Arterial and venous access in the cardiac catheterization lab 9780813572161, 9780813572178, 9780813572185, 0813572177, 0813572185

Table of contents :
Common femoral artery access / Mazen Abu-Fadel --
Complications of common femoral artery access / Fahmi Farah, Mazen Abu-Fadel --
Common femoral artery access : hemostasis and closure / Mazen Abu-Fadel --
Radial artery access / Beau Hawkins --
Brachial artery access / Faisal Latif --
Popliteal artery access / Aneesh Pakala, Mazen Abu-Fadel --
Pedal artery access / Jose Exaire --
Ultrasound guided arterial & venous access / Ajay Patel, Arnold Seto --
Access in the pediatric patient / Anas Salkini.

Citation preview

Arterial and Venous Access IN THE CARDIAC CATHETERIZATION LAB

Arterial and Venous Access IN THE CARDIAC CATHETERIZATION LAB

Edited by Mazen Abu-­Fadel Associate Professor of Medicine Director, Interventional Cardiology and Cardiac Cath Lab Director, Interventional Cardiology Fellowship Program Associate Director, Internal Medicine Residency Program Director, Interventional Cardiology Research Group University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Rutgers University Press Medicine

New Brunswick, New Jersey, and London

Library of Congress Cataloging-­i n-­P ublication Data Name: Abu-­Fadel, Mazen, 1973–­, editor. Title: Arterial and venous access in the cardiac catheterization lab /   edited by Mazen Abu-­Fadel. Description: New Brunswick, New Jersey : Rutgers University Press,   [2016] | Includes bibliographical references and index. Identifiers: LCCN 2015042990| ISBN 9780813572161 (hardcover :   alk. paper) | ISBN 9780813572178 (e-­book (epub)) |   ISBN 9780813572185 (e-­book (web pdf)) Subjects: | MESH: Cardiac Catheterization—­methods. | Arteries—­  surgery. | Endovascular Procedures—­methods. | Laboratories, Hospital. | Ultrasonography, Interventional. Classification: LCC RC683.5.C25 | NLM WG 141.5.C2 |   DDC 616.1/20754—­dc23 LC rec­ord available at http://­lccn​. ­loc​.­gov​/­2 015042990 A British Cataloging-­i n-­P ublication rec­ord for this book is available from the British Library. This publication was supported in part by the Eleanor J. and Jason F. Dreibelbis Fund. This collection copyright © 2016 by Rutgers, The State University Individual chapters copyright © 2016 in the names of their authors All rights reserved No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, or by any information storage and retrieval system, without written permission from the publisher. Please contact Rutgers University Press, 106 Somerset Street, New Brunswick, NJ 08901. The only exception to this prohibition is “fair use” as defined by U.S. copyright law. Visit our website: http://­r utgerspress​.­r utgers​.­edu Manufactured in the United States of Amer­i­ca

I would like to dedicate this book to all my colleagues and contributing authors, for their help and support in getting this manuscript ready, and to all my mentors, who pushed me hard during my training and post-­training years to make me the physician I am ­today. I would also like to dedicate this book to all my trainees—­past, pres­ent, and f­ uture—­for keeping me interested and engaged in teaching and training f­ uture cardiologists. Last but not least, I would like to dedicate this work to my parents, my wife, Cynthia, and my three kids, Romy, Noah, and Luka, for their continued unconditional love, sacrifice, and support in every­thing I do.

Contents Preface and Acknowl­edgments  ix Contributing Authors  xi

1  Common Femoral Artery Access  1 Mazen Abu-­Fadel

2  Complications of Common Femoral Artery Access  21 Fahmi Farah Mazen Abu-­Fadel

3  Common Femoral Artery Access: Hemostasis and Closure  42 Mazen Abu-­Fadel

4  Radial Artery Access  68 Beau M. Hawkins

5  Brachial Artery Access  84 Faisal Latif

6  Popliteal Artery Access  97 Aneesh Pakala Mazen Abu-­Fadel

7  Pedal Artery Access (Dorsalis Pedis and Anterior Tibial)  108 Jose E. Exaire

8  Ultrasound-­Guided Arterial and Venous Access  117 Arnold H. Seto Ajay Patel

vii

viii

Contents

9  Vascular Access in Pediatrics  152 Anas Salkini

Index 173

Preface and Acknowl­edgments

I

nvasive cardiac and endovascular procedures are increasing in number and complexity on a daily basis. Most of ­these procedures are done in the cardiac or endovascular suits. The initial approach to all ­t hese procedures require vascular access into the arterial or venous circulation. While access is just a means to an end, it remains one of the most challenging and life-­threatening procedures we perform. Newer equipment and techniques require larger than usual sheaths inserted into the vascular beds, and optimal access and regress techniques are crucial for the success of any of ­these procedures. In addition, due to the complex interventions we perform, many newer access sites that w ­ ere not traditionally used are being accessed, such as the popliteal and pedal arteries. In this book, the authors describe how to best access the arterial and venous beds in cardiac catheterization labs and endovascular suits. We touch upon the use of specific equipment to help facilitate the pro­cess and decrease complications. Multiple figures are available to help understand the anatomy and facilitate a step-­by-­step approach to vascular access. We also discuss the best use of vascular closure devices and help teach when and how best to use them. This book is intended for ­every health care professional who w ­ ill be seeing and working with patients in the procedural area. Understanding how to and where to obtain vascular access is the first and most impor­ tant step in taking good care of our patients and keeping them out of harm’s way. I would like to acknowledge Ms. Candice Edwards for her help in editing and formatting this book and Dr. Alain Waked for contributing an image to Chapter 4, Radial Artery Access.

