Left Femoral Access Research Articles

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

Abstract Background There are many feasible ways to reach the coronary arteries through a percutaneous technique. Till now, the most commonly used approach is the radial artery approach because it has the lowest risk of known vascular adverse events. However, it could not be an option in some situations as congenital radial artery hypoplasia and radial artery spasm. In these cases, the second most common access is the femoral artery access. The current literature over the brachial artery access is controversial. Our study's objective is to verify the brachial artery approach's effectiveness and safety. Methods We studied 300 patients who underwent elective coronary angiography and percutaneous angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients in a group with brachial access and 150 in a group with femoral access. Baseline clinical and demographic traits of all enrolled patients were obtained from hospital records and the cardiovascular risk factors were identified. Venous blood samples, resting 12-lead electrocardiogram and transthoracic echocardiography were done before the coronary angiography. Access, procedural and fluoroscopy times were recorded. Doppler evaluations of both brachial and femoral arteries were done the day after the procedure. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Results Our data showed that no statistically significant difference between the studied groups regarding the cardiovascular risk factors, demographic, clinical and laboratory characteristics. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, p= 0.05), but no significant difference regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not differ significantly (p=0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ±1.1 vs. 3.4 ± 0.7 minutes, p=0.05) and shorter hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, p<0.001). Regarding complications, both major and minor complications were significantly lower in the brachial arm (p=0.04 and 0.05, respectively). Conclusion Brachial artery access is a safe, efficient alternative and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Comparing Obtura Vascular Closure Device to Manual Compression for Achieving Hemostasis After Percutaneous Transfemoral Procedures: A Randomized Study.

This trial was designed and aimed to compare safety and efficacy of Obtura™ vascular closure device (VCD) to manual compression (MC) among patients undergoing transfemoral catheterization. This prospective, randomized, controlled, multicenter trial of Obtura VCD against MC randomized patients in 1:1 (n=268; 134:134) ratio. Safety and efficacy were measured by primary endpoints (time to hemostasis [TTH] and deployment success) and secondary endpoints which included technical success, device-related adverse events, and time to ambulation (TTA). The procedural access using right femoral artery was performed in 95.52% of patients in Obtura VCD versus 96.27% in standard MC method, whereas 2.99% of patients in each group underwent left femoral access. Bilateral access was performed in 1.49% (n=2) versus 0.75% (n=1) in Obtura VCD versus MC, respectively. Both the technical success and deployment success were 100%. Patients in Obtura VCD group had shorter TTH (3.26±3.39 vs 23.95±8.24 minutes; p<0.0001) and TTA (155.44±125.32 vs 723.84±197.98 minutes; p<0.0001) than MC group. No access site complications (re-bleeding, infection, arteriovenous fistula, and transient access site nerve injury) were noted at 2-week, 1-month, and 3-month follow-ups. There were 4 (3%) and 6 (4.5%) cases of hematoma, respectively, in Obtura VCD versus MC and 1 case (0.7%) of post-procedural arterial pseudoaneurysm each in both the groups which were successfully resolved and patients were discharged with no further complications. Further follow-up was without any adverse events. The study demonstrated favorable safety and efficacy of Obtura™ VCD with a significantly short TTH and TTA compared to MC. In patients undergoing cardiac catheterization, vascular closure devices (VCDs) can achieve hemostasis faster after successful implantation of the device with fewer complications such as bleeding and ambulation can be achieved faster. In terms of effectiveness, Obtura VCD was found to be better than manual compression in achieving early hemostasis and higher technical and deployment success was accomplished. Obtura VCD does not require enlargement of the route through the tissues, uses the same existing arterial sheath as its conduit, and does not cause patients' access sites to feel uncomfortable while it is being deployed.

Safety and efficacy of brachial approach for coronary angiography and percutaneous coronary intervention

BackgroundThere are many percutaneous coronary approaches. The most commonly used one is the radial artery because of its lowest risk of adverse vascular events. However, it could not be an option in some situations as congenital radial artery hypoplasia and spasm. In these cases, the second most common access is the femoral artery. The current literature over the brachial artery access is controversial. Thus, the aim of this study was to verify the brachial artery approach's effectiveness and safety.ResultsWe studied 300 patients who underwent elective coronary angiography and angioplasty in our institution with failed radial access between August 2022 and February 2023. They were classified into two groups; 150 patients with brachial access and 150 with femoral access. Access, procedural and fluoroscopy times were recorded. All patients were examined carefully immediately after the procedure and before discharge to assess any complications. Left brachial access was used more frequently than left femoral access (32.7% vs. 22.7%, P = 0.05), but no significant difference noted regarding right sided or bilateral access. Procedure time, fluoroscopy time, and contrast volume did not significantly differ (P = 0.19, 0.06 and 0.1 respectively). However, brachial group had shorter access time (2.6 ± 1.1 vs. 3.4 ± 0.7 min, P = 0.05) and hospital stay (3.5 ± 1.1 vs. 5.9 ± 1.3 days, P < 0.001). Regarding major and minor complications (especially hematomas), they were significantly less in the brachial arm (P = 0.04 and P = 0.05, respectively).ConclusionsBrachial access is a safe, efficient and non-inferior to the femoral route for coronary intervention whenever radial access is not an option.

