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

2. Vascular Access History
Beginning of modern vascular access
Sven Seldinger 2

3. 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

4. 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

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

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

7. 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

8. 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.

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

10. 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.

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

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

13. 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:

14. 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

15. 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

16. 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

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