ix

Contributing Authors Mazen Abu-­Fadel, MD, FACC, FSCAI

Associate Professor of Medicine Director, Interventional Cardiology and Cardiac Cath Lab Director, Interventional Cardiology Fellowship Program Associate Director, Internal Medicine Residency Program Director, Interventional Cardiology Research Group University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Jose E. Exaire, MD

Associate Professor of Medicine Director, Coronary Care Unit Veterans Affairs Hospital University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Fahmi Farah, MD

Cardiology Fellow University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Beau M. Hawkins, MD

Assistant Professor of Medicine Cardiovascular Section Director, Heart, Lung and Vascular Clinic University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

xi

xii

Contributing Authors

Faisal Latif MD, FACC, FSCAI

Associate Professor of Medicine Director, Cardiac Cath Lab Veterans Affairs Hospital University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Aneesh Pakala, MD

Assistant Professor of Medicine Cardiovascular Section University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Ajay Patel, MD

Cardiology Fellow University of California Irvine Medical Center Orange, California

Anas Salkini, MD

Assistant Professor of Pediatrics Department of Pediatric Cardiology University of Oklahoma Health Sciences Center Oklahoma City, Oklahoma

Arnold H. Seto, MD, MPA

Section Chief, Cardiology Long Beach Veterans Affairs Medical Center Long Beach, CA Assistant Clinical Professor Director of Interventional Cardiology Research University of California Irvine Medical Center Orange, California

Arterial and Venous Access IN THE CARDIAC CATHETERIZATION LAB

1

CHAPTER

Common Femoral Artery Access MAZEN ABU-­FADEL

D

espite a steady increase in the number of cardiac and peripheral pro­ cedures performed from the radial approach, femoral access remains the most widely used technique in the United States. Mastery of femoral access is critical for any interventionalist as it remains necessary for pro­ cedures requiring larger sheaths and ­because transradial approaches are not feasible for many peripheral and structural interventions. In addition, a proper femoral access technique is crucial to decrease bleeding rates and vascular complications as well as allow the use of vascular closure devices. Multiple techniques have been described to facilitate proper access into the common femoral artery (CFA), including using anatomic landmarks, flu­ oroscopy, Doppler sound waves, and ultrasonography.

ANATOMY

The CFA is the continuation of the external iliac artery ­a fter it traverses the inguinal ligament, which extends from the spine of the anterior superior iliac crest to the pubic tubercle. From t­ here, the artery follows the medial side of the head and neck of the femur inferiorly and laterally before split­ ting into the superficial femoral artery and deep femoral artery (also known as the profunda). The CFA artery traverses medial to the anterior crural nerve and lateral to the femoral vein in the femoral or Scarpa’s triangle com­ prising what is commonly referred to as the “groin” area. The artery is cov­ ered anteriorly with the inferior extension of the fascia of the transverse abdominal and iliac muscle. The most superficial part of the CFA lies at the 1

2

Arterial and Venous Access in the Cardiac Catheterization Lab

level where the artery traverses over the head of the femur.1 This is the area where the strongest femoral pulse can be palpated and the artery accessed. The CFA is a relatively large artery, making it an ideal site for access. The dia­meter of the CFA is related to age, body size, and sex. In a study of healthy h­ uman subjects by Sandgren et al, the mean and median dia­meters for the CFA w ­ ere found to be 9.8 mm and 9.7 mm, respectively, in male subjects and 8.2 mm and 8.2 mm, respectively, in female subjects.2 How­ ever, other studies that included patients coming to the cath lab for vari­ ous procedures showed the mean dia­meter of the CFA to be smaller in both males and females (6.9 ± 1.4 mm).3 The CFA bifurcation may occur at any level along the course of the ves­ sel. One study analyzed 972 femoral angiograms for the level of the CFA bifurcation and noted that, in 64.8% of patients, the bifurcation occurred below the inferior border of the head of the femur. In addition, the bifur­ cation was at or below the midline of the head of the femur in the study population in 98.5% of patients.4 This becomes very impor­tant when can­ nulating the CFA in order to avoid puncturing at or below the bifurcation as this may cause an increase in vascular access site complication. Another impor­tant anatomic landmark is the take-­off and course of the inferior epigastric artery (IEA) and its relation to the arteriotomy site. The origin of the IEA arises from the external iliac, immediately above the ingui­ nal ligament. It curves forward in the subperitoneal tissue; it then ascends obliquely along the medial margin of the abdominal inguinal ring and continues its course upward. Multiple variations exist, and the origin may take place from any part of the external iliac between the inguinal ligament and a point 6 cm above it; less frequently, it may arise below this ligament, from the CFA.5 CONSIDERATIONS IN FEMORAL ARTERIAL ACCESS

Prior to any procedure in the catheterization lab, a thorough history and physical, as well as a review of prior angiograms, are of utmost importance. While the femoral artery provides an excellent access site, ­there are many ­factors that may persuade operators to consider an alternative access sites. Some of t­ hese considerations include the following:6

• Body habitus, especially morbidly obese patients. • Inability to lie flat and cooperate post-­procedure.



Common Femoral Artery Access

3

• Signs or symptoms of peripheral arterial disease in the lower extrem­ ities.

• Prior vascular surgery or intervention, especially femoral-­femoral bypass.

• Prior surgery and/or radiation to the groin area. • Prior femoral vascular access site complications or femoral bruit on exam.