Single access covered endovascular reconstruction of the aortic bifurcation

We describe the feasibility of covered endovascular reconstruction of the aortic bifurcation (CERAB) through a single femoral access and a steerable sheath. We present the technique, which we used for a patient with severe aortoiliac calcification and bilateral involvement of the common femoral artery. The patient underwent endarterectomy of the left common femoral artery plus CERAB with an aortic stent graft and bilateral covered stents for the common iliac artery with kissing dilatation with a steerable sheath using only left femoral access. CERAB can be performed using unilateral access with the aid of a steerable sheath, reducing the potential for access site complications.

Leadless pacemaker implantation after transcatheter aortic valve replacement

Abstract Funding Acknowledgements Type of funding sources: None. Background Impairment of the conduction system may occur in 9-30 % of patients undergoing transcatheter aortic valve replacement (TAVR). Since this is typically an elderly and frail patient population, leadless pacing potentially offers benefits over conventional transvenous pacemaker devices. However, available efficacy and safety outcome data of leadless pacing in a population who underwent a TAVR procedure is still limited. Purpose Retrospective analysis of efficacy and safety outcome data in patients who underwent leadless pacemaker implantation after TAVR due to relevant bradycardias. Methods and Results In this retrospective analysis from two large Swiss implantation centres, 257 consecutive patients undergoing leadless pacemaker were included. Of the total cohort, 26 subjects had a previous TAVR complicated by early (within 30 days)- or late-onset (after 30 days) bradycardias (Table 1). The TAVR group did not differ compared to the non-TAVR with regard to age, gender and left-ventricular ejection fraction (LVEF). Median duration between valve intervention and leadless pacemaker implantation was 8 days (range 0 to 368 days). After a TAVR procedure, left femoral access was chosen in 30.8% (8 of 26 of cases) for the leadless pacemaker implantation as compared to 5.2% (12 of 231 of the cases) in the remaining population (P &amp;lt; 0.01). Mean implantation duration was 56 ± 22 min in the TAVR group compared to 48 ± 20 min (P = NS) and a successful implantation rate of 100.0 % in the TAVR group vs 98.7% in the remaining population (P = NS). There were no significant differences in pacing parameters (sensing, impedance and threshold, respectively) between the two groups. A total of eight major periprocedural complications (3.1%) were encountered in the entire cohort within 30 days, of which one (pericardial effusion) occurred in the TAVR population (P = 0.04), which was managed conservatively with pericardiocentesis. Conclusions Leadless pacemaker implantation appears to be safe and effective in patients after TAVR in need of antibradycardia pacing.

Percutaneous treatment of a Right Axillary Pseudoaneurysm

We present a very rare case of a 62-year-old male who was presented to our department with a large pulsatile mass on the upper lateral part of the right hemi thorax. He had undergone multiple vascular surgeries in the past months, last one including right axillary-femoral artery bypass grafting (AFBG). Last few days a large, growing pulsatile mass was identified. Contrast computed tomography identified 6x8 cm pseudoaneurysm of the right axillary artery. An open surgical repair was unsuccessful. He underwent an endovascular treatment using a stent graft via left femoral access. The patient had an uneventful recovery and remained well on follow-up.

Left femoral venous access for leadless pacemaker implantation: patient characteristics and outcomes

