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14 Safe and strategic vascular access

inguinal ligament traced from the anterosupe-

rior iliac spine to the pubic tubercle. The goal

is to puncture the proximal to middle common

femoral artery. In most patients this represents

a segment 4–8 cm in length. The operator must

anticipate the trajectory of the needle with

an angle of approach of 45 degrees or steeper.

The more calcified or scarred the artery, the

more a steep trajectory approach is required

in order to spear the artery so that the needle

does not simply bounce off it. Guidance with

ultrasound is extremely helpful (see “Puncture

guidance with ultrasound”). Fluoroscopy

also helps in the situation of a heavily calci-

fied artery, because as the needle pushes the

hardened artery, the whole structure can be seen

moving.

The operator uses the nondominant hand to

trap the common femoral artery. A right-handed

surgeon uses their left hand to trap the artery

between the forefinger and the third finger. The

third, fourth, and fifth fingers fan out on one

side of the artery and the thumb and forefinger

on the other side of the artery to hold back the

surrounding tissue. The hand is adjusted until

the impression of the pulse is equal on the tips of

the second and third fingers. Once the left hand

(or nondominant hand) is correctly placed, it is

not moved again until pulsatile backbleeding

iscoming from the needle. Plain lidocaine (1%)

is injected into the skin and subcutaneous tissues

in the area for the prospective puncture between

the forefinger and the third finger of the opera-

tor’s left hand. Infiltration with local anesthetic

causes induration and this increases the trans-

mission of femoral artery pulsation to the sur-

rounding soft tissue, which can be appreciated

if the fingers are in the correct location. ANo.

18 straight angiographic entry needle is then

used to approach the artery at a 45-degree angle.

Either a single-wall or a double-wall puncture

needle may be used (Figure 2.6). The vessel is

usually 2–5 cm beneath the skin entry site. The

anterior wall of the common femoral artery can

usually be palpated with the tip of the needle and

identified by the pulsation of the artery against

the needle. The needle tip is advanced through

the anterior wall of the artery.

Because the anterior wall is usually soer and

the posterior wall is more rm, the needle may

immediately abut the posterior wall of the com-

mon femoral artery. Occasionally, the needle must

be withdrawn just slightly to allow guidewire pas-

sage (Figure2.7).

When pulsatile backbleeding is achieved, the

operator’s nondominant hand is released from

its location over the common femoral artery.

e nondominant hand is then used to hold the

Fig. 2.6 Single-wall or double-

wall puncture technique.

(A) The single-wall puncture

18-gauge entry needle has a

beveled tip that is placed into

the anterior wall of the artery.

The micropuncture needle is

a similar but smaller caliber

version (21 gauge). (B) The

double-wall puncture needle

has a trochar with a sharp

beveled tip that is inserted

through the artery. (C) The tro-

char is removed. (D) The blunt

tip outer casing is then gradu-

ally withdrawn until its tip is in

the arterial lumen and pulsatile

backbleeding is evident. In

general, double-wall puncture

is of historical interest and has

mostly been abandoned.

B C D

https://t.me/med1917

Percutaneous retrograde puncture of the femoral artery 15

needle until the guidewire can be passed through

the needle. At this point, the needle must be held

by the nondominant hand since the needle is in an

unstable position in the ar tery and must be secured.

e contralateral hand will be busy inserting and

advancing the guidewire. e several-centimeter

oppy tip portion of the guidewire is advanced

through the needle until the stier portion of

the wire is traversing the arterial entry site. If the

lesion is near the puncture site (e.g., distal exter-

nal iliac artery lesion), uoroscopy is initiated

immediately.

Most puncture site complications are related

to arteriotomies that are too high, too low,

or forced into an area too hostile for simple

puncture (Figure 2.8). The anterior wall of the

Fig. 2.7 The guidewire hits the

posterior wall. The tip of the

needle often pushes the softer

anterior wall of the common

femoral artery against the thicker

posterior wall before it enters the

lumen. (A) When the guidewire is

advanced through the needle, it

hits the posterior wall of the artery

and is unable to pass. (B) The

needle is withdrawn 1–2mm and

the guidewire is passed again. The

needle position against the pos-

terior wall may also be visualized

with ultrasound.

