AP technique (1.1 ± 0.39 vs. 1.4 ± 0.78, respectively; P < 0.01). In high CFA bifurcations, the rate of CFA access was higher with the oblique vs. AP technique (76 % vs. 52 %, respectively; P < 0.01). Vascular complications were lower with the oblique vs. AP technique (1 % vs. 7 %, respectively; P < 0.05).

CONCLUSIONS

Our data suggest that the oblique technique, compared with the AP technique, significantly increased the rates of first pass and access to the CFA, and decreased the number of punctures and vascular complication.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03955653.

Management of Vascular Access in the Setting of Percutaneous Mechanical Circulatory Support (pMCS): Sheaths, Vascular Access and Closure Systems

The use of percutaneous mechanical circulatory support (pMCS), such as intra-aortic balloon pump, Impella, TandemHeart and VA-ECMO, in the setting of cardiogenic shock or in protect percutaneous coronary intervention (protect-PCI) is rapidly increasing in clinical practice. The major problem related to the use of pMCS is the management of all the device-related complications and of any vascular injury. MCS often requires large-bore access, if compared with common PCI, and for this reason the correct management of vascular access is a crucial point. The correct use of these devices in catheterization laboratories requires specific knowledge such as the correct evaluation of the vascular access performed, when possible, with advance imaging techniques in order to choose a percutaneous or a surgical approach. In addition to conventional transfemoral access, other types of access, such as transaxillary/subclavial access and the transcaval approach, have emerged over the years. These other approaches require advanced skills of the operators and a multidisciplinary team with dedicated physicians. Another important part of the management of vascular access is the closure systems used for hemostasis. Currently, two types of devices are typically used in the lab: suture-based or plug-based ones. In this review we want to describe all these aspects related to the management of vascular access in pMCS and describe, finally, a case report from our center's experience.

Inferior Epigastric Artery Injury due to Femoral Venipuncture for Neuroendovascular Intervention: Two Cases Requiring Transcatheter Arterial Embolization

Objective

Injury to the inferior epigastric artery (IEA) caused by femoral puncture may lead to retroperitoneal hematoma. We report on two cases of IEA injury due to femoral venipuncture for neuroendovascular intervention that resulted in hemorrhagic shock and required transcatheter arterial embolization.

Case Presentations

A 67-year-old woman and a 71-year-old man receiving dual antiplatelet therapy sustained injury to a branch of the IEA in the process of right femoral venipuncture for neuroendovascular intervention. In both cases, stent placement in the intracranial artery was accomplished as intended with systemic heparinization throughout the procedure; however, the patients became hypotensive during the procedure, and contrast-enhanced CT scans taken after the stenting revealed extravasation of contrast from the IEA and retroperitoneal hematoma. Transcatheter arterial embolization of the bleeding branch of the IEA was performed with the left femoral approach, and subsequent angiography confirmed the disappearance of the extravasation of contrast.

Conclusion

Femoral venipuncture for neuroendovascular intervention in patients receiving antithrombotic agents may cause IEA injury requiring transcatheter arterial embolization. The risk of IEA injury may be reduced by using the femoral head as a reference, performing ultrasound-guided puncture, and confirming the course of the IEA by femoral angiography before venipuncture.

High Deep Femoral Artery Bifurcation Can Disturb Safe Femoral Venous Access: CT Assessment in Patients Who Underwent Femoral Venous Access Under Doppler Ultrasound Guidance

PURPOSE

To retrospectively evaluate the variations of deep femoral artery (DFA) bifurcation on computed tomography (CT) and technical success in femoral venous access.

MATERIALS AND METHODS

CT images of 353 patients who underwent adrenal venous sampling were evaluated. Height with relation to the inferior border of the femoral head and direction of DFA bifurcations were classified as follows: type L, low bifurcation; type H1, high lateral bifurcation; type H2, high posterior to posterolateral bifurcation; type H3, high posteromedial bifurcation; and type H4, high medial bifurcation crossing in front of the femoral vein. Technical success and complications during femoral venous access were also evaluated.

RESULTS

The frequencies of types L, H1, H2, H3, and H4 were 82.7%, 9.1%, 6.9%, 0.4%, and 0.9%, respectively. In 92.2% of type H1 and 69.4% of type H2, the superior femoral artery displaced medially by the high DFA partially overlapped the femoral vein. Upon the inclusions of H3 and H4, in 14.4% of cases, the high DFAs could obstruct the access route to the femoral vein. Using Doppler ultrasound guidance, no significant differences were observed in the rates of success for puncture in the first attempt (84.5% vs. 75.4%, p = 0.122) and accidental arterial puncture (1.0% vs. 0%, p = 1.00) between low and high DFA bifurcations, respectively.

