Pratica di Shadowing: Femoral access: step-by-step and troubleshooting - Mazen Abu-Fadel, MD - Impara a parlare inglese con YouTube
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Welcome to Cardiovascular Innovations 2020.
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Welcome to Cardiovascular Innovations 2020.
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My name is Mazan Abu-Fadal
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and I'm an interventional cardiologist at the Oklahoma Heart Hospital North Campus
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and a clinical professor of medicine at the University of Oklahoma.
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Today we're going to be discussing femoral access,
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step by step, and troubleshooting.
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I have no disclosures related to this talk.
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Of course, whenever possible, radial first is a good idea.
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However, femoral access is still needed for a variety of procedures,
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and knowing how to do good femoral access can save the patient a lot of complications.
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The ideal puncture site is what we're going to start with.
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If we can puncture the femoral artery right in the middle of the head of the femur with one anterior stick,
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the risk of complications is going to be much less than
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if we puncture the femoral artery above the most inferior border of the inferior epigastric artery,
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or if we puncture the femoral artery below the most inferior border of the head of the femur.
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Even though we may still be in the common femoral artery,
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this can still cause complications because manual pressure is not going to give us good.
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This is because this area of the common femoral artery above the femoral head
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is the closest to this bony landmark where compression can cause hemostasis.
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Access above or below the femoral head is going to increase complication rates.
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And another important thing we can see from this picture is how the femoral artery,
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when it transitions to the iliac artery,
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starts diving down into the pelvis.
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This is important when we're talking about ultrasound.
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Now, first, we started using fluoroscopic markers to try and tell us where the femoral head is,
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where the inferior border is,
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and to try and start our axis at that point so we don't have low axis and hopefully not high axis.
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The problem with this approach is even
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when we put the landmark at the inferior border of the head of the femur
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and we start our axis at 45 degrees with the needle there,
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if the patient is very thin and there's not a lot of subcutaneous tissue,
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we're going to access that artery.
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On the other hand, if the patient actually has a lot of subcutaneous tissue and is obese,
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which is most of the patients we see these days,
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even when we start from the inferior border of the head of the femur,
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by the time the needle gets into the artery, it's already too high.
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Ultrasound guided access can help with that quite a bit.
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Ultrasound guided access can help with the artery and the bifurcation
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and can also help us detect the needle insertion in the anterior wall of the artery.
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Doing ultrasound requires some good technique and there's a learning curve.
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However, after around 15 procedures,
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you can be good at it.
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Usually we like to start looking with the ultrasound either at the inferior border
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or in the middle of the head of the femur
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and then scan up and down until we see the bifurcation
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and go above the bifurcation where the common femoral artery is located.
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The nice thing about the ultrasound is we can also do longitudinal views to see the wire,
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make sure it's not going sub-intimal
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or make sure there's not a lot of calcifications or disease in the artery before we even get access.
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Ideally, we want to get the access above the bifurcation of the femoral artery.
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So here, even though the sheath is perfect in the middle of the head of the femur,
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you can see it did go in the bifurcation.
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The goal is to have an access which is above the bifurcation in the common femoral artery
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and still below the most inferior border of the head of the,
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oh, sorry, of the inferior epigastric artery.
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This can be achieved with ultrasound guidance much better than with a fluoroscopic guidance.
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In addition, ultrasound guidance will help us decrease the number of attempts.
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First pass success rate is actually higher,
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time to sheet insertion is lower,
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and risk of venipuncture is lower.
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The use of micropuncture is also very important if used properly.
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When we get access with micropuncture,
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we are using it with ultrasound guidance,
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and we use the micropuncture that had the braided tip so
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that we can reflect the sound wave and see them on the ultrasound.
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After access obtained and the wire is advanced and before removing the needle,
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a quick fluoroscopy at the site of insertion will show you the transition between the needle head and the wire.
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If this transition is at the level of the middle of the head of the femur,
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then that's perfect.