A B C D E

Fig. 2.8 Variability in femoral artery punctures. Entry site complications result from poorly

placed femoral artery punctures. (A) Proximal SFA puncture is too low and may cause punc-

ture site thrombosis. The proximal SFA is frequently the site of signiﬁcant plaque formation.

(B)

A proximalprofunda femoris artery entry is difﬁcult to compress and may result in hem-

orrhage. Ultrasound guidance is very useful for avoiding unintended puncture of the SFA or

profunda femoris artery. (C) The needle tip may disrupt posterior wall common femoral artery

plaque. This is more likely in proximity to the bifurcation. (D) Puncture of the distal external iliac

artery is contiguous with the retroperitoneal space and is prone to hemorrhage. (E) Ultrasound

guidance may not detect the inguinal ligament very well and does not always protect the patient

from a groin puncture that is too proximal. After placement of the needle, consider a single radio-

graph of the needle location. If the tip is proximal to the outline of the femoral head, consider

removing the needle and starting again to obtain a lower placement. This helps avoid a retroperi-

toneal hematoma.

A B

https://t.me/med1917

16 Safe and strategic vascular access

common femoral artery often has a soft spot,

even when the artery and its bifurcation are

heavily diseased. Puncture of the external iliac

artery is difficult to compress and it is sur-

rounded by the potential space of the retroperi-

toneum (Figure 2.9). Hemorrhage from a high

puncture may require a stent–graft or surgical

control. Unfortunately, an external iliac artery

puncture is often not recognized until after

the access is removed and the patient develops

pain or vital sign instability. The proximal pro-

funda femoris artery is also difficult to compress

because of its deep course. The proximal SFA is

usually calcified and often a site of substantial

plaque formation, and puncture site compres-

sion at the SFA origin may cause thrombosis.

Since common femoral artery plaque forms

preferentially along the posterior wall, dou-

ble-wall puncture confers no advantages and

may add some risk, and should therefore be

avoided.

Strategy: What to do if the guidewire

will not pass through the needle

1. e guidewire may be trapped between the

tip of the needle and the posterior wall of the

artery. If the tip of the entry needle is against

the posterior wall of the artery, withdraw

the needle 1–2 mm very slowly while gently

attempting to pass the guidewire (Figure2.7).

As the needle pulls back far enough, the guide-

wire oen will pass.

2. If the guidewire encounters a common femoral

artery lesion, irregular posterior wall plaque

may be disrupted, form a dissection plane, or

embolize. Do not force the guidewire. Tactile

feedback is important here and it is a good time

to move slowly. Bringing in uoroscopy at this

point is oen helpful in order to see the shape

and direction of the wire tip.

3. Withdraw the guidewire to ensure that the

needle tip is still intra-arterial and that

backbleeding is pulsatile. However, if using

a hydrophilic guidewire, care must be taken

to avoid shearing of the hydrophilic coating

of the tip of the wire by the sharp bevel of

theneedle.

4. Establish that arterial return is consistent

with the clinical impression of inow to that

level (e.g., dampened arterial inow should be

expected if the patient has aortoiliac disease).

5. Reinsert the guidewire and use uoroscopy to

see where the wire hangs up. Sometimes, the

guidewire goes just beyond the needle tip and

into a medial or lateral collateral (Figure2.10).

If the guidewire tip forms a loop or appears to

go on a circuitous course just aer it exits the

needle, do not force it. e wire is likely subin-

timal and you will probably have to pull it out.

6. If there is appropriate blood return from the

needle, put an extension tube on the hub

of the needle and pu contrast while under

uoroscopy or use road mapping. Visualize

the puncture site and the cause of the

obstruction.

7. Consider a new puncture at the same location

or a dierent approach altogether.

8. e needle may be too low and hitting femoral

bifurcation plaque. Pull the needle and hold

pressure at the arterial puncture site. Repeat

the puncture 1–2 cm more proximally along

the common femoral artery.

