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embolus, thrombosis, sub intimal passage of the guide

wire or catheter and dissection, are known to occur either

during or immediately after the procedure, whereas

haematoma and bleeding are normally evident shortly after

completion of treatment (Redman 1987). Complications

can be stratiﬁed on the basis of outcome. A major com-

plication should be thus deﬁned if there is a consequent

need for inpatient admission for therapy, an unplanned

increase in the level of care resulting in prolonged hos-

pitalisation, permanent adverse sequeale, or death. Minor

complications result in no sequeale; they may require a

short overnight observation or minimal therapy (Singh

et al. 2003).

Burns et al. (2000) reported on 14 complications within

their study cohort of 240 patients who had undergone

angioplasty with or without stent placement. Of all

complications, 86% were detected before the patient had

left the angiography suite, with the remainder evident

within 4.5 h of the procedure. Similarly, Kruse and Cragg

found early discharge did not lead to an increased read-

mission rate as a consequence of delayed complications,

with none of their 87 patients requiring hospitalisation

within a 7 day follow-up period post-discharge (Kruse and

Cragg 2000).

The nature and site of the procedure either diagnostic or

interventional can alter the associated risk proﬁle. Certain

complications are non-speciﬁc, especially those directly

related to the vascular anatomy. The RCR has published

recommended standards for both diagnostic and interven-

tional procedures based on data collected and presented in

the British Iliac Angioplasty and Stenting report (BIAS III)

(British Society of Interventional Radiology 2008) and the

Table 2 Details of the recommended standards for diagnostic and interventional vascular radiology

(A) Diagnostic vascular procedures Angiography

Upper limit of complications

Threshold (%) – –

Puncture site

Haematoma (requiring transfusion, surgery or delayed discharge) 0.5 – –

Occlusion 0.2 – –

Pseudoaneurysm/AV ﬁstula 0.2 – –

Non-puncture site

Distal embolisation 0.5 – –

Arterial dissection/subintimal passage of catheter 0.5 – –

(B) Interventional vascular procedures Iliac artery angioplasty ± stenting

Rate (%) Conﬁdence intervals

95%

Upper alert 99%

Upper alarm

Outcome

[50% residual stenosis 3.7 3.2–4.3 3.0–4.6

Unplanned Intervention

Delayed discharge 1.3 1.0–1.8 0.9–2.0

Unplanned endovascular procedure 0.9 0.6–1.3 0.6–1.5

Unplanned surgery 0.9 0.6–1.3 0.6–1.5

Amputation 0.2 0.1–0.5 0.1–0.6

Puncture site

Haematoma (requiring transfusion, surgery or delayed discharge) 1.5 1.2–2.0 1.1–2.1

Occlusion

0.5 – –

Pseudoaneurysm 0.2 0.07–0.36 0.06–0.45

Non-puncture site

Distal embolisation 0.8 0.54–1.10 0.48–1.22

Unintended occlusion of selected vessel/ﬂow-limiting dissection 0.5 0.34–0.81 0.3–0.90

Vessel rupture/perforation requiring intervention or surgery 0.5 0.28–0.73 0.25–0.83

Emergency/unplanned surgery 0.9 0.6–1.3 0.6–1.5

Reproduced with permission of the Royal College of Radiologist, United Kingdom (Society of Interventional Radiology Standards of Practice

Committee (2003) Quality guidelines for diagnostic arteriography. J Vasc Interv Radiol 14:S283–S288 [22])

**The British Society of Interventional Radiology (2008) Third BIAS report (2008). Dendrite Clinical Systems [24], Oxfordshire

95% alert—should trigger an informal review of practice; does not necessarily reﬂect unsatisfactory practice in itself

99% alarm—trigger for formal review of practice; should raise questions concerning operator performance/case selection

Day Case Vascular Intervention 39

https://t.me/med1917

Quality Improvement Guidelines for Diagnostic Arteriog-

raphy (Society of Interventional Radiology (SIR) Standards

of Practice committee) (Singh et al. 2003) (Table 2). It can

be appreciated that most related complications have a

threshold of below 1%, therefore, conducting favourable

procedures on a day-case basis should not lead to an

unmanageable inpatient conversion rate.

Huang et al. (2008) in their study of 310 patients

(401 procedures) presented a complication rate comparable

to the recommended thresholds described by the RCR. In

total, 2.1% of the diagnostic procedure group required

hospital admission; one patient for pain (1/144; 0.7%) and

two (2/144; 1.4%) for major puncture site haematoma.

