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4 Case preparation
are for treatment, and the expectations of the patient
and family all play important roles. roughout this
book, there is advice about these issues. Chapter 2
details access choices and how to use them. e
chapters included in Part III oer a number of
ideas about treatment strategy. Chapter 13 discusses
where we work and related issues. is chapter deals
with some of the logistical issues that everyone faces
in performing endovascular surgery.
SIZING UP THE CASE
Issues to address with regard to medical manage-
ment of the patient may be numerous. e ones
that occur most frequently are management of dia-
betes, renal insuciency (contrast tolerance), and
anticoagulation or antiplatelet agents. Each of these
must be appropriately balanced based on an esti-
mation of what needs to be done, how long it will
take, how extensive it will be, and whether or not
it will solve the patient’s problem. In the midst of
all this, the patient must be prepared by the physi-
cian and sta for the shortest possible hospital stay,
maybe only a few hours. Logistical issues around
transportation, mobility, and accompany home by
a family member must be addressed. In prepar-
ing for the technical part of the case, check old
angiograms and procedure notes. Examine the
patient and perform a complete vascular examina-
tion. Palpate the arteries and assess puncture sites.
Obtain and analyze some type of preprocedure
noninvasive study to assist with planning.
PRIOR TO THE PUNCTURE
Informed consent is best obtained in the oce
when the patient is aorded time to consider issues
and to consult with family. Patients on warfarin
or other anticoagulants should be considered on
a case-by-case basis. It is usually safe to perform
either arteriography or endovascular interven-
tion in patients on antiplatelet therapy as long as
there are no other factors that are likely to promote
hemorrhage, such as dialysis dependency. It is
usually not necessary to stop antiplatelet agents
prior to endovascular intervention. If for some
reason the antiplatelet agent must be stopped, it
should be 10 days prior to the procedure. If endo-
vascular intervention is required, warfarin should
be stopped approximately 5 days prior to the
procedure. Patients who require anticoagulation
to be continued, except for a “window” when it
is stopped, may oen be treated with outpatient
enoxaparin sodium to shorten the hospital stay.
At the operator’s discretion is whether a pro-
thrombin time should be obtained on the day of
the procedure. Patients with renal insuciency
are managed with preoperative hydration with a
bicarbonate infusion and mucomyst. Methods of
preprocedural evaluation are available that help
to limit the contrast required for the study. ese
are discussed in Chapter 11. A contrast agent that
is less toxic to the kidneys (e.g., CO
2
) should also
be considered. Patients with a history of contrast
allergy should be treated before the procedure with
prednisone and diphenhydramine. is protocol is
detailed in Chapter 13.
WORKING ENVIRONMENT
Experts understand that top performance is some-
thing that does not happen randomly. It develops
with preparation. Judgment and technical skills
take time, eort, and enthusiasm to develop. e
sta that assist you, the equipment available, and
the facility where you use those skills can either
promote or detract from your ability to guide sick
patients through dicult situations. ese prepa-
rations help to limit the variables and optimize
results. Endovascular work is no dierent. ere is
a substantial learning curve associated with each
procedure. Creating a working environment where
high-quality endovascular practice can be carried
out is essential.
It is imperative to ensure the presence of the
proper interventional equipment when perform-
ing endovascular interventions. e necessary
catheters, guidewires, guiding catheters and
sheaths, balloons, and stents must be available. e
room must be equipped to adequately monitor the
patient. Medications must be available, including
anticoagulants, antiplatelet agents, hemodynamic
medications as needed, and sedation as required.
e sta must be knowledgeable in the inven-
tory of the supplies, devices, and equipment used
during interventional procedures. e surgeon
must be comfortable with the ability of the sta to
assist in performing these procedures. Educating
the sta beforehand on the nature of the proce-
dure to be performed, the important points of the
case, and the specic assistance that will be nec-
essary are critical to ensuring smooth progression
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Facilities and room setup 5
through the case. Adequate monitoring of the
patient allows rapid assessment of the patient’s
status, thereby allowing intervention for hemody-
namic problems early and limiting their impact on
the outcome. Itis important that the person per-
forming the intervention is condent that the peo-
ple assisting can quickly deal with hemodynamic
or other problems. Fixed imaging equipment is not
mandatory but is best and facilitates performance
of endovascular procedures. A room stocked with
adequate disposable inventory is desirable. It is
helpful to develop a method of arranging the room
for dierent procedures, depending on the pro-
posed access site and the area of intended imaging
and target site for treatment.
