Hello everyone, my name is Ashley D'Armiento, I'm an RN at Mount Sinai Cath Lab, and here with me is Dr. Sahil Kira, Interventional Director of the Structural Heart Program at Mount Sinai Hospital, and we're here today to talk to you about the femoral access management. Hi everyone. So objectives for today, after completion, we want you to be able to know femoral anatomy and safe access best practices, vascular closure devices, manual assist devices, and complications associated with femoral access. So let's just jump right into the femoral artery anatomy, which I think is the most important thing to know about femoral access. If you look here, you can see that there's this diagonal line crossing the artery and the vein, and that's your inguinal ligament, which gives you that femoral triangle, so we just want to hone in right underneath it. You have your common femoral head here, and then your common femoral artery, highlighted in red appropriately, and then your common femoral vein here. So when we look at femoral access, we want to look for, this is like the money spot here, so you have mid-femoral head of the artery, you want to be above the bifurcation of this common femoral artery, meaning where the artery splits. So you have the superficial artery and the profunda here, so you want to be above that point. And then also, it's not imaged here, but there's this epigastric artery that you want to be below. Do you want to add anything to that? Yeah, no, I think Ashley summed up really well. The key point here is that you want to be below the inferior sweep of the inferior epigastric artery, and you want to be at least one centimeter above the branch points of the profunda and the superficial femoral, ideally on top of the femoral head, but obviously it may vary in different patients. Right, and we'll see that as well. In fact, we see it right here. So this is a fluoroscopy angiogram of the common femoral of the same patient. This is the common femoral right here on the right side of the patient. You can see they have good access points. You have the mid-femoral head. We're right at that spot here, above the bifurcation of the profunda and SFA, and then it's hard to see, but there is a shadow of the epigastric artery here. So this is very good femoral access, but you can see on the left side that the anatomy is very different. You can see that the bifurcation is very high, so it's very difficult to get the common femoral at the mid-femoral head, and then the epigastric artery is up close. So this would, and they're accessed, would you say that's the profunda there? Yeah, so I think that's actually the profunda. The only issue is that we should not go by fluoroscopy alone, because just going by the femoral head sort of misleads us, and even in the same patient. So you could have variable location of CFA in the same patient, and some patients have reasonable length. Most of the patients will have a reasonable three to four centimeter long CFA, but some patients have very short CFAs, and what can happen is trying to aim for CFAs in those cases and very high bifurcation points, you can actually have retroperitoneal complications. So something to be mindful of, and we often teach our fellows that, listen, if you have only high bifurcation points in all vessels, it's sometimes safer to take the SFA access, as long as it's within the six to seven French range. Now if you're talking about a large pore, it's a total separate issue, but yes, within the same patient, you can have a variable location of CFA. Yeah, it's quite different in this patient. Okay, so a couple more points about femoral access. Ideally you could use ultrasound and fluoroscopy to identify the safe anterior landing zone on top of the femoral head, below the inferior sweep of the inferior epigastric artery, which we discussed prior, and above the bifurcation of the femoral head. Micropuncture needle and a sheath that's forefront for access, that's to make sure that you can do an angiogram without putting a large sheath, so in case we do need to adjust, we can do that safely. Just a mini injection, 5cc, meaning with contrast, so we can visualize well where our landing zones are, with wire inside the micropuncture sheath, also ensuring that the wire isn't too close to the vessel wall, and this prevents inadvertent hydraulic iliac dissection during injection, and also ideally doing the image in two views, both AP and oblique. Anything to add? Yeah, no, I think, so this is sort of my technique that I've been using for the longest time, partly because I do a lot of large pore access. I have felt it's very safe to have a wire connector attached to your micropuncture sheath. You maintain your wire access, and what happens is when you have extreme tortuosity in the external iliac, with calcification, you have less chances of hydraulic dissection compared to when you're just injecting without a wire safety. So I think it's really an important thing, and if you want to try this practice, I think it's absolutely fine. A lot of people do it without the wire, but that's sort of what we've been doing here for the longest time. So one more thing we'll talk about is the importance of two views, and sort of very paramount when you're getting access, small bore or large bore. I think you want to look at the RAO view for right CFA or an LAO view for left CFA, because then you can delineate your bifurcation points, so you can confirm your entry into the desired part of the CFA. You always want to look at an AP view, and I think it's very important for large bore because the AP view exactly tells you whether it's a side versus a center stick. Obviously, a lot of questions will come about whether we should routinely use ultrasound. I routinely use ultrasound. That sort of ensures an anterior stick, but an AP view actually tells you whether you truly had a side stick or not. So RAO view for right CFA and LAO view for left CFA will delineate your bifurcation points, and an AP view will actually tell you whether it's a side or a center stick. Okay, so now that the procedure is