Within the interventional subgroup, the admission rate was

5.8% with four patients (4/257; 1.6%) requiring emergency

surgery for post-procedure complications (arterial dissec-

tion n = 1; retroperitoneal haematoma, n = 2; pseudoan-

eurysm, n = 1). On telephone follow-up of successfully

discharged patients (24 h post-procedure), only one patient

(1/144) required readmission for the treatment of a puncture

site pseudoaneurysm. MacDonald et al. in their 2 year ret-

rospective analysis of 690 procedures reported a minor

complication rate of 4.5%, major complication rate of 3.4%,

delayed complication rate of 1.7% and readmission rate of

1.7% (MacDonald et al. 2002). Direct comparison between

other day-case studies is hindered by contrasting deﬁnitions

of the severity of complications, variation in sample size

and differing patient selection. Reported rates can range

between 0 and 3.7% for major complications, 0 and 15%

for minor complications and 0 and 3.2% for delayed

complications (Lemarbre et al. 1987; Kruse and Cragg

2000; Manashil et al. 1983; Peterson et al. 2000). Overall,

studies show that in selected outpatients, complications

following discharge are comparatively rare and overnight

observation may not necessarily inﬂuence outcome

(Manashil et al. 1983; Mathie et al. 1999). There also

appears to be no increase in complication rate for inter-

ventional procedures if arterial stenting is performed as

opposed to balloon angioplasty alone (Huang et al. 2008;

Mathie et al. 1999). Even in patients presenting with ‘limb

threat’, it has been shown that the site of intervention,

length of arterial segment treated, nor the number of stents

placed determine a subsequent need for inpatient admis-

sion (Akopian and Katz 2006).

9 Current Status

Despite a multitude of published reports conﬁrming an

adequate safety proﬁle, high patient satisfaction and mon-

etary savings, the general uptake of day-case procedures

has historically been relatively laboured. Even after a

change in guidance in the early nineties supporting short-

observation periods post-procedure, a survey conducted by

the British Society of Interventional Radiologists in 1995

indicated that only 10% of the respondents performed any

day-case angioplasty (Paul and Moss 1997). Undoubtedly,

the uptake of day-case procedures has increased since but

the more recent BIAS III report still highlights a wide

discrepancy between the participating institutions (British

Society of Interventional Radiology 2008). With the report

concentrating on iliac angioplasty and stent placement, the

overall trend conﬁrms a continuing increase in the per-

centage of day-case procedures from 12 in 2001 to 25%

in 2008, however, variations between institutions ranged

from 0 to almost 90%. This variation in practice leads

the authors to conclude that an expansion of day-case

facilities is needed in many of the participating centres.

The reasons for the current status are probably better

explained by limitations of infrastructure and capacity, as

opposed to the historic concern of safety. As has been

shown, however, expansion of the day-case facilities not

only allows for a more patient focused service but notable

cost beneﬁts.

10 Conclusion

The establishment and continuing expansion of day-case

procedures is advocated by a large body of evidence

conﬁrming the overall safety and efﬁcacy of the service.

With careful initial consideration with regard to appro-

priate patient selection, adequate infrastructure and the

training of staff, the positive beneﬁts for both the patient

and department are substantial. Although the merits of a

multi-disciplinary approach are without question, the lack

of reliance on inpatient beds allows for a more efﬁcient

utilisation of interventional lists and hence a greater

overall autonomy. Whilst there have been great strides

in the advancement of day-case procedures, further work

is needed to achieve a more uniform and optimised

practice.

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discharge in patients with intermittent claudication. J Vasc Surg

44:115–118

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(2007) ACR-SIR practice guideline for the performance of

diagnostic arteriography in adults. American College of Radiology,

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Burns BJ, Phillips AJ, Fox A, Boardman P, Phillips-Hughes J (2000)

The timing and frequency of complications after peripheral

percutaneous transluminal angioplasty and iliac stenting: is a

change from inpatient to outpatient therapy feasible? Cardiovasc

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(1996) Outpatientpercutaneous nephrostomy. Radiology 198:85–88

Huang DY, Ong CM, Walters HL et al (2008) Day-case diagnostic and

interventional peripheral angiography: 10-year experience in a

radiology specialist nurse-led unit. Br J Radiol 81:537–544

Hvelplund A, Jeger R, Osterwalder R et al (2011) The Angio-Seal

femoral closure device allows immediate ambulation after coro-

nary angiography and percutaneous coronary intervention. Euro-

Intervention 7:234–241

Kruse JR, Cragg AH (2000) Safety of short stay observation after

peripheral vascular intervention. J Vasc Interv Radiol 11:45–49

Lemarbre L, Hudon G, Coche G, Bourassa MG (1987) Outpatient

peripheral angioplasty: survey of complications and patients’

perceptions. Am J Roentgenol 148:1239–1242

Lombardi JV, Calligaro KD, Dougherty MJ (2002) Safety and cost

savings of endovascular procedures: are outpatient interventions

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Surg 36:231–235

Macdonald S, Thomas SM, Cleveland TJ, Gaines PA (2002)

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vasc Intervent Radiol 25:403–412

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ment of patients with urinary obstruction following urinary

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Manashil GB, Thunstrom BS, Thorpe CD, Lipson SR (1983)

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Mathie AG, Bell SD, Saibil EA, Magissano R, Kucey DS (1999)

