A good PCI starts with a good puncture! In this video, you'll learn about the basic technique, benefits, and challenges of using femoral artery access in PCI, three situations that could stop you from using femoral access, and how to avoid dangerously puncturing the wrong place.
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[00:00:00] The femoral route was historically the main go-to route for arterial access for PCI. First, we should review the femoral triangle. It's comprised superiorly of the inguinal ligament, laterally of the sartorius muscle, and medially by the adductor longus muscle. In terms of the arteries in this region, the external
[00:00:30] iliac artery becomes the common femoral artery as it passes under the inguinal ligament just distal to the inferior epigastric branch and enters the femoral triangle. It bifurcates into the superficial and deep or profunda femoral arteries. The main benefits of using the femoral artery are that it's usually of good caliber and can ordinarily accommodate the size of equipment used for PCI and for other adjunctive technology such as intraortic balloon
[00:01:00] pumps and impella devices. The downsides are that it is often subject to significant atheromatous disease in patients with cardiovascular risk factors and associated coronary artery disease. It is often deep within the groin depending on the patient's size and build and depending on where it's punctured may or may not be easily compressible as remember, an artery needs to have tissue behind it and ideally bone to compress
[00:01:30] it against to stop it bleeding unless you plan to use a closure device. Some challenges to femoral access include a tortuous or calcified iliofemoral system and the presence of an abdominal aortic aneurysm. Ideally, the common femoral artery should be punctured above the bifurcation and over the medial head of the femur to allow it to be compressed or closed as required. The problem is that unless you
[00:02:00] image with ultrasound, before you gain access and perform a femoral angiogram, it's not possible to know where this is accurately. The maximal pulsation is normally felt where the common femoral artery is compressible against the medial head with a femur. This is usually also the safest place to cannulate the common femoral artery. We need to note where this is in relation to the surface anatomy on the skin. We often assume that the skin crease in the groin is a good representation
[00:02:30] of the position of the inguinal ligament. Sadly, this is not the case. It can differ in position by over 10 centimeters. We can, however, use some radio graphical landmarks to help us determine the best place to puncture. If we perform the fluoroscopy of the groin using an externally placed metal object to mark the position on the skin where we intend to puncture, we can try to aim for puncturing in the so-called triangle of safety.
[00:03:00] The needle should puncture the vessel where it passes over the medial head of the femur providing a solid structure to compress the artery against for hemostasis and usually ensuring puncture of the common femoral artery rather than one of its more distal and thinner-walled branches. Puncturing the femoral artery higher than the inguinal ligament is dangerous as it offers no structure to compress the artery against and is in direct continuity with the retroperitoneal space should bleeding
[00:03:30] from the vessel occur. In this frozen fluoroscopic image, you can see localization of a good puncture site in action. The operator locates the best palpable pulse and using surface anatomy with all the caveats that we've mentioned, then determines their preferred puncture site. They then mark where they intend to puncture by lying a metal object such as scissors or forceps on the patient and perform fluoroscopy. If, as in this case,
[00:04:00] the tip of the scissors, i.e., the assumed puncture site lies over the medial femoral head then you're good to go. If it does not, then you need to reposition the marker so that it does lie over the femoral head radiographically. Then, using this marker to reorient yourself on the patient determine the best puncture site. Sometimes it may be challenging to feel the femoral pulsation if it's deep or the artery is diseased. Remember to check the pulse [00:04:30] in the other leg, the left common femoral artery as this may be better as disease can sometimes be unilateral. Consider using ultrasound to obtain direct puncture. With the availability of portable ultrasound devices, this technique is becoming more popular. Consider using a micropuncture set which can be useful if you're concerned about obtaining arterial access as this produces a very small hole which is unlikely to cause significant damage or bleeding.
[00:05:00] This has been common practice by interventional radiologists for some time now but for some reason, only just gaining traction with cardiologists. This is a femoral angiogram via a sheath to show the puncture site above the bifurcation. Note that the entry point of the artery is where the sheath seems to bend slightly and is opposite the femoral head. Sometimes waggling the sheath a little during fluoroscopy helps identify the puncture site better. Just remember not to get
[00:05:30] your fingers in the x-ray beam and not to pull the sheath out by over-vigorous waggling.