Antegrade Femoral Artery Access A Primer to Percutaneous Endovascular intervention Antegrade Femoral Artery Access Nelson Lim Bernardo, MD Director, Peripheral Vascular Laboratory Medstar Heart Institute at Washington Hospital Center Washington, D.C.

Terumo Cardiovascular Systems Group Nelson L. Bernardo, MD Honoraria: Abbott Vascular Cook Group Incorporated Cordis Corporation Covidien Medtronic, Inc. Terumo Cardiovascular Systems Group

Faculty Disclosure Abbott Vascular – Training Site Cook Medical – Training Site Cordis Endovascular – Training Site Covidien/eV3 – Training Site Medtronic – Training Site No conflict of interest related to this presentation Non-IFU use of devices will be discussed

Vascular Access Proficiency in access of any vascular bed is of foremost importance Cross-over femoral artery (retrograde) Antegrade femoral artery Retrograde SFA/popliteal/pedal artery Axillary/brachial artery Radial/ulnar artery

Vascular Access Proficiency in access of any vascular bed is of foremost importance Cross-over femoral artery (retrograde) Antegrade femoral artery Retrograde SFA/popliteal/pedal artery Axillary/brachial artery Radial/ulnar artery NO Access = NO Intervention

Vascular Access for L.E. intervention Retrograde - Cross-over femoral artery access Most commonly used access to the lower extremity from the contralateral femoral artery Familiar, easy & convenient (‘Comfort zone’) Have limitations

Cross-over FA access: Limitations AAA stent-graft

Cross-over FA access: Limitations AAA stent-graft Bilateral common iliac artery stents

Cross-over FA access: Limitations AAA stent-graft Bilateral common iliac artery stents Aorto-bifemoral artery bypass; Fem-femoral bypass grafts Steep iliac bifurcation Non-compliant heavily Ca+2 ileo-femoral arteries

Cross-over FA access: Limitations AAA stent-graft Bilateral common iliac artery stents Aorto-bifemoral artery bypass; Fem-femoral bypass grafts Steep iliac bifurcation Non-compliant heavily Ca+2 ileo-femoral arteries  Impediments to successful cross-over

Cross-over FA access: Limitations AAA stent-graft Bilateral common iliac artery stents Aorto-bifemoral artery bypass graft Steep iliac bifurcation Non-compliant heavily Ca+2 ileo-femoral arteries Needed ‘support’ to cross femoral-popliteal/tibio- peroneal lesions & CTO Limited balloon and device catheter ‘working’ length

Cross-over FA access: Limitations AAA stent-graft Bilateral common iliac artery stents Aorto-bifemoral artery bypass graft Steep iliac bifurcation Non-compliant heavily Ca+2 ileo-femoral arteries Needed ‘support’ to cross femoral-popliteal/tibio- peroneal lesions & CTO Limited balloon and device catheter ‘working’ length  Cross-over vascular access NOT ideal

Antegrade Femoral Artery Access Antegrade access of common femoral artery with placement of sheath into the ipsilateral femoral or popliteal artery Technical consideration: Previous imaging study showing patent CFA and proximal to mid SFA segments - ‘landing’ zone Ipsilateral Femoral Artery Antegrade Approach

Antegrade Femoral Artery Access Advantages: Better ‘support’ & higher success to cross complex L.E. lesions/CTO Can reach distal pedal lesions Less contrast use Novice operator: Learning curve Radiation exposure Ipsilateral Femoral Artery Antegrade Approach

Antegrade Femoral Artery Access Technical considerations: Previous imaging study showing patent CFA and proximal to mid SFA segments - ‘landing’ zone ‘Difficult’ to access in obese patients – ‘difficult’ hemostasis and risk for groin complication(s) - NOT ideal for access

Antegrade Femoral Artery: Step-by-step Work on the left, Image Intensifier on the right Less radiation ‘Comfortable’ - Ergonomical

