12/8/2013
Femoral Approach
Dr Sameh Emil , M.D. , FSCAI
Introduction
• Coronary angiography is performed under local
anesthesia. The procedure is sterile, and all
potential access sites must be disinfected,
shaved, and sterilized.
• Coronary angiography is performed with the
patient in the fasting state, except in emergency
cases.
• The choice of catheterization approach (femoral,
radial or brachial) is usually a function of
operator, institution, and patient preference.
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Arterial puncture
• The standard technique of arterial puncture used
today is Seldinger technique, developed by SvenIvar Seldinger, a Swedish radiologist, in 1953.
• At the site of arterial puncture, an appropriate
pulse has to be palpated in order to locate the
artery, using the three middle fingers of left hand.
• A local anesthesia is applied, usually with 10-15
ml of 1% or 2% lidocaine for local infiltration of
the skin and subcutaneous tissues.
Arterial puncture
• The needle is held in the operator's hand like a pencil,
at an angle of 30º-45º against the surface of the skin.
• The pointy tip at the distal end of the needle is the first
one in contact with the skin, and subsequently with the
artery, while the distal needle opening faces upwards.
• Arterial puncture is made by advancing the needle to
the site of the arterial pulse.
• Arterial pressure will produce a pulsatile jet of blood
when the needle tip reaches the arterial lumen.
• After the arterial puncture, an atraumatic, curvedtipped guide wire (J-wire) is passed through the needle
and advanced into the artery without any resistance.
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Puncture Site
• The most commonly used is right femoral site, as
it is the most comfortable access for the operator.
• Transfemoral approach is favored because of the
larger artery diameter, and therefore the
possibility to insert larger arterial sheaths,
catheters and bulkier devices.
• The proper site is 1-2 cm below inguinal ligament
which is attached between anterior superior iliac
spine and pubic bone .
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Puncture Site
The most reliable landmark is probably the junction between the middle and the
lower third of the femoral head (radiographic landmark).
Advantages of Femoral Access
• Clear landmarks : Inguinal crease , bony
landmarks , radiological ( head of Femur ) ,
Doppler guided and Ultrasound guided.
• Easier access site .
• Shorter learning curve.
• Flexibility of sheath size.
• Less radiation exposure.
• Comfortable operator position.
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Limitations of Femoral Access
• Delayed ambulation.
• Patient discomfort.
• Higher vascular complications esp. in anticoagulated and obese patients.
• CFA lies just near a major vein (Femoral Vein)
and nerve (Femoral Nerve).
• CFA is the unique blood supply to the leg.
• Time of personnel post cath.
Difficulties in Femoral Puncture
Weak femoral blood flow: branch , subintimal.
• The needle should be removed and the groin
should be compressed for 5 minutes. The
operator should verify the correctness of the
anatomic landmarks and attempt repuncture of
the femoral artery.
• If the second attempt is unsuccessful in allowing
wire advancement, a third attempt on the same
vessel is unwise, and an alternative access site
should generally be selected.
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Difficulties in Femoral Puncture
Difficult wire motion : subintimal , iliac disease.
• The wire should be pulled back slightly under
fluoroscopic control , reassess the blood flow ,
small bolus of contrast medium is then
injected gently under fluoroscopic monitoring.
This should disclose the anatomic reason for
difficult wire advancement-generally either
iliac tortuosity, stenosis, or dissection .
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Difficulties in Femoral Puncture
Problems advancing the wire above the aortic
bifurcation : suggest the presence of an
abdominal aortic aneurysm or bifurcation
stenosis. Which warrants use of soft-tip
hydrophilic guidewires and extreme care to
avoid perforation or dislodgment of cavitary
thrombus or debris.
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Femoral Vein Puncture
• The femoral venous puncture is usually
performed prior to arterial puncture. With the
left hand palpating the femoral artery along
its course below the inguinal ligament, the
needle is introduced through the more medial
position with a 10-mL syringe is attached to
the needle , gentle suction is applied to the
syringe , as the tip of the needle is in the
lumen, venous blood will flow freely into the
syringe. Then continue as arterial puncture.
