Access Complications

Introduction

The common femoral artery (CFA) is considered the most frequently used percutaneous arterial access site. Multiple methods are used as a landmark for entry, including pulse palpation, fluoroscopic guidance, and ultrasound-guided puncture to achieve arterial access. Many access-related complications can occur, and some are life and limb threatening, such as retroperitoneal hemorrhage or arterial occlusion. Older studies have reported femoral access site complication rates ranging from 2% to 17% in patients undergoing diagnostic and interventional procedures. A more recent study has shown femoral access complications of 1.8% for diagnostic and 4% for interventional procedures. Arterial sheath placement into the CFA, and not the deep or superficial femoral artery (SFA), has been shown to decrease access complications. The purpose of this chapter is to discuss the common complications caused by femoral artery access and their management.

Risk Factors

Vascular access site complications are the most frequent cause of complications during peripheral vascular and coronary interventions. Risk factors for access complications can be divided into physiological (patient related) and anatomical (procedure related). Physiological risk factors include female gender, body mass index, older age, peripheral vascular disease, renal failure, and low platelet count. Anatomical related factors include previous catheterization, high doses of anticoagulation and prolonged anticoagulation, use of thrombolytic agents, use of GP IIb/IIIa inhibitors, larger arterial sheaths, concomitant venous sheaths, prolonged sheath placement, and prolonged procedure duration.

Identifying patients with these risk factors is a crucial step in planning the appropriate access site and technique to decrease the incidence of access complications. Most of these complications are preventable by following a good patient selection process, utilizing a thorough history and physical examination and a good access technique. History of prior interventions, previous groin complications, use of closure devices, prior groin radiation, and use of anticoagulation should be documented prior to the procedure. A thorough physical examination, including inspection of the groin for any signs of infection, scars from previous surgeries, and palpation of the femoral pulse, will minimize surprises on the day of the procedure and will decrease the risk of complications.

Ideal Puncture Site

The CFA is defined as the continuation of the external iliac artery from the level of the inguinal ligament to its bifurcation into the profunda femoris artery and the SFA. It is relatively large, less involved with atherosclerosis, and compressible against the underlying head of the femur. The ideal site of femoral arterial puncture is at the CFA at a point approximately 1 cm lateral to the most medial aspect of the middle of the femoral head ( Fig. 1.1 ). Caudal punctures usually result in more tendencies for sheath insertion below the bifurcation into the SFA or the profunda femoral artery. These vessels don’t have the underlying bony structure, resulting in increased incidents of bleeding, hematoma, and pseudoaneurysm (PSA) formation. The inferior epigastric artery courses toward the inguinal ligament, then turns upwards in a U-shape configuration. The lowest point of the inferior epigastric artery corresponds to the inguinal ligament. Any arterial puncture above the level of the lowest point of inferior epigastric artery is associated with a significant increase in the risk of retroperitoneal hemorrhage.

Despite agreement on the optimal location for artery puncture, there is a large variation in the landmarks utilized to identify the puncture site. The most commonly used landmarks are the inguinal skin crease, maximal pulsation, and bony landmarks. The inguinal skin crease is located 3 cm below the inguinal ligament in 95% of cases and doesn’t correlate with its location. It is the least reliable method and should be avoided. The point of maximum pulse can often be obscured by obesity, prior hematoma, or scarring from previous surgery; this makes it less reliable.

The anatomic relationship of the CFA to the underlying femoral head is relatively constant. Garrett et al. found that the CFA overlies the femoral head in 92% of cases. They also concluded that the femoral head has a consistent relationship to the CFA, and localization using fluoroscopy is a useful landmark. However, there are critical issues that must be considered in the application of this technique, including the impact of parallax. Placing a hemostat on an obese patient to identify the femur head may be misleading, and correction of the parallax is important prior to arterial cannulation ( Fig. 1.2 ).

During the past decade, real-time ultrasound guidance has gained popularity among angiographers. It allows the user to visualize, in real time, the needle as it enters the ideal point in the mid-CFA. The Femoral Arterial Access with Ultrasound Trial (FAUST) randomized patients to fluoroscopic- versus ultrasound-guided puncture. This study showed no significant difference in successful CFA cannulation rates between the fluoroscopic group versus the ultrasound-guided group. However, in the subgroup of patients with a high bifurcation, there was a significant difference in favor of ultrasound. Ultrasound guidance also improved the first-pass success rate, reduced the number of attempts, decreased inadvertent venipuncture, reduced median time to access, and decreased subsequent vascular complications. Visualizing the tip of the needle entering the mid portion of the CFA is a very critical step when using real-time ultrasound guidance. Failure to perform this step adequately can result in a higher puncture rate by “losing sight” of the needle tip that transverses the tissue in a cephalad trajectory.

Most physicians in the authors’ institution prefer a combined approach. First, the femur head is identified by fluoroscopy. Then, real-time ultrasound guidance is used to identify the CFA bifurcation. The tip of the puncturing needle has to be identified in the middle of the CFA prior to advancing the wire and placing the sheath. If the CFA can’t be safely identified using ultrasound guidance, a fluoroscopy-assisted technique using a Doppler needle (SMART needle) is used. The CFA is identified using fluoroscopy and the artery is punctured using the Doppler needle. This allows the operators to identify the CFA waveform, which reduces inadvertent venous and arterial branch punctures.

Groin Hematoma and Pseudoaneurysm