Abstract Funding Acknowledgements Type of funding sources: None. Background Leadless pacing has become an alternative approach for patients requiring a single-chamber pacemaker. Conventionally, Leadless Micra Transcatheter Pacing System (TPS) pacemakers are implanted via a right femoral venous access. However, due to various reasons, a left sided femoral venous approach may benecessary. We hypothesized that a left sided femoral venous approach is as safe and effective as compared to a right sided approach. Objective We assessed indications, procedural characteristics, safety and mid-term outcomes of Micra TPS implantation via a left femoral venous approach as compared to the conventional right sided approach. Methods and Results: In this retrospective single-center analysis, 143 consecutive patients undergoing Micra TPS implantation were included. 87% (125/143) underwent Micra TPS implantation via a right, and 13% (18/143) via a left femoral venous access. The mean age at implantation was 79.8 ± 7.5 years. Acute procedural success, mean procedure and fluoroscopy times as well as device parameters at implantation and follow-up (mean 15 ± 11.5 months) were similar between the two groups. Five major complications (3.5%) were encountered, all using a right-sided approach. After a transfemoral TAVI procedure, left femoral venous access was used in 42% of cases as compared to 8% in the remaining population (p = 0.003). Final leadless pacemaker position within the right ventricle was mid-septal in 82% (102/125) for right femoral access vs 72% (13/18) for left femoral access (p = 0.16). In the remaining cases (28 %, 5/18), the device was placed infero-septal following a left femoral venous access, as compared to 14% (18/125) for a right sided approach (p = 0.19). No repositioning was needed in 68% (85/125) using a right femoral access vs 72% (13/ 18) patients with a left femoral access (p = 0.84). Conclusions A left femoral venous access for Micra TPS implantation is safe and effective with an excellent implantation success rate similar to a conventional right femoral venous access without longer implantation and fluoroscopy times. The most frequent reason for choosing left- vs. right femoral venous access was a previous transfemoral TAVI procedure.

Frequency, Impact, and Predictors of Access Complications With Plug-Based Large-Bore Arteriotomy Closure - A Patient-Level Meta-Analysis

Background/purposeThe MANTA is a dedicated plug-based large-bore vascular closure device (VCD) providing safe hemostasis in most patients, but data on the clinical impact and mechanisms of MANTA related complications are limited. This study sought to determine the frequency, impact and predictors of MANTA-related access complications. Methods/materialsThis patient-level meta-analysis included data from 2 medical device approval studies and 1 post-approval registry. The primary endpoint was the composite of major and minor access complications. Technical success was defined as hemostasis with MANTA closure device without need for vascular surgery or stenting. ResultsEight hundred ninety-one patients (mean age 80) underwent transcatheter aortic valve replacement (n = 814), endovascular aortic repair (n = 71), balloon aortic valvuloplasty (n = 4) or mechanical circulatory support (n = 2). Technical success was 96.4% and median time to hemostasis was 31 (interquartile range: 17–76) seconds. The primary endpoint occurred 9.1% and bailout vascular surgery or stenting was necessary in 32 patients (3.6%). Female gender (OR: 2.63, CI: 1.46–4.73, p = 0.001), left femoral access (OR: 2.18, CI: 1.17–4.06, p = 0.015) and unfavorable arteriotomy phenotype (combination of a small femoral artery diameter with a deep arteriotomy; OR 2.27: 1.26–4.10, p = 0.006) independently predicted access complications. Access complications most often consisted of vessel dissection, stenosis or occlusion and predominantly occurred in patients with an unfavorable arteriotomy phenotype. ConclusionsLarge-bore arteriotomy closure with MANTA VCD provided fast and safe hemostasis with an acceptable complication rate. Refined procedure planning and risk-stratification may further improve MANTA VCD performance.

Real world data on non-complex catheter ablations performed on zero fluoroscopy in a secondary centre in the south of Belgium

Objective We have designed a study, whose aim was to confirm the feasibility and safety of the zero fluoroscopy approach in the treatment of supraventricular tachycardias (SVT) and premature ventricular contractions (PVCs) originating in the right ventricle in a secondary centre located in the south of Belgium. Methods We included in our retrospective analysis patients with a clinical history and/or electrocardiographic documentation of SVT or frequent symptomatic monomorphic PVCs referred to our centre from November 2019 to March 2020 for catheter ablation. Results A total of 49 patients were considered eligible for potential enrolment in the study, 3 were excluded because of presence of a manifest left sided atrio-ventricular accessory pathway, 5 because of left ventricular PVCs and 4 because of left atrial tachycardia. 4 patients were instead excluded because of need of utilisation of fluoroscopy during the procedure. A total of 33 patients were therefore included in the analysis. Right atrial flutters and typical AVNRT were the most common arrhythmia treated, corresponding together to the 81% of the total. Right femoral access was obtained in 86% of cases with left femoral access used in the remaining when right femoral access was not successful after the third attempt. Coronary sinus cannulation was efficacious within 10 min in 76% of cases. There were four minor complications overall. Conclusion The main finding of our study is that non-complex ablations can be performed on zero-fluoroscopy safely and with a good clinical outcome also in a secondary centre.

