Retrograde Femoral Access Research Articles

Complications Related to Femoral Artery Access for Transcatheter Procedures

Percutaneous-based procedures continue to increase as endovascular techniques improve and provide a less morbid approach than the open vascular procedures. The most common complications associated with either cardiac interventions or peripheral interventions involve the access point of the procedure. The retrograde femoral access has and is currently the most frequently used arterial access. Vascular surgeons have been responsible for management of complications following femoral-based procedures and now are a significant contributor to catheter-based diagnostic and interventional procedures. This review provides in-depth review of the literature on specific complications encountered during percutaneous femoral artery puncture. This review includes access complications related to the method of obtaining access (ie, best pulse fluoroscopic guided), direction of access either retrograde or antegrade, risk factors and incidence of complications based on best literature sources, and management strategies for specific complications.

Real-Time Ultrasound Guidance Facilitates Femoral Arterial Access and Reduces Vascular Complications: FAUST (Femoral Arterial Access With Ultrasound Trial)

The aim of this study was to compare the procedural and clinical outcomes of femoral arterial access with ultrasound (US) guidance with standard fluoroscopic guidance. Real-time US guidance reduces time to access, number of attempts, and complications in central venous access but has not been adequately assessed in femoral artery cannulation. Patients (n = 1,004) undergoing retrograde femoral arterial access were randomized 1:1 to either fluoroscopic or US guidance. The primary end point was successful common femoral artery (CFA) cannulation by femoral angiography. Secondary end points included time to sheath insertion, number of forward needle advancements, first pass success, accidental venipunctures, and vascular access complications at 30 days. Compared with fluoroscopic guidance, US guidance produced no difference in CFA cannulation rates (86.4% vs. 83.3%, p = 0.17), except in the subgroup of patients with CFA bifurcations occurring over the femoral head (82.6% vs. 69.8%, p < 0.01). US guidance resulted in an improved first-pass success rate (83% vs. 46%, p < 0.0001), reduced number of attempts (1.3 vs. 3.0, p < 0.0001), reduced risk of venipuncture (2.4% vs. 15.8%, p < 0.0001), and reduced median time to access (136 s vs. 148 s, p = 0.003). Vascular complications occurred in 7 of 503 and 17 of 501 in the US and fluoroscopy groups, respectively (1.4% vs. 3.4% p = 0.04). In this multicenter randomized controlled trial, routine real-time US guidance improved CFA cannulation only in patients with high CFA bifurcations but reduced the number of attempts, time to access, risk of venipunctures, and vascular complications in femoral arterial access. (Femoral Arterial Access With Ultrasound Trial [FAUST]; NCT00667381).

Easy technique for retro-antegrade superficial femoral artery catheterization

The antegrade femoral approach is a routinely used technique for the percutaneous treatment of the lower extremities vascular disease. However, this approach can be challenging in case of obese patients or due to special anatomy of the femoral bifurcation. We present a simple and inexpensive alternative by means of the use of a Fogarty catheter to convert a retrograde femoral access to an antegrade catheterization.

A percutaneous arterial closure protocol can decrease complications after endovascular interventions in vascular surgery patients

Complications following percutaneous femoral access are a significant source of morbidity and cost in patients undergoing peripheral vascular interventions. Our purpose in this study is to determine if access complications could be reduced by the use of a standardized protocol. We studied prospectively 210 consecutive patients in our vascular surgery practice undergoing peripheral arterial interventions via percutaneous retrograde femoral access. First, we prospectively collected data to determine current outcomes during a 4-month observation phase. Based on these experiences, we designed and implemented a uniform arterial closure protocol, with closure device use guided by sheath size, arterial calcification, and previous groin scarring. Our main outcome measures were major complications (need for operation) or minor complications (access site bleeding or hematoma). Outcomes were compared between the two phases using chi-squared analysis and analysis of variance (ANOVA). In the observation phase, 119 patients underwent 140 arterial punctures, and in the postprotocol phase, we performed 112 punctures in 91 patients. Between the observation and postprotocol phases, patient demographics were similar; average sheath size was unchanged (sheaths over 6F 6% vs 8%, respectively, P = .55), and percentage of patients receiving heparin did not change significantly (76% vs, 86%, P = .08). No major complications occurred in either the observation or the postprotocol phases. While 24 minor complications occurred in the observation phase, only seven minor complications occurred in the postprotocol phase (17% vs 7%, P < .02). Closure device use decreased with protocol implementation (57% to 32%, P < .01), but closure device failures also decreased from 23% to 7% (P < .01). Process improvement, achieved by instituting a standardized percutaneous arterial closure protocol based on selective closure device use guided by sheath size, arterial calcification, and previous access scarring. Implementation of our protocol resulted in a decrease in the incidence of minor complications at the access site and refined patient selection for closure device use.