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268–271

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contributions of diabetic neuropathy and vasculopathy in foot

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bosed hemodialysis grafts: percutaneous mechanical balloon

declotting versus thrombolysis. Radiology 196:73–77

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tee, European society of urogenital radiology (ESUR). Eur Radiol

9:1602–1613

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after angiographic procedures. J Vasc Interv Radiol 16:13–23

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(2008) Lower extremity endovascular interventions: can we

improve cost-efﬁciency? J Vasc Surg 47:982–987

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Day Case Vascular Intervention 41

https://t.me/med1917

Sites of Arterial Access and the Role of Closure

Devices in Percutaneous Arterial Intervention

Jon K. Bell and Nicholas Chalmers

Contents

1 Introduction.......................................................................... 43

2 Femoral Access .................................................................... 44

2.1 Retrograde.............................................................................. 44

2.2 Antegrade............................................................................... 44

3 Upper Limb Access ............................................................. 45

3.1 Axillary .................................................................................. 46

3.2 Brachial.................................................................................. 46

3.3 Radial..................................................................................... 46

4 Distal Lower Limb Access.................................................. 47

4.1 Popliteal ................................................................................. 47

4.2 Calf Vessels ........................................................................... 47

5 Alternative Approaches ...................................................... 47

5.1 Translumbar........................................................................... 47

5.2 Carotid.................................................................................... 47

6 Closure Devices .................................................................... 47

6.1 Technologies.......................................................................... 47

6.2 Complications ........................................................................ 48

6.3 Comparison with Manual Compression ............................... 49

6.4 Current Indications ................................................................ 49

6.5 Evidence for Early Mobilisation ........................................... 50

References...................................................................................... 50

Abstract

Arterial access is the essential ﬁrst step for all arterial

vascular interventions. This chapter reviews the range of

sites of arterial access and discusses the merits of each.

Selecting theappropriate accessroute maybe crucialto the

success of the procedure. Operators need to be aware of

the options available and the potential risks involved. The

common femoral artery is the standard access site because

it is a large vessel which is readily accessible and has the

hard bony surface of the femoral head posteriorly to

facilitate haemostasis bymanual compression.Alternative

access via various upper and lower limb sites are

sometimes useful. The arterial puncture is the most

common source of complications of arterial intervention.

Indeed retroperitoneal haemorrhage particularly after

antegrade femoral puncture is clinically difﬁcult to detect

and canbe fatal. Management ofthe puncture siteafter the

procedure is crucial to patient safety. The range of arterial

closure devices is discussed along with the evidence for

their effectiveness and complications. The use of closure

devices is compared to haemostasis by manual compres-

sion in terms of the complications associated with each

technique and the evidence for safe early mobilisation.

1 Introduction

Percutaneous access to the arterial tree is a prerequisite to

undertaking diagnostic arteriography or endovascular

intervention. Although the transfemoral route of access is

the most commonly used, there are many other choices

available to the radiologist. At times the alternatives can

be invaluable in facilitating procedures that would not

otherwise be possible. The use of closure devices reduces

the need for groin compression. However, this appears to

be at the expense of anincreased riskof complications. While

closure devices are undoubtedly useful in selected cases,

the current evidence does not support their routine use.

J. K. Bell  N. Chalmers (&)

Department of Radiology,

Manchester Royal Inﬁrmary,

Oxford Road, Manchester,

M13 9WL, UK

e-mail: Nicholas.Chalmers@cmft.nhs.uk

M. G. Cowling (ed.), Vascular Interventional Radiology, Medical Radiology. Diagnostic Imaging,

DOI: 10.1007/174_2011_514,  Springer-Verlag Berlin Heidelberg 2012

https://t.me/med1917

2 Femoral Access

2.1 Retrograde

Retrograde puncture of the common femoral artery has been

the gold standard for arterial access since Seldinger’s

landmark innovation in 1953 (Seldinger 1953). The com-

mon femoral artery has the advantages of being a relatively

large and superﬁcial artery that lies anterior to the hard bone

surface of the femoral head. The large calibre ensures that

large sheath sizes will be tolerated without causing intimal

injury, spasm or occlusion of blood ﬂow. The superﬁcial

location facilitates needle puncture. The hard surface pos-

teriorly makes the artery easy to palpate and provides

support for manual compression to achieve haemostasis.

Retrograde puncture of the common femoral artery is

therefore a relatively safe approach associated with a com-

plication rate of about 1%. Apart from haematoma, which is

to some extent inevitable, the commonest puncture site

complication is false aneurysm formation. This is frequently

associated with a low puncture below the level of the femoral

head and often at the common femoral artery bifurcation or

lower. The risk of a low puncture is greater in obese patients

as the femoral head is covered by a large abdominal apron

and palpation of the artery isdifﬁcult. Some operators use the

groin skin crease as a marker for arterial puncture. This

practice is to be deplored as the groin crease varies consid-

erably in its relation to the femoral head, depending mainly

on obesity. Palpating the bony attachments of the inguinal

ligament, namely the anterior superior iliac spine and the

pubic tubercle, helps toavoid this error. If there is doubt as to

the correct level for arterial puncture, ﬂuoroscopic screening

of the femoral head or ultrasound guidance is recommended.