• Anticoagulation, bleeding, and transfusion issues. • Vessel tortuosity and/or aneurysmal dilatations. • Groin infection or skin breakdown. • Recent access and use of some vascular closure devices (Angioseal). • Nonpalpable femoral pulses. • Patient preference. Sedation and Local Anesthesia

Like any other invasive procedure, it is very impor­tant to administer the correct amount of conscious sedation and local anesthetic. Many physi­ cians give the sedation just before they attempt vascular access without allowing time for the sedation to take effect. Vascular access, especially in the groin area, is usually uncomfortable for the patient and, in some instances, may be painful; patients ­w ill then remember and fixate on the discomfort they experienced. We recommend that sedation be given 3 to 5 minutes prior to attempting access to allow enough time for the patient to be sedated and give more medi­cations if needed. Once the patient is well sedated, and a­ fter identifying the point of nee­ dle entry by one of the methods subsequently described, local anesthetic is ready to be given. In the author’s opinion, it is impor­tant to locate the point of skin entry before giving anesthetic to decrease the total number of skin punctures with the anesthesia needle and to decrease the overall volume of lidocaine given, especially in patients with feeble or deep pulse, ­because the lidocaine may obscure the arterial pulsations. Once this is done, a 25-­gauge needle is used to administer local anesthesia. Many ways have been described to inject the medi­cation, but, in general, while the pulse is located between your index and m ­ iddle fin­ger, local anesthesia is given below the skin to form a wheel or bleb followed by advancing the nee­ dle deeper into the tissue t­ oward the CFA. It is impor­tant to draw back on the plunger before injecting in the subcutaneous space to avoid injecting into a vascular structure. We then inject lidocaine at a constant rate while

4

Arterial and Venous Access in the Cardiac Catheterization Lab

drawing the needle backward t­ oward the skin, thus anesthetizing the track that the access needle is ­going to take all the way to the CFA. We believe that injecting local anesthesia in multiple planes at multiple ­angles does not provide any benefit and may increase the likelihood of skin ecchymosis. If using ultrasound-­g uided access, first start by locating the ideal access site, then use the local anesthesia needle to deliver the medi­cation in the track that the access needle is ­going to take all the way down to the CFA. With ultrasound, the operator can actually observe live the lidocaine being injected and may be able to give it just on top of the CFA without entering the artery and then all the way back to the skin. Ideal Puncture Site of the CFA

Ideally, the anterior wall of the CFA should be punctured 1 to 2 cm below the inguinal ligament but proximal to its bifurcation into the superficial femoral and profunda arteries. At this site, the CFA can be easily com­ pressed against the head of the femur to achieve manual hemostasis. Puncture below the CFA bifurcation—­even if the bifurcation is anterior to the femoral head—­w ill increase the risk of vascular complications (such as hematoma and pseudoaneurysm) and may prevent the use of larger sheaths if needed. ­Because it is well established that the origin of the IEA in most cases is immediately above the inguinal ligament, the author believes femoral access should occur below the origin of the IEA. The ideal access site should be below the level of the most inferior horizontal reflection of the IEA. The IEA descends to, but does not cross, distal to the inguinal ligament. Entry above the most inferior point of the course of the IEA can be used to define an unmistakably high puncture. Thus, access should be below that point but above the CFA bifurcation. (See Figure 1.1.) The puncture above the level of the most inferior horizontal reflection of the IEA may predispose patient to an increased risk of potentially life threatening retroperitoneal bleed due to the lack of an under­lying bony structure to help with hemostasis during compression.7 In a review of 989 femoral angiograms from the FAUST study, the most inferior reflection of the IEA occurred 92.2% of the time below the superior border of the head of the femur.8 In addition, the CFA bifurcated below the most inferior border of the head of the femur in almost 65% of patients.4 In this case, the length of the CFA that extends from the inferior border of the femoral



Common Femoral Artery Access

5

FIGURE 1.1 ​Femoral angiogram showing ideal access site into the common femoral artery (CFA). Arteriotomy should be below the most inferior border of the inferior epigastric artery (IEA) and above the CFA bifurcation but still anterior to the head of the femur. Zone 1 and above represent a high access site above the most inferior boarder of the IEA, even though the access site may still be anterior to the femoral head. An arteriotomy in zone 1—­and especially above zone 1—­will increase the risk of retroperitoneal bleeding significantly. Zone 2 represents a low access site. Even though the arteriotomy may still be in the CFA (above the bifurcation), this location does not provide the femoral head as a support when compressing the artery to achieve hemostasis, thus increasing the risk of a hematoma or pseudoaneurysm.

head to its bifurcation is considered a suboptimal access site ­because ­t here is no bony structure to help compress the CFA ­a fter the sheath is pulled, and thus, the risk of hematoma and pseudoaneurysms increases significantly. Taking all this into consideration, the ideal access site into the CFA should be below the most inferior point of the IEA and above the CFA bifurcation anterior to the femoral head. As such, in the majority of patients, the ideal access site falls midway between the superior and the inferior borders of the head of the femur.9 This may be accomplished more easily in patients with previous femoral angiography where the relation­ ship among the head of the femur, the CFA bifurcation, and the most infe­ rior border of the IEA can be seen. In patients with no previous femoral angiography, multiple methods have been described to assist the opera­ tor achieve an ideal access site.