Clip-based arterial haemostasis after antegrade common femoral artery puncture

Background Given the frequent involvement of infra-popliteal arteries, an ipsilateral antegrade common femoral artery puncture (ACFAP) is usually preferred to a contralateral retrograde femoral access for percutaneous transluminal angioplasty (PTA) in patients with critical limb ischemia (CLI). Because of the frequent difficulty to get a sufficient manual pressure on the puncture site, ACFAP is burdened by a high number of bleeding local complications, including retroperitoneal haematoma. We report a series of patients who consecutively received a clip-based arterial closure device after ACFAP and ipsilateral PTA for CLI. Methods Thirty patients (73 ± 6 years; 18 men; 100% diabetes) admitted to our hospital because of CLI consecutively underwent peripheral PTA after an ACFAP and received a clip-based arterial closure device. Time to haemostasis was defined as the interval elapsed between clip deployment and first observed haemostasis. All patients were mobilized after 6 h. Follow-up was 30 days. Results All patients were on double anti-platelet therapy. At the end of the procedure, Activation Clotting Time was 226 ± 37 s. Procedural success in delivering the clip was 100%. Time to haemostasis was 21 ± 19 s. No major local vascular complications and in particular no retroperitoneal bleeding were documented. All patients could be discharged within the following 3 days. No major complications were noted during a 30 days follow-up. Conclusions The use of a clip-based arterial closure device after ACFAP for peripheral PTA in CLI seems to be safe and effective.

An improved reversal technique from retrograde to antegrade femoral artery cannulation.

Converting retrograde femoral access to antegrade access may be required following diagnostic arteriography to perform an interventional procedure. This technical note describes a modification of a previously described technique that allows reliable catheter reversal which was successful in 27 attempted procedures. There were no complications.

Percutaneous transluminal angioplasty of supra-aortic vessels.

To retrospectively review the techniques and results of percutaneous transluminal angioplasty (PTA) in the supra-aortic vessels. Over a 5-year period, 112 patients underwent percutaneous treatment of 151 lesions in the innominate, subclavian, carotid, and vertebral arteries. The percutaneous technique included standard retrograde femoral artery access in the majority of patients with balloon dilation of the lesion site. In the more recently treated patients, stents were deployed for suboptimal PTA; primary stent deployment was used rarely. Symptom resolution and > 50% increase in flow were criteria necessary for a successful procedure. In this population, 141 (93%) of 151 lesions were successfully treated. PTA achieved 100% success in stenotic lesions in the internal (n = 9) and external (n = 2) carotid; common carotid (n = 8); subclavian (n = 67); and innominate (n = 13) arteries. Ninety-two percent (36/39) of vertebral artery stenoses were successfully treated. In 13 cases of subclavian occlusion, however, only 6 (46%) were recanalized. There were 3 periprocedural complications, but only 1 was major; a focal stroke manifesting as right arm weakness occurred in a patient with left common carotid PTA and stenting. Five cases of reocclusion have been seen in 5 years of follow-up. All occurred in the subclavian artery, and 3 of the 5 were in arteries originally occluded. Brachiocephalic PTA can achieve excellent immediate and long-term results in proximal stenoses. Subclavian occlusions do not respond well to PTA, and those successfully recanalized have a high restenosis rate (50%). PTA of the arch vessel branches, particularly the vertebral artery, should be attempted only by experienced interventionists. Atherosclerotic lesions in the internal carotid arteries are best treated with endarterectomy at present, but fibromuscular dysplasia in the carotid arteries is an appropriate indication for PTA therapy.

Percutaneous Transluminal Angioplasty of Supra-aortic Vessels

To retrospectively review the techniques and results of percutaneous transluminal angioplasty (PTA) in the supra-aortic vessels. Over a 5-year period, 112 patients underwent percutaneous treatment of 151 lesions in the innominate, subclavian, carotid, and vertebral arteries. The percutaneous technique included standard retrograde femoral artery access in the majority of patients with balloon dilation of the lesion site. In the more recently treated patients, stents were deployed for suboptimal PTA; primary stent deployment was used rarely. Symptom resolution and > 50% increase in flow were criteria necessary for a successful procedure. In this population, 141 (93%) of 151 lesions were successfully treated. PTA achieved 100% success in stenotic lesions in the internal (n = 9) and external (n = 2) carotid; common carotid (n = 8); subclavian (n = 67); and innominate (n = 13) arteries. Ninety-two percent (36/39) of vertebral artery stenoses were successfully treated. In 13 cases of subclavian occlusion, however, only 6 (46%) were recanalized. There were 3 periprocedural complications, but only 1 was major; a focal stroke manifesting as right arm weakness occurred in a patient with left common carotid PTA and stenting. Five cases of reocclusion have been seen in 5 years of follow-up. All occurred in the subclavian artery, and 3 of the 5 were in arteries originally occluded. Brachiocephalic PTA can achieve excellent immediate and long-term results in proximal stenoses. Subclavian occlusions do not respond well to PTA, and those successfully recanalized have a high restenosis rate (50%). PTA of the arch vessel branches, particularly the vertebral artery, should be attempted only by experienced interventionists. Atherosclerotic lesions in the internal carotid arteries are best treated with endarterectomy at present, but fibromuscular dysplasia in the carotid arteries is an appropriate indication for PTA therapy.

Use of a guiding catheter for contralateral femoral artery angioplasty

We describe a unique method employing a transseptal sheath as a "guiding catheter" that allows contralateral retrograde femoral artery access to perform balloon angioplasty of proximal superficial femoral artery lesions. This technique simplifies arterial access, provides support for crossing lesions, and allows angiographic visualization of target lesions during the procedure.