The skin incision should be made 1–2 cm distal to the tar-

geted point of puncture, allowing for a 45 angle of entry of

the needle into the artery.

Retrograde puncture of an impalpable common femoral

artery is often required for iliac intervention. The impal-

pable artery can be located in various ways. Fluoroscopy

will show the anticipated path of the artery and the ideal

puncture site and the artery may be delineated by the

presence of calciﬁcation in its wall. If using a bilateral

approach, it is sensible to catheterise the contralateral artery

ﬁrst. In this situation, an angiographic roadmap of the

common femoral artery on the impalpable side can be used

to guide the needle.

Ultrasound can also be used to locate the artery and to

visualise the needle tip. Ultrasound demonstrates the arcu-

ate shadow of the femoral head with an echo bright surface

directly posterior to the optimal puncture site. Proximal to

this the common femoral artery is seen to dip into the

pelvis. Distally, the common femoral bifurcation can be

deﬁned. These anatomical features facilitate puncture at the

correct level. Ultrasound localisation has been shown to

reduce the number of needle passes required to access the

artery (Zealley and Chakraverty 2005). Intraoperative

ultrasound-guided puncture has been found to signiﬁcantly

improve the success rate and reduce complications related

to percutaneous endovascular aneurysm repair (Arthurs

et al. 2008). Also, ultrasound-guided injection of local

anaesthetic prior to femoral catheterisation has been shown

to achieve superior levels of analgesia compared to the

standard method of palpation (Spiliopoulos et al. 2011).

2.2 Antegrade

Antegrade puncture of the common femoral artery is a

useful option for infrainguinal procedures. Operators fre-

quently have to make the choice between an antegrade

approach and a retrograde approach from the contralateral

side. An antegrade approach has the advantage of providing

more direct access to infra-inguinal (and especially infra-

popliteal) lesions compared to retrograde access. There is

more stability compared to retrograde crossover sheaths,

enabling greater torque control of the guidewire and push-

ability of the catheter. With retrograde access, it can

sometimes be difﬁcult to advance a long sheath over the

bifurcation in tortuous and calciﬁed vessels.

Antegrade puncture is frequently more difﬁcult than

retrograde, particularly in the obese. The location of the

arterial puncture is ideally the same as for retrograde,

namely the mid-common femoral artery. The oblique pas-

sage of the needle through the soft tissues therefore

necessitates a skin puncture on the lower anterior abdominal

wall. In obese patients, it is often necessary to push the

abdominal apron out of the way. An assistant may be

required to do this and should maintain their grip until

stable access is achieved to prevent the needle from with-

drawing when the abdominal apron gravitates.

If an antegrade puncture is too low, the needle will almost

always enter the profunda femoris artery in preference to the

superﬁcial femoral artery. If the common femoral artery is

punctured within 1 cm of the bifurcation, the guidewire will

generally enter the profunda. In this situation, a catheter with

a short angulated tip, such as a 5F biliary manipulation

catheter (Cook, Bloomington, IN, USA), should be intro-

duced intothe profundafemoris artery.By carefulwithdrawal

of the catheter under ipsilateral oblique ﬂuoroscopy it is

usually possible to steer an angled guidewire into the super-

ﬁcial femoral artery (Fig. 1). Alternatively, a guidewire with

a 15 mm J tip may be used through the puncture needle:

the gently angled tip may deﬂect off the posterior wall of the

common femoral artery and selectively enter the superﬁcial

femoral artery in preference to profunda femoris.

44 J. K. Bell and N. Chalmers

https://t.me/med1917

Antegrade puncture of the common femoral artery car-

ries the risk of puncture above the inguinal ligament. On

ﬂuoroscopy, the puncture site will be seen to be anterior to

the upper third of the femoral head or the acetabulum. This

is associated with an increased risk of retroperitoneal

haemorrhage and false aneurysm formation. Most infrain-

guinal work can be performed using a 4 French sheath.

Therefore risks can be reduced by avoiding placement of

larger sheaths if a high puncture is suspected. The clinical

presentation of retroperitoneal bleeding can be insidious

and requires a high index of suspicion. The bleeding may

not be visible and there may only be an ill-deﬁned fullness

in the iliac fossa associated with minor discomfort. There is

usually moderate tachycardia, but the blood pressure is

frequently maintained for several hours until the rapid onset

of hypotension during the following night. Clinical suspi-

cion of a high puncture and vague symptoms post-procedure

should therefore prompt a switch from a day-case to an

overnight stay. As the risk of vascular complications is

higher with antegrade access, the operator should have a

low threshold for using ultrasound guidance, particularly in

obese patients.