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If it's too high or too low,
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then you want to repeat the access after you remove the wire and the needle and hold.
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There's been claims that micropuncture can increase vascular complications and specifically it can increase retroperitoneal bleeding.
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The micropuncture wire goes into one of the smaller pelvic wires like you see in panel A.
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This is why it's very important when you get access to look at the needle wire interface,
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and if it's too high like you see in the first panel,
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remove, hold pressure, then access again like you see in the middle panel.
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However, in the middle panel,
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after we got access and we advanced the wire a little bit,
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we took a fluoro and it was going in one of the pelvic arteries,
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which, especially if the wire is hydrophilic,
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can perforate that pelvic artery and cause bleeding and with anticoagulation retroperitoneal hematoma.
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This is why looking at the insertion site as well as the direction of the wire,
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make sure it's going in the iliac arteries up to the aorta.
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It's going to be very important before we exchange to the micropuncture dilator and wires.
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After coronary, sorry, after sheet insertion,
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you want to do femoral ingiography.
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Femoral ingiography is very important and in my opinion,
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should be done before the procedure is started and before any anticoagulation is given.
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You can see from this picture how the sheet is actually touching the wall of the artery,
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and if injection is being done,
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this can dissect the artery.
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This can be prevented from getting a wire through the sheath when taking ephemeral angiogram,
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which is standard we use all the time now.
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And this will deflect the tip of the sheath away from any tortuosity in the artery
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and allow you to inject even using an injector or a syringe without worrying about dissection.
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So what is the ideal technique for femoral access?
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Locate the femoral head.
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Make sure where the lowest point is and where the middle of the head of the femur is.
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Use ultrasound guidance to use a micropuncture with it and try to access the femoral artery at the correct level.
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Make sure you scan up and down to see the bifurcation.
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And when you're scanning up,
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if you see the femoral artery start to dive down into the tissue further away from the ultrasound,
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this means you're too high.
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You're most likely in the iliac arteries.
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After you put the, after you access with the needle and you advance the wire,
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take a quick flora, make sure the transition of the tip of the needle
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and the wire is in the middle of the head of the femur
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and make sure that the wire is going towards the aorta and not the pelvic arteries.
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After all that is done,
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put a wire through the sheath,
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take a femoral angiogram, and then if needed,
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you can upsize the sheath for structural interventions or hemodynamic support,
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or just give anticoagulation for your intervention.
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The femoral angiogram also helps you make sure the size of the artery is good
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and there's no disease or complications there that prevent you from using vascular closure devices if
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Thank you very much for your attention.
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For any questions or comments,
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please feel free to email me at this email.
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I hope you enjoyed this meeting.
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Contesto e Sfondo
Il dottor Mazen Abu-Fadel è un cardiologo interventista presso l'Oklahoma Heart Hospital North Campus e professore clinico di medicina presso l'Università dell'Oklahoma. Durante la presentazione dal titolo "Femoral access: step-by-step and troubleshooting", il dottore discute l'importanza dell'accesso femorale in varie procedure cardiologiche, sottolineando come una buona tecnica possa ridurre il rischio di complicazioni per i pazienti. La sua esperienza non solo offre una panoramica tecnica operativa, ma funge anche da fonte di conoscenza su come affrontare situazioni impreviste durante le procedure.
Le 5 Frasi Chiave per la Comunicazione Quotidiana
- “Whenever possible, radial first is a good idea.” - Questo suggerisce che l'accesso radiale dovrebbe essere considerato prima.
- “Knowing how to do good femoral access can save the patient a lot of complications.” - Riconosce l'importanza delle competenze tecniche.
- “The ideal puncture site is what we’re going to start with.” - Introduzione sulla scelta del sito di puntura.
- “Ultrasound guided access can help with that quite a bit.” - Sottolinea l'utilizzo dell'ultrasuono nella procedura.
- “We want to get the access above the bifurcation of the femoral artery.” - Indica l'area ottimale per la puntura.
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