0:01

So let's talk about common sites of arterial access.

0:04

So in terms of our arterial access anatomy,

0:07

let's do a little bit of a review here.

0:08

So what's the yellow arrow pointing at?

0:11

So that's our access point in our middle,

0:14

medial aspect of the femoral head.

0:19

This is the midpoint of the common femoral artery.

0:23

We're not accessing the superficial femoral artery.

0:26

We're not accessing the external iliac artery.

0:28

So pretty much an ideal point.

0:30

So, good job.

0:32

So if we initiate femoral artery access in our patient,

0:36

so why do we make sure that the access is under the

0:39

inguinal ligament and above the femoral bifurcation?

0:43

Well, if you think that injuring

0:46

the external iliac artery is a little

0:47

problematic and it may lead to, sort of,

0:50

retroperitoneal hemorrhage, you would be spot on.

0:53

If you think injuring, sort of, below this region,

0:56

superficial or deep to the femoral artery, may actually

1:00

lead to a thigh hematoma, you may also be right.

1:03

You may also, sort of, understand that the

1:06

common femoral artery is parallel to the

1:09

common femoral vein as it courses alongside,

1:12

or along, or superficial to the femoral head.

1:15

But when it goes inferiorly, oftentimes there

1:18

is sort of the common femoral, or superficial

1:21

femoral, or femoral vein dives deep to this vessel.

1:25

And so if you were to do a back wall sort of

1:27

puncture, you could end up hitting the vein.

1:31

And that would possibly result in a what?

1:33

Arteriovenous fistula.

1:35

So we initiate femoral artery access in our patient.

1:38

So why do we make sure to access under the inguinal

1:40

ligament and above the femoral bifurcation?

1:42

You said it.

1:44

Because we want to make sure that

1:47

we don't hit additional structure.

1:50

And that additional structure below would be the what?

1:53

The vein. The risk of thigh hematoma cannot be overstated,

1:58

and this is a case that we're going to

2:00

look at in a bit, so that we are very clear

2:02

how easily this complication can happen.

2:06

So one of the things that I like to sort

2:07

of suggest is let's use that fluoroscopy

2:10

initially when we do our scout to determine

2:12

that inferior margin of the femoral head.

2:14

Where do we want to sort of get

2:15

access into the skin, the dermatotomy?

2:19

Where do we want to hit the vessel,

2:21

medial, middle margin of the femoral head?

2:25

Okay.

2:26

We have all that in mind so that when we get

2:27

access, everything is sort of very much marked out.

2:31

We then want to use the ultrasound to

2:32

determine the bifurcation of the common

2:34

femoral artery to make sure that we're what?

2:38

We're hitting actually the common femoral artery

2:40

and not the SFA, the superficial femoral artery,

2:43

which could be a little higher in a high bifurcation.

2:47

So what do we see here?

2:49

What does this look like?

2:52

What is this complication?

2:54

So this is a little bit of active extravasation.

2:57

Okay, this is bleeding from an arterial injury, likely

2:59

the cause of an access above the inguinal ligament.

3:04

So should we use ultrasound-guided access?

3:06

Is it like just a thing of preference,

3:09

always, sometimes, or no never?

3:13

I would say probably always. You know,

3:14

ultrasound guidance has been shown to decrease

3:16

risk and complications of vascular access.

3:19

It's been shown to enhance the rate of actual

3:21

successful cannulations of the common femoral

3:23

artery in patients with high bifurcations of the

3:27

common femoral artery into the profunda femoris

3:30

and superficial femoral artery by about a third.

3:32

It actually can enhance patient comfort, and it's

3:35

particularly beneficial in challenging cases.

3:37

So of course our goal is to minimize complications,

3:39

and ultrasound guidance actually allows us

3:41

to see our needle as it enters the vessel.

3:44

Okay, and it doesn't rely on landmarks, which

3:48

in the case of landmarks, they get shifted

3:50

depending on a patient's abdominal girth.

3:52

If we're looking at sort of a thigh crease or a groin

3:54

crease in every patient, you know, my groin crease

3:57

may be at a different level than your groin crease.

3:58

And so landmarks may not be as reliable as

4:01

sort of real sonographic imaging guidance.

4:05

So this is going to reduce the risk of complications,

4:08

and it's going to sort of help enhance the rate of

4:10

successful cannulations of the common femoral artery.

4:13

In patients with high bifurcations,

4:16

it is going to enhance it by about 30 percent

4:18

from a technical success standpoint, okay?

4:21

So when we're thinking about common femoral artery

4:23

cannulations, really think about these high-risk

4:26

patients with difficult access and understand that

4:28

this is why ultrasound guidance is so important.

4:31

So, when we look at ultrasound guidance, am

4:34

I just sort of suggesting that ultrasound

4:36

guidance is sort of a good thing to do?