It is also possible to reverse a retrograde puncture to

establish antegrade access. The ‘‘improved reversal tech-

nique’’ (Hartnell 1998) involves withdrawing a Sos Omni

catheter (Angiodynamics, Queensbury, NY, USA) and

guidewire within the external iliac artery until the loop of

the catheter abuts the tip of the introducer sheath. The

sheath is then withdrawn and the wire is redirected down

the superﬁcial femoral artery. The sheath, catheter and wire

are then withdrawn together to straighten out the curve in

the catheter. The external segment of the sheath is then

tilted cranially and the sheath and catheter advanced cau-

dally over the wire. Switching the direction of access is

easier in thin patients and with a near vertical initial arterial

puncture. In our experience, the reversal technique is

associated with increased risk of substantial haematoma.

3 Upper Limb Access

When femoral access is not available for diagnostic angiog-

raphy due to iliac occlusion, historically alternative access

sites have been used, initially thetranslumbar route and more

recently the brachial route. The translumbar approach was

popular for many years and associated with a low compli-

cation rate. The development of small diameter steerable

catheters led to a preference for the brachial approach

although it is generally acknowledged that the risks were

higher (Watkinson and Hartnell 1991; Lienemann et al.

1993). In recent years, non-invasive imaging modalities such

as CT have rendered the need for arterial catheterisation for

diagnostic purposes redundant in most cases. Arterial access

via the upper limb is sometimes particularly useful for renal

Fig. 1 Guidewire enters the profunda following distal common

femoral arterial (CFA) puncture: how to access the superﬁcial femoral

artery (SFA). a The standard-J guidewire is located in the profunda.

The needle tip is located over the lower third of the femoral head. This

usually corresponds to the distal CFA. b A BMC (Cook, Bloomington,

IN, USA) catheter with a short angled tip has been advanced into the

profunda. c The catheter is carefully withdrawn while injecting

contrast using the ipsilateral oblique projection until the catheter tip is

just proximal to the CFA bifurcation. d The hydrophilic guidewire is

advanced into the SFA. The catheter is advanced over the wire which

is exchanged for a standard-J wire prior to sheath placement

Sites of Arterial Access 45

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artery or superior mesenteric artery procedures due to the

downward slope of these vessels.

To access small calibre arteries we favour the use of a

coaxial micropuncture introducer set (Cook, Bloomington,

IN, USA). The set is composed of a micropuncture needle,

an inner catheter matched with a 0.018 inch guidewire and

an outer 4 French 10 cm long catheter. The coaxial catheter

is designed for replacing the 0.018 inch guidewire with a

standard 0.035 inch guidewire. This equipment increases

the likelihood of successful atraumatic passage of the wire

into the vessel lumen. Operators should be aware that, due

to the small calibre of the micropuncture needle, only a

slow trickle of blood ﬂow is seen at the needle hub rather

than the obvious arterial spurt of a standard 18G or 19G

needle when the tip is in the lumen.

3.1 Axillary

Historically axillary (or, more likely, high brachial) puncture

was favoured because of its larger diameter compared with

the brachial artery atthe elbow or theradial artery atthewrist.

The axillary artery can be palpated with the arm exter-

nally rotated and abducted. The humeral head lies posteri-

orly, so some degree of compression can be achieved at the

end of the procedure. This vessel segment has two major

disadvantages compared with the common femoral: its

smaller diameter and its proximity to the brachial plexus

and nerves of the upper limb, the latter of which can give

rise to temporary or permanent neurological sequelae. The

axillary artery and the nerves of the upper limb traverse the

axilla within a fascial sheath. Thus even a small haematoma

within the sheath may exert pressure on the adjacent nerves

resulting in debilitating neuropraxia.

A recently described use of an axillary or high brachial

puncture is to establish upper limb access when a chimney

graft technique is employed to preserve ﬂow to vital side

branches covered by an aortic stent graft (Ohrlander et al.

2008). The covered stent is deployed parallel to the main

body of the aortic stent graft and protrudes proximally like a

chimney. This technique is used when urgent intervention is

required and a fenestrated device is not available, when

there is complex aneurysm neck morphology and when a

vital side-branch is unintentionally covered.

3.2 Brachial

The brachial artery is easily palpated at the elbow. It can be

rather mobile, but is otherwise easily punctured and good

post-procedure compression is possible against the distal

humerus. The main disadvantages of the brachial approach

are the adjacent median nerve and the fact that, being an

unpaired vessel of relatively small calibre, local dissection

at the puncture site may have serious consequences. The

median nerve is usually medial to the artery at the elbow,

but the relationship is inconstant. The median nerve is

frequently numbed by the local anaesthetic, or touched by

the puncture needle resulting in transient paresthesiae.

Persistent nerve damage occurs occasionally.

The risk of permanent neurological damage following

brachial or axillary puncture is small, but given its severity,

an alternative non-invasive imaging modality such as CT

angiography should be considered for diagnostic purposes

when the femoral pulses are impalpable.