CONCLUSIONS

High DFA bifurcation is observed in 17.3% of patients and could obstruct the access route to the femoral vein. This can be evaluated using Doppler ultrasound guidance to avoid accidental arterial puncture during femoral venous access.

Managing vascular access and closure for percutaneous mechanical circulatory support

Even with current generation mechanical circulatory support (MCS) devices, vascular complications are still considerable risks in MCS that influence patients’ recovery and survival. Hence, efforts are made to reduce vascular trauma and obtaining safe and adequate arterial access using state-of-the-art techniques is one of the most critical aspects for optimizing the outcomes and efficiency of percutaneous MCS. Femoral arterial access remains necessary for numerous large-bore access procedures and is most commonly used for MCS, whereas percutaneous axillary artery access is typically considered an alternative for the delivery of MCS, especially in patients with severe peripheral artery disease. This article will address the access, maintenance, closure and complication management of large-bore femoral access and concisely describe alternative access routes.

Ultrasonography-guided antegrade common femoral artery approach: Factors associated with access time

INTRODUCTION

The aim of this study was to evaluate the feasibility and safety of ultrasonography-guided antegrade common femoral artery puncture and subsequent superficial femoral artery access without the aid of fluoroscopy. Factors that could affect access time were also assessed.

METHODS

A total of 294 cases from 218 consecutive patients (163 men, 55 women; mean age: 66.9 ± 12.7 years) who underwent lower extremity endovascular procedures were retrospectively evaluated. The time between the injection of local anesthetic and the insertion of the microsheath into the superficial femoral artery was measured. The common femoral artery diameter, cutis thickness, distance between arterial puncture site and common femoral artery bifurcation, degree of common femoral artery calcification, body mass index, and history of previous access were investigated to assess their relationship with access time. Furthermore, all cases were assessed with ultrasonography for access-site complications before discharge.

RESULTS

Technical success was achieved in 293 of 294 procedures (99.7%). The mean time for superficial femoral artery access was 1.9 ± 0.8 min (range, 0.7-3.7 min). Additional fluoroscopic guidance was needed in one case. There were moderately positive correlations of body mass index (r = 0.75; p < 0.001) and cutis thickness (r = 0.58; p < 0.001) with access time. The other variables failed to reveal significant correlations with access time. Five groin hematomas occurred after percutaneous transluminal angioplasty. Complications such as pseudoaneurysm, arteriovenous fistula, or retroperitoneal hematoma were not observed.

CONCLUSION

Antegrade common femoral artery puncture with subsequent superficial femoral artery access conducted solely under ultrasonography guidance was feasible and safe. In addition, the antegrade access time showed positive correlations with body mass index and cutis thickness.

The REBOA window: a cadaveric study delineating the optimum site for austere cannulation of the femoral artery for resuscitative endovascular balloon occlusion of the aorta

INTRODUCTION

Haemorrhage is the major cause of early mortality following traumatic injury. Patients suffering from non-compressible torso haemorrhage are more likely to suffer early death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) can be effective in initial resuscitation; however, establishing swift arterial access is challenging, particularly in a severe shock. This is made more difficult by anatomical variability of the femoral vessels.

METHODS

The femoral vessels were characterised in 81 cadaveric lower limbs, measuring specifically the distance from the inferior border of the inguinal ligament to the distal part of the origin of the profunda femoris artery (PFA), and from the distal part of the origin of the PFA to where the femoral vein lies posterior to and is completely overlapped by the femoral artery.

RESULTS

The femoral vein lay deep to the femoral artery at a mean distance of 105 mm from the inferior border of the inguinal ligament. The PFA arose from the femoral artery at a mean distance of 51.1 mm from the inguinal ligament. From the results, it is predicted that the PFA originates from the common femoral artery approximately 24 mm from the inguinal ligament, and the femoral vein is completely overlapped by the femoral artery by 67.7 mm distal from the inguinal ligament, in 95% of subjects.

CONCLUSIONS

Based on the results, proposed is an 'optimal access window' of up to 24 mm inferior to the inguinal ligament for common femoral arterial catheterisation for pre-hospital REBOA, or more simply within one finger breadth.

Redefining the fluoroscopic landmarks for common femoral arterial puncture during cardiac catheterization: Femoral angiogram and computed tomography angiogram (FACT) study of common femoral artery anatomy

BACKGROUND

The mid-femoral head (F₅₀ ) is a common fluoroscopic target for common femoral artery (CFA) puncture during cardiac catheterization. Punctures above the inguinal ligament (marking the proximal end of CFA) increase the risk of retroperitoneal hemorrhage and are classified as high punctures.