EQUIPMENT
e patient must be monitored during and aer
the procedure. Otherwise, the attractive advan-
tages of a less morbid and less invasive procedure
may be negated by some unfortunate complicating
event. It is imperative to have monitoring equip-
ment in both the procedure room and the recov-
ery room. Monitoring necessitates the presence of
someone in the room whose primary responsibility
is assessing and managing the patient. is person
has a signicant role in assuring that the subject
is stable and that the monitoring equipment is
functioning properly. Resuscitation equipment
must be available should it become necessary.
is includes a functioning suction device,
oxygen, and intravenous solutions along with a
cart equipped with standard emergency resuscita-
tion material. Standard oxygen monitoring equip-
ment should be available. is probe is placed
away from the extremity in which arterial access is
obtained to ensure that distal vessel spasm or dis-
ease, if present, does not impair the readings of the
monitor. ere should be continuous monitoring
of the electrocardiographic tracing. Insome cases,
it may also be mandatory to have the ability to
continuously monitor arterial pressure. is may
be achieved with a separate arterial line, andmay
be useful in performing carotid stents or in major
aortic cases.Arterial pressure monitoring may also
be performed as part of the manifold system con-
nected to the arterial sheath. It is helpful to have
an additional port o the manifold that allows
pressure monitoring. e pressure system can,
however, be added to the side arm of the sheath,
attaching the side port of the sheath to a separate
pressure monitoring system. In addition to this
invasive arterial pressure monitor, it is necessary
to have a noninvasive method of monitoring the
pressure in case the invasive system is not func-
tioning or is impaired for a period of time during
the procedure. Imaging equipment is described in
Chapters 8 and 12. e table should be a oating-
point table that is made of carbon ber and allows
imaging in all rotations. Floating-point tables
allow rapid positioning of the table and decrease
the time necessary for performing the procedure.
It is also helpful to have a sterile tabletop on which
to work. In order to move expeditiously through
the performance of these procedures, arranging
two tables behind the team is helpful. e space
oered by an additional “back table” provides an
area on which the items to be used are prepared
and placed, available in their order of use. e time
saved not searching for an item on a crowded sur-
face will easily oset the small space loss incurred
by the additional table.
FACILITIES AND ROOM SETUP
Inventory items should be assembled prior to the
procedure, which should be previewed in a step-by-
step manner. It is important to have the facility and
room arranged so that the surgeon is comfortable
performing the procedure and all the equipment
necessary for the procedure is readily available. e
room should be large enough to allow movement
around the patient and sterile eld. e patient
should be comfortably positioned. Safety straps
and side restraints help maintain patient posi-
tion and safety. e interventionalist is positioned
tableside with easy access to the equipment tables.
It is essential to have adequate assistance during
these procedures and to ensure that the assistant is
well versed in the technique. e assistant should
be positioned on the side of the interventionalist
and should also have easy access to equipment. e
imaging system is best positioned on the opposite
side of the table to where the surgeon is located and
the monitor bank for images should be positioned
at eye level opposite the surgeon. e monitor bank
should include three monitors. e rst should
contain the working images. e second monitor
is a reference monitor to allow posting of reference
images that can be used to assist with position-
ing catheters and guidewires. e nal monitor
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6 Case preparation
should be a physiologic monitor, which contains
the output of any hemodynamic measurements,
oxygen saturation, electrocardiographic tracing,
and pressure measurements. Maximize the poten-
tial for success in each case. Preprocedure analysis
makes a dierence. Practice settings that have
some particular disadvantage with respect to setup
or equipment can still be made to work, but plan-
ning around those issues is essential.