3.3 Radial

The radial artery at the wrist is increasingly the approach

of choice for diagnostic and interventional cardiology

(Archbold et al. 2004). The radial approach has much to

recommend it, assuming that the ulnar artery supply to the

hand is adequate. This is assessed by Allen’s test during

which the ﬁst is clenched during compression of both ulnar

and radial arteries. The ﬁst is then opened and the ulnar

artery is released. If patent, colour returns to the hand within

10 s. Allen’s test demonstrates satisfactory ulnar collaterals

in 94% of patients. Pulse oximetry and plethysmography are

more sensitive and will demonstrate adequate collaterals in

all but 1.5% of candidates for radial approach (Barbeau

et al. 2004). The radial artery can safely accommodate

catheter sizes up to 6 F with a low complication rate.

Sheaths of 7 F are tolerated by 70% of males and 45% of

females (Saito et al. 1999). Temporary occlusion occurs in

about 5%, and permanent occlusion in fewer. In most cases

the artery can be repunctured in the future if necessary.

A multicentre trial that compared radial versus femoral

access for cardiac intervention, reported a 60% reduction in

major vascular access site complications with radial access

(Jolly et al. 2011). They concluded that radial and femoral

approaches are both safe and effective for percutaneous

coronary intervention. However, the lower rate of local

vascular complications with radial access may be a reason

to favour the radial approach.

There is little literature on radial access for non-cardio-

logical procedures. Apart from isolated case reports, the

literature appears to be limited to three series of (mainly)

lower limb diagnostic angiography (Al-Kutoubi et al. 1996;

Cowling et al. 1997; Michel 2004) and one of renal artery

stenting (Kessel et al. 2003). Disadvantages include the

need for long catheters for visceral and iliac intervention,

with consequently reduced torque control. There is also the

small stroke risk associated with emboli from any upper

limb access. Use of this route for non-cardiological inter-

vention warrants further investigation.

46 J. K. Bell and N. Chalmers

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4 Distal Lower Limb Access

4.1 Popliteal

The popliteal artery can be approached with the patient

prone on the X-ray table (Tønnesen et al. 1988). The artery

can be opaciﬁed with contrast (if a catheter has already been

deployed in the common femoral). Alternatively, ultrasound

guidance can be used (Heenan et al. 1994). The artery lies

deep to the vein in the popliteal fossa, so a route that avoids

transﬁxing the vein may be desirable to minimise the risk

of arteriovenous ﬁstula formation. The popliteal approach

is sometimes useful after a failed attempt at antegrade

recanalisation of a femoral artery occlusion where the ret-

rograde approach may be successful. Other indications for a

popliteal approach include recanalisation of ﬂush SFA ori-

gin occlusions and angioplasty of tandem lesions in the iliac

and femoral segments from a single puncture (Saha et al.

2001). The popliteal line is more direct than the contralat-

eral approach. Disadvantages of the popliteal approach are

the discomfort to the patient of the prone position and the

inability to achieve good manual pressure on the puncture

site deep in the popliteal fossa. Despite that, haemorrhagic

complications appear to be rare although there are a limited

number of studies (Yilmaz et al. 2002).

4.2 Calf Vessels

Spinosa et al. (2005) have reported experience with cathe-

terisation of the dorsalis pedis, anterior tibial or posterior

tibial arteries at the ankle to permit combined antegrade and

retrograde subintimal recanalisation of occlusions where

distal re-entry cannot be achieved following antegrade

approach alone, or where there is only a limited length

of distal patent vessel. This technique has been named

‘‘subintimal arterial ﬂossing with antegrade-retrograde

intervention (SAFARI)’’.

Distal vessel puncture is achieved using a micropuncture

kit with ultrasound or ﬂuoroscopic guidance—arterial cal-

ciﬁcation or contrast medium injected through the antegrade

catheter delineates the vessel. Limb salvage rates at

6 months are promising.

5 Alternative Approaches

5.1 Translumbar

Prior to the production of high quality preformed shaped

catheters and modern non-invasive imaging modalities, the

translumbar route was for many years the favoured access

for peripheral and renal angiography but there will be few

angiographers still active who have much experience of

this. More recently the translumbar approach has been

described in isolated case reports for coronary intervention

(Henry et al. 1999). The indications for this approach today

would seem to be very rare.

5.2 Carotid

The standard approach for diagnostic angiography of the

cerebral vessels prior to the production of good quality pre-

formed diagnostic catheters was by direct needle puncture

of the carotid and vertebral arteries. New developments in

catheters and in non-invasive imaging have rendered this

obsolete. However, there has been some interest in the

carotid approach for abdominal (May et al. 2000; Estes

et al. 2001) and thoracic (Murray et al. 2005) stent graft

placement, when infradiaphragmatic access is impossible.

The common carotid artery has the advantages of relatively

large calibre (8–10 mm) and relatively superﬁcial location.

