Femoral Basics. Zoltan G. Turi, M.D. Rutgers Robert Wood Johnson Medical School New Brunswick, NJ
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1 Femoral Basics Zoltan G. Turi, M.D. Rutgers Robert Wood Johnson Medical School New Brunswick, NJ
2 Vascular Access in the New Percutaneous Technologies Era is: Taken for Granted Under-investigated but Way Over-represented in Complications
3 We All Know How to Do This Sven-Ivar Seldinger Little Change in Past 63 Years
4 Local complications of FA access: 2-10% Hematoma (1-10%) Pseudoaneurysm (1-6%) AV fistula (<1%) Vessel laceration (<1%) Free bleeding Intimal dissection Ante- or retro-grade Acute vessel closure (<1%) Thrombosis (small artery lumen) Retroperitoneal hemorrhage ( %) Thickening of the perivascular tissues Neural damage Infection Venous thrombosis Pericatheter clot Complication rate persistent over many decades Most common: hematoma Most lethal: retroperitoneal hemorrhage
5 TAVR Complications NEJM 2010
6 Usual Approach Keep poking until you get a gusher
7 Landmarks for Femoral Access What is your primary landmark? X 3. Bone landmarks 2. Maximal pulsation 4. Prior puncture site 1. Inguinal crease X
8 Landmarks Used for Femoral Puncture Skin Crease Maximum Pulse Bony Landmarks Crease/Bone 1% Crease/Pulse 13% Pulse/Bone 7% All Three 1% Crease 40% Bone 13% Pulse 25% Skin Crease Most Common Grier D. Br J Radiol 1990;63:602.
9 Inguinal Crease UC San Diego New Brunswick, NJ
10 This is NOT Normal Anatomy CFA PFA SFA 3 Misconceptions despite 50 years experience
11 PFA SFA
12 Odds Ratio RPH 18:1
13 Femoral Artery Anatomy: A Prospective Study 200 consecutive patients All undergoing coronary angiography Femoral angiography at end of procedure Quantitative angiography
14 Femoral Head and the CFA Bifurcation 1.5% 4.0% V IV III II 17% 22% 55.5% I PFA SFA Number of patients I: 111 II: 44 III: 34 IV: 8 V: 3 Below inferior border At inferior border Below center of head At center of head Above center of head n=200 Schnyder G CCI 2001
15 LAO Femoral Angiogram RAO External Iliac IEA IEA PFA SFA
16
17 Common Femoral Artery Classic Measurements From top of femoral head to femoral bifurcation Does not take IEA into consideration Does not consider implications of CFA stick above bifurcation, but below femoral head
18 Target Zone
19 TYPE 1 Target Zone Centerline
20 TYPE 2 Target Zone Centerline
21 Cumulative Probability of Being Outside Target Zone FH Centerline 100 Probability of Below Being Outside Above Target Zone (%) mm from Femoral Head Centerline
22 FH Centerline Cumulative Target Zone IEA BIF Frequently correlates with point of maximal pulsation
23 Recommended Approach
24 N=296 Below CTZ In CTZ Above CTZ # of Patients 8 6 Above Centerline Distance from Centerline (mm)
25 A. Seto TCT 2009
26 Courtesy Dr. Walter Tan
27 Seto AH JACC CI 2010; 3:751
28 Micropuncture Micropuncture
29 Some simple math ~ 7 th grade Flow = Pressure/Resistance Resistance = viscosity * length radius 4 If Pressure, viscosity and length fixed Then Flow ~ radius 4
30 18 # Fold Increase in Blood Loss (Flow) Std needle (18g) = 1.27 mm Micropuncture (21g) =.813 mm In size = 56% 5.9 fold in blood loss % Increase in Size of Residual Hole (Radius)
31 How to Decrease Risk of Complications 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in safe zone
32 How to Decrease Risk of Complications 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in safe zone
33 How to Decrease Risk of Complications 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in safe zone
34 How to Decrease Risk of Complications 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in target zone
35 How to Decrease Risk of Complications 1. Access using fluoroscopy and/or ultrasound 2. Needle entry below centerline of femoral head 3. Femoral angiogram regardless of closure device use 4. Proceed to PCI (and anticoagulate) only if puncture in target zone 5. Use micropuncture
36 Better Technique Better Result 6 F sheath 18 Gauge needle Poke until gusher 18 F sheath Micropuncture Fluoro guided
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