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

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

3. 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

4. TAVR Complications
NEJM 2010

5. Usual Approach
Keep poking until you get a gusher

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

7. 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.

8. Inguinal Crease
UC San Diego
New Jersey

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

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

11. 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.

12. Odds Ratio RPH 18:1

13. 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

14. 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

15. Femoral Angiogram
LAO
RAO

17. 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  

18. Target Zone
The Target Zone

19. 
Target Zone
Centerline
TYPE 1 

20. 
Target Zone
Centerline
TYPE 2

21. Cumulative Probability of Being Outside Target Zone
Below Above
FH Centerline

22. 
IEA
FH Centerline
Cumulative Target Zone 
BIF

23. Step 3 – Iterative Fluoroscopy

24. N=296

25. 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

26. 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.

27. 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

28. 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

29. 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

30. 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

31. 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

32. Step 4 – Micropuncture
Micropuncture

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

34. 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

35. 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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