Percutaneous Vascular Access: Transfemoral, Transseptal, Apical, and Transcaval Approach
Michael David Dyal, MD, FACC
Claudia A. Martinez, MD
INTRODUCTION
Arterial and venous access are essential components of all cardiac catheterization procedures. Arterial access sites include the common femoral artery, the radial, ulnar, brachial, and the axillary arteries. In addition, the carotid artery,1 the iliac, and the subclavian artery have been used for direct access to the ascending aorta. Vascular access site complications are common,2 and intimate knowledge of vascular anatomy and proper technique are critical for a successful and safe procedure. In this chapter, we will review femoral access and closure, left-sided heart catheterization via the transseptal and transapical routes, and the recently introduced transcaval approach. For radial access and open cut down, the reader is referred to chapters 4 and 6.
FEMORAL ACCESS
The common femoral artery (CFA) has traditionally been used for percutaneous cardiac interventions.3 Despite the adoption of radial artery access, CFA access remains the most commonly used approach for coronary and peripheral vascular procedures.4 Furthermore, CFA access has been shown to have more favorable outcomes when compared with alternative access sites for transcatheter aortic valve replacement.5 Vascular complications are increased significantly when arterial access is obtained below the common femoral artery bifurcation or above the inguinal ligament (external iliac artery).6 Successful CFA access can be obtained in nearly all procedures with proper training and technique using multiple modalities including anatomic landmarks, fluoroscopic landmarks, and real-time ultrasound guidance (FIGURES 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.7 and 3.8, 
Videos 3.1-3.3).7
Videos 3.1-3.3).7 FIGURE 3.1 Femoral anatomic landmarks. A, Skin landmarks. B, Fluoroscopic landmarks with the aid of a hemostat. |
 FIGURE 3.2 Femoral anatomy: Femoral angiogram with fluoroscopic and vascular landmarks illustrating the ideal puncture zone below the IEA and above the femoral bifurcation. CFA, common femoral artery; IEA, inferior epigastric artery; PFA, profunda femoris artery; SFA, superficial femoral artery. |
 FIGURE 3.3 High bifurcation. The utility of ultrasound guidance is illustrated here. The very high femoral bifurcation leaves a very narrow window for common femoral artery puncture. Ultrasound guidance can help in preventing a low arteriotomy, while the fluoroscopic landmarks help in preventing a high arteriotomy. |
 FIGURE 3.4 Ultrasound-guided femoral access. A, Sonosite ultrasound machine. B, Sonosite vascular probe with needle guide attachment, probe cover, sterile gel, and assorted needle guides. |
 FIGURE 3.5 A-I Pulsatile arterial blood flow seen on color Doppler. A-F, Systolic frames; G-I, diastolic frames. |
 FIGURE 3.6 Continuous venous blood flow seen on color Doppler. |
 FIGURE 3.7 Ultrasound of the CFA and vein as the operator scans distally to illustrate the bifurcation into profunda femoris and the superficial femoral artery (A) then back proximally to the common femoral artery (B). Ultrasound is used to ensure puncture proximal to the bifurcation and to avoid any large calcific femoral artery plaques. With ultrasound alone, there is a small risk of a high arterial puncture. Fluoroscopic landmarks and proper ultrasound technique can ensure CFA arteriotomy in the optimal location. The operator clearly identifies the CFA bifurcation. From here, the operator scans the vessel proximally with either a slight tilt or slide of the probe. |
 FIGURE 3.8 Arterial and venous access, basic technique. After identifying the skin and fluoroscopic landmarks, real-time ultrasound guidance with the assistance of a needle guide and micropuncture system is used for venous puncture (A-C). A 0.035″ wire is left in the vein and the artery is also accessed using real-time ultrasound guidance (D-F). A sheath is placed in the femoral artery and finally the venous sheath is inserted over the wire (G-H). |
LARGE BORE ACCESS AND PRECLOSURE
Femoral vascular complications increase relative to access sheath size.2,6 The current era of interventional cardiology has been characterized by a surge in interventions for structural heart disease and in the use of percutaneous left ventricular assist devices requiring large bore arterial access. The importance of proper technique is even more critical for patient safety and procedural success. In the following section, we will discuss large bore access and closure techniques (FIGURES 3.9 and 3.10).
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