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Pitfalls associated with the use of current recommendations for fluoroscopy-guided common femoral artery access
Vamsee Yaganti1, Nicolai Mejevoi, Omar Hasan
1Division of Cardiology, Newark Beth Israel Medical Centre, Newark, New Jersey 07112, USA.
Insights
Patient anatomy influences vascular access during cardiac catheterization. High BMI patients often have a low inguinal ligament, increasing risks of "high sticks," while the inferior epigastric artery location is not always a reliable predictor.
Area of Science:
- Cardiology
- Vascular Surgery
- Medical Imaging
Background:
- Vascular access complications are a major cause of morbidity following cardiac catheterization.
- Fluoroscopy guidance is recommended but does not eliminate risks of high or low arterial access.
- Current fluoroscopic guidance may lead to arterial access above the inferior epigastric artery (IEA) or below the common femoral artery (CFA) bifurcation.
Purpose of the Study:
- To investigate the impact of patient characteristics, including age, body mass index (BMI), and pelvic anatomy, on current fluoroscopic guidance recommendations for vascular access.
- To evaluate the reliability of anatomical landmarks in predicting optimal common femoral artery access.
- To identify factors contributing to suboptimal arterial access during cardiac catheterization procedures.
Main Methods:
- Prospective collection of clinical, anatomical, and angiographic data from 631 patients undergoing procedures via CFA access.
- Identification of the anatomical locations of the IEA loop, CFA bifurcation, public tubercle (PT), and anterior superior iliac spine relative to the femoral head.
- Use of IEA loop location as a surrogate for the inguinal ligament (IL).
Main Results:
- 12% of patients exhibited a low-lying IEA loop, associated with significantly higher BMI compared to those with a higher IEA loop (P = 0.018).
- The public tubercle (PT) was located below the femoral head's lower border more frequently in patients with a low-lying IEA loop (P < 0.0001).
- Fifteen percent of patients had a high CFA bifurcation; no significant differences in access complications were observed between groups during hospitalization.
Conclusions:
- The anatomical position of the public tubercle (PT) can serve as an additional fluoroscopic landmark to predict inguinal ligament (IL) location.
- Patients with higher BMI tend to have a lower IL, potentially increasing the risk of 'high sticks'.
- The inferior epigastric artery (IEA) location is not universally reliable as a surrogate for the inguinal ligament (IL).
Background:
Vascular access complications remain the leading cause of morbidity after cardiac catheterization procedures. Fluoroscopy-guided vascular access has been recommended to reduce these complications. However, the use of current recommendations still results in arterial access above the inferior epigastric artery (IEA) (high stick) or below the common femoral artery (CFA) bifurcation (low stick).
Objectives:
The goal of our study was to evaluate the influence of patient characteristics like age, body mass index, and pelvic anatomy on current recommendations.
Methods:
We prospectively collected clinical, anatomic, and angiographic data on 631 consecutive patients who underwent coronary and noncoronary procedures via CFA access. Anatomic location of IEA loop, CFA bifurcation, public tubercle (PT), and anterior superior iliac spine were identified in relationship to the femoral head Location of IEA loop was used as a surrogate for inguinal ligament (IL).
Results:
Approximately 12% of patients had a low-lying IEA loop (group B). These patients had a significantly higher BMI compared with patients with IEA loop above the centerline of femoral head (group A) (P = 0.018). The anatomic location of PT was below the lower border of femoral head significantly more frequently in group B compared to group A (P < 0.0001). Fifteen percent of patients had a high CFA bifurcation. On clinical follow-up during index hospitalization, there was no significant difference between the two groups, in terms of complications including retroperitoneal hemorrhage, access site hematoma >5 cm, bleeding requiring transfusion or pseudoaneurysm.
Conclusions:
Anatomic location of PT on fluoroscopy can be used as an additional surrogate to predict the location of IL. Patients with high BMI have a low lying IL, which may predispose them to "high sticks." The location of IEA cannot be used as a surrogate for IL in all patients.
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