Fig. 2.9 Retroperitoneal hemorrhage from a

proximal groin puncture. A groin puncture that

is too far proximal may enter the external iliac

artery and cause hemorrhage into the retro-

peritoneal space. If it is unrecognized, pressure

at the skin puncture site, which is somewhat

distal to the arterial puncture site, may exac-

erbate hemorrhage by creating additional

outﬂow resistance downstream from the bleed-

ing arteriotomy, as in the example shown. If

the abdominal wall is relaxed, manual pressure

can often be held satisfactorily over a distal

external iliac artery puncture site with a little

extra effort.

https://t.me/med1917

Percutaneous antegrade puncture of the femoral artery 17

PERCUTANEOUS ANTEGRADE

PUNCTURE OF THE FEMORAL

ARTERY

Antegrade femoral artery access permits optimal

control of guidewires and catheters for infraingui-

nal endovascular intervention, especially if tibial or

pedal artery treatment is contemplated. e punc-

ture in the skin must be proximal to the level of the

inguinal ligament to allow entry of the needle into

the proximal to middle common femoral artery,

taking into account a 45-degree angle of approach

(Figure 2.11). Oen a steep approach angle of the

needle works best for antegrade puncture. A high

puncture in the distal external iliac artery may result

in hemorrhage. A distal puncture, which is too near

the femoral bifurcation, results in inadequate work-

ing room to selectively catheterize the origin of the

SFA and may also be in an area where it cannot be

safely compressed to achieve hemostasis.

A right-handed operator stands on the patient’s

le side for forehand delivery of the needle and

guidewire. e image intensier should hover over

the patient from the side opposite the operator.

is arrangement may be a problem in an angio-

graphic suite where the C-arm unit is mounted on

ceiling rails or on the oor. e le or nondomi-

nant hand is used to trap the common femoral

artery between the forenger and the third nger

in the same way as for a retrograde femoral artery

puncture. e proposed arterial puncture site is

visualized in juxtaposition to the location of the

inguinal ligament. e skin puncture site is then

chosen and inltrated with 1% plain lidocaine. e

angiographic entry needle is advanced at an angle

of 45 degrees or steeper toward the pulse, which

is trapped between the forenger and third nger.

When pulsatile backbleeding is achieved, the nee-

dle is held steady by the dominant hand momen-

tarily. e nondominant hand position over the

artery is relinquished. e nondominant hand

rests on the patient on its ulnar side and takes over

the needle in its intra-arterial position. e domi-

nant hand reaches for the guidewire and inserts

Wire goes in a short distance and

then stops as wire tip hits obstruction

and begins to curl

Wire goes out of needle only

a short distance then begins

to coil up

Wire goes in but then

goes the wrong direction

Wire passes into iliac artery

Floppy tip on the

wire forms a loop

Wire goes up the common femeral

arrtery but then goes out into the

medial or lateral iliac circumex

arteries

A B C

E F

Fig. 2.10 Guidewire advancement problems. Some examples of how an advancing guidewire may be

hampered are shown. (A) Guidewire tip in a dissection plane. (B) Guidewire encounters a lesion and

rolls into a ball. (C) Guidewire redirects itself inferiorly. (D) Guidewire enters a medial or lateral iliac

circumﬂex branch. (E) Guidewire tip forms a loop and then encounters a lesion or friction. (F) The

transition point along the guidewire, from the soft ﬂoppy tip to the ﬁrmer shaft, is at the angle of the

needle entry and forces a hesitation in advancement.

https://t.me/med1917

18 Safe and strategic vascular access

it into the needle hub. e wire is then advanced

with the dominant hand.

In patients with a large abdominal pannus, wide

silk adhesive tape is used as a truss to hold the pan-

nus back (Figure2.12). A large pannus is a relative

contraindication to the antegrade approach. Using

a tape as a truss can be helpful with either a retro-

grade or an antegrade femoral puncture. It might

also help to put the patient in the Trendelenberg

position in order to tilt the pannus away from the

access site.