done, we're going to think about commonly used vascular closure devices. So we have intravascular, which there's a suture base, which is the Abbott ProGlide, the perclose, which is an internal stitch that kind of dissolves on its own. We also have an anchor, a collagen plug base, that's the Terumo Angioseal. We have extravascular, which is the Vascade, and then also the CortisMix. I think when we talk about closure devices, that's why the image of the femoral access is so important, because some are not amenable to closure devices, and we need to do manual compression. So in addition to looking at the access points of that mid-femoral head above the bifurcation and below the epigastric artery, you also have to look at the health of the vessel. Is there stenosis? Is there calcium? Is it okay to put closure devices in? Not everyone is a candidate for a closure device. Yeah, I think that's a very important point, what Ashley just mentioned, because I think when you're starting out or when you're in a program, you want to make sure what device really works for you, what experience you have. So here we have consistently kept ProGlide and Angioseal for our post-PCI cases, and the Vascade and minks we actually use for diagnostic cath cases, the FIFREN sheets. You need to have proficiency and experience in using vascular closure devices. The labs are getting busier. Everyone is in rush of time, and we have seen that vascular closure devices are faster hemostasis, but we should not forget manual closure as well, which we're going to discuss in one of the later slides. Also, just as an off-note, the Angioseal cannot be re-accessed for 90 days, so if you have a patient that needs to come back for a stage intervention, this is good for the nurses and techs to know, because sometimes we have to just give a gentle reminder, hey, this patient's coming back within the next couple of months for a PCI, you know, Angioseal wouldn't be the preferred, unless they want to use contralateral or radial access. Yes. Great reminder, Ash. She always reminds us, so, thank you. So just to kind of piggyback off what we were just saying, you know, when to avoid these vascular closure devices, severe peripheral arterial disease, and that's not just that there's narrowing at the vessel, but also calcification. Somebody that has a very high BMI, greater than 40 to 45, these might not be patients that you want to use them in. Somebody who's septic or has acute systemic infection, that could put them at higher risk for infection. The process that we use is that if somebody is diabetic and we're giving an closure device, we do give prophylactic antibiotics, that's, you know, per hospital protocol, but it's not a bad idea. Localized groin infection, bleeding diathesis, previous vascular grafts at access sites, if somebody's had a FEMPOP bypass, we would not want to use the closure device. We would not want to compromise that. And then follow IFU-based time constraints when prior closure devices have been deployed at the ipsilateral site. Yes, that's what Ashley was referring to when she said the angiocele cannot be accessed for a certain amount of time. So, make sure you follow all the IFU-based time constraints because there's a reason why they are, you know, written down, so. Yeah. To my knowledge, I think angiocele is the one with the longest time constraint. That is correct. So, per close, you can still remember it's a suture-based device, so you can go at least a one centimeter higher or lower, depending on your previous access site. Again, this is not in the IFU and it's not something I can tell everyone to generalize, but yes, you can do it if need be. Yeah. And in emergencies, you have to do what you have to do, so. Right. There's also, so we'll talk about manual access as well, but if you do use a closure device or you do have manual hemostasis, if you need or are concerned about somebody maybe not being as compliant or there's some oozing, these are great devices that can help manage that without having to be at the bedside constantly. So, we have the FemStop, which is the compression system that gives, you know, we use the blood pressure to kind of help us tell us how much pressure to put. It's very stable and we put it, you can use it on either the right or left side. And then the Safeguard puts up maybe 30 cc's, you put 30 cc's in a bigger one and 10 cc's in the smaller one. That gives a little less, it's more just like a pressure dressing, but it works great when you just have like this little track ooze or a slight ooze and it's much more comfortable for the patient. So Ashley, for Safeguard, we use it mostly for venous cases or we do it for arterial as well? Yeah, we used to primarily just use it for venous cases, but more and more we're seeing that maybe a little bit of a compression dressing right after like per clothes when you have to make a bigger track for the closure device and it's really just like the surface ooze where we don't need this high pressure of the FemStop. We just use the Safeguard, the bigger one, not the smaller one, to just give some additional pressure to just kind of close off that side. Got it. And what is your ACT range? When can you not use it and what French sizes we can use the Safeguard in? Yeah, so I think Safeguard is more up to the user itself and if you're having continuous bleeding, whether it's venous or arterial, Safeguard would not be the option, but likely the FemStop as well. You need to have some pretty decent hemostasis before you swap these. These are not to substitute for manual compression. So if you don't have very good hemostasis, we should not be using these manual assist devices. Ideally, when we do manual compression, our ACT, it depends on the system that you're using, but about 150 to 170 for the ACT. So if the ACT is very high, again, you still want to use manual compression or keep the sheet in place until your ACT is better. No, I think that's a very important point. So if you're using Safeguard, make sure it's not actively bleeding. So we are just talking about track rules and you