Reducing Access-Site Complications

Success (or failure) of any endovascular, structural, or coronary procedure always starts (and ends) with the vascular access. Many 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. Access-related complications yield added morbidity and healthcare costs and, in some situations, can be catastrophic. It is imperative for the interventional community to rally around methods for mitigating these untoward, and sometimes avoidable, events related to vascular access. As we collectively strive for perfection with vascular access and closure, ongoing research efforts in this arena are vitally important. In the current issue of Vascular Disease Management, investigators from Newark Beth Israel Medical Center suggest that perhaps our ability to accurately visually identify true femoral arterial puncture sites on fluoroscopy may be flawed. Theoretically, this can have implications with regards to suitability for femoral artery closure and access-related complications.
Significant strides have been made with femoral arterial access over the decades. Dr. Seldinger is credited with the most substantial improvement by transitioning us away from the surgical cut-down to the more practical percutaneous approach in 1953. It is important to remember, however, that his original technique called for a through-and-through puncture which would not be advocated today given its potential for enhanced complications. In the current era, through-and-through punctures risk unopposed posterior wall bleeding, especially with concomitant use of potent anticoagulants, and are unsuitable for vascular closure devices, which are designed to only close anterior wall punctures. It is encouraging to note that rates of femoral artery access complications have declined since the 1990s. This is likely attributable to better technique, smaller sheath sizes, evolving anticoagulation strategies, and vascular closure devices. Unfortunately, perfection has remained elusive with rates of hematomas and pseudoaneurysms at roughly 5%, arteriovenous (AV) fistulas at 1% to 2%, and retroperitoneal bleeding at .5%.
Our ability to reduce access complications starts with a thorough understanding of the anatomy of the femoral artery and surrounding structures. It is well established that high sticks above the inguinal ligament risk retroperitoneal hemorrhage, whereas low sticks risk pseudoaneurysm and AV fistula. Also, the inadvertent cannulation of a wire, such as the angled tip .018˝ micropuncture wire, into the lateral circumflex femoral artery during access can cause perforations. The method of access is also vitally important. Fluoroscopic landmarks, vascular ultrasound, and micropuncture access are all methods that may be effective in reducing the potential for complications. Of these methods, ultrasound is gaining the strongest momentum and is perhaps the most intriguing option, given the ability for the properly trained operator to directly visualize the artery and puncture the anterior wall at a suitable, disease-free segment. Intuitively, this allows for a cleaner, more accurate puncture, which could have significant impact on the success of vascular closure devices and reduction in femoral access complications.  
The radial revolution that has also gained substantial momentum around the world will certainly play a role for reducing bleeding complications in the future. However, the common femoral artery will continue to be a primary access point as opposed to the radial artery in cases where large-bore sheaths are required or when peripheral arterial interventions of the lower extremities are performed because of the current dearth of equipment dedicated for this purpose. Ultimately, interventionalists should closely monitor the incidence of femoral access-related complications in their own invasive laboratories, and if needed adjust their own techniques (by using ultrasound or other methods) to mitigate these unwanted events. We should continue our research efforts in vascular access and pay particular attention to those populations known to have the highest risk of bleeding (e.g., females, elderly, cachectic, obese, glycoprotein IIb/IIIa inhibitor use, and those with renal dysfunction). The best approach to access and closure is the method the interventionalist is most comfortable with that yields the best possible outcome for his or her patient.