Since the SFA is on the level plane and the pro-

funda femoris artery proceeds posteriorly from

the bifurcation, the guidewire usually enters the

profunda femoris artery preferentially following

antegrade puncture. e guidewire must be redi-

rected into the origin of the SFA (see Chapter 9

for a detailed discussion of selective catheteriza-

tion). e working distance between the antegrade

puncture site in the common femoral artery and

the femoral artery bifurcation is limited. Any pre-

viously acquired arteriograms should be assessed

to determine the level of the femoral bifurcation.

Even if only contralateral lower extremity lms

are available, evidence of an unusually high femo-

ral bifurcation may alter the puncture site choice.

Prior to performing antegrade femoral artery

puncture, any previous arteriograms should be

checked for the location of the profunda femo-

ris artery origin and the length of the common

femoral artery. Duplex ultrasound evaluation and

marking of the common femoral artery bifurca-

tion may also be performed before proceeding with

antegrade puncture. e micropuncture approach

Fig. 2.11 Percutaneous antegrade puncture of a femoral artery. (A) A right-handed operator stands

on the patient’s left side to permit a forehand approach to either femoral artery. A towel is placed on

the patient’s lap with the tools needed for arterial puncture. (B) Consider using ultrasound guidance

to locate the best puncture site in the artery. If not using ultrasound guidance, the common femoral

artery is trapped between the foreﬁnger and third ﬁnger of the nondominant hand. The intended

arterial puncture site is at the proximal to middle common femoral artery, with the needle approach

at 45 degrees. The skin puncture site is proximal to the inguinal ligament. (C) The common femoral

artery available for antegrade puncture is limited. Puncture above the inguinal ligament must be

avoided because of the risk of hemorrhage. Puncture near the common femoral artery bifurcation

leaves inadequate working room for cannulation of the SFA. (D) After the needle tip enters the artery,

the position of the nondominant hand is modiﬁed to hold the needle rather than trap the artery. The

guidewire is advanced with the dominant hand. While using ultrasound guidance, the probe can be

turned in the longitudinal orientation to visualize the wire entering the SFA. (Catheterization of the

SFA using an angled catheter and an antegrade approach is demonstrated in Chapter 9.)

https://t.me/med1917

Percutaneous puncture of a pulseless femoral artery 19

works well for an antegrade puncture. e punc-

ture is small and can be directed under uoroscopy

or ultrasound. e guidewire is relatively steerable

and can be rolled between the ngers and twirled

into the SFA.

Technique: How do you enter the

proximal femoral artery during

antegrade femoral puncture?

1. It is best when performing an antegrade

approach to enter the proximal common

femoral artery to maximize the working

distance between the puncture site and the

femoral bifurcation.

2. Use a micropuncture set, which has a guide-

wire that is somewhat steerable.

3. Under ultrasound guidance, aim to hit the

artery even with the very proximal part of the

head of the femur, just inferior to the level of

the bony cortex. Go at a sharp angle from the

skin down toward the artery if you need to.

Putthe needle down close to where you think

the artery is and then use uoroscopy to obtain

conrmation of the appropriateness of the

location.

4. Calcification can often be visualized, which

helps to identify the location of the SFA

origin.

5. If the guidewire repeatedly passes into the

profunda femoris artery and cannot be passed

into the SFA, a catheter is placed to direct the

wire. A slightly more robust wire, such as a

Rosen wire, is advanced deep into the pro-

funda. Ashort (40-cm) angle tip 4-Fr catheter,

such as a Kumpe catheter, is advanced over the

wire. e catheter is slowly withdrawn while

contrast is administered. e contrast will

reux into the femoral bifurcation and opacify

the proximal SFA. e image intensier is

placed in an anterior oblique position. A road

map is created and the catheter used to direct a

steerable guidewire, such as a Glidewire

, into

theSFA.

6. Once the guidewire is in the artery, guide the

catheter down over the wire by pushing on the

subcutaneous tissue with a free hand to keep it

straight and avoid kinking under the skin.

7. Use ultrasound to visualize the guidewire

entering the SFA.