Contraindications to Femoral
Approach
• Peripheral vascular disease (femoral bruits or
diminished lower extremity pulses).
• Abdominal aortic aneurysm.
• Marked iliac tortuosity.
• Prior femoral arterial graft surgery.
• Gross obesity.
• Inability to obtain hemostasis after catheter
removal.
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Complications
Complications
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Bleeding - Hematoma
•
•
•
•
Most common complication post PCI.
90% of bleeding at the access site.
Either minor oozing or frank bleeding.
Manifests as a hematoma.
Bleeding - Hematoma
• Symptoms & Signs :
- Site pain.
- Difficulty in moving leg / hip.
- Possible tachycardia or hypotension.
- Red / purple skin discoloration.
- Swelling at insertion site ( hematoma ).
- Loss of pedal pulse in affected leg.
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Bleeding - Hematoma
• Management :
- Prolonged manual compression.
- Mark the hematoma boundaries.
- Close observation of vital signs.
- Measure the thigh girth.
- Stop or correct anticoagulation (Protamine).
- Blood transfusion ( if needed ).
Pseudoaneurysm
• Accumulation of blood forming a sac
surrounding an intimal disruption of the
arterial wall without involvement of other
layers.
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Pseudoaneurysm
• Symptoms & Signs :
- Groin pain.
- Back pain.
- Swelling at groin site.
- Ecchymosis.
- Pulsatile mass.
- Bruit.
• Management :
- Close observation.
- Prolonged
compression.
- Thrombin injection.
- Surgery ( if needed ).
Retroperitoneal Hematoma
• Results from blood leak
into the retroperitoneal
compartments as a
result of puncturing the
posterior wall of the
femoral artery above
the inguinal ligament or
the presence of
peripheral arterial
disease in external iliac
artery.
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Retroperitoneal Hematoma
• Symptoms & Signs :
- Groin pain.
- Low abdominal pain.
- Hypotension , tachycardia.
- Anemia.
- Abdominal tenderness.
- Brusies around umbilicus & flanks.
Retroperitoneal Hematoma
• Diagnosis :
- High clinical suspicion.
- Clinical manifestations.
- Ultrasound.
- CT or MDCT.
- MRI.
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Retroperitoneal Hematoma
• Management :
- Stop anticoagulation.
- Fluid replacement.
- Blood transfusion.
- Conservative close observation.
- Endovascular ( graft stent ).
- Surgery.
Arterio-Venous Fistula
• Rare.
• Usually occurs when needle puncture artery &
vein , more likely with a low femoral puncture
as the vein is posterior to the artery.
• Manifests as groin swelling & leg pain.
• Possible tachycardia & hypotension.
• Possible high-output manifestations.
• Bruit.
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Arterio-Venous Fistula
• Management :
- Small : spontaneously close.
- Indications for repair :
* High output failure .
* Persistent tenderness .
* Leg edema .
* Vascular steal .
- Repair : Surgery – Covered stent – Coils .
Neuropathy
• Rare.
• After large hemorrhage
or pseudoaneurysm:
- Pressure exerts on
medial & intermediate
cutaneous nerves.
- Usually resolves when
cause resolves.
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Arterial Occlusion
Endovascular intervention
From contra-lateral limb.
Sheath Removal
• When to Remove :
- Diagnostic procedures : immediately.
- PCI : 4-6 hours to give Heparin time to dissipate & to be
a ready access if abrupt closure occurs.
• Ways to achieve Hemostasis :
- Manual compression.
- Compression Devices ( C- clamp – Femostop ).
- Vessel Closure Devices ( VCD ).
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Manual Compression
Typically 2 hands are used initially, one over the top
of the other without the use of gauze.