HOW PRETREATMENT HISTORY
AND PHYSICAL EXAMINATION
HELP TO PLAN THERAPY
Your patients will benet substantially if you go
into the procedure with a good sense of how the
patient is doing, a good feeling of how strongly
indicated the treatment might be, and a reason-
able understanding of the whole range of treat-
ment options. Here are some examples of how
this information helps. Obtaining a good sense
of the history will help to indicate the trajectory
of the vascular problem. If it is chronic and the
patient is having problems during the procedure, it
makes more sense to stop and come back another
day. If the problem is more acute, then other fac-
tors related to the acute illness may be anticipated.
If the patient has profound ischemia, they may not
be able to tolerate having the limb on a level sur-
face. If there is signicant cardiopulmonary com-
promise, the patient may not be able to lay at. It is
good to know if palpation of the pulses reveals that
the femoral arteries are rock hard. If an antegrade
puncture is being considered, does the patient
also have a popliteal pulse or could there be occlu-
sive disease near and just inferior to the puncture
site? If an upper extremity access is anticipated,
it is good to know what the pulses feel like and
also whether the bilateral brachial pressures are
equal. Is the skin of the groin that is intended for
access clean? Factors such as these help to drive the
decision-making process that takes place before
the procedure even starts.
PRETREATMENT IMAGING
Pretreatment imaging, especially noninvasive
imaging with duplex ultrasound, magnetic reso-
nance angiography (MRA), or computed tomog-
raphy angiography (CTA), saves a tremendous
amount of grief. It may help you anticipate a
puncture site and may show a disease burden that
makes certain puncture sites too risky. It may help
you decide whether a diagnostic arteriogram is
needed prior to the therapeutic procedure. It might
also help you know when some type of hybrid
procedure is better than a purely endovascular
procedure. If there is signicant calcication, one
might consider atherectomy in the case planning
for a lower extremity or shy away from a stent in
a carotid repair, or it may aect the stent choice
in an aortoiliac occlusive case. Understanding the
hemodynamics of a limb is also extremely helpful
for planning the case and anticipating what the
ischemic hand or foot should look like aer treat-
ment of specic lesions. Pretreatment imaging
also saves a tremendous amount of contrast and
intraprocedural time. With angiography, it can
occasionally be challenging to identify the exact
severity of a lesion. If the severity of the lesion has
a bearing on whether or not to treat, such as in
the carotid circulation, then some type of prepro-
cedure corroboration of the severity of the lesion
should be obtained.
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7
2
Safe and strategic vascular access
OVERVIEW OF PERCUTANEOUS
ACCESS
e simpler and more routine you can make your
approach, the fewer complications your patients
will experience. Use of the vascular system itself to
assist the therapist in arriving at the site of the lesion
for treatment has tremendous appeal. It is simple,
direct, less morbid, and leaves little external evi-
dence of what has taken place. Much resources and
development have been brought to bear in order to
make standard open surgery a thing of the past, and
this eort has been relatively successful. As devices
are miniaturized, guidance more accurate, and clo-
sure more secure, vascular access becomes simpler.
A well-placed access site sets the operator up for
success. A poorly chosen or conducted access can
make a simple case complicated and possibly make a
complicated case impossible. Access site issues must
be considered for every case. Access-related com-
plications are still the most common complications
of endovascular intervention. An access mistake
almost guarantees a complication. Consider the
need for access as a breach of the vascular system,
a necessary evil that should be minimized as far
as possible. Although a percutaneous access site is
much smaller than a standard surgical incision, it is
still what the patient notices most during the recov-
ery process. Vascular access also has potentially
fatal complications associated with it.
Strategy: What are the principles of
percutaneous access?
1. Choose the puncture site with the individual
patient’s needs in mind.
2. Determine the likelihood of performing an
endovascular intervention during the proce-
dure at hand as an extension of the angiogram
and take that into account when choosing a
puncture site, knowing that the sheath will
require upsizing.
3. Pick an access site that is far enough from the
lesion that a sheath may be placed without
encountering the lesion itself, and gives the
operator working room.
4. Feel the artery intended for puncture so you
know what to expect. Is it so or hard, and
what is the quality of the pulse?
