Hello everyone, I'm Saurabh Joshi, an interventional cardiologist, and we'll be talking about femoral artery access site complications. Common femoral artery is one of the common access sites for coronary angiography in intervention. The complication rate depends on the population studied, but this access site complication category is one of the most common complications for coronary angiography in interventions. It is important because it increases morbidity, mortality, and cost. Complications can be divided into minor and major categories. Minor complication includes minor bleeding, stable hematoma, and echymosis, and usually this does not require any intervention. Major complications include hematoma requiring transfusion, seroaneurysm, AV fistula, retroperitoneal bleed, arterial dissection or perforation, embolism, thrombosis, leading to limb ischemia or infection. There are certain factors which increases the risk of femoral artery access site complications. One is under the category of patient-related factors, which is female gender, older age, extremes of weight, renal insufficiency, and located count. There are procedure factors that include sheet size, PCI has more complication rates than diagnostic cath, duration of the procedure, use of anticoagulation, thrombolytics, or IV antiplatelets like GP2V3 inhibitors. Another important factor is access technique, the location of the puncture site, and how the access is obtained. Let's talk about common femoral artery anatomy and access. So here in cartoon you see the femoral artery, it's a continuation, this is an external iliac artery, it's a continuation of external iliac artery, common femoral artery, it starts at the inguinal ligament and further down it bifurcates into SFA and profunda. One wants to access the femoral artery at the level of the mid-femoral head because if one has to achieve hemostasis with manual compression of the femoral artery, the femoral head provides a hard structure, solid bony structure against which the femoral artery can be compressed. If the access is obtained higher up, then it leads to retroperitoneal bleeding and also there is lack of any bony structure against which the access site can be compressed for achieving hemostasis. If the access is obtained lower down, as a low access, one may enter the branch vessels and it may not be a big branch, and also there are certain complications which are more common with the lower access which includes pseudoaneurysm and AV fistula, there's a tributary of a vein that crosses over the artery and there's a higher incidence of AV fistula in lower access. So to obtain common femoral artery access, one should first identify the anatomic landmark, then should use fluoroscopy to identify where on the skin one wants to enter to have a good access, and that one can identify a lower head of the femur using the clamp under fluoro and that could guide as an entry site on the skin with a needle at an angle entering and trying to enter the femoral artery in the mid-femoral head. Next one should use ultrasound to look for the bifurcation, if one starts scanning with ultrasound can identify a branch vessels of the common femoral artery, SFA and profunda, if you go more proximally from here on can identify common femoral artery and that would be the site of entrance, can use short access, long access to confirm. To obtain access one should use micropuncture needle, it is important to use a micropuncture needle which is a 21 gauge needle because it leads to more than 50 percent smaller hole than using an 18 gauge cook needle. Once you have an access, an advanced micropuncture sheath should perform an ephemeral angiogram unless it's absolutely contraindicated, maybe due to severe renal dysfunction, should perform this angiogram to confirm the access site and if you find that you have a high or low access then can remove it, hold pressure, obtain hemostasis and then reattempt. So about access site complication it's important to know about the hemostasis, at the end of the procedure hemostasis can be achieved with manual compression or assisted compression for example using femSTAR. Hemostasis can also be achieved with vascular closure device which can be divided into plug-based vascular device for example angioseal or a suture-based device example perclose. There is more and more use of vascular closure device that is because it leads to more patient satisfaction, less discomfort, early mobility but so far it has failed to demonstrate convincingly that vascular closure device reduces the incidence of access site complication and part of it is contributed to vascular closure device use itself as these devices can themselves lead to bleeding or lower limb ischemia if not used appropriately and there is a learning curve for that so more a person is trained and familiar with these devices and comfortable the incidence of complications related to these devices decreases and then overall one will find it to be leading to better closure better than manual compression. So when such complications arises due to femoral access site one may hear from the patient about ipsilateral groin pain, flank pain, abdominal pain and also should think about the access site complication if the patient becomes hypotensive it could be because of the bleeding from the excess site if there's an ipsilateral groin swelling flank or abdominal pain or tenderness. On blood work if there's a significant drop in hemoglobin or hematocrit one should again think about access site complication and can use imaging like ultrasound cd scan or invasive angiogram to confirm the access site complication and type of it to decide on further management. So the management depends on the severity of the complication and hemodynamic compromise if the patient has soft blood pressure or hypotensive should be given IV fluid bolus blood transfusion and may need to reverse or interrupt the anticoagulation or antiplatelet. Vascular surgery consultation should be obtained. Now talking about individual complications if there is a perforation or nick at the access site then an angiogram should be performed from the contralateral side. If there's a leak around the sheath leading to the bleeding then one may decide to upsize the sheath and that can seal that area and can see that there is no further bleeding. If that does not help or if the bleeding or perforation is from a site other than the access site higher up in the femoral iliacs can pursue any endovascular interventions from the contralateral side can have a wire up and up around and go across the site of the perforation and then can advance a balloon for balloon temponade. Depending on the site if the balloon temponade does not help can decide to pursue covered stent. If endovascular interventions do not help then should be sent for surgery. Retroperitoneal bleed if the patient has retroperitoneal bleed it may at times stop on its own because of the temponade effect of the blood that accumulates around it but if the bleed continues then would require endovascular intervention once again with balloon temponade can use a stent graft or a selective arterial embolization and if this does not work the patient can undergo surgical repair. If there's lower extremity ischemia one needs to perform an angiogram to identify the problem or the etiology leading to the lower extremity ischemia and depending on that an endovascular intervention can be pursued. For example if the patient has a thrombotic occlusion then a thrombectomy can be performed and once again if endovascular intervention does not help or cannot be pursued then a surgical repair can be done. Pseudoaneurysm presents as a swelling in the groin. The management depends on the size of the pseudoaneurysm. If it is less than three centimeter it usually spontaneously clots off in few weeks time and it's conservatively managed. If the aneurysm is bigger than three centimeter then it requires closure. One can start with ultrasound guided compression but that's usually very discomforting. Can also inject thrombin to clot it off and endovascular interventions include a stent graft, coil or detachable balloon and if these fail then surgical repair. Heavy fistula also presents as a swelling in the groin. It's conservatively managed as it closes spontaneously. Closure is required when there is increased shunting leading to distal leg swelling or tenderness. It is closed with external compression and endovascular covered stent or coil if that fails surgical repair. Dissection. When dissection happens it's usually non-flow limiting from the femoral excess site and the reason for that is the blood flow is in the opposite direction of the flap so it helps seal that and so usually conservative management if non-flow limiting. If it is flow limiting then needs intervention which includes endovascular with balloon angioplasty and stent and if that does not work surgical repair. Thank you.

femoral artery access site complications

coronary angiography

hematoma

AV fistula

thrombosis