PERCUTANEOUS PUNCTURE OF

A PULSELESS FEMORAL ARTERY

The clinical situation that requires puncture of

a pulseless femoral artery usually includes plans

for iliac artery reconstruction or recanalization,

rather than simple arteriography. Aortoiliac

duplex scanning or CTA is valuable in this set-

ting to assess the severity, location, and length

of the lesion. The patent but pulseless femoral

artery is cannulated using a combination of sev-

eral techniques (Figure 2.13). The artery itself

is often palpable, even when there is no pulse.

The artery can be visualized with ultrasound

guidance and this is an excellent indication for

this procedure, even in operating rooms where

ultrasound guidance is rarely used. The com-

mon femoral artery almost always passes over

the medial half of the femoral head. Its loca-

tion may be revealed by a previous arteriogram

Fig. 2.12 The abdominal pannus can be taped

up during the procedure to better expose the

femoral areas.

https://t.me/med1917

20 Safe and strategic vascular access

or is identifiable by vascular calcification using

fluoroscopy. Ablood pressure cuff placed on the

ipsilateral thigh can increase peripheral resis-

tance and enhance a diminished pulse. A cath-

eter can be placed through another access site,

either on the contralateral side or the proximal

side, and contrast can be injected to road map

the femoral artery. Delayed filming is required.

Technique: Fluoroscopically-guided

femoral access

1. Mark out anatomic landmarks by palpation.

Identify the approximate location of the

inguinal ligament. Place a marker, either the

needle or a clamp tip, over the location that

estimates the correct place to puncture the

arter y.

2. Perform fluoroscopy of the femoral area.

Often the femoral artery is visible on plain

fluoroscopy due to calcification. Check the

proximal SFA for calcification because this

will indicate the trajectory of the common

femoral artery.

3. If the artery is vaguely visible over the

femoral head, but you are not sure, use an

oblique projection to see if the longitudinal

image of the common femoral artery moves

with respect to the femoral head. (Because

the common femoral artery passes within

1–3 cm anterior to the very sizeable femo-

ral head, completely separating the images

of the two structures is almost impossible.

To separate the image of the two structures

requires a very steep oblique, almost lateral

projection. At this angle, contralateral struc-

tures contaminate the image.)

4. Anesthetize the skin. Advance the needle

down toward the artery. If it is really close, the

needle will be bobbing with the pulsation of

the artery.

5. Do not put the image intensier too close

to the eld, so you can work under it. You

must be able to see the blood return from the

micropuncture needle. Position the intensier

so that the eld does not include your hands.

ere is a lot of scatter in this position so do

not perform the procedure for longer than is

necessary.

6. When the needle hits the artery, the artery

oen moves back and forth a bit and becomes

a lot more obvious to see on uoroscopy. If the

artery is really rolling back and forth, the other

hand can press from the side to provide a little

back pressure.

7. A common tendency when starting out with

this task is to use uoroscopy continuously and

to use it more than is necessary. ere is also a

tendency to place the needle at too oblique an

angle and end up with the tip of the needle fur-

ther proximal along the artery than intended.

In addition, uoroscopically-guided puncture

is oen chosen because the artery is calci-

ed. In this situation, a more direct (not quite

straight down, but almost that steep) trajectory

works best for puncturing the artery.

Fig. 2.13 Percutaneous

puncture of a pulseless

femoral artery. (A) The

patent but pulseless

femoral artery can often

be palpated. (B)Areview

of previous arteriograms

shows the location of the

artery relative to the femo-

ral head. It usually passes

over the medial half of the

femoral head.

https://t.me/med1917

Percutaneous puncture of the brachial artery 21

When to start over again with a

femoral artery access?

Femoral artery access is the author’s usual method

of entering the vascular system. ere are situa-

tions in which it makes sense to stop at some point

during the access and change to another option.

If the arterial puncture is too high, so that it is

through the inguinal ligament or into the exter-

nal iliac artery, it is best to stop and hold pressure

rather than enlarging the access site. If therapy is

intended and the artery is so hard that a small-

bore sheath will not go in or causes excessive pain,

consider an alternative access. If the puncture site

is near a preocclusive lesion, this is a situation

where a larger sheath may result in low ow past

the access site or even puncture site thrombosis, or

disruption of the lesion near the puncture site.