5. Palpate the anatomic landmarks. For example,
with every femoral puncture, the anterosu-
perior iliac spine, the pubic tubercle, and the
inguinal ligament should be dened by physi-
cal examination and palpation.
6. Visualize the artery and its relationship to
anatomic landmarks before skin puncture.
7. Standardize your technique.
8. Use uoroscopy for guidance once the wire is
introduced.
9. Do not be afraid to abandon the access and
puncture elsewhere if the risk is too high.
10. No one gets in every single time.
11. If there is a problem, hold pressure for a few
minutes and start again.
12. It is rare to have any signicant damage to the
access artery from the needle alone. Larger
problems occur when a poor puncture place-
ment is not recognized and larger devices are
placed through that site.
13. In recent years, the use of ultrasound guid-
ance and micropuncture has made access
safer.
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8 Safe and strategic vascular access
CHOOSING YOUR APPROACH
e most important maneuver for successful vas-
cular access occurs prior to the procedure, and
that is choosing the puncture site. e optimal
puncture site choice should provide a low risk of
complications and reasonable proximity to the
site of intended intervention. Table 2.1 provides
a list of puncture sites. e retrograde femoral
puncture is the most commonly used since it is
safest and oers the highest degree of versatil-
ity. In the author’s practice, when a proximal
approach is required, the brachial artery punc-
ture is chosen, with preference for the le brachial
artery since the pathway from the right brachial
artery crosses the origin of the right common
carotid artery and the innominate artery. Many
procedures are also being performed using the
radial artery, especially diagnostic cardiac cath-
eterization. When upper extremity access is
required for a sheath of more than 7-Fr in caliber,
it may be obtained using open exposure of the
brachial artery. Open axillary artery exposure,
with or without a conduit, is typically reserved for
larger sheaths or multiple simultaneous sheaths
required for aortic branch vessel reconstruction
during aortic aneurysm repair. Other puncture
sites that have been used less commonly include
Table 2.1 Percutaneous puncture site choices
Puncture site Approach Provides access to… Comments
Femoral artery Retrograde Aorta and its branches When either femoral artery can be used,
most right-handed operators will stand
on the patient’s right side and puncture
the right common femoral artery
Antegrade Ipsilateral
infrainguinal
Contraindicated when there is inflow
disease or a high profunda femoris artery
origin or when the patient is obese
Superficial
femoral artery
(SFA)
Antegrade Ipsilateral SFA SFA occlusion or occluded SFA stent with
reconstitution of distal SFA that cannot
be crossed from antegrade direction
Brachial artery Retrograde Aorta and its branches Prefer the left side. Access site for sheath
larger than 7-Fr should be closed
through open exposure. Risk higher than
with femoral puncture
Radial artery Retrograde Aorta and its branches 6-Fr sheath is maximum. Controlled with
local pressure. Alternative to brachial
puncture
Retrogeniculate
popliteal artery
Retrograde Ipsilateral SFA Disadvantage: patient in prone position
Tibial or pedal
artery
Retrograde Ipsilateral SFA,
popliteal, tibial
Crossing long occlusions that cannot be
crossed from antegrade direction.
Requires wire rendezvous technique
Common carotid
artery
Retrograde Aorta and its branches Increased risk of stroke and bleeding.
Usually through open exposure
Antegrade Carotid bifurcation Measure working room to bifurcation;
must be minimum of approximately
5cm, usually through open exposure
Translumbar Aorta and its branches Prone position, limited to arteriography,
increased risk of bleeding. Used primarily
for treatment of type II endoleak
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Femoral anatomy for arterial access 9
the retrogeniculate popliteal artery and the
common carotid artery. Tibial and pedal arter-
ies have been used for retrograde access to the
ipsilateral lower extremity, especially in patients
with critical limb ischemia and extensive occlu-
sion that cannot be crossed in the antegrade
direction. More information about using tibial
and pedal arteries can be found in Chapter 25,
which covers complex lower extremity revascu-
larizations. Using this approach has signicantly
increased the number of patients with chronic
lower extremity ischemia that can be treated with
endovascular techniques. Translumbar access is
only rarely performed for diagnostic procedures
but has recently been performed commonly to
gain access to a patent aneurysm sac in a patient
with an endoleak aer stent–gra exclusion of an
abdominal aortic aneurysm. Chapter 10 includes
a detailed discussion of puncture site evaluation
prior to arteriography. Once the puncture site has
been chosen, the operator should set up the case
so that the work can be performed forehand if
possible. e options for a forehand approach are
demonstrated in Figure2.1.