Antegrade Femoral Artery: Step-by-step Work on the left, Image Intensifier on the right Less radiation ‘Comfortable’ - Ergonomical Access CFA using micropuncture needle Duplex ultrasound guidance Fluoro guidance - landmarks from ‘old’ angio

Common Femoral Artery Anatomy Inguinal skin crease (non-obese male)

Common Femoral Artery Anatomy Ideal Needle Entry Site

Antegrade CFA Access: Considerations Approximately 3 cm of common femoral artery (CFA) lies between inguinal ligament and femoral bifurcation – segment to access with micropuncture needle inguin

Antegrade Femoral Artery: Step-by-step Access of CFA: Too low - not enough room to access the SFA Skin entry above the inguinal ligament (top of the femoral head) Ideal Needle Entry Site inguin

Antegrade Femoral Artery: Step-by-step Access of CFA: Less acute, i.e. <45O angle, entry is usually required for smooth insertion of sheath and catheters. Ideal Needle Entry Site inguin

Antegrade Femoral Artery: Step-by-step Work on the left, Image Intensifier on the right Less radiation ‘Comfortable’ - Ergonomical Access CFA using micropuncture needle Duplex ultrasound guidance Fluoro guidance - landmarks from ‘old’ angio Insert micropuncture sheath & do angio Angio: Ipsilateral 30-50O angle Ensure CFA ‘stick’ and access into SFA Right SFA

Antegrade FA Access: “Wire” in DFA Stick ‘too-low’ in the CFA with guidewire into the deep femoral artery Options: ‘repositioning’ of wire into SFA Re-access higher in CFA Use of SFA-’redirecting’ access device CFA DFA SFA

Antegrade FA Access: SFA access device Side hole on device allows redirecting the guidewire from the lumen of the terminal hole to the lumen of the side-hole

Antegrade FA Access: Use of SFA access device Insert SFA access device over guidewire into the deep femoral artery with guidewire into the deep femoral artery CFA DFA SFA

Antegrade FA Access: Use of SFA access device Reposition SFA access device with side-hole directed towards SFA CFA DFA SFA

Antegrade FA Access: Use of SFA access device Pull guidewire from the lumen of the terminal hole and advance through the side-hole into the lumen of the SFA Pull out access device and advance sheath over guidewire into the SFA CFA DFA SFA

Antegrade Femoral Artery: Step-by-step Work on the left, Image Intensifier on the right Less radiation ‘Comfortable’ - Ergonomical Access CFA using micropuncture needle Duplex ultrasound guidance Fluoro guidance - landmarks from ‘old’ angio Insert micropuncture sheath & do angio Angio: Ipsilateral 30-50O angle Ensure CFA ‘stick’ and access into SFA Insert ‘long’ sheath Use stiff guidewire, i.e. Supracore Proceed with PEI Popliteal artery AT TP trunk Right BTK Right Foot

POBA of dorsalis pedis A. Antegrade Femoral Artery: Step-by-step Work on the left, Image Intensifier on the right Less radiation ‘Comfortable’ - Ergonomical Access CFA using micropuncture needle Duplex ultrasound guidance Fluoro guidance - landmarks from ‘old’ angio Insert micropuncture sheath & do angio Angio: Ipsilateral 30-50O angle Ensure CFA ‘stick’ and access into SFA Insert ‘long’ sheath Use stiff guidewire, i.e. Supracore Proceed with PEI - Recanalize AT CTO POBA of dorsalis pedis A.

MP: Successful Recanalization for CLI Post-PEI – Right BTK Post-PEI – Right foot

Antegrade Femoral Artery: Step-by-step Hemostasis Manual compression Remember: Arteriotomy site is ‘distal’ or ‘lower’ to the skin entry site Vascular closure device

Antegrade Femoral Artery Access Successful vascular access with good hemostasis are key to a successful percutaneous endovascular intervention. Know femoral/vascular anatomy and ‘nuances’ of antegrade femoral artery access. This technique is an important armamentarium in a vascular interventionalist’s toolbox.

A Primer to Percutaneous Endovascular intervention Thank You