Femoral Artery Access Using Landmarks and Fluoroscopy Zoltan G. Turi, M.D. Rutgers Robert Wood Johnson Medical School New Brunswick, NJ

Disclosure Statement of Financial Interest Affiliation/Financial Relationship Company Grant/Research Support Abbott Vascular Arstasis Marine Polymer Technologies St. Jude Medical

Way Over-represented in Complications Step 1 Recognize That Vascular Access in the New Percutaneous Technologies Era is: Taken for Granted Under-investigated but Way Over-represented in Complications

TAVR Complications NEJM 2010

Usual Approach Keep poking until you get a gusher

Step 2 – Choose a Landmark 3. Bone landmarks X 2. Maximal pulsation 1. Inguinal crease 4. Prior puncture site

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

Inguinal Crease UC San Diego New Jersey

This is NOT Normal Anatomy SFA CFA PFA 3 Misconceptions despite 60 years experience

Stick at the crease Right at the inguinal crease Steep angle of attack Some difficulty with inserting sheath over wire

PFA The post procedure angiogram in the LAO view demonstrates a low stick (well below the femoral head) with a kink at the site of sheath entry into the artery – a consequence of too steep an angle. Subsequent frames of the angiogram demonstrate that the puncture was actually into the profonda femoris. When compared with the cartoon in the center, also from the article by Grier and colleagues, it can be seen that the sheath entry is exactly at the site that would be predicted from the data in the paper – namely the skin crease is a mean 6 mm below the bifurcation, not above as suggested by the earlier textbook cartoon. The idea that the skin crease is located over the center of the femoral head is an unfortunate but very common misconception.

Odds Ratio RPH 18:1

Femoral Artery Anatomy: A Prospective Study 200 consecutive patients All undergoing coronary angiography Femoral angiography at end of procedure Quantitative angiography Schnyder et al CCI 2001

Femoral Head and the CFA Bifurcation 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 I Number of patients I: 111 II: 44 III: 34 IV: 8 V: 3

Femoral Angiogram LAO RAO

Common Femoral Artery – Classic Measurements From top of femoral head to femoral bifurcation Does not take IEA into consideration Does not consider implications of CFA stick above bifurcation, but below femoral head  

Target Zone The Target Zone

 Target Zone Centerline TYPE 1 

 Target Zone Centerline TYPE 2

Cumulative Probability of Being Outside Target Zone Below Above FH Centerline

 IEA FH Centerline Cumulative Target Zone  BIF

Step 3 – Iterative Fluoroscopy

N=296

FAUST: Ultrasound RCT Outcomes And the randomized FAUST trial by SETO et al compared fluoroscopic and ultrasound guided access showing compellingly fewer puncture attempts, and lower risk of inadvertent venipuncture with ultrasound. Seto AH, Abu-Fadel MS, Sparling JM. JACC CV Interv ’10; 3:751

Fluoro guidance is not just using a hemostat 56% Abu-Fadel CCI 2009 However, they used a single fluoro of the hemostat and not the iterative technique described – as a result, note that punctures into zones I, II and III, that is above the femoral head, or at or over the top half, occurred in 56% - hence more than half were high compared to our fluoroscopic results using iterative fluoro. Ultrasound prevents low but not HIGH sticks, and the latter is more dangerous, so much to be said for both techniques.

How to Decrease Risk of Complications Access using fluoroscopy and/or ultrasound Needle entry below centerline of femoral head Femoral angiogram regardless of closure device use Proceed to PCI (and anticoagulate) only if puncture in safe zone

How to Decrease Risk of Complications Access using fluoroscopy and/or ultrasound Needle entry below centerline of femoral head Femoral angiogram regardless of closure device use Proceed to PCI (and anticoagulate) only if puncture in safe zone

How to Decrease Risk of Complications Access using fluoroscopy and/or ultrasound Needle entry below centerline of femoral head Femoral angiogram regardless of closure device use Proceed to PCI (and anticoagulate) only if puncture in safe zone

How to Decrease Risk of Complications Access using fluoroscopy and/or ultrasound Needle entry below centerline of femoral head Femoral angiogram regardless of closure device use Proceed to PCI (and anticoagulate) only if puncture in target zone

How to Decrease Risk of Complications Access using fluoroscopy and/or ultrasound Needle entry below centerline of femoral head Femoral angiogram regardless of closure device use Proceed to PCI (and anticoagulate) only if puncture in target zone Use micropuncture

Step 4 – Micropuncture Micropuncture

Some simple math ~ 7th grade Flow =  Pressure/Resistance Resistance = viscosity * length radius4 If  Pressure, viscosity and length fixed Then  Flow ~  radius4

Std needle (18g) = 1.27 mm Micropuncture (21g) = .813 mm  In size = 56% To make the case for micropuncture, if you apply Ohm’s and Poseiulle’s laws, the flow rate increase to the fourth power of any increase in radius. Thus, since the 18 gauge needle is 56% larger than the micropuncture needle, if you follow the animation by clicking, you will see that there is a theoretical 5.9 fold higher blood loss if you have a bad puncture with an 18 G needle than with a micropuncture needle. 5.9 fold  in blood loss

Controversies regarding access and closure has generated a fair amount of editorial comment, the above examples by this presenter. The evidenc base remains inconsistent.; with regard to vascular closure devices, the possibility that those of us who use these devices are guilty of an emperor’s clothes syndrome, whereby it will eventually be shown that the risk/benefit ratio of vascular closure devices is unfavorable, remains.

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