want to make sure your ACT is low because these pressure assisted devices are really not going to help you if your ACT is very high. So you want to keep your ACTs less than 140 and make sure you use it in less than or equal to six French sheets. So I think they cannot be used in lieu of either a good manual compression or a good vascular closure device. So something to be cognizant of. You can't just do a procedure, take the sheet out, put this device and send the patient to the wards. I don't think that's going to go well. Yeah. These are just to help enhance and prevent some manual access complications, not to create hemostasis. Great. Okay. So a little bit more about manual compression, acceptable closure strategy in five French or lower profile sheet and the contraindications to vascular closure devices. So again, we talked about this before, ideally an ACT less than 150, it depends on the hospital that you work for, what their policy is. We like it to be below between 170 to 150. And then manual compression is associated with lower infection rate compared to vascular closure. So if you want to refer back to that slide of contraindications for closure devices, we did talk about infection being, you know, if somebody is actively having an infection, but for some reason they needed this cath, it couldn't be deferred, then you certainly would want to use manual compression. And we do have a little algorithm that we use for manual compression. You take the sheet size and use every sheet size is three minutes. Yep. So for diagnostic, you multiply the sheet size by three minutes. If it's a five French sheet, you want to hold for 15 minutes. Obviously this can, these numbers are designed when your ACT is borderline or normal, basically. Yes. If your ACT is high, you really have to hold a longer pressure. So even five to six minutes per French of sheet size. So it all depends. But yes, as a basic benchmark, if your ACT is normal, it's a diagnostic cath, three minutes per French would be ideal. Yeah. And if your ACT is high at the end of the procedure, you know, the safest thing to do if this patient cannot receive a closure device, then you want to suture the sheet in place and wait for the ACT to go down. So it's a safe manual compression. So complications that can occur during access, obviously we can have persistent bleeding for various reasons. You can develop a hematoma, that's why there should be frequent checks of the groin post-procedure and alerting the providers when you do have suspicion or seeing that the patient's in a lot of pain. If you see visual swelling, if there's a lot of bruising, you want to confirm with the ultrasound as well, get that at the bedside. Another complication would be a pseudoaneurysm, which you would also confirm with ultrasound. You're going to have a patient with a lot of pain, swelling, pulsatile mass and bruit. Also it might be an indication of when you did the access and you took an angiogram, if they were in within that bifurcation region, you're actually at higher risk for pseudoaneurysm. And likewise, if you were a little bit high on the access, you're at higher risk for retroperitoneal bleed. You're going to see patients with hypotension, terrible flank pain or abdominal pain. You can even have abdominal distension. That's an emergency. You want to get the patient to the CAT scan right away. You can also develop an AV fistula, which you're going to have through your throat. Also can be seen on ultrasound, acute limb ischemia. Sometimes that can occur from a closure device. Just because we're closed and the procedure is done, doesn't mean that something couldn't have migrated. It's not very common, but we have seen it. We just have to be aware that these are possible complications. The patient can be complaining of a lot of pain in their leg, pallor, paresthesia, pulselessness, the Ps. We want to do ultrasound. We want to assess the distal pulses continuously. If there's any change, you want to alert a provider. And then of course, infection, erythema, abscess at the access site. We give the prophylactic antibiotics, but that's based on your hospital protocol. We give strict instructions to the patient to keep the area clean and dry and free of any powders, ointments or anything like that. Obviously also if they had developed a fever of unknown source. Great. I think that's a very good summarization of the complications. So Ashley, how often should the staff who are taking care of these post-procedure patients check the pulses or ask the patients, are you having any pain in your legs? Because we all tend to discuss these things, but unfortunately sometimes it's delayed. So what would you recommend for us and for the nurse practitioners, for the PAs, for the nurses who are taking care of these patients? Yeah. So at a minimum, every 15 minutes we should be checking vital signs, groin checks, pulse checks, checking on the patient themselves. Obviously if you see any change in the hemodynamics, suddenly there's a drop in blood pressure. And some people don't like to complain. They always say, are you having any pain? Oh, my back's been bothering me. Right away you kind of just hone in on maybe this is a retroperitoneal bleed. Obviously you would need further assessment, but these patients should be continuously monitored post-procedure. I know if it was diagnostic, a lot of times patients go home pretty quickly, but within that two, three hour period, the patient should be monitored every 15 minutes for a change in hemodynamics. Great. I think that's a very important tidbit that everyone should know that the procedure does not end just after the PCI or after the cath. I think there's a time period of two to four hours when these patients recover on the post-op side and these things are important. You want to make sure you don't miss any of the complications because these complications can be catastrophic. Definitely. Great.

femoral access management

anatomy of the femoral artery

ultrasound and fluoroscopy

closure device

manual compression

complications of femoral access