PROXIMAL ACCESS

Proximal access may be secured through percu-

taneous or open approaches to the brachial artery

or a percutaneous approach to the radial artery

(Figure 2.14). Axillary artery puncture was used

in the past for arteriography but this is rarely done

nowadays. It is much more common to use the bra-

chial artery or radial artery for access. e brachial

artery may be punctured and managed percutane-

ously or using an open exposure. Another option

is to enter the artery percutaneously and, if there is

any problem, take the sheath out using open expo-

sure and direct suture closure. Diagnostic studies

and therapeutic procedures may be performed

through the radial artery. is has been devel-

oped primarily for coronary intervention, where

the caliber and distance requirements are fairly

standardized.

Advantages of the proximal approach

include the following: (1) it provides an alterna-

tive to the transfemoral approach when the femo-

ral puncture sites are hostile or when the pathway

between the groin and the pathology is blocked;

(2) when a femoral approach is not possible for

some reason, it provides an opposite approach for

crossing some lesions in certain arteries. ere

are several disadvantages to a proximal approach.

Although percutaneous puncture can be safely

performed, the complication rate is higher and the

complications are generally worse when they occur.

e arteries of the upper extremity are smaller, less

forgiving, and more prone to spasm than arteries

of the lower extremity. A constrictive fascial sheath

encircles the artery and nerves in the upper arm,

and a small hematoma may be enough to cause a

brachial plexopathy. Passage of larger endovascu-

lar devices for the performance of procedures more

complex than arteriography is accompanied by a

proportionately greater risk of puncture site com-

plications. e extra distance from the proximal

access site to the infrarenal vasculature requires

longer guidewires and catheters, which are more

cumbersome and less responsive to manipulation.

PERCUTANEOUS PUNCTURE OF

THE BRACHIAL ARTERY

e most common location for brachial artery

puncture is just proximal to the antecubital crease.

e le side is the rst choice since the carotid

artery origin may be avoided. In average-sized

patients, sheaths up to 6-Fr may be placed without

Fig. 2.14 Proximal access. Brachial or axillary artery entry is usually performed on the left side.

(A)Brachial artery cutdown is performed just proximal to the antecubital crease. (B) A brachial

arterypuncture may be performed at the same location.

https://t.me/med1917

22 Safe and strategic vascular access

major risk of puncture site hemorrhage or throm-

bosis. Open access should be considered for larger

devices or in smaller individuals.

The patient’s arm is abducted and placed on

an armboard (Figure 2.15). A circumferential

preparation of the arm is performed. The bra-

chial artery pulse is palpated just proximal to the

antecubital crease where the biceps has generally

thinned to its tendinous portion. Ultrasound

guidance is strongly recommended. If not avail-

able, the artery can be trapped between the

forefinger and the third finger of the nondomi-

nant hand. The tips of the two fingers are held

at enough distance to allow the artery to pass

underneath without compressing it signifi-

cantly. The 21-gauge micropuncture needle is

advanced at a 45-degree angle by the dominant

hand. The goal is for the needle tip to enter the

anterior wall of the artery in the space between

the two fingers. When backbleeding occurs, a

short 0.018-inch diameter guidewire is passed.

Backbleeding through the micropuncture needle

is usually not pulsatile because of its small cali-

ber. The needle must be moved and manipulated

slowly and any backbleeding carefully assessed.

Heparin is administered to prevent thrombo-

sis. Intra-arterial nitroglycerine or papaverine

may be required if spasm of the upper extremity

Fig. 2.15 Percutaneous puncture of the brachial artery. This should be considered for interventions

requiring a sheath of 6-Fr or less. (A) The left arm is fully abducted. (B) The brachial artery is trapped

between the foreﬁnger and third ﬁnger just proximal to the antecubital crease. A 21-gauge micro-

puncture needle is advanced into the artery. (C) A 0.018-inch guidewire is advanced through the

needle. (D) A coaxial dilator system is advanced over the guidewire. (E)After the 0.018-inch guidewire

and the inner 3-Fr trochar have been removed, a 4-Fr catheter may be used to introduce the desired

wire forthecase.

https://t.me/med1917

Percutaneous puncture of bypass grafts 23

arteries occurs. Ultrasound can be used to visu-

alize the guidewire advancing into the axillary

artery. If the brachial artery is really small (less

than 3–4 mm), consider moving to the contra-

lateral side. Such patients may have a high origin

of the radial artery.

