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Interventional Cardiology


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      CHAPTER 2

      The Essentials of Femoral Vascular Access and Closure

       Francesco Meucci, Miroslava Stolcova, Flavia Caniato, Mohammad Sarraf, Alessio Mattesini, and Carlo Di Mario

      While we are often preoccupied with the coronary and cardiac complications of catheterization and intervention, it is femoral access complications that occur more frequently, and which are certainly more recognized and remembered by patients. The incidence of local vascular complications that are considered major, as defined by the need for prolonged hospitalization, transfusion, or vascular surgery, ranges between 1% and 1.5% in diagnostic catheterization procedures, and typically between 3% and 5% in interventional procedures. More recently, refinements in techniques and antithrombotic regimes have reduced femoral vascular complications in interventional procedures to 2–3%, but they still remain frequent adverse events [1–3]. Risk factors for vascular complications include advanced age, female gender, low body surface area (BSA), aggressive antithrombin or antiplatelet agent use (e.g. GP IIb/IIIa inhibitors), emergent procedures, vascular disease, vessel size, sheath size, and puncture location [1,4]. The subjects of femoral access and management of femoral puncture after sheath removal are of vital importance in cardiac catheterizations and interventions, especially in patients with high risk of complications.

      Anatomy

      A good understanding of some key features of the local anatomy is essential for both optimal access and ideal management of the puncture site. Careful attention to access and careful evaluation of the access site are fundamental to reduce sheath insertion trauma and lead to uncomplicated sheath removal and the safe use of vascular closure devices.

Schematic illustration of femoral artery angiogram taken after sheath insertion. Schematic illustration of bilateral femoral artery angiograms.

      Puncture technique

      The basic technique of arterial access has changed very little since it was initially introduced by Seldinger [10]. Puncture of the common femoral artery is basically unchanged, save that the original concept used a through and through puncture and withdrawal of needle into the arterial lumen, while our current approach ideally punctures only the anterior surface of the femoral artery.

      However, the technique can be substantially improved by using fluoroscopy of bony landmarks to identify the likely course of the common femoral artery followed by confirmation with femoral angiography after sheath insertion [11]. A point of entry into the common femoral artery at the mid femoral head or slightly above is ideal. The femoral skin crease, which is a very commonly used landmark for puncture, is distal to the common femoral bifurcation in 72% of cases [12]. Generally speaking, younger patients have a mid‐femoral head location relatively close or slightly above the femoral crease. Older patients have a femoral head significantly above the femoral crease, since the crease tends to sag with age. Obese patients may have two or sometimes even three femoral creases.