6

Arterial and Venous Access in the Cardiac Catheterization Lab

FLUOROSCOPY VS. TRADITIONAL ANATOMIC LANDMARKS GUIDANCE FOR CFA ACCESS

Anatomic landmarks have been utilized to identify the CFA, including the inguinal skin crease, maximal femoral pulse, and bony landmarks.10 Even though many operators use it, the inguinal crease—­which is wrongly con­ sidered a marker of the inguinal ligament—is the least reliable among ­these landmarks. In patients with lean body habitus, the skin crease may be on top of the inguinal ligament. However, in the majority of patients, especially the obese, it may be as low as 11 cm (mean 6.5 cm) from the liga­ ment and below the CFA bifurcation in as many as 75.6% of patients.11 Using the point of maximal femoral pulsation to access the CFA is more reliable. The site of maximal pulsation is over the CFA in 92.7% of patients.10 However, in obese patients, the point of maximal pulse may be below the CFA ­because this is the only area in which a pulse can be palpated due to the thickness of the subcutaneous tissues more cranially. In addition, up to 20% of patients who require femoral access do not have a strong or even palpable pulse to start with, making this landmark useless. The third com­ monly used anatomic landmark is the imaginary line connecting the ante­ rior superior iliac spine and the pubic tubercle. This line represents the outline of the inguinal ligament, and accessing the CFA 2 to 3 cm below the midpoint of this landmark has been used by many as a guide for arte­ rial sheath insertion.9 This, again, may be a good way to access the CFA at the desired location for lean patients, but for so many ­others (especially with obesity), the bony landmarks are not as prominent or palpable. In the Fluoro Access study, the use of the bony landmarks to obtain access in the CFA was assessed. Results showed that the arteriotomy site was at the midlevel of the head of the femur in only 20.4% of the cases. In addition, the access site was below the m ­ iddle of the femoral head in 36.8% of patients. Among t­ hese low arteriotomies, 17.4% ­were below the inferior border of the femoral head, thus making the bony landmark technique suboptimal as well. Arteriotomies below the femoral head ­were seen more frequently in obese patients with BMIs over 32 kg/m2.4 Fluoroscopy is being used more frequently to help obtain access into the CFA. Historically, this technique was used for patients with decreased or absent pulses, but recently, multiple operators are using it routinely. The technique has also evolved significantly and has been studied by multiple researchers to help perfect it. As previously described, the ideal access



Common Femoral Artery Access

7

site into the CFA is halfway between the superior and inferior borders of the femoral head. To achieve access at this mark, the level of entry point through the skin should be more caudal when performing retrograde access (or more cranial for antegrade access). When originally described, a straight-­tip hemostat or radiopaque marker was placed on the skin to mark the lower edge of the femoral head ­under fluoroscopy in the posterior–­ anterior projection. This was considered the skin entry level for retrograde femoral access. From that level, the needle ­w ill then be advanced at a 45-­degree ­angle into the subcutaneous tissue t­oward the pulse ­until the needle crosses the anterior wall of the CFA and pulsatile blood is obtained. This technique was tested in a prospective randomized study against the use of bony anatomical landmarks. In this study, fluoroscopy-­g uided access decreased arterial punctures below the femoral head, especially in obese patients (3.3% vs. 6.4% in the traditional arm p = 0.03). Fluoroscopy however, did not increase the percentage of patients with ideal arteriot­ omy sites.4 It is now obvious that the skin entry site should vary, and this depends on the amount of subcutaneous tissue between the skin and the CFA. Figure 1.2 shows how using the inferior border of the femoral head as a marker of skin entry may lead to low or high arteriotomy site in the CFA. This is also true if the operator is using the bony landmarks as a refer­ ence and is inserting the needle 2  cm below the imaginary line repre­ senting the inguinal ligament without adjusting for the amount of fat below the skin. For thin ­people, the tip of the metallic clamp should be just below the midline of the femoral head. For obese patients with a thick fat pad over the CFA, the skin entry site should start below the fem­ oral head, or, if entering at the level of the inferior border of the femoral head, a steeper ­angle—60 degrees or more—of the access needle should be utilized. Optimal fluoroscopic guidance requires a repetitive technique that goes multiple steps beyond ­simple fluoroscopy to locate the bottom of the fem­ oral head. ­A fter fluoroscopically locating the inferior border of the femoral head, repeat fluoroscopy is performed ­a fter the needle has been advanced into the subcutaneous tissue but has not entered the CFA. This ­w ill help the operator guide the tip of the needle ­toward the ­middle of the femoral head to achieve an ideal puncture site. Brief, low-­dose fluoroscopy should be used to locate the tip of the needle and its path ­toward the CFA. Dur­ ing ­these fluoroscopy runs, the operator should remove his or her hands

8

Arterial and Venous Access in the Cardiac Catheterization Lab

FIGURE 1.2 ​Illustrations showing how the distance between the skin and the common femoral artery can affect the location of the arteriotomy even when the access needle is advanced at the same ­angle. In both illustrations A and B, the skin entry site is at the level of the inferior border of the femoral head.

from the x-­ray field. This technique may be repeated as needed u­ ntil the needle enters the CFA. Imaging should be done in the posterior–­anterior projection, and the head of the femur should be projected in the ­middle of the viewing screen. ­There is no doubt that this method ­w ill increase the radiation exposure to the patient and, to a certain extent, the operator. It is crucial to keep fluoroscopy use to the least amount pos­si­ble.12 It is impor­ tant to mention that this access method, in my opinion, is best done with the use of a micropuncture needle (discussed ­later in this chapter) and accompanying 0.018-in. wire. A modification of this technique is where the operator may be able to directly visualize a calcified CFA and access it with the micropuncture needle.



