Curr Cardiol Rep (2015) 17:44 DOI 10.1007/s11886-015-0596-6
INTERVENTIONAL CARDIOLOGY (S RAO, SECTION EDITOR)
Achieving Safe Femoral Arterial Access Michael S. Lee 1 & Jeremy Kong 1
# Springer Science+Business Media New York 2015
Abstract Percutaneous coronary intervention can lead to vascular access complications that prolong patient hospital stay and costs as well as increase patient morbidity and mortality. Given its ease of use and familiarity, transfemoral access is still the preferred method of approach by many operators. The transfemoral approach is used when large bore access is required or if transradial access is not feasible due to variations in the anatomy of the upper extremity artery. The use of fluoroscopy, ultrasonography, and femoral angiography can help the operator obtain proper arteriotomy of the common femoral artery. Measures to decrease vascular access complications include proper technique, optimal pharmacotherapy, and avoiding the use of arterial sheaths >6 Fr. Optimal pharmacotherapy includes the use of bivalirudin and weight-based unfractionated heparin to avoid supratherapeutic activated clotting times, and to avoid glycoprotein IIb/IIIa inhibitors. When used appropriately, vascular closure devices can decrease the risk of bleeding complications. Randomized trials are needed to confirm these recommendations. Keywords Bleeding . Vascular access . Vascular complications
Introduction Refinements of percutaneous coronary intervention (PCI) have improved safety and efficacy. Key factors in patient safety include successful arterial cannulation and closure of the arteriotomy. Survival is improved by reducing major hemorrhagic complications at the arteriotomy site [1•]. Although the
adoption of transradial access is increasing in the USA, the most frequent vascular access site for cardiac catheterization is the common femoral artery. Transfemoral access may be required when the radial artery anatomy is unfavorable, if radial artery spasm occurs, or when large bore hemodynamic support devices are needed. Transfemoral access may be challenging due to the inability to directly visualize the common femoral artery and variations in the anatomy, leading to a greater risk of vascular complications including hematoma, arteriovenous fistula, retroperitoneal hemorrhage, and pseudoaneurysm [2–12]. Transfemoral access is also associated with patient dissatisfaction, increased cost, need for blood transfusion, longer hospitalization, and increased morbidity and mortality. Appropriate techniques for femoral arterial access can minimize the risk of these complications. The association between increased mortality and bleeding complications may be due to various mechanisms such as hemodynamic compromise, especially in patients who present with myocardial infarction; premature discontinuation of oral antiplatelet therapy, which increases the risk of stent thrombosis; and the discontinuation of agents such as statins, beta blockers, and angiotensin-converting enzyme inhibitors [13, 14]. Blood transfusion is associated with prothrombotic and proinflammatory effects, microvascular obstruction, and impaired oxygen delivery of transfused erythrocytes [4, 5, 15]. Strategies to minimize bleeding complications include proper vascular access technique and optimal pharmacotherapy (Table 1). Many operators still prefer femoral access because of ease of use, familiarity, and less radiation exposure [16, 17]. We review the data and discuss potential strategies to minimize the risk of femoral artery access site-related complications.
This article is part of the Topical Collection on Interventional Cardiology
Access Technique * Michael S. Lee [email protected] 1
Division of Cardiology, UCLA Medical Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, USA
Fluoroscopic Guidance Locating the common femoral artery is difficult in obese patients, especially in those who have their crease inferiorly
44 Table 1
Page 2 of 8 Strategies to optimize femoral artery access
Access technique Fluoroscopic guidance Ultrasound guidance Micropuncture technique Femoral angiography Procedural and peri-procedural factors Arterial sheath size Bivalirudin Weight-adjusted heparin Avoidance of glycoprotein IIb/IIIa inhibitor Access site management Management of hypertension Early removal of vascular sheaths Potentially vascular close device
Curr Cardiol Rep (2015) 17:44
Studies suggest a benefit with the use of fluoroscopy compared to palpation alone, while three randomized trials did not show benefit for fluoroscopic guidance in non-common femoral artery cannulations compared to the use of only traditional anatomic landmarks [25–27]. However, in another study, fluoroscopy guidance was associated with fewer arterial punctures below the inferior border of the femoral head without increasing the number of punctures above the femoral head’s superior border [25]. One registry showed that in women, fluoroscopyguided femoral access was an independent predictor for fewer bleeding complications [28]. Another prospective registry established a positive association between fluoroscopy prior to PCI arteriotomy and lower incidences of arterial injury (0.7 vs. 1.9 %, p
