Let "US" Guide the Way?

Success (or failure) of any endovascular, structural, or coronary procedure always starts (and ends) with the vascular access. Most of us have felt the pendulum swing from satisfaction to dismay after achieving a great result on an interventional procedure only to see the patient suffer from an access-site related bleeding or occlusive complication. The consequence of access-site related complications is not always without penalty and can contribute to substantial morbidity and added healthcare costs, in addition to some mortality.^1-3 Therefore, it is imperative for the interventional community to rally around methods for mitigating these untoward events related to vascular access. 

The optimist would note that improvements, albeit modest, have occurred slowly over time. Seldinger should be credited for the most significant improvement by transitioning us away from surgical cut-down to the more practical percutaneous approach to vascular access.⁴ However, the original Seldinger technique supported an anterior-to-posterior wall (through-and-through) puncture. This antiquated approach could potentially lead to enhanced complications from unabated posterior wall bleeding, especially with concomitant use of anticoagulants, antiplatelets, and vascular closure devices. Nevertheless, the overall rates of vascular access complications for percutaneous coronary interventions have declined since the 1990s.^1,5-7 Improved puncture techniques, smaller sheath sizes, vascular closure devices, and evolving anticoagulation/antiplatelet strategies are likely a few reasons for these improvements. The pragmatist, on the other hand, would quote the unacceptable contemporary rates of hematomas (3.6%-5.5%), pseudoaneurysms (2.0%-5.6%), arteriovenous (AV) fistulas (0.6%-2.2%), vessel occlusion (1.0%-1.6%), and retroperitoneal bleeding (0.1%-0.7%).^8-11 

 Clearly, there is room for improvement. A thorough understanding of the anatomy of the femoral artery and surrounding structures is critical for reducing bleeding risk. It is well established that high sticks above the inguinal ligament risk retroperitoneal hemorrhage, whereas low sticks risk pseudoaneurysms and AV fistulas.¹² The inadvertent cannulation of a wire into the lateral circumflex femoral artery during access can cause perforations. The radial revolution that is finally gaining momentum in the United States will certainly play a role in reducing bleeding complications in the future. However, the radial artery is a small-caliber vessel that cannot accommodate large-caliber devices that are required for certain interventional procedures. Additionally, treating peripheral arterial disease of the lower extremity is not practical via the radial approach given the anatomical distance between the vascular beds and the dearth of interventional equipment dedicated for this purpose. Unequivocally, femoral artery access has an important role now and will continue to have one in the future. Thus, the safest and most reliable method for obtaining vascular access is vital for success. Traditional anatomic landmarks, fluoroscopic guidance, and micropuncture access have all been employed. Gaining momentum among many interventionalists, however, is ultrasound (US)-guided vascular access. 

Ultrasound is a modality that has been around for over 40 years. In the last decade, US guidance for central venous access has become commonplace on the wards at many hospitals. Proponents for US-guided vascular access will relate its ability for direct visualization of the target vessel (including calcification) and surrounding, non-target vessels. Additionally, needle entry into the vessel lumen can often be visualized on US, which may help prevent posterior-wall punctures or multiple needle passes. Intuitively, this may allow a cleaner, more accurate stick. The bulk of research has previously focused on US guidance for central venous access, with evidence and guidelines strongly supporting its use for internal jugular vein access.^13,14 Whether this translates to the femoral artery and provides substantial benefit for the patient to warrant its routine use is debated and not yet universally recommended.¹³ Given the explosion of interventional procedures performed worldwide via the arterial system and noted complication rates, US guidance has garnered heightened interest. 