ALTERNATIVE ACCESS TO THE

LOWER EXTREMITY: SUPERFICIAL

FEMORAL, POPLITEAL, TIBIAL, AND

PEDAL ARTERIES

In situations where lower extremity access from

the femoral level alone is not adequate for cross-

ing the lesion, other options include direct punc-

ture of the lower extremity artery at the level of the

supercial femoral, popliteal, tibial or pedal arter-

ies. is is almost always used for retrograde access

distal to a lesion that could not be crossed in the

antegrade direction. erefore, by denition, this

is usually a secondary access and not the primary

access used to perform therapy. More information

about this can be found in Chapter 25, which cov-

ers complex lower extremity revascularizations.

ere is also a brief description of the approach to

secondary lower extremity access.

e most common of these approaches is a

tibial or pedal puncture for a secondary retro-

grade access. e puncture may be anywhere

along the length of the posterior or anterior tib-

ial artery or the dorsalis pedis artery. eclini-

cal scenario is usually one in which antegrade

femoral or up-and-over femoral access has been

obtained and an attempt has been made from an

antegrade direction to cross a supercial femo-

ral, popliteal, or tibial artery occlusion or, oen,

a combination of these. When re-entry can-

not be obtained to the true lumen, a retrograde

access can be performed. e access itself may

be performed under ultrasound guidance using

a smaller hockey stick probe or it may be per-

formed by direct and angiographic visualization.

In the tibial and pedal vessels distal to an occlu-

sion, ow is usually fairly slow. erefore, con-

trast may be administered through the femoral

sheath proximally and, as it enters the intended

puncture site, the artery can be punctured real

time or a road mapping can be performed.

A 4-Fr micropuncture set is the best option,

usually with a 4-cm length, 21-gauge needle.

eguidewire from the micropuncture set may

be used to enter the vasculature or one might use

a V-18™ ControlWire Guidewire. is guidewire

is 0.018 inches in diameter, has a hydrophilic tip,

is good for encountering chronic total occlu-

sions, and has a fairly sti sha. It is usually

best to support the guidewire at the access site

using the 4-Fr micropuncture sheath or even the

3-Fr micropuncture trochar. With the develop-

ment of tibial and pedal artery punctures, use

of the popliteal artery for access has been less

common in the author’s practice. e challenge

with the popliteal artery is that the patient must

be in the prone position. is complicates any

other access that there may be to the femoral

artery. e popliteal vein is a useful access site

for venous thrombolysis and is readily avail-

able for puncture under ultrasound. e SFA

may also be used directly for retrograde access

with the patient in the supine position. e usual

place to do this is at the level of the adductor

canal. Cases where this might be used are where

a patient has a very heavily calcied SFA occlu-

sion or an occluded stent that cannot be crossed.

is structure may be punctured directly. Very

oen in these cases, the artery is easily visible

under uoroscopy because of the calcication or

the occluded stent and it can be punctured uo-

roscopically. A 0.018-inch diameter guidewire,

such as a V-18

™

, is inserted and supported with

the micropuncture sheath or with the standard

4-Fr access sheath.

PERCUTANEOUS PUNCTURE OF

BYPASS GR AFTS

Substantial scar tissue may surround a pros-

thetic graft, especially in an area where an

extensive open arterial exposure was performed.

This is most common in the femoral area.

Antibiotics are administered prior to puncture.

Positioning of the patient is the same as for

standard retrograde femoral artery puncture.

The position of needle entry should be proxi-

mal to the anastomosis with the native artery

so that anastomotic sutures and/or thrombi

are not disrupted. Dacron grafts have a tightly

knitted fabric matrix that may be challenging to

puncture. Considerable force may be required to

push the needle through the anterior wall of the

prosthetic graft. Care should be taken to avoid

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