Closure of Alternative Vascular Sites, Including Axillary, Brachial, Popliteal, and Surgical Grafts

Although common femoral arterial access remains the cornerstone for endovascular interventions, alternative arterial access sites such as the brachial, axillary, and popliteal arteries as well as surgical bypass grafts offer additional options when the conventional approach is unavailable or impractical. Each of these alternative access sites features a unique blend of risks and benefits, and the interventionalist should be well versed not only in how to safely enter the arterial system at these locations but also in how to safely exit. Manual compression represents the gold standard method for hemostasis at all vascular access sites, though variations and modifications in the technique exist based on anatomical factors in different arteries. Vascular closure devices widely used for common femoral arteriotomy closure have also been applied in "off-label" settings for multiple additional arteries. In this article, we discuss the pertinent anatomy as well as summarize the literature and anecdotal experience regarding methods for achieving hemostasis at multiple alternative arterial access sites.