1. Zoltan G. Turi, M.D. Cooper University Hospital Cooper Medical School of Rowan University Camden, NJ Vascular Access and Closure

2. Conflict of Interest Grant SupportAbbott Vascular Arstasis Cordis Marine Polymer Technologies St. Jude Medical ConsultationMitralign

3. Vascular Access in the New Percutaneous Technologies Era: Taken for Granted Under-investigated but Way Over-represented in Complications

4. “We All Know How to Do This” Little Change in Past 59 Years Sven-Ivar Seldinger Turi

5. Landmarks for Femoral Access What is your primary landmark? 1. Inguinal crease 2. Maximal pulsation 3. Bone landmarks X X 4. Prior puncture site

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

7. Inguinal Crease advertisement Your patients

8. This is NOT Normal Anatomy SFA CFA PFA 3 Misconceptions despite 50 years experience

10. Odds Ratio RPH 18:1

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

12. Femoral Angiogram LAORAO IEA

14. 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  

15.   Target Zone TYPE 1 Centerline

16. Target Zone   TYPE 2 Centerline

17.   BIF IEA Cumulative Target Zone FH Centerline

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

19. Arora n=12,937 Vascular Closure Devices Early hemostasis, early ambulation Class III indication – VCD use to lower complication rates Some complications – infection, RPH - clearly  1992 2007 Sanborn Circ CI 2009 ACUITY

20. How to Decrease Risk of Complications 1.Access using fluoroscopy and/or ultrasound 2.Needle entry below centerline of femoral head 3.Femoral angiogram regardless of closure device use 4.Proceed to PCI (and anticoagulate) only if puncture in safe zone

21. 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in safe zone How to Decrease Risk of Complications

22. 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in safe zone How to Decrease Risk of Complications

23. 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in target zone How to Decrease Risk of Complications

24. 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in target zone 5. Use micropuncture How to Decrease Risk of Complications

25. Newer Evidence Base Ultrasound guided access Micropuncture

26. Better Technique  Better Result