Furthermore, most patients will have adequate collateral

supply and will therefore tolerate temporary occlusion of

the vessel. With surgical exposure, and control of the

internal and external carotid arteries, the risks of dissection

and air or particulate embolus can be minimised.

6 Closure Devices

Use of closure devices to rapidly seal the arterial puncture

site and eliminate the need for manual compression found

ready acceptance when the devices started to be introduced

some years ago. They were perceived as permitting faster

mobilisation and enabling more rapid throughput of patients

particularly in cardiac catheter labs.

6.1 Technologies

Various ingenious technological approaches have been

developed. The Angioseal (St Jude Medical, St Paul, MN,

USA) consists of an external collagen plug as well as an

absorbable polymer footplate, which is deployed within the

artery and held in place by a thread. The Vasoseal (Data-

scope Corporation, Mahwah, NJ, USA) and the Duett

(Vascular Solutions, Minneapolis, MN, USA) devices

consist of a collagen plug, which is positioned on the

external surface of the arterial wall at the puncture site. The

Perclose (Abbott Vascular, IL, USA) device deploys a

suture in the arterial wall to achieve haemostasis. The

Starclose (Abbott Vascular, IL, USA) device deploys a

circumferential nitinol clip that mechanically binds the

Sites of Arterial Access 47

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surface of the artery. The Mynx (Biosensor) device releases

a polyethylene glycol sealant onto the external surface of

the artery. The sealant dissolves within 30 days. Finally,

the Exoseal (Cordis, Miami Lakes, FL, USA) releases a

polyglycolic acid plug onto the external surface of the

artery; this resorbs in 60–90 days.

Each type of closure device has its own speciﬁc strengths

and drawbacks, so familiarity with more than one type is

advisable. Common femoral artery disease is a contraindi-

cation to the use of the Perclose suture device, the Starclose

clip device and the Angioseal device that relies on the

intravascular footplate. Thus a common femoral angiogram

is recommended prior to deployment of these devices.

On the other hand, common femoral artery disease is not a

contraindication to the use of the Vasoseal, Duett, Mynx or

Exoseal devices.

The Perclose and Starclose devices are the only ones that

are completely independent of clotting factors, haemostasis

being dependent only on the adequacy of the suture or clip.

Therefore these devices have the advantage in patients

with severe coagulopathy and those who have received

substantial doses of anti-coagulant, anti-platelet or throm-

bolytic agents.

Repuncture at the same site is possible at any time after

the use of the Perclose and Mynx devices. Immediate

repuncture is not possible after use of the Angioseal because

of the intravascular footplate. Repuncture after an interval

of 3 weeks is permitted. The safety of repuncture and

reclosure with the Starclose has not been established but

bench studies suggest that it is safe.

The success rates in deployment of the closure devices

are generally high, although there is a deﬁnite learning

curve with the Perclose in particular and a failure of proper

deployment in a small percentage. Almost immediate hae-

mostasis can be achieved in the great majority without the

need for manual compression of the artery. This is popular

with both patients and staff.

6.2 Complications

Puncture site infection has been documented as a compli-

cation of closure devices, but not of manual compression,

presumably as a result of the suture thread or collagen plug

acting as a conduit or nidus for bacterial infection from the

skin surface (Carey et al. 2001).

Ischaemic sequelae are described with both the Perclose

and Angioseal devices. The mechanism may be due to

physical obstruction of the artery by the Angioseal foot-

plate, or to late neointimal hyperplasia. Flow limiting dis-

section has been observed following Perclose deployment,

with or without thrombosis and distal embolisation (Wagner

et al. 2003). Arterial narrowing, probably due to some of the

collagen plug entering the arterial lumen has been described

after use of the Vasoseal device (Foran et al. 1993).

Misplacement of the Angioseal footplate is reported and

may be associated with a low puncture (Fig. 2). Common

femoral angiography is recommended prior to deployment

to ensure that the arterial puncture is at an appropriate level

in a disease-free artery. Late migration of the footplate has

also been observed.

Devices that are deployed in an extraluminal location

avoid the potential complication of distal ischaemia sec-

ondary to embolisation of synthetic material and re-access

is not an issue. A study comparing Mynx versus Angio-

seal devices demonstrated a signiﬁcant reduction in the

need for surgery after using the Mynx device (Noor et al.

2010).

Closure devices have been used with success following

antegrade femoral puncture (Duda et al. 1999). The

Cardiovascular and Interventional Radiological Society of

Europe registry of closure devices using an anchor and a

plug reported no difference in complications between

antegrade and retrograde access (Reekers et al. 2010).

Fig. 2 Misplaced Angioseal footplate. The misplaced footplate is

clearly seen as a well-deﬁned ﬁlling defect in the distal common

femoral artery. The initial puncture was too low, probably in the

proximal superﬁcial femoral or profunda femoris artery. Hence the

footplate has deployed across the common femoral bifurcation

48 J. K. Bell and N. Chalmers

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6.3 Comparison with Manual Compression

There are numerous substantial series in the literature

describing the use of closure devices. These are usually

non-randomised and heterogeneous, involving various reg-

imens of anticoagulation and antiplatelet agents. None has

shown any advantage over manual compression in terms of

complication rates.

