0:01

So let's talk about the key

0:02

procedural steps of vascular access.

0:05

Which vessel is most commonly used for arterial access?

0:09

I'd say the common femoral artery.

0:11

You know, it's really due to its

0:12

large size, its superficial location.

0:15

You know, the common femoral artery

0:16

is pretty much the standard access point

0:17

for the majority of interventional

0:18

endovascular arterial interventions nowadays.

0:23

So when we think about transfemoral arterial access,

0:24

it's the sort of mainstay for vascular access, okay?

0:29

So, the interventional catheterizations

0:31

that sort of occur across the globe,

0:34

the vast majority of them are sort of occurring

0:37

intraluminally through transfemoral arterial access.

0:41

Here we see a case in point of this.

0:45

So for every indication to do a thing, there's

0:47

a contraindication, and as I mentioned before,

0:49

we want to know what are those things that are

0:51

going to move us away from performing an access.

0:55

If a patient is unstable

0:57

to the point whereby, you know, this procedure is

0:59

of no benefit because perhaps, you know, this ball

1:03

that's been thrown out of the window, we're trying

1:05

to jump out of the window to catch it and,

1:07

you know, at some point it's just going to hit the ground.

1:09

So if we are going to actually intervene

1:11

and do good, we want to make sure that, uh,

1:14

we're doing good with the prospects of the

1:17

outcome actually being reversed or optimized.

1:19

If that's not the case, then vascular

1:22

access should not be performed.

1:24

If the patient has coagulopathy, bleeding

1:25

risks are heightened. As we talked

1:27

about before, we can correct that.

1:29

If the patient has type 4, the vascular Ehlers-Danlos

1:33

as it's commonly called now,

1:36

that's a high risk for arterial injury or dissection

1:38

so you want to be kind of clued into that as well.

1:41

So, a patient is ready for her procedure.

1:43

So, how do we, how do we get access?

1:46

So, the Seldinger technique, which was

1:47

developed by Sven Ivar Seldinger in 1953,

1:51

is really the most common vascular access technique.

1:54

We'll attempt to access through the common femoral artery today.

1:55

48 00:01:56,850 --> 00:01:57,620 So let's proceed.

1:58

So what we're marking off

1:59

here is the inguinal ligament.

2:01

And that is really the point in which the common

2:04

femoral artery becomes the external iliac artery.

2:07

Common femoral artery, soft tissues, superficial

2:09

thigh, external iliac artery diving into the pelvis,

2:14

deep pelvis course.

2:16

We're drawing this line from the anterior inferior

2:18

iliac crest or spine to the pubic symphysis.

2:22

That's a nice little sort of demarcation,

2:25

anatomically or landmark-wise, for us to denote

2:28

where this sort of demarcation between common

2:31

femoral and external iliac artery is located.

2:35

So the way we prepare our sterile site is

2:37

by shaving, mechanical cleansing, sterile

2:40

cleansing with either iodine or chlorhexidine.

2:43

Chlorhexidine is, sort of, a little bit,

2:44

sort of stronger, more effective of an antiseptic.

2:47

Then we drape the patient to include

2:50

the sterile areas and exclude the, what?

2:52

Non-sterile areas.

2:54

So as mentioned before, you want to

2:56

anticipate things that can go wrong.

2:59

And here we have a 47-year-old patient that's MRSA

3:01

positive, that had an abdominal endograft placed

3:03

via the common femoral artery access, that developed

3:06

an ulcerating indurated site post-op day four.

3:10

And the question here is, was this

3:11

patient prepped and draped appropriately?

3:14

What went wrong to create the environment for this

3:19

highly unusual indurated site infection to occur?

3:23

So proper prevention and sterile technique is key.