Introduction

The steady increase in percutaneous interventional procedures for the treatment of cardiovascular diseases in a variety of vascular territories is associated with closer attention to access-site management. The more aggressive level of anticoagulation used during therapeutic procedures requires the achievement of safe and reliable hemostasis of the access site. Coronary interventions are usually performed by the femoral approach; however, to reduce complications and increase patient comfort, radial access is increasingly used and is becoming the preferred access site by many interventionalists.¹ Patients undergoing the femoral approach are usually immobilized overnight, which may result in significant discomfort because of increased back pain and the need for analgesics. Noncompliance of patients regarding strict bed rest after the procedure has been reported to be a substantial factor for femoral complications. During the last decade, there has been a rapid increase in the percutaneous treatment of aortic aneurysms, aortic dissections, and aortic valve replacement using much larger sheaths that require special attention to the access site. The most common catheterization problem involves the access site.^2,³ Additionally, major access-site complications increase the length of hospital stay and medical costs. Moreover, vascular complications are also associated with an increased risk of nonfatal myocardial infarction or death in the year following the procedure, in particular when accompanied by significant bleeding.⁴ The use of manual or mechanical compression was until recently the only way to control bleeding by allowing clot formation at the arteriotomy site. The clinical use of vascular closure devices for rapid hemostasis after femoral access was first reported in 1991. Since then, these devices have improved patient comfort by enabling early ambulation, and their use has decreased the burden of the medical staff. However, they have not produced a reduction in groin complication rates. This chapter summarizes the concepts of arterial access puncture, the use of arterial closure devices, and postprocedural management.

Planning Access

The selection of an appropriate access site is frequently a key issue for the successful completion of coronary or peripheral vascular procedures. Proficiency with all available vascular puncture techniques is therefore a basic requirement for the interventionist. It is important to review clinical reports and perform preprocedural vascular assessment of the quality of all peripheral pulses, presence of bruits, blood pressure difference between arms, and other pertinent findings, such as skin color, trophic changes, ulcerations, or the presence of intermittent claudication. Body habitus, such as extreme obesity, may dictate the use of the radial artery instead of the femoral approach. This important decision deserves full analysis of the target vessel for treatment, consideration of the patient’s preference, and assessment of the interventionist’s skills. Some aspects of the vascular access are crucial to the safety and success of the procedure.

Retrograde femoral access and radial access, with the choice based on the patient’s limitations or the operator’s preferences, are the two preferred approaches for coronary interventions. There are several techniques for endovascular peripheral therapies according to the target treatment vessel: the crossover femoral approach for contralateral iliofemoral treatment; anterograde femoral puncture for ipsilateral treatment of below-the-knee arteries; femoral retrograde access for aortic, carotid, iliac, and renal vessels; and local puncture for dialysis access treatment. Moreover, the common femoral artery is the preferred access for aortic artery and aortic valve interventions.

Retrograde Puncture Technique for the Femoral Artery

The common femoral artery is preferred for percutaneous arterial cannulation because it is large, accessible, and easily compressible. However, strict adherence to meticulous vascular access technique is necessary to avoid vascular complications while using manual compression or femoral closure devices, in particular when larger sheaths are being used. The mean luminal diameter of the common femoral artery is between 6 and 7 mm. This is theoretically large enough to comfortably accommodate the typical range of femoral sheath sizes for most diagnostic and interventional procedures. Diabetics and women have disproportionately smaller common femoral arteries. The vascular access is generally the only painful part of the procedure. Patient sedation and generous local anesthesia are needed, as well as adequate pressure and rhythm monitoring. The operator should be careful in choosing the site of cannulation of the femoral artery. In drawing an imaginary line between the anterosuperior iliac spine and the pubis, arterial pulsation is near or at the midpoint of the line. It is important not to rely on the inguinal crease to select the puncture site because the distance from the inguinal ligament to the inguinal crease varies, particularly in overweight patients. Fluoroscopy should be used to ascertain the relative location of the femoral head and pelvic brim in this subgroup of patients. Puncture at or just above the center of the femoral head is particularly important.

Ideally, the femoral artery is entered about 1 or 2 cm below the inguinal ligament (Fig. 29-1). If cannulation of the artery is too low, the chance of entering the superficial femoral artery rather than the common femoral artery is increased. This entry site may predispose to dissection, arterial occlusion, pseudoaneurysm, bleeding, and arteriovenous fistula formation. Entering the artery above the inguinal ligament may lead to problems in compressing the artery against the inguinal ligament, thus increasing the risk of hematoma formation and favoring retroperitoneal hemorrhage. The use of femoral closure devices is contraindicated in higher or lower femoral punctures. The other important aspect is careful puncture of only the anterior wall of the femoral artery with open-bore needles, which have the advantage of demonstrating blood return immediately. Appropriate vascular hemostasis can be achieved with the use of manual compression or femoral closure devices (Fig. 29-2). A reduction in the sheath size was presumed to result in fewer access complications, but there was no clear association with a decrement in the bleeding rate. Retrograde femoral access can be considered the standard technique for coronary, renal, iliac, and crossover for contralateral femoral interventions (Fig. 29-3). Endovascular repair of abdominal and thoracic aortic aneurysms has become the standard of care for anatomically appropriate patients. All the devices developed to date are deployed through relatively large (12- to 24-Fr) sheaths. Moreover, transcatheter aortic valve implantation is a rapidly emerging treatment option for patients with aortic valve stenosis and high surgical risk. Different access routes have been proposed, including transapical, transsubclavian, and transfemoral, with percutaneous transfemoral being preferred because it is the least invasive and potentially nonsurgical. However, vascular access-site complications due to the large-bore (18- to 24-Fr) delivery catheters remain an important clinical issue, particularly with respect to elderly patients. Traditionally, this access has required arterial exposure with open cut-down; but with the development of suture-mediated arterial closure devices, there is an increasing trend toward percutaneous endovascular repair. This is an effective and safe approach in a select group of patients. The procedure should be performed in a sterile operating room environment with the support of vascular surgeons in the event that the closure device should fail to close the arteriotomy. The need for larger sheaths for these interventions requires a meticulous puncture technique in the anterior wall of the common femoral artery.