Common Femoral Artery Access

9

­A fter the needle enters the artery, multiple techniques have been used to confirm the arteriotomy site in the CFA. The first technique involves advancing the wire through the micropuncture needle into the iliac ves­ sels and then examining the needle/wire interface ­under fluoroscopy. This locates precisely the relationship of the puncture site to the femoral head (Figure 1.3).13 The second technique involves injecting contrast through the micro­ puncture needle and recording an angiogram of the entry site. The author does not recommend this technique b­ ecause ­there are multiple risks involved with it, including a risk of losing access to the vessel lumen, dis­ secting the CFA, and direct radiation to the operator hands. The third method involves advancing the 0.018-in. wire through the micropuncture needle, removing the needle, and then advancing the inner dilator of the

FIGURE 1.3 ​Fluoroscopy showing the tip of the micropuncture needle and its 0.018-­inch wire advanced into the iliac arteries. The white arrow represents the needle/wire interface and, thus, the accurate site of access into the common femoral artery. If the access site is not where desired, the needle and wire may be removed and manual pressure applied before a second attempt.

10

Arterial and Venous Access in the Cardiac Catheterization Lab

FIGURE 1.4 ​A femoral angiogram is obtained through the dilator of a micropuncture sheath and inadvertently c­ auses a localized hemodynamically significant dissection (white arrows) in the external iliac artery at the tip of the dilator (black arrow).

micropuncture sheath over the 0.018-in. wire and using this small dilator for femoral angiography rather than injecting directly through the micro­ puncture needle.12 While this is a safer way to do the femoral angiogram, ­there is still a possibility of dissecting the iliac artery with the tip of the inner dilator of the micropuncture sheath, especially if the iliac artery is tortuous (Figure 1.4). On the other hand, transducing a pressure with an extension tubing to ensure an appropriate waveform may reduce the risk of inadvertently injecting contrast into the suboptimal ­plane. ULTRASOUND-­GUIDED CFA ACCESS

Fluoroscopy cannot always identify the optimal access site due to the ana­ tomic variation in the CFA and its bifurcation. Ultrasound-­g uided access is emerging as an efficient and safe method to access the CFA. This tech­ nique offers multiple advantages over fluoroscopy (Figure 1.5):

FIGURE 1.5 ​(A) The right common femoral bifurcation is imaged in the axial plane, demonstrating the profunda femoral artery (PFA) and superficial femoral artery (SFA). Compression is used to differentiate arteries from the femoral vein (FV). (B) The probe is moved or angled superiorly to the common femoral artery (CFA). During needle advancement, the anterior wall of the vessel is indented by the needle tip. (C) The guide wire insertion point (arrow) can be imaged in the axial plane a­ fter cannulation to confirm that the insertion is above the CFA bifurcation. (D) Longitudinal view shows the guide wire entry (arrow) is superior to the CFA bifurcation (arrowhead). Image courtesy of Arnold Seto, MD, Irvine, CA.

12

Arterial and Venous Access in the Cardiac Catheterization Lab

• ­There is direct visualization of the CFA and its bifurcation. • ­There is direct visualization of disease in the CFA at the access site, including atherosclerosis, aneurysmal dilatation, dissections, e­ tc.

• The operator can visualize the needle puncturing the anterior wall of the CFA and prevent a posterior wall puncture, as well as prevent a venous puncture. • ­A fter wire insertion through the needle, the operator can again verify the puncture site by following the course of the wire through the artery from the subcutaneous tissues. • It decreases the amount of fluoroscopy and radiation to both the patient and operators.

The author believes that e­ very catheterization laboratory should be equipped with a dedicated, mobile ultrasound machine that can be used for arterial and venous access. In general, interventional radiologists ­adopted this technology earlier than, and use it more frequently than, inter­ ventional cardiologists. More recently, and ­after multiple studies proved the safety and efficiency of ultrasound arterial access in the CFA and radial artery, this technique has been used and taught in many institutions. In

FIGURE 1.6 ​An angiogram of a patient with high common femoral artery (CFA) bifurcation is shown. Access was obtained with fluoroscopy guidance only. Even though the arteriotomy site is in a good position, just below the midline of the femoral head (black arrow), it is still below the CFA (star). If ultrasound-­guided access has been utilized, the operator would have directly visualized the CFA bifurcation and obtained access above it.



Common Femoral Artery Access

13

the FAUST study—­a multicenter, randomized controlled trial—­routine, real-­time ultrasound guidance improved CFA cannulation in patients with high CFA bifurcations (Figure 1.6). It also reduced the number of attempts to obtain access, decreased the total time to sheath insertion, and decreased the risk of venipuncture. Similar improvements in procedural efficiency ­were noted with the use of ultrasound for transradial procedures.14 In addition, real-­t ime ultra­ sound guidance significantly decreased the formation of femoral access site hematomas. One complete chapter in this textbook is dedicated to discussing ultrasound-­g uided venous and arterial access. Please refer to Chapter 8 for details on CFA ultrasound-­g uided access. USE OF A MICROPUNCTURE NEEDLE FOR CFA ACCESS