METHODS

We retrospectively analyzed 114 CT angiograms for the anatomic relationship of the inguinal ligament to the femoral head (FH) and inferior epigastric artery (IEA). We analyzed 114 CT angiograms and 500 femoral angiograms, for the relation of the mid-point of CFA to F₅₀ and F₇₅ (the junction of upper 3/4th and lower 1/4th of FH).

RESULTS

The proximal third of femoral head (F₃₃ ) (-1.4 mm) and IEA nadir (-2.9 mm) were closer approximations to the inguinal ligament than the IEA origin (-12.8 mm) or cranial end of FH (-15.2 mm). The inguinal ligament correlated better with the IEA nadir than F₃₃ (R²  = 0.49 vs. 0.001). F₇₅ was a closer approximation for the mid-point of the CFA than F₅₀ (0.3 mm vs. -9.2 mm). Using F₇₅ as the target for CFA puncture carried the lowest risk for non-CFA punctures (18.6%), while using F₅₀ had a 41.2% risk for non-CFA punctures. F₇₅ had an increased risk for low punctures (14.2%) but F₅₀ had a far higher risk for high punctures (36.6%).

CONCLUSIONS

The nadir of IEA is the best landmark for identifying the inguinal ligament (the proximal end of CFA) and defining high punctures. F₇₅ is a more accurate target for successful CFA puncture than F_50.

Redefining landmarks to improve #safefemoral outcomes

Retroperitoneal hemorrhage (RPH) and other femoral artery access site complications are associated with "high" arterial punctures. Using the nadir of inferior epigastric artery (IEA) as the landmark for identifying the inguinal ligament and high punctures can reduce access site complications. Traditional teaching of aiming for the middle of the femoral head while obtaining femoral access can result in higher than desired puncture site more frequently than aiming for the lower quarter. Enhanced understanding of anatomical landmarks, use of imaging guidance and strict adherence to safe access practices can help improve outcomes.

Contemporary Arterial Access in the Cardiac Catheterization Laboratory

Obtaining femoral and radial arterial access in the cardiac catheterization laboratory using state-of-the-art techniques is essential to optimize outcomes, patient satisfaction, and procedural efficiency. Although transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, femoral access remains necessary for numerous procedures, many requiring large-bore access, including complex high-risk coronary interventions, structural procedures, and procedures involving mechanical circulatory support. For femoral access, contemporary access techniques should combine the use of fluoroscopy, ultrasound, micropuncture needle, femoral angiography, and vascular closure devices, when feasible. For radial access, ultrasound may reveal important anatomic features and expedite access. Despite randomized controlled trials supporting use of routine ultrasound guidance for femoral and/or radial arterial access, ultrasound remains underused in cardiac catheterization laboratories. This article reviews contemporary techniques to achieve optimal arterial access in the cardiac catheterization laboratory.

Reduction of vascular complication rates from femoral artery access in contemporary women undergoing cardiac catheterization

BACKGROUND

Femoral arterial access (FAA) during diagnostic coronary angiography (CAG) and percutaneous coronary interventions (PCI) are associated with several vascular complications (VC). VC rate in our experience a decade ago was 3.02% and higher in women (4.7% in women, and 1.67% in men, p < 0.0006), with an OR of 2.81 (95% CI: 1.51-5.22).

METHODS

Patients who underwent CAG and PCI utilizing FAA (n = 2617) were separated into Period 1 (2005 to 2008; 1970 patients; Male 1045; Female 925) and Period 2 (2016-2017; 647 patients; Male 357; Female 290). FA access was preceded by anatomic FA localization during Period 1 vs. additional fluoroscopic marking of femoral head during Period 2. Ultrasound guidance was not utilized during either period. VCs were defined as hematoma>3 cm, major bleeding requiring blood transfusion or hemoglobin drop >2 g, retroperitoneal bleed, pseudoaneurysm, AV fistula, arterial thrombosis, distal embolism, dissection, and transient limb ischemia.

RESULTS

Rate of VCs did not differ from Periods 1 to 2 (2.44% vs. 2.32%, p = 1.0). An elevated rate of VCs experienced by women in Period 1 (Female 3.68% vs. Male 1.34%, p < 0.05) is no longer noted in Period 2(Female 2.07% vs. Male 2.52%, p = 0.79). Vascular closure device (VCD) use was protective in both Periods 1 and 2.

CONCLUSIONS

The use of fluoroscopic marking of femoral head prior to access, smaller sheath size, and being a high femoral volume center may have contributed to the reduced incidence of VCs in women. VCD utilization is continuing to reduce VC rates in both men and women.