FEMORAL ANATOMY FOR
ARTERIAL ACCESS
e most common complications following arte-
riography or endovascular intervention occur at
the puncture site. An understanding of the anat-
omy helps avoid complications. e goal is a single
perfect pass of the entry needle in every case. e
inguinal ligament extends from the anterosuperior
iliac spine to the pubic tubercle. is landmark
is usually possible to dene by palpation, even
in obese patients, and is essential in helping to
determine how far superior or inferior the punc-
ture should be. A puncture of the mid-common
femoral artery is desirable. Ultrasound guidance is
extremely helpful in achieving this goal. Once the
location of the inguinal ligament has been dened,
the landing of the needle on the artery depends on
the angle at which the entry needle passes from the
skin to the artery.
The quality of the artery may be evaluated
prior to the procedure by palpating it. The artery
may be rolled under the fingers. A thicker-
walled or calcified artery presents as a firm
Fig. 2.1 Working forehand. The operator should work forehand whenever possible. In this example,
a right-handed surgeon stands on the patient’s right side to puncture either femoral artery. Brachial
puncture is also performed forehand.
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10 Safe and strategic vascular access
structure that can be rolled a little bit back and
forth, and it has more body than just the palpa-
tion of a pulse. If the patient has a poor femoral
pulse and has stronger pulses more distally, at
the popliteal or pedal levels, the common femo-
ral artery is likely calcified. If the patient has a
femoral bruit and yet the femoral pulse is stron-
ger than expected, it may be the waterhammer
effect caused by a lesion in the distal common
femoral artery, just distal to the point of palpa-
tion. If the artery is not easy to locate because of
a diminished pulse, there are several steps that
may be taken. These are outlined in the section
“Puncture of the pulseless femoral artery”.
Fluoroscopy may also be used prior to punc-
ture to locate the head of the femur and iden-
tify the artery. Puncture of the artery proximal
to the femoral head is likely to be too far proxi-
mal and to enter the external iliac artery. The
artery usually passes over the medial side of the
femoral head. The temptation is to use the groin
crease to determine the location of the puncture.
Obese patients often have a groin crease that is
significantly distal to the location of the ingui-
nal ligament, and this may lead to a puncture
that is too low (Figure2.2). The fossa ovalis may
also be palpated as a discontinuity in the fascia
of the leg at the location where the saphenous
vein dives toward the deeper common femoral
vein. Since this is directly over the lower aspect
of the common femoral vein, it may also be used
as an anatomic marker, with the femoral artery
just lateral (usually the proximal superficial
femoral artery [SFA] is present at this level).
Occasionally, it is helpful to use a marker on
the skin to define the inguinal ligament and the
location of the common femoral artery.
PUNCTURE GUIDANCE WITH
ULTRASOUND
In the author’s practice, ultrasound is used for
nearly every puncture, arterial or venous. The
likelihood of a clean first pass is higher, as well
as a properly placed puncture. Ultrasound pro-
vides the opportunity to avoid lesions located
near a puncture site and it may help permit the
use of a closure device, even in a diseased artery,
by helping to avoid a severely calcified area. It
also helps avoid a puncture that is too distal orin
the side of the artery wall (which is suboptimal
for closure). In the case of femoral artery access,
where either the right or left side could be punc-
tured, if one side looks severely diseased or the
common femoral artery is too short due to a
high profunda femoris artery origin, the con-
tralateral side can be accessed instead. In the
case of brachial artery puncture, ultrasound-
guided access is essential to obtain the clean-
est possible vessel entry. There are a couple of
Fig. 2.2 Identifying the anatomic landmarks before arterial puncture. Identification of landmarks for
arterial puncture may be challenging in the obese patient. The groin crease is usually substantially dis-
tal to the actual inguinal ligament and this must be taken into account when planning femoral access.