As compared to the regular 18-­gauge needle, the micropuncture needle is a 21-­gauge access needle that decreases the size of the CFA arteriotomy by 56%. It also decreases the blood flow through the hole in the CFA six-­fold, resulting in decrease bleeding in cases of a failed attempt or posterior wall puncture.13 The micropuncture needle has been widely used anecdotally to obtain access into the CFA. Its use was mainly for smaller calcified arteries or, in coagulopathic patients, in an attempt to decrease access site complications. More recently, the use of the micropuncture system has been more widely ­adopted—­despite the lack of concrete data to show that it decreases vascular access site complications. However, the micropunc­ ture system makes it easier to obtain hemostasis and reattempt access on the same site if the original arteriotomy in the CFA is not at the ideal level or if it is in one of the CFA branches. The micropuncture kit comes with a 21-­gauge needle, 0.018-in. guide wire, 4 or 5F micropuncture sheath with a respective dilator for initial access and exchange to a 0.035-in. system. Some micropuncture kits come with a hydrophilic-­coated guide wire, but t­hese are better used in non-­CFA access such as radial and tibial vessels. The guide wire used for CFA is usually the stainless-­steel, soft-­tip, tapered wire. If using micro­ puncture with ultrasound, a micropuncture needle with an echogenic tip should be used, which makes the tip of the needle more vis­i­ble and facili­ tates access through the anterior wall of the CFA. ­A fter locating the skin

14

Arterial and Venous Access in the Cardiac Catheterization Lab

entry site and injecting local anesthetic, the micropuncture needle is advanced into the CFA. When a flash of bright red blood comes out of the back end of the needle, the 0.018-in. guide wire is advanced into the CFA/ iliac arteries. It is very impor­tant to visualize the wire advancing into the iliac arteries ­under live fluoroscopy b­ ecause this wire tends to enter small branches without much re­sis­tance and may lead to wire perforation and potentially catastrophic retroperitoneal bleeds (Figure 1.7). In a single center study that evaluated complication rates between the micropuncture system and usual 18-­gauge needle access into the CFA, no difference in the overall complication rates was seen, but the risk of ret­ roperitoneal bleed, even though small, was significantly higher in the micropuncture group.15 ­A fter the guide wire is advanced, the needle is exchanged to the micropuncture dilator and sheath system. The wire and the dilator are then removed. If desired, a femoral angiogram may be per­

FIGURE 1.7 ​Fluoroscopy of the groin area showing the 0.018-­inch micropuncture wire traversing small arteries in the pelvis instead of advancing through the iliac arteries. This may increase the risk of retroperitoneal bleeds. The micropuncture wire should be advanced ­under fluoroscopic guidance to avoid such complications.



Common Femoral Artery Access

15

formed at this point (as discussed previously), and if the sheath entry site is at the desired location, a 0.035-in. guide wire (J-­tipped or straight soft tip in case of presence of peripheral arterial disease [PAD] or tortuosity) is  advanced through the micropuncture sheath; that sheath is then exchanged to the desired sheath for the procedure. CFA ACCESS WITH THE SMARTNEEDLE

The SmartNeedle Percutaneous Doppler Vascular Access Device (Vascu­ lar Solutions, Minneapolis, MN) consists of a detachable probe situated inside the lumen of a standard introducer needle. The needle and probe are attached by means of a luer adapter. It is used for detecting and locating blood flow from arteries and veins within the access site. Flow is detected by an audio output from the SmartNeedle Monitor that is wrapped with a sterile sleeve. It is helpful for patients with decreased or difficult-­to-­palpate pulses. ­A fter locating the desired skin entry level, the needle is advanced ­toward the CFA while listening to the Doppler signals. As the needle approaches the artery, the signal becomes louder; when it enters the artery, pulsatile blood flow should be seen. This is followed by guide wire advance­ ment and sheath insertion. The signal from the artery is dif­fer­ent from that of the vein. If both arterial and venous signals are heard concurrently, the artery and vein may be superimposed on one another with re­spect to the ultrasonic beam. In a study of 114 patients undergoing coronary angiogra­ phy, the use of the SmartNeedle resulted in a significant increase in first-­ pass success rate into the CFA and was also associated with a reduction in the risk of hematoma formation compared with the standard needle.16 One of the disadvantages of the SmartNeedle (as with other non–­ ultrasound-­guided access techniques) is that it cannot differentiate between CFA and its bifurcation branches based on the Doppler signal alone. ACCESS AND SHEATH INSERTION INTO THE CFA

Some operators perform a nick-­and-­tunnel approach prior to access into the CFA. This approach entails a 2-­to 3-mm skin nick with a scalpel par­ allel to the skin crease ­a fter giving local anesthetic in that area. The nick is then enlarged and deepened with the use of a blunt-­curved hemostat. This is followed by needle access into the CFA and sheath insertion. This approach provides less re­sis­tance to large size sheath when needed and

16

Arterial and Venous Access in the Cardiac Catheterization Lab

may prevent hematomas by allowing the blood to seep to the skin level rather than accumulating in the subcutaneous space.6 This technique may also make it easier to deploy some vascular closure devices such as an Angi­ oseal or Starclose. It is my opinion that this technique is not necessary and may be replaced with a small skin nick only with the tip of the scalpel a­ fter access is obtained into the CFA at the desired level and the wire is advanced into the iliac arteries or aorta. The more common way to insert a sheath into the CFA is to use the mod­ ified Seldinger’s technique where only the anterior wall of the CFA is punc­ tured with the access needle. The steps involved include the following:

• Conscious sedation should be given prior to this step. • Find the ideal skin entry site as described earlier and, if necessary, mark with a sterile marker.

• Palpate the pulse at the skin entry site with the index and m ­ iddle fin­ger.