Risk Factors for Closure Failure following Percutaneous Transfemoral Transcatheter Aortic Valve Implantation

The percutaneous access site of transfemoral transcatheter aortic valve implantation (TAVI) procedures is commonly closed using a preclosure technique with suture-type closure devices. We sought to evaluate the predictors and outcomes of percutaneous closure device (PCD) failure during transfemoral TAVI. This single-center retrospective analysis included 184 patients who underwent transfemoral TAVI using 2 ProGlide sutures for severe aortic stenosis between July 2011 and September 2018. PCD failure was observed in 11.4%. The causes of PCD failure included 5 cases of insufficient hemostasis, 13 cases of arterial stenosis or occlusion, and 3 cases of dissection. Closure failures were managed by surgical repair in 10 patients and endovascular treatment in 11 patients. In a multivariate binary logistic model, a minimum lumen diameter of the common femoral artery (CFA) (odds ratio [OR] 0.35, 95% confidence interval [CI] 0.15-0.83, P=0.017) and left femoral access (OR 2.89, 95% CI 1.01-8.30, P=0.048) was identified as a predictor of PCD failure. PCD failure was not associated with increased mortality (0% vs. 2.5%, P=1.000) or a major adverse cardiovascular event (MACE; 4.8% vs. 4.3%, P=1.000) at 30days. PCD failures were not uncommon in patients undergoing percutaneous transfemoral TAVI. Small CFA diameter and left femoral access are predictors of PCD failure. However, PCD failures were not associated with increased mortality or MACE.

Intravascular Cement Leak after Vertebroplasty Treated with Stent Graft Placement in the Inferior Vena Cava

A 75-year-old man presented with a large amount of cement extravasation into the inferior vena cava (IVC) after undergoing L4-S1 surgical fusion with vertebroplasty for prostate cancer metastases. Cement extended from L4 to the suprarenal IVC (Fig 1). Given the risk for embolization, a decision was made to intervene. The brittle consistency of set cement raised concern for fracture and embolization during snaring maneuvers. It was decided to stabilize this cement column and exclude it from the flow lumen. Under general anesthesia, a 3-pronged approach was used. Through a 16-F internal jugular vein sheath, a Coda balloon (Cook, Inc, Bloomington, Indiana) was positioned in the suprahepatic IVC and inflated for flow interruption and embolic protection; the acute drop in preload was mitigated by aggressive fluid resuscitation with pressor support. A second Coda balloon positioned from the right groin was used to displace and compact the cement into the infrarenal IVC, allowing for deployment of a 32 mm × 57 mm Endurant II aortic extension stent graft (Medtronic, Minneapolis, Minneapolis) caudal to the renal veins, placed from a left groin access (Figs 2, 3). This stabilized most of the cement, excluding it from the flow lumen (Fig 4). Inadvertent embolization of a small piece of cement to the left lung occurred without clinical consequences (Fig 5). The patient was discharged on aspirin and clopidogrel. Six-month clinical follow-up was uneventful. The patient had no further embolization or IVC thrombosis on 1-month follow-up computed tomography (CT) (Fig 6). Figure 2Fluoroscopy image demonstrates undeployed stent graft placed from left femoral access (short arrow), positioned just caudal to lowest (right) renal vein—marked by wire placed from jugular approach (black arrow). The large cement piece extended from the level of L5 up to intrahepatic IVC (white arrows). Note an additional guide wire that had been advanced from a right common femoral vein access (asterisk). View Large Image Figure Viewer Download Hi-res image Figure 3A Coda balloon (black arrow) placed from the jugular access was inflated in the suprarenal IVC to interrupt blood flow and minimize embolization risk. A second Coda balloon placed from a right femoral access was inflated above the cement piece and pulled down to displace cement (white arrows) caudal to the ostia of the renal veins. Note a small fragment of cement that inadvertently broke off (short arrow), which was seen only retrospectively. View Large Image Figure Viewer Download Hi-res image Figure 4The stent graft was deployed in the infrarenal IVC while trapping most of the cement against the vein wall (white arrow). A wire placed from jugular access into the right renal vein courses through the uncovered portion of the stent graft (black arrow), designed for suprarenal fixation. View Large Image Figure Viewer Download Hi-res image Figure 5Fluoroscopy of the chest demonstrates a small cement fragment in the left lung (arrow) owing to embolization. View Large Image Figure Viewer Download Hi-res image Figure 6Coronal oblique multiplanar reformat from contrast-enhanced CT performed 1 month after procedure confirms exclusion of cement from the IVC lumen by the stent graft (white arrow) and patency of IVC and right renal vein draining through the uncovered portion of the stent graft (short arrow). The left renal vein was also patent, draining above the stent graft (not shown). Hyperdensities to the left of the IVC correspond to aortic atherosclerotic plaques (asterisk). View Large Image Figure Viewer Download Hi-res image

Modified candy-plug device for aneurysmal false lumen occlusion in chronic type B aortic dissection

Modified candy-plug device for aneurysmal false lumen occlusion in chronic type B aortic dissection

Entrapment of a micro-guidewire during stenting of basilar stenosis

Entrapment of a microwire related to intracranial endovascular therapy is an uncommon complication. A 64-year-old man with symptomatic basilar artery stenosis was treated with stenting. A 300 cm Synchro microwire...