INTERVENTIONAL CARDIOLOGY (S RAO, SECTION EDITOR)
Achieving Safe Femoral Arterial Access Michael S. Lee 1 & Jeremy Kong 1
# Springer Science+Business Media New York 2015
Abstract Percutaneous coronary intervention can lead to vascular access complications that prolong patient hospital stay and costs as well as increase patient morbidity and mortality. Given its ease of use and familiarity, transfemoral access is still the preferred method of approach by many operators. The transfemoral approach is used when large bore access is required or if transradial access is not feasible due to variations in the anatomy of the upper extremity artery. The use of fluoroscopy, ultrasonography, and femoral angiography can help the operator obtain proper arteriotomy of the common femoral artery. Measures to decrease vascular access complications include proper technique, optimal pharmacotherapy, and avoiding the use of arterial sheaths >6 Fr. Optimal pharmacotherapy includes the use of bivalirudin and weight-based unfractionated heparin to avoid supratherapeutic activated clotting times, and to avoid glycoprotein IIb/IIIa inhibitors. When used appropriately, vascular closure devices can decrease the risk of bleeding complications. Randomized trials are needed to confirm these recommendations. Keywords Bleeding . Vascular access . Vascular complications
Introduction Refinements of percutaneous coronary intervention (PCI) have improved safety and efficacy. Key factors in patient safety include successful arterial cannulation and closure of the arteriotomy. Survival is improved by reducing major hemorrhagic complications at the arteriotomy site [1•]. Although the
adoption of transradial access is increasing in the USA, the most frequent vascular access site for cardiac catheterization is the common femoral artery. Transfemoral access may be required when the radial artery anatomy is unfavorable, if radial artery spasm occurs, or when large bore hemodynamic support devices are needed. Transfemoral access may be challenging due to the inability to directly visualize the common femoral artery and variations in the anatomy, leading to a greater risk of vascular complications including hematoma, arteriovenous fistula, retroperitoneal hemorrhage, and pseudoaneurysm [2–12]. Transfemoral access is also associated with patient dissatisfaction, increased cost, need for blood transfusion, longer hospitalization, and increased morbidity and mortality. Appropriate techniques for femoral arterial access can minimize the risk of these complications. The association between increased mortality and bleeding complications may be due to various mechanisms such as hemodynamic compromise, especially in patients who present with myocardial infarction; premature discontinuation of oral antiplatelet therapy, which increases the risk of stent thrombosis; and the discontinuation of agents such as statins, beta blockers, and angiotensin-converting enzyme inhibitors [13, 14]. Blood transfusion is associated with prothrombotic and proinflammatory effects, microvascular obstruction, and impaired oxygen delivery of transfused erythrocytes [4, 5, 15]. Strategies to minimize bleeding complications include proper vascular access technique and optimal pharmacotherapy (Table 1). Many operators still prefer femoral access because of ease of use, familiarity, and less radiation exposure [16, 17]. We review the data and discuss potential strategies to minimize the risk of femoral artery access site-related complications.
This article is part of the Topical Collection on Interventional Cardiology
Access Technique * Michael S. Lee [email protected] 1
Division of Cardiology, UCLA Medical Center, 100 Medical Plaza, Suite 630, Los Angeles, CA 90095, USA
Fluoroscopic Guidance Locating the common femoral artery is difficult in obese patients, especially in those who have their crease inferiorly
44 Table 1
Page 2 of 8 Strategies to optimize femoral artery access
Access technique Fluoroscopic guidance Ultrasound guidance Micropuncture technique Femoral angiography Procedural and peri-procedural factors Arterial sheath size Bivalirudin Weight-adjusted heparin Avoidance of glycoprotein IIb/IIIa inhibitor Access site management Management of hypertension Early removal of vascular sheaths Potentially vascular close device
Curr Cardiol Rep (2015) 17:44
Studies suggest a benefit with the use of fluoroscopy compared to palpation alone, while three randomized trials did not show benefit for fluoroscopic guidance in non-common femoral artery cannulations compared to the use of only traditional anatomic landmarks [25–27]. However, in another study, fluoroscopy guidance was associated with fewer arterial punctures below the inferior border of the femoral head without increasing the number of punctures above the femoral head’s superior border [25]. One registry showed that in women, fluoroscopyguided femoral access was an independent predictor for fewer bleeding complications [28]. Another prospective registry established a positive association between fluoroscopy prior to PCI arteriotomy and lower incidences of arterial injury (0.7 vs. 1.9 %, p