• Give an adequate amount of local anesthetic as described previously. • Advance the access needle (with the bevel facing upward) with the

other hand. The a­ ngle of entry may vary as discussed earlier but, in general, should be around 45 degrees. With ultrasound access and in obese patients, the ­angle of the needle may be much more than 45 degrees. When access is achieved, the needle hub may be lowered cautiously to a shallower ­angle without losing brisk blood flow to allow easier passage of the guide wire. • When good pulsatile flow is ensured, the guide wire should be advanced cautiously. If any re­sis­tance is encountered, fluoroscopy should be used to ensure the wire is advancing freely. If it is not, the J-­w ire should be replaced with a soft-­tip straight wire such as the Wholey wire (Covidien, Masfield, MA) or the Magic Torque wire (Bos­ ton Scientific, Marlborough, MA) and advanced ­under fluoroscopy. • ­After the wire reaches the distal aorta, the needle is removed while apply­ ing manual pressure on the access site with the fin­gers. A sheath with its dilator is advanced over the wire into the CFA. A skin nick may be done prior to sheath advancement if needed. Most of the time, especially when using a sheath size less than 7F, ­there is no need for a skin nick. • While it is preferred to obtain an alternate access for patients with bypass grafts in the CFA area, femoral access is sometimes needed. In



Common Femoral Artery Access

17

t­hese situations, a micropuncture needle should be used to obtain access into the graft, and the smallest size sheath pos­si­ble should be used (preferably 4 or 5F). A modified Seldinger’s technique should be used, and, at the end of the procedure, hemostasis should be obtained with manual pressure only. • ­After the sheath is placed and the dilator removed, it should be flushed; it is recommended that a femoral angiogram be performed at this point if it has not already been done. This allows the operator to plan ahead for anticoagulation and upsizing the sheath for a specific interven­ tion if needed. • The last step—­but one of the most impor­tant steps in CFA access— is femoral angiography through the access sheath. Femoral angiog­ raphy should be performed for all patients with groin sheath. This should be done as soon as access is obtained ­because it ­w ill help diag­ nose complications early and help the operator plan the rest of the pro­ cedure. The side arm of the sheath is connected to the manifold or injector where the operator can see and rec­ord pressures from the sheath. If the pressures are dampened or not pres­ent, caution should be taken before any injection is done through the sheath b­ ecause the tip may be against the vessel wall or in a dissection plane. Other pos­ sibilities include severely diseased or occluded iliac arteries. Dye is then injected from the side arm of the sheath, and an angiogram is recorded in a 30-­degree, ipsilateral, anterior oblique projection. Some operators prefer to keep the guide wire through the sheath when per­ forming the femoral angiogram to keep the tip of the sheath from touching a tortuous iliac artery. The operator should review this angio­ gram carefully before proceeding. It is not enough to visualize the sheath entry site and the suitability for vascular closure devices from this angiogram. Many times, when viewed carefully, the physician can see extravasation of contrast from a posterior wall puncture or from a previous attempt at access. Wire dissections or perforations even out­ side the iliac system may be visualized, and blood extravasation from around the sheath entry site due to CFA laceration is pos­si­ble. In addi­ tion, the operator can assess the size of the arteries and any severe peripheral arterial disease that may prevent upsizing of the sheath. If the arteriotomy is too high or too low (and ­a fter confirming in the posterior–­anterior projection), the operator may elect to proceed

18

Arterial and Venous Access in the Cardiac Catheterization Lab

with a diagnostic angiogram but not with anticoagulation and inter­ vention to decrease the risk of vascular access site complications. SPECIAL CONSIDERATION FOR LARGE SHEATH ACCESS

The common femoral artery is used more than any other access site for pro­ cedures that require very large sheaths, such as aortic interventions for aneurysms and structural cardiac interventions such as transcatheter aor­ tic valve replacement (TAVR). Vascular access site complications remain a major cause of mortality and morbidity during and a­ fter ­these procedures. Even though still used by some, femoral cut-­down to explore the CFA for direct access and closure is losing ground; pure percutaneous procedures are the current prevailing technique. Avoiding vascular complications dur­ ing ­these procedures is very impor­tant, and as such, multiple imaging modalities are used for screening of the aortoiliac and femoral vessels prior to the ­actual procedure. Three-­dimensional, contrast-­enhanced CT images are revolutionizing TAVR screening and procedural planning. This imaging technology is particularly useful for identifying circumfer­ ential calcification, excessive tortuosity, and areas of the iliofemoral system that are too narrow to accommodate a large sheath. The access location can be planned and sheath delivery success predicted well before the start of the procedure.17 During the procedure, micropuncture access with femoral angiography through the microcatheter sheath or ultrasound-­ guided access seems to be the technique of choice. Some operators elect to obtain femoral access in the contralateral CFA and proceed with a cross­ over catheter to perform angiography of the iliofemoral arteries where the TAVR sheath is g­ oing in. This w ­ ill allow the operator to visualize the CFA as well as the surrounding arterial anatomy, including the bifurcation of the CFA and the IEA. A road map can be utilized to get direct access in the ideal zone of the CFA with a micropuncture needle and then upsize the sheath for the procedure. CONCLUSION

Vascular access remains one of the most impor­tant steps during any diag­ nostic or interventional procedure. Even though the use of the CFA for diagnostic and interventional procedures is decreasing, this route remains



Common Femoral Artery Access

19

a very impor­tant one for complex coronary, peripheral, and structural interventions. Proper sedation, anesthesia, and access techniques into the CFA ­w ill keep the patient content and ­w ill decrease the risk of access site complications and bleeding. R EFER ENCES