Three meta-analyses have been published in interven-

tional cardiology patients, with aggregate data on all com-

parative studies. In the ﬁrst of these (Koreny et al. 2004),

when all randomised trials totalling 4,000 patients are

included, there was no signiﬁcant difference in outcome in

terms of haematoma or false aneurysm. The time to hae-

mostasis was reduced in the closure-device cohort by

17 min. However, when analysis is restricted to a sub-group

of high quality studies (those with allocation concealment,

blinded outcome analysis and intention to treat analysis) a

different outcome was observed; there was a signiﬁcantly

higher risk of both haematoma [relative risk (RR) 1.9] and

false aneurysm (RR 5.4) in the closure-device group.

A second meta-analysis (Nikolsky et al. 2004) included

all randomised, case control and cohort studies for a total of

37,066 patients. The three main types of closure device

were compared with manual compression. Individually,

there was no difference between the closure devices

and manual compression in terms of complications.

Collectively, there was an increased risk of complications

associated with closure devices (odds ratio 1.34, 95% CI

1.10–1.79).

A third meta-analysis (Vaitkus 2004), with a total of

5,405 patients, found a risk reduction with Angioseal [odds

ratio (OR) 0.51] yet a neutral result with Perclose [OR 1.0]

and an increased risk with Vasoseal [OR 1.18].

The ﬁrst systematic review and meta-analysis in inter-

ventional radiology has recently been published (Das et al.

2011). The publication included twenty-one non-compara-

tive studies and thirteen comparative studies. Pooled anal-

ysis for Angioseal, Starclose, Perclose and Duett versus

manual compression showed no signiﬁcant difference.

There was a marginal trend favouring Angioseal compared

with manual compression and manual compression com-

pared with Perclose. However, interpretation is limited by

study heterogeneity and a randomised controlled trial is

advocated.

Two case-controlled studies comparing suture-mediated

closure with manual compression have suggested a signiﬁ-

cantly higher rate of complications, some serious, associated

with theuse ofthe closuredevices. (Careyet al.2001; Wagner

et al. 2003). A review of the surgery required to deal

with complications associated with arterial access (Boston

et al. 2003) concludes that the complications associated with

closure devices (infection, ischaemia) are more complex and

difﬁcult to deal with than those associated with manual

compression (haematoma, false aneurysm).

6.4 Current Indications

Some workers use closure devices routinely for procedures

such as uterine ﬁbroid embolisation in the belief that this

permits safer same-day discharge. This is a subgroup with

typically healthy femoral arteries. Recently the occurrence of

some serious ischaemic and infective complications in the

lower limb has led many to question the justiﬁcation for their

use anda moderation in enthusiasm employing themin routine

cases. On theother hand, somecentres continue to reportgood

results with no serious complications (Chrisman et al. 2005).

There remains a subgroup of patients in whom closure

devices are undoubtedly helpful. This includes patients with

severe coagulopathy, or those who require continuous treat-

ment with high does anticoagulation, antiplatelet or throm-

bolytictherapy. Inthese patientsclosure devices producerapid

haemostasis that would otherwise not be achievable. Other

valid indications for theiruse includepatients at increasedrisk

of recurrent bleeding due to restlessness, confusion, inability

to lie ﬂat, etc. There are also reports of their successful use to

close subclavian artery punctures following inadvertent arte-

rialcatheterisationduring attempted subclavian centralvenous

catheter placement (Nicholson et al. 2004).

Endoluminal repair of aortic aneurysm is usually per-

formed following surgical exposure of the common femoral

artery. This is becausethe delivery systems of the stent-grafts

measure up to 8 mm in diameter (24 F). An ingenious mod-

iﬁcation of the Perclose device has been developed to permit

its use in closing percutaneous punctures of much greater

diameter thanthe device itselfenabling theseprocedures tobe

done entirely percutaneously. This modiﬁed device, called

Prostar (Abbott Vascular, IL, USA), involves the initial

deploymentof twosutures inthe arterialwall, atright angles to

one another. The sutures are not tightened at this stage. The

puncture site is then dilated progressively to enable the stent

graft delivery system to be introduced. At the end of the pro-

cedure, thedelivery system is withdrawn and the suture knots

are tightened. A reasonable success rate has been reported,

with a total percutaneous closure rate of 79%, the remainder

requiring some sort of surgical repair of the arteriotomy

(Malkawi et al. 2010). The overall access-related complica-

tion rate in the same systematic review was 4.4%. Femoral

artery calciﬁcation, groin scarring, obesity and increased

sheath size are associated with increased vascular complica-

tions. Percutaneous endovascular aneurysm repair has been

shown to reducehospital stay,operative time,blood loss,time

to ambulationand cost comparedto openendovascular repair.

Sites of Arterial Access 49

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