If you palpate the anterosuperior iliac spine and the pubic tubercle, the location of the inguinal liga-
ment will be more clear.
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Puncture guidance with ultrasound 11
situations in which ultrasound is not used. In
cases where puncture is being performed distal
to an occlusion that could not be crossed in the
antegrade direction (e.g., tibial or pedal artery
access), ultrasound may be used but direct visu-
alization of the artery may also be achieved by
injecting contrast proximal to the occlusion and
watching the vessel fill. Otherwise, ultrasound
is a routinely used tool that makes endovascular
procedures safer. Portable ultrasound machines
are being marketed for vascular access and are
widely and readily available.
The area intended for puncture is surveyed
quickly with the ultrasound probe. The depth of
the beam and the gain are adjusted. If the artery
is difficult to find, locate the vein first, which
is larger and easily compressible. Find the vein
with the probe in the transverse orientation.
After locating the vein, orientation of the probe
as to medial and lateral is checked and this gives
clues as to where the artery should be anatomi-
cally next to the vein. The artery can usually be
seen to be pulsatile, thicker walled, noncom-
pressible or minimally compressible, and smaller
than the vein. The dynamic presentation of the
artery on ultrasound may change depending
on flow conditions. In patients with congestive
heart failure, the vein may also appear pulsatile.
In patients with an occlusion just distal to the
insonation site, the artery may appear hyper-
dynamic. When evaluating the vascular sheath
in cross-section (transverse), the vein is larger,
thin-walled, and compressible, while the artery
is smaller in caliber, thick walled, and pulsatile
(Figure 2.3). Ultrasound works well for venous
puncture since veins are larger and compress-
ible and can be enlarged by manipulating the
patient’s position, but they have no pulse that
A
B C
D
E F
Fig. 2.3 Ultrasound-guided puncture can facilitate access under challenging circumstances. (A)The
operator evaluates the artery with the probe in transverse orientation, while inserting the needle at an
angle that is anticipated to encounter the artery directly under the beam of the probe. (B) The artery
is smaller, thicker walled, and more pulsatile than the vein and is located lateral to the vein. (C) The
artery can be followed more distally to observe the location of the common femoral artery bifurca-
tion. At this level, it is usual for the saphenofemoral junction to be visible. (D) Further inferiorly, below
the confluence of the profunda femoris and superficial femoral veins, the superficial femoral vein is
posterior to the superficial femoral artery. (E) The inguinal ligament may or may not be visible and is
typically seen as a uniform, echogenic structure crossing the artery. If a closure device is anticipated,
it is safer to be well inferior to the inguinalligament. (F) Gentle compression with the ultrasound
probe causes compression of the common femoral vein while the higher pressure common femoral
artery maintains its shape despite the external compression. The pulsatility of the common femoral
artery typically becomes more obvious with the maneuver of gentle external compression.
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12 Safe and strategic vascular access
can help an operator who is using external land-
marks to guide the puncture.
The middle of the probe should be placed
over the intended puncture site in the artery.
Advance the needle at an angle with the inten-
tion of having the needle hit the vessel directly
under the probe. Needles create a shadow when
the sound waves reflect off them and when it is
in the field of the ultrasound beam, it is usually
readily identified. Needles are also available that
have scuffed up tips and are even more visible on
ultrasound. When the needle hits the artery, the
artery wall can be seen in motion. The operator
may have to tap on the anterior artery wall a few
times to confirm the position prior to entering
the artery.
MICROPUNCTURE TECHNIQUE
A coaxial micropuncture set (e.g., Micropuncture
®
Access Set) includes a 21-gauge needle to enter the
artery, a 0.018-inch guidewire with a oppy tip,
and a 4-Fr or 5-Fr short catheter with an inner
smaller diameter dilator that passes over the wire
(Figure2.4).
e 21-gauge needle is placed into the artery.
When backbleeding occurs, the so-tipped,
steerable 0.018-inch guidewire is advanced
through the needle under uoroscopic guidance.