In this issue of the Journal of Invasive Cardiology, Sobolev et al collate the data from the few available prospective studies looking at US-guided femoral artery access versus palpation ± fluoroscopic guidance.¹⁵ Their primary outcome of overall complication rates (composite of hematoma, retroperitoneal bleed, femoral vein puncture, superficial femoral artery puncture, pseudoaneurysms, AV fistulas, and arterial dissection) was lower with US guidance (2.2% vs 4.8%; P=.02). They also indicate that first-pass success with US was higher. When interpreting these data, one should acknowledge the fact that these results are heavily dominated by the Femoral Arterial Access with Ultrasound (FAUST) trial conducted by Seto et al, which enrolled 1004 patients.¹⁶ Only in the FAUST trial did access complications (a secondary outcome) yield statistical significance favoring US guidance, and this was driven largely by a reduction in hematomas. Additionally, the meta-analysis included a study that used only antegrade femoral artery punctures, which some may argue is analogous to comparing “apples to oranges” versus the retrograde approach with regard to safety and operator experience.¹⁷ Finally, all studies incorporated both diagnostic and interventional procedures. The use of periprocedural anticoagulants intuitively may yield higher rates of access-site related bleeding complications and it is difficult to ascertain its overall effect. 

The trends noted with US guidance should not be trivialized. The FAUST trial demonstrated less access-related bleeding, primarily by a reduction of non-lethal hematomas. Developing a hematoma can lead to significant patient discomfort, increase healthcare costs, and may also necessitate the cessation of important anticoagulant, antiplatelet, or thrombolytic therapy. There also seems to be improved first-pass success with US-guided access. This potentially could avoid the risk of inappropriate punctures (eg, posterior wall) and improve patient comfort. Whether this could translate to improved efficacy for vascular closure devices that are only designed to close anterior wall punctures is an intriguing question that requires further study. 

So, should we now let US guide the way for all femoral artery access? We believe that while the data are intriguing, more evidence is required to confirm its superiority over other commonly employed techniques for access (such as the use of micropuncture access needles) before it can be advocated as the standard of care. It has yet to be conclusively shown that US guidance improves technical success of common femoral artery cannulation over other methods. Relying solely on US can also have negative implications for the less trained operators. Specifically, it may potentially lead some to ignore anatomical landmarks visualized well on fluoroscopy. This is especially important among obese patients where high sticks above the femoral head may yield difficulty in hemostasis. If an obese patient has a high bifurcation, US use alone may lead some operators to access a site that potentially is not compressible. Perhaps the solution is that fluoroscopy and US are not mutually exclusive of one another. Every patient is unique, and maybe the correct approach should individualize the access technique based upon a patient’s risk factors and the operator’s skill set. 

Interventionalists should closely monitor the incidence of femoral access-related complications in their own invasive laboratories, and if needed adjust their techniques (perhaps by incorporating US or other methods) to mitigate these unwanted events. Future studies should look at US use in higher bleeding risk cohorts (eg, females, elderly, obese, cachectic, renal dysfunction, concurrent use of glycoprotein IIb/IIa inhibitors, etc), and also assess whether US use can indeed reduce healthcare costs, morbidity, and potentially mortality. In the meantime, we believe that operators should continuously critique their own techniques for femoral artery access. The ideal approach for access should be the one the interventionalist is most comfortable with that yields the best possible outcome for his or her patient. 

References

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10. Frank JJ, Kamalakannan D, Kodenchery M, et al. Retroperitoneal hematoma in patients undergoing cardiac catheterization. J Interv Cardiol. 2010;23:569-574. Epub 2010 Aug 27.
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13. Troianos CA, Hartman GS, Glas KE, et al. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and Society of Cardiovascular Anesthesiologists. J Am Soc Echocardiogr. 2011;24:1291-1318.
14. Weiner MM, Geldard P, Mittnacht AJC. Ultrasound-guided vascular access: a comprehensive review. J Cardiothorac Vasc Anesth. 2013;27:345-360. 
15. Sobolev M, Slovut DP, Chang AL, et al. Ultrasound-guided catheterization of the femoral artery: a systematic review and meta-analysis of randomized controlled trial. J Invasive Cardiol. 2015;27:318-323.
16. Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complication. JACC Cardiovasc Interv. 2010;3:751-758. 
17. Slattery MM, Goh GS, Power S, et al. Comparison of ultrasound-guided and fluoroscopy-assisted antegrade common femoral artery puncture techniques. Cardiovasc Intervent Radiol. 2014 Oct 24 [Epub ahead of print].

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From the Cardiovascular Institute of the South (CIS), Houma, Louisiana.

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Address for correspondence: Pradeep K. Nair, MD, Cardiovascular Institute of the South, 225 Dunn Street, Houma, LA 70360. Email: Pradeep.Nair@cardio.com