4:38

Or am I recommending it because the data

4:41

suggests it's a good thing to do?

4:43

There have been multicenter randomized controlled

4:45

trials that have compared fluoroscopic

4:47

guidance versus ultrasound guidance, you know,

4:49

for sort of common femoral arterial access.

4:51

And what they've noticed is that in ultrasound

4:53

guidance, and you know, that in and of

4:55

itself sort of reduces the risk of vascular

4:57

access complications by about 60 percent.

4:59

This improved first-pass success rate,

5:02

you know, jumps to about 80 percent.

5:04

And, you know, we don't sort of get these accidental

5:06

venipunctures that can occur if you're just kind of

5:09

doing blind sticks, right? If you're trying to hit,

5:11

you know, two structures side by side, you know,

5:13

and you're using sort of a palpation technique or

5:16

a little fluoroscopic technique and you're trying

5:18

to go medial or trying to go lateral, like, you

5:20

know, this action may not be particularly sort of...

5:24

And so this allows us to see sort of the

5:26

number of attempts, the first-pass success,

5:29

the risk of inadvertent sort of venipuncture.

5:31

When we use ultrasound, we kind of see

5:34

sort of how helpful this

5:38

ultrasound guidance actually is.

5:41

What other procedures can actually be

5:43

completed with common femoral access?

5:47

Well, this is the case of a patient that actually

5:50

had a port that was placed in the artery. A hematoma

5:55

developed, and then it was ultimately placed correctly

5:57

in the vein. But that port that was placed in the

5:59

artery was pulled, and so a stent had to be placed.

6:02

Okay, so we, in this case, went through the

6:04

common femoral artery in order to accomplish this.

6:08

If you're performing stroke management, thrombectomy,

6:10

thrombolysis, an aortic aneurysm repair, embolization

6:13

for bleeding, you know, you're given chemotherapy

6:16

and sort of radioembolization—those are performed

6:19

through common femoral or radial artery access.

6:22

Uterine and prostate artery embolizations

6:24

for fibroids and BPH, same thing.

6:26

Treatment of PAD, same thing.

6:28

So, all these things just

6:30

allow us to get the job done.

6:32

So again, arterial access—

6:34

understanding how it's performed.

6:37

So what are the contraindications that

6:39

may sort of, you know, arise as it

6:40

relates to femoral artery access?

6:43

So let's test your knowledge.

6:46

So therapeutic anticoagulation—if this is a

6:49

setting where it cannot be reversed, I would take a

6:52

pause and sort of think through: is your procedure

6:55

actually indicated, or is it contraindicated?

6:58

Okay, if it's contraindicated because of this

7:00

anticoagulation piece, then you shouldn't proceed.

7:04

Does the patient have thrombocytopenia

7:05

that cannot be reversed?

7:07

Do they have platelets of 10?

7:08

Do you really want to jump in that situation?

7:12

You want to assess the actual need for

7:14

the procedure and any alternatives.

7:17

Extensive atherosclerotic disease at

7:20

the access site, that, that's an issue.

7:22

And so we're going to be mindful of

7:23

these issues as we manage these patients.

7:27

So let's talk about the complications

7:28

of femoral artery access.

7:29

What do you think they are?

7:31

Well, of course, there's hematomas, there's

7:33

hemorrhage, there's pseudoaneurysms that

7:36

could occur, there's thrombus formation

7:38

that could occur within the access points.

7:42

So all these things are very important.

7:44

And of course, this is one we've talked about

7:46

before, which is an arterial dissection, which

7:48

could be flow-limiting or non-flow-limiting.

7:51

So let's get back to our Miss G.

7:54

Let's see how she's been doing.

7:55

So she has been worked up for a renal

7:58

artery stent placement, she's at the

7:59

hospital, she's ready to rock and roll.

8:03

So what gives?

8:04

Well, uh, we had some issues there.

8:07

So the common femoral artery access was actually

8:09

a little unsuccessful because of extensive

8:11

atherosclerotic disease on the access site, huh?

8:13

I wish I could have anticipated that.

8:15

Well, maybe we could have, given

8:17

the patient's comorbidities—the

8:19

hypertension, hyperlipidemia, and diabetes.

8:22

Hmm.

8:22

Okay.

8:24

So what other site may actually be attempted?

8:26

Well, thinking about alternative sites, you may

8:30

actually say, oh, well, you know, actually we are

8:32

doing, you know, a stent, maybe a radial artery, maybe

8:35

I can get a stent through the radial artery access.

8:38

You know, what size is the, the delivery sheath for

8:41

what I need to get through the radial artery access?

8:43

Let's look into that.

8:44

So the radial artery may actually be a particularly

8:46

viable access point in patients who fail CFA access.