• Downward pressure on the artery with fingertips
just superior to the skin puncture site .
• Puncture site should always be visible, ensuring
blood has stopped oozing.
• Maintain direct, non-occlusive arterial pressure
for a minimum of 5 minutes.
• If oozing should occur, apply additional nonocclusive pressure until hemostasis is achieved.
Manual Compression
Incorrect
Correct method
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C - Clamp
The C-clamp device
consists of a hand
adjustable clamp that
applies pressure to the
artery.
A transparent sterile disc
is applied over the
femoral artery puncture
site until hemostasis is
obtained.
Femostop
The FemStop device uses a
small pneumatic pressure
dome, a belt and a pump.
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Mechanical Compression Devices
• Advantages :
- Hands-free operation.
- Decreased contact with blood.
- Controlled pressure.
• Disadvantages :
- Cannot be used on obese.
- Severe peripheral vascular disease.
- Femoral artery or femoral venous grafts .
Vessel Closure Devices ( VCD )
• Vascular closure devices are an
alternative to manual and
mechanical compression to
achieve hemostasis after PCI.
• Suture Based: Perclose
• Collagen Based: Angio-Seal,
VasoSeal
• Synthetic Biosealant Based: Mynx
• Gel/foam Based: Duett, QuickSeal
• Staple Based: StarClose, Angiolink
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Vessel Closure Devices ( VCD )
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•
•
•
Advantages :
Minimize patient discomfort associated with
sheath removal.
Reduce the need for long recumbent position
following procedure.
Decrease the time to ambulation.
Shorten time to potential hospital discharge.
Vessel Closure Devices ( VCD )
Indications:
• Discomfort Associated with Sheath Removal
• Inability to tolerate prolonged supine position in
selected patients due to a variety of Co-morbid
conditions including:
- Genital Urinary Problems (e.g. BPH)
- Spinal Stenosis
- Congestive Heart Failure
- Severe COPD
- Severe Valvular Disease
- Patients with Various Mental Disable Conditions
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Vessel Closure Devices ( VCD )
Although most of the currently
available access site closures
devices have reduced time to
ambulation and hemostasis with
similar complication rates
compared to manual
compression, the adoption rate is
relatively low due to limitations
associated with these devices.
Perclose
Starclose
Angioseal
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THANK YOU FOR ATTENTION
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Question 2
• An 81 y woman develops groin pain and
hypotension 2 hours after manual 6F
sheath removal with manual compression.
The most important next steps in
management include all of the following,
except:
A. Compression of the groin access site
B. Secure large-bore IV access
C. Abdominal CT scan
D. Reverse anticoagulation
Question 3
• You are preparing to obtain femoral access in a morbidly
obese patient. Which strategy is most likely to yield the
most accurate sheath insertion in the target zone of the
common femoral artery?
A. Check fluoroscopic position of a clamp at intended
puncture site, while palpating femoral pulse
B. Insert the needle at the inguinal crease and advance
until the artery is entered
C. Palpate the anterior iliac crest and the symphysis
pubis, then insert the needle along the line midway
between the two landmarks
D. Assume a shallow angle with the needle, to glide under
the pannus
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Question 4
• One day after cardiac catheterization from 6F
right common femoral access, your patient is
asymptomatic, but has a new bruit in the groin.
Duplex ultrasound showed arterio-venous
fistula. What do you recommend to the
patient?
A. Continue to observe, unless symptoms
develop
B. Surgical ligation
C. Consider PTFE-covered self-expanding stent
D. Coil embolization
Question 5
• At the conclusion of a PCI you elect to use a
collagen-plug mediated VCD. The patient later
asks you why you chose to use a closure device,
when during prior catheterizations, she has
always had MC . Which statement best
justifies your decision ?
A. It will reduce the risk of bleeding
B. It will shorten the time to hemostasis
C. It will reduce the likelihood of developing a
groin infection
D. It will reduce the chance of requiring
vascular surgery
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