Arterial backbleeding through a 21-gauge needle
is usually much less pulsatile than through the
larger 18-gauge needle. e needle is removed
and the 4-Fr or 5-Fr short catheter with the 3-Fr
inner dilator is passed over the guidewire. Aer
the catheter is in place, the dilator and guidewire
are removed. A longer, appropriately sized guide-
wire (usually 0.035-inch diameter) is passed. e
short catheter is removed and the desired access
sheath placed. Puncture sites beyond the femo-
ral artery, including the brachial or radial artery,
bypass gras, and alternative access sites, are
preferentially approached using the micropunc-
ture technique.
When should the micropuncture technique
be used? Some operators use it for every case and
some use it selectively. It is particularly useful
for brachial or radial artery access, for pulseless
arteries, scarred groins, and calcified arteries,
or for antegrade access to the lower extremity.
Inthe author’s practice, it is used for nearly every
case. The advantages of the micropuncture tech-
nique include a smaller initial arterial hole, use
of a steerable wire, and graduated enlargement
between the inner stiff trochar and the 4-Fr or
5-Fr dilator. There are disadvantages of micro-
puncture. It requires extra steps. The catheter is
not long enough so if there is a lesion nearby, you
end up crossing it with the introducing guide-
wire and then crossing it again with the 0.035-
inch wire required for access sheath placement.
If you are working with a scarred groin, a redo
groin, or a super calcified femoral artery, the
catheter may not pass over the 0.018-inch guide-
wire. A number of tricks may be required to
make up for a guidewire that does not have the
backbone to support passage through a hostile
scarred area. The advantages of the technique
are significant in that it promotes optimal place-
ment, especially when used with ultrasound
guidance, and permits the operator to abandon
an unacceptable access with a low chance of
having done harm.
A
B
C
Fig. 2.4 This micropuncture set includes:
(A)a21-gauge needle; (B) a 0.018-inch floppy
tip guidewire; and (C) a 4-Fr short catheter
with an inner 3-Frtrochar to slide over the
low-profile guidewire.
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Percutaneous retrograde puncture of the femoral artery 13
PERCUTANEOUS RETROGRADE
PUNCTURE OF THE FEMORAL
ARTERY
Both groins are prepared and draped. A towel
holding each of the items immediately required
for puncture and guidewire placement (a syringe
for local anesthetic, a scalpel, a mosquito clamp,
a micropuncture set or a puncture needle, and a
guidewire) is placed on the patient’s lap. Aright-
handed operator stands on the patient’s right
side for the puncture of either groin so that the
forehand approach can be used (Figure 2.5).
Thefemoral artery of choice is palpated and the
B
C
D
F
E
A
Fig. 2.5 Percutaneous retrograde puncture of a femoral artery. (A) A sterile towel is placed on the
patient’s lap or on a nearby sterile table with the tools immediately required for percutaneous arte-
rial entry (from left to right): a scalpel, a hemostat, a percutaneous entry needle, a syringe with local
anesthetic, and a guidewire. (B) A right-handed operator stands on the patient’s right side for puncture
of either femoral artery to permit a forehand approach. If the left femoral artery requires puncture, the
operator leans over the patient. (C) The prospective location of the middle to proximal common femoral
artery puncture is evaluated by tracing the inguinal ligament from the anterosuperior iliac spine to the
pubic tubercle. The artery is trapped between the forefinger and third finger of the operator’s nondomi-
nant hand. The thumb and forefinger hold back the surrounding soft tissue, as do the third, fourth, and
fifth fingers. When local anesthetic is administered into the subcutaneous tissue, the femoral pulse usu-
ally becomes more pronounced. The entry needle approaches the artery at a 45-degree angle. (D)The
femoral arteriotomy is safest in the proximal to middle common femoral artery. (E)When pulsatile
backbleeding indicates that the needle tip is in the artery, the nondominant hand is released from its
position trapping the artery. The nondominant hand accepts the needle and steadies it. (F) The domi-
nant hand retrieves the guidewire, straightens its tip, and inserts it into the needle hub.
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