Fluoroscopically-Guided Micropuncture Femoral Artery Access for Large-Caliber Sheath Insertion

ABSTRACT: Over the last decade, significant developments have been made in the treatment of structural heart disease. Some of these techniques require placement of large arterial sheaths for device delivery. Optimal vascular access is essential for successful large-vessel sheath insertion as well as to avoid vascular complications. The critical step for ideal percutaneous vessel entry is single anterior wall-only puncture of the common femoral artery in a location above the femoral bifurcation and below the inguinal ligament. We describe a fluoroscopically-guided micropuncture technique for accurate placement of large-caliber arterial sheaths. J INVASIVE CARDIOL 2011;23:157–161 ———————————————————— The need for large-sheath arterial access has increased with the introduction of transcatheter aortic valve implantation (TAVI),^1–4 and consequently, attention to optimal common femoral artery (CFA) puncture has increased. Previously the province of endovascular aortic repair and a few left ventricular assist technologies, these larger devices require arterial sheath sizes ranging from 18–24 Fr. As such, fenestrations in the CFA for these procedures range from a little over 6 to approximately 9 mm, accounting for the 0.7–1.3 mm greater outside diameter (OD) over the inner lumen (ID) described by the sheath sizes. Techniques for arterial access to optimize sheath insertion for TAVI and other large-sheath procedures such as aneurysm repair have been described by several operators.^5–7 During the early experience with percutaneous valves, many centers opted for an elective surgical approach for vascular access and closure, with suturing of the access site performed under direct vision. However, there has been a gradual evolution toward both percutaneous access and closure.^6,9–15

Common Femoral Artery Access for Large-Caliber Sheath Insertion

Complications of vascular access remain the most common cause of morbidity with all percutaneous procedures including TAVI.^15–18 In the case of the latter procedure, vascular access complications have been associated with significant mortality.^18,19 Puncture of the CFA is ideally performed at the level of the mid-CFA, and at least 1–2 cm below the inguinal ligament. If the puncture is too proximal, the external iliac artery (EIA) may be entered, dramatically increasing the risk of retroperitoneal hemorrhage (RPH). Even in routine percutaneous coronary intervention utilizing sheaths typically only in the 6 Fr range, the odds ratio for RPH increases 18-fold in the setting of high puncture. In contrast, if the puncture is too distal, either the profunda femoris artery (PFA) or the superficial femoral artery (SFA) may be entered, with increased risk of local complications such as vessel laceration, pseudoaneurysm, arteriovenous fistula, thrombosis or excessive bleeding.^20–28 There is a consensus that the larger the sheath-to-artery size ratio, the greater the risk of vascular obstruction and closure failure. The SFA and profunda both taper as they branch from the common femoral artery. An ideal “landing zone” may be defined by vascular entry above the femoral bifurcation and below an upper margin conservatively defined as several centimeters below the inferior excursion of the inferior epigastric artery (IEA). The IEA descends to, but does not cross, distal to the inguinal ligament; thus, entry above the lowest point of the course of this vessel, which typically then turns cranial to supply circulation to the epigastrum, can be used to define an unequivocally high puncture. In general, the level of the mid-third of the femoral head is an approximation of the level of puncture for the CFA (Figure 1).^29–32 Although the literature has not uniformly confirmed the advantage of fluoroscopy over traditional external landmark-guided access,³³ these studies were limited by use of fluoroscopy without the iterative methods outlined in the next paragraph³¹ as well as the use of 18 gauge rather than micropuncture access. Traditional landmark-guided access targets the inguinal crease, the point of maximal pulsation or uses a line drawn between the anterior superior iliac crest and the symphysis pubis,³⁴ all of which may be misleading, especially in obese patients^28–35 (Figure 2). In a retrospective review that compared vascular complications of physicians who did or did not use fluoroscopy-guided access, Fitts el al reported decreased vascular complications when fluoroscopic guidance was utilized.³⁶ Importantly, optimal fluoroscopic guidance requires an iterative technique that goes several steps beyond simple fluoroscopy to locate the bottom of the femoral head.³² These techniques allow for a more sophisticated fluoroscopic technique, which add, we believe, a significant margin of safety for patients undergoing large-sheath placement.