1603 Angiographic Embolization and Trauma: Successful Treatment in two Adolescents

Background and AimsSince 1990s angiographic embolization is used in adult trauma for bleeding control and organ preservation. Experience in children is limited probably because of a higher success rate of...

Balloon mitral valvotomy from left femoral access in a patient with restenosis following earlier balloon mitral valvotomy

Successful Re-do balloon mitral valvotomy was done from left femoral access because of abnormality in right lower limb venous system in a patient who underwent BMV in past before 6 years. This is an unusual case of its kind in which redo BMV as a second procedure was done using left femoral vein as an access.

Technical Factors Affecting the Accuracy of Bedside IVC Filter Placement Using Intravascular Ultrasound

To compare the accuracy of inferior vena cava (IVC) filter placement using a bedside technique guided by intravascular ultrasound (IVUS) with a concurrent experience of filter deployment with fluoroscopic venogram imaging. From November 2006 to December 2009, 195 consecutive IVC filters were placed to prevent pulmonary embolism in 120 high-risk patients without lower limb deep vein thrombosis (DVT) and 75 patients with DVT and anticoagulation contraindications. Filter insertion techniques included bedside IVUS-guided (n = 97) and fluoroscopic-guided (n = 98) procedures. Before mid-2008, 2 bedside IVUS-guided protocols were used evolving from a single-puncture, pullback technique (n = 48), in which the measured distance from the venous access site to the IVC landing zone then allowed a calibrated reinsertion of a 7F delivery sheath and filter deployment. After mid-2008, a single puncture 8F sheath technique (n = 48) using IVUS to position the delivery sheath tip within the IVC landing zone without catheter or sheath measurement or reinsertion was used. Venous access was via the right femoral (84 IVUS and 56 fluoroscopy), left femoral (10 IVUS and 16 fluoroscopy), or right internal jugular vein (3 IVUS and 26 fluoroscopy). The 3 filter insertion techniques were compared for "optimal" IVC placement defined as the filter positioning between L1 and L4 vertebrae with tilt <15° based on postprocedure abdominal x-rays or venography. Filter malposition occurred with 6% (6 of 97) bedside IVUS-guided procedures with no malpositions during fluoroscopic imaging. Malposition was lower with the evolved sheath (4%, 2 of 48) compared with the earlier pullback (8%, 4 of 48) insertion technique (P = .03). The incidence of the filter malposition during IVUS-guided deployment was highest using left femoral access (4 of 10) compared with right femoral (2 of 84) or internal jugular (0 of 3) vein access (P < .01). Filter tilt occurred more after IVUS-guided procedure (10 of 97) than fluoroscopic procedure (3 of 98; P = .05) and was most frequent for left femoral access (5 of 10 IVUS and 1 of 16 fluoroscopy; P < .01) and was not related to filter type (P = .13). Our current bedside IVUS-guided IVC filter technique using a single venous puncture and single sheath positioning has improved the placement accuracy. Left femoral venous access should be avoided to minimize the occurrence of filter malpositioning and tilt.

Contralateral Iliac Occlusion can be Successfully Achieved Using an Amplatz Vascular Plug During Aorto-uni-iliac Endovascular Aneurysm Repair

IntroductionAorto-uni-iliac endovascular aneurysm repair is usually accompanied by contralateral iliac occlusion, but access limitations may make plug deployment impossible. ReportA 73-year-old male underwent aorto-uni-iliac endovascular aneurysm repair via left femoral access for a 5.8 cm abdominal aortic aneurysm; the right common iliac artery was occluded by a 16 mm Amplatz Vascular Plug II via a 7Fr Flexor Ansel Sheath, followed by femorofemoral crossover. The aneurysm was successfully excluded with no endoleaks at follow-up. DiscussionAccess limitations are a consideration for both device deployment and contralateral occlusion whilst undertaking aorto-uni-iliac endovascular aneurysm repair. This paper describes a simple and effective method for achieving iliac occlusion when access vessels are stenosed.