University Emergency Hospital «Pirogov» Sofia Femoral Access Valeri Gelev University Emergency Hospital «Pirogov» Sofia

Vascular Access History Beginning of modern vascular access Sven Seldinger 2

Vascular Access Overview Femoral Brachial Radial (6-9 mm) (4-7 mm) (3-5 mm) Ease of access ++++ ++ + Learning curve short some yes Flexibility in sheath size ++++ ++ + Anticoagulation (cath) no yes yes Complication rates +++ ++ +

Optimal Vascular Access Site Determine type of procedure/sheath size needed Coronary Renal, ilio-femoral Infra-inguinal Support devices; percutaneous AoV Consider access sites-any limitations/obstructions Femoral Brachial Radial Co-morbid illnesses/diseases CKD; PVD Bleeding risk

Common Femoral Artery (R or L) Accessible 4-9mm in diameter Sex (Males 20% larger than females) Age Body Size (proportional) Compressable

Complication Rates Vascular complications are predominant Chandrasekar 11,821 catheterizations CCI 2001

Local complications of FA access Rate 2-10% Hematoma (1-10%) Pseudoaneurysm (1-6%) AV fistula (<1%) Vessel laceration (<1%) Free bleeding Intimal dissection Ante- or retro-grade Acute vessel closure (<1%) Thrombosis (small artery lumen) Retroperitoneal hemorrhage (0.2 – 0.9% w mortality rate 4-10%) Thickening of the perivascular tissues Neural damage Infection Venous thrombosis Pericatheter clot

How to Optimize Femoral Puncture (Avoid Complications) History Prior cath; prior femoral angios; History of PVD Define your goal ( Dg or interventional) Estimate bleeding risk Physical Examine cath sites; Auscultate; Record pulses Puncture technique Location – skin, artery. Needle and wire management.

Optimal Puncture site Under the Inguinal Ligament Above the bifurcation of CFA

Landmarks Used for Femoral Puncture Crease/Pulse 13% Crease/Bone 1% Pulse/Bone 7% All Three Crease 40% Skin Crease Pulse 25% Maximum Pulse Bone 13% Bony Landmarks Site of previous puncture Grier D. Br J Radiol 1990;63:602.

Skin Crease Bifurcation above crease (71%) More than one crease Grier D, Br J Radiol. 1990;63:602

Fluoro guided puncture Bone Land Marks Inguinal Ligament Skin Crease FH Centerline FH Bottom Inferior Epigastic Artery

Femoral Head and the CFA Bifurcation ~80 % below FH bottom 55.5% 22% 17% 4.0% 1.5% Above center of head At center of head Below center of head At inferior border Below inferior border n=200 V IV III II FH Bottom I PFA SFA Schnyder G, et al. Cath Cardiovasc Intervent 2001;53:289-295.

Safety Margins Increased risk of RPH Inability to compress the artery Bone Land Marks Inguinal Ligament Increased risk of RPH Inability to compress the artery Skin Crease FH Centerline FH Bottom Increased risk of puncture bellow the CFA bifurcation Inferior Epigastic Artery

Needle and wire management Modified Seldinger Technique single anterior wall puncture Angle of Entry 30° to 45° Skin Nick Avoid multiple sticks, posterior wall sticks Stop and compress if failed puncture Anterior wall only, good blood flow, no resistance to wire Always remain PARALLEL to the femur with your needle

Predictors of Complications Age Gender (♀) Diabetes Body surface area ( or ) Sheath size Sheath dwell time Vessel size* Anticoagulation, thrombolytics, ± IIb/IIIa Renal failure Wide pulse pressure Puncture location* Prior instrumentation Vascular disease at puncture site* * = requires femoral angio

Limitations to Femoral Access Peripheral Vascular Disease Tortuosity Obesity High bifurcation anatomy Potential for long bed rest