Technique of Fluoroscopically Guided Micropuncture Access

The micropuncture vascular access technique involves the use of needles and wires typically in the 21 gauge and 0.018″ range. For femoral access, these needles are usually 7 cm in length. The outer diameter of this needle is 0.8 mm; in contrast, the 18 gauge needle used by most operators is 56% larger, resulting in as much as 6 times the blood flow rate through an inadvertent back wall puncture or from an arterial entry with failed sheath placement.³²The CFA is punctured under fluoroscopic guidance using the mid-third of the femoral head to guide the needle to the anticipated puncture site, although restricting puncture to a point below the centerline of the femoral head may be the most prudent approach. Thus, after the initial localization of the bottom of the femoral head (Figure 3), repeat fluoroscopy is performed after the needle has been placed deep in the tissue track, but not yet into the femoral artery to achieve an ideal location of puncture. The operator should remove his or her hand from the field and perform brief fluoroscopy only to assess the location of the needle and adjust its path, several times if necessary, as it traverses deep into the subcutaneous tissue. The variable depth of the artery, as well as fluoroscopic projection, affect the perception of the needle path versus the actual needle location, and the operator is frequently surprised to find that the needle is well away from the intended area of puncture. Fluoroscopy should be done in the anterior-posterior view, since the patient’s femoral head and femoral artery do not lie in a 100% sagittal plane and in most cases, ipsilateral angulation of the imaging tends to shift the appearance cranial with respect to the femoral head, and contralateral tends to shift it caudally.³¹ The use of multiple iterations of the needle position with fluoroscopic checks maximizes the likelihood of entering the CFA at the ideal target. Once the needle is in the vessel and there is blood return, some operators perform a limited femoral angiogram via the micropuncture needle using a 3 cc syringe with half-strength contrast (Figures 2–4). If acceptable CFA access location is confirmed, a 0.018″ guidewire is advanced through the needle. The needle-wire interface can be recorded for localization of the puncture site (Figures 3D and 4D). A 4 Fr micropuncture sheath is advanced over the wire and exchanged for a 0.035″ guidewire to support passage of a larger sheath size. There are also larger, highly tapered sheaths designed to go directly over the micropuncture wire. Importantly, this technique allows relatively safe removal of the micropuncture needle or sheath after ineffective entry prior to inserting a larger sheath, with manual pressure applied (typically for 3–5 minutes) before re-attempting arterial access (Figure 4). In our experience, the errant punctures have not resulted in bleeding complications. Overall, the technique described is particularly helpful when the landing zone is narrow (Figure 5). Some operators do not favor injecting through the micropuncture needle, a technique that incurs additional radiation for the operator and has potential risks of losing intraluminal positioning as well as vessel dissection. A modification, therefore, is to access the vessel with the micropuncture needle, advance the 0.018″ guidewire and place the smaller inner dilator of the micropuncture sheath over the 0.018″ guidewire and use this small dilator for angiography rather than injecting directly through the micropuncture needle or the larger outer 4 Fr sheath. The micropuncture technique can also be used as an adjunct to other recently published TAVI vascular management strategies. These utilize crossover angiography to help locate the femoral puncture site;¹⁴ in Figure 6 a contralateral multipurpose catheter has been placed as a fluoroscopic target to guide the right-sided needle puncture. An alternative approach for controlled arterial entry is the use of ultrasound guidance,^7,37–40 which may have results that are comparable or perhaps even superior to the technique described. A randomized study by Seto and colleagues,⁴⁰ however, based its findings on a fluoroscopy method that did not utilize the iterative technique described in this manuscript. Ultrasound is routinely used by interventional radiologists, but has little penetration in the cardiology community. Although several systems have been developed primarily for this purpose, most catheterization laboratories do not have dedicated ultrasound vascular access guidance systems, whereas fluoroscopy utilizes technology and methods that are uniformly available.

Conclusion

As the use of large-sheath arterial access is rapidly growing, fluoroscopically-guided micropuncture of the CFA is a simple, useful technique. Although technological advancements in regard to reduction of delivery sheath sizes and the development of dedicated large-vessel closure devices are in process, optimal puncture of the CFA will remain key in a variety of interventional procedures.

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———————————————————— From the NorthShore University HealthSystem, Evanston, Illinois, and ^†Cooper University Hospital, Camden, New Jersey. Disclosure: Dr. Turi: consultant for Cook Medical; the other authors report no relevant disclosures. Manuscript submitted January 19, 2011, provisional acceptance given January 24, 2011, final version accepted February 1, 2011. Address for correspondence: Ted Feldman, MD, FACC, FESC, FSCAI, Evanston Hospital, Cardiology Division-Walgreen Building 3rd Floor, 2650 Ridge Avenue, Evanston, IL 60201. Email: tfeldman@northshore.org