  1. ​Spijkerboer AM, Scholten FG, Mali WP, et  al. Antegrade puncture of the femoral artery: morphologic study. Radiology. 1990;Jul;176(1):57–60.   2. ​Sandgren T,  Sonesson B,  Ahlgren R, et  al. The dia­meter of the common femoral ­a rtery in healthy h­ uman: influence of sex, age, and body size. J Vasc Surg. 1999;Mar;29(3):​ 503–510.   3. ​Schnyder G, Sawhney N, Whisenant B, et  al. Common femoral artery anatomy is influenced by demographics and comorbidity: implications for cardiac and peripheral inva­ sive studies. Catheter Cardiovasc Interv. 2001;Jul;53(3):289–295.   4. ​Abu-­Fadel MS Sparling JM, Zacharias SJ, et al. Fluoroscopy vs. traditional guided fem­ oral arterial access and the use of closure devices: a randomized controlled trial. Catheter Cardiovasc Interv. 2009;Oct 1;74(4):533–539.  5. ​W illiams PL. Gray’s Anatomy. 38th ed. Edinburgh: Churchill Livingstone; 1995:1563.   6. ​Bangalore S, Bhatt DL. Femoral arterial access and closure. Circulation. 2011;Aug 2;124(5):e147-156.   7. ​Ellis SG, Bhatt D, Kapadia S, et al. Correlates and outcomes of retroperitoneal hemor­ rhage complicating percutaneous coronary intervention. Catheter Cardiovasc Interv. 2006;Apr;67(4):541–545.   8. ​Seto AH, Abu-­Fadel MS, Sparling JM, et al. Real-­t ime ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC Cardiovasc Interv. 2010;3:751–758.   9. ​Rupp SB, Vogelzang RL, Nemcek AA Jr, et al. Relationship of the inguinal ligament to pelvic radiographic landmarks: anatomic correlation and its role in femoral arteriography. J Vasc Interv Radiol. 1993;4:409–413. 10. ​Grier D, Hartnell G. Percutaneous femoral artery puncture: practice and anatomy. Br J Radiol. 1990;Aug;63(752):602–604. 11. ​Lechner G, Jantsch H, Waneck R, et al. The relationship between the common femo­ ral artery, the inguinal crease, and the inguinal ligament: a guide to accurate angiographic puncture. Cardiovasc Intervent Radiol. 1988;11:165–169. 12. ​Cilingiroglu M, Feldman T, Salinger MH, et al. Fluoroscopically-­g uided micropunc­ ture femoral artery access for large-­caliber sheath insertion. J Invasive Cardiol. 2011;Apr;23(4):​ 157–161. 13. ​Turi ZG. Overview of vascular closure. Endovasc ­Today. 2009;8:24–32. 14. ​Seto, AH, Roberts JS, Abu-­Fadel MS, et al. Real-­t ime ultrasound guidance facilitates transradial access: RAUST (Radial Artery Access With Ultrasound Trial). JACC Cardiovasc Interv. 2015;Feb;8(2):283–291. 15. ​Ben-­Dor I, Maluenda G, Mahmoudi M, et  al. A novel, minimally invasive access technique versus standard18-­gauge needle set for femoral access. Catheter Cardiovasc Interv. 2012;Jun 1;79(7):1180–1185.

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16. ​Blank R, Rupprecht HJ, Schorrlepp M, et al. Clinical value of Doppler ultrasound con­ trolled puncture of the inguinal vessels with the “Smart Needle” within the scope of heart catheter examination [in German]. Z Kardiol. 1997;86:608–614. 17. ​Perlowski A, Levisay J, Salinger M, et al. Optimal femoral access and closure for TAVR: improving the safety and accuracy of large-­sheath femoral access for TAVR using micro­ puncture, fluoroscopic guidance, and the crossover technique. Cardiac Interventions T ­ oday. 2014;5:46–52.

CHAPTER

2 Complications of Common Femoral Artery Access FAHMI FARAH MAZEN ABU-­FADEL

T

he common femoral artery (CFA) remains the most widely used access site for coronary, peripheral, and structural interventions. Vascular access and hemostasis require a dedicated and experienced team to take care of the access site and the patients. Education and training of the entire team is of utmost importance to achieve good outcomes and decrease related costs. As discussed in Chapter 1, utilizing the right technique for femoral access is critical to decreasing access site complications and bleeding. How­ ever, even when the most experienced operator utilizes the best technique to achieve an arteriotomy at the most ideal location, access site complications and bleeding may still occur a­ fter sheath removal or closure device deploy­ ment. When reviewing the lit­er­a­ture, the specific definition of a complica­ tion, the publication year of a certain study, and the techniques used for identification of complications seem to play a role in the reported incidence rates of such access site complications. Th ­ ese complications, however, are well known to increase patients’ morbidity and mortality. In this chapter, we review CFA access site complications and the steps needed to prevent them.

PREDICTORS OF FEMORAL ARTERIAL ACCESS SITE COMPLICATIONS

Multiple ­factors increase the risk of complications ­a fter vascular access into the CFA. Some of ­t hese ­factors are modifiable, while o­ thers are not. Some are patient related, while o­ thers are procedural and post-­procedural related. Patient related f­ actors include patients’ sex, age, body mass index, 21

22

Arterial and Venous Access in the Cardiac Catheterization Lab

compliance with bed rest, and the presence of chronic diseases such as hyper­ tension and renal dysfunction. On the other hand, procedural-­related ­factors include operators’ experience, faulty access techniques (including venous punctures or multiple arterial punctures), a too high or too low arte­ riotomy site, sheath size, sheath dwelling time, and periprocedural medi­ cations (including thrombolytics, anticoagulation, and antiplatelet agents). In a study by ­Piper et al, variables associated with increased risk of vas­ cular access site complications in a multivariate analy­sis model included age ≥ 70 (odds ratio [OR] 2.7), female sex (OR 2.4), body surface area