ฝึกพูดภาษาอังกฤษด้วยเทคนิค Shadowing จากวิดีโอ: Femoral access: step-by-step and troubleshooting - Mazen Abu-Fadel, MD

Welcome to Cardiovascular Innovations 2020.

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Welcome to Cardiovascular Innovations 2020.

My name is Mazan Abu-Fadal

and I'm an interventional cardiologist at the Oklahoma Heart Hospital North Campus

and a clinical professor of medicine at the University of Oklahoma.

Today we're going to be discussing femoral access,

step by step, and troubleshooting.

I have no disclosures related to this talk.

Of course, whenever possible, radial first is a good idea.

However, femoral access is still needed for a variety of procedures,

and knowing how to do good femoral access can save the patient a lot of complications.

The ideal puncture site is what we're going to start with.

If we can puncture the femoral artery right in the middle of the head of the femur with one anterior stick,

the risk of complications is going to be much less than

if we puncture the femoral artery above the most inferior border of the inferior epigastric artery,

or if we puncture the femoral artery below the most inferior border of the head of the femur.

Even though we may still be in the common femoral artery,

this can still cause complications because manual pressure is not going to give us good.

This is because this area of the common femoral artery above the femoral head

is the closest to this bony landmark where compression can cause hemostasis.

Access above or below the femoral head is going to increase complication rates.

And another important thing we can see from this picture is how the femoral artery,

when it transitions to the iliac artery,

starts diving down into the pelvis.

This is important when we're talking about ultrasound.

Now, first, we started using fluoroscopic markers to try and tell us where the femoral head is,

where the inferior border is,

and to try and start our axis at that point so we don't have low axis and hopefully not high axis.

The problem with this approach is even

when we put the landmark at the inferior border of the head of the femur

and we start our axis at 45 degrees with the needle there,

if the patient is very thin and there's not a lot of subcutaneous tissue,

we're going to access that artery.

On the other hand, if the patient actually has a lot of subcutaneous tissue and is obese,

which is most of the patients we see these days,

even when we start from the inferior border of the head of the femur,

by the time the needle gets into the artery, it's already too high.

Ultrasound guided access can help with that quite a bit.

Ultrasound guided access can help with the artery and the bifurcation

and can also help us detect the needle insertion in the anterior wall of the artery.

Doing ultrasound requires some good technique and there's a learning curve.

However, after around 15 procedures,

you can be good at it.

Usually we like to start looking with the ultrasound either at the inferior border

or in the middle of the head of the femur

and then scan up and down until we see the bifurcation

and go above the bifurcation where the common femoral artery is located.

The nice thing about the ultrasound is we can also do longitudinal views to see the wire,

make sure it's not going sub-intimal

or make sure there's not a lot of calcifications or disease in the artery before we even get access.

Ideally, we want to get the access above the bifurcation of the femoral artery.

So here, even though the sheath is perfect in the middle of the head of the femur,

you can see it did go in the bifurcation.

The goal is to have an access which is above the bifurcation in the common femoral artery

and still below the most inferior border of the head of the,

oh, sorry, of the inferior epigastric artery.

This can be achieved with ultrasound guidance much better than with a fluoroscopic guidance.

In addition, ultrasound guidance will help us decrease the number of attempts.

First pass success rate is actually higher,

time to sheet insertion is lower,

and risk of venipuncture is lower.

The use of micropuncture is also very important if used properly.

When we get access with micropuncture,

we are using it with ultrasound guidance,

and we use the micropuncture that had the braided tip so

that we can reflect the sound wave and see them on the ultrasound.

After access obtained and the wire is advanced and before removing the needle,

a quick fluoroscopy at the site of insertion will show you the transition between the needle head and the wire.

If this transition is at the level of the middle of the head of the femur,

then that's perfect.

If it's too high or too low,

then you want to repeat the access after you remove the wire and the needle and hold.

There's been claims that micropuncture can increase vascular complications and specifically it can increase retroperitoneal bleeding.

The micropuncture wire goes into one of the smaller pelvic wires like you see in panel A.

This is why it's very important when you get access to look at the needle wire interface,

and if it's too high like you see in the first panel,

remove, hold pressure, then access again like you see in the middle panel.

However, in the middle panel,

after we got access and we advanced the wire a little bit,

we took a fluoro and it was going in one of the pelvic arteries,

which, especially if the wire is hydrophilic,

can perforate that pelvic artery and cause bleeding and with anticoagulation retroperitoneal hematoma.

This is why looking at the insertion site as well as the direction of the wire,

make sure it's going in the iliac arteries up to the aorta.

It's going to be very important before we exchange to the micropuncture dilator and wires.

After coronary, sorry, after sheet insertion,

you want to do femoral ingiography.

Femoral ingiography is very important and in my opinion,

should be done before the procedure is started and before any anticoagulation is given.

You can see from this picture how the sheet is actually touching the wall of the artery,

and if injection is being done,

this can dissect the artery.

This can be prevented from getting a wire through the sheath when taking ephemeral angiogram,

which is standard we use all the time now.

And this will deflect the tip of the sheath away from any tortuosity in the artery

and allow you to inject even using an injector or a syringe without worrying about dissection.

So what is the ideal technique for femoral access?

Locate the femoral head.

Make sure where the lowest point is and where the middle of the head of the femur is.

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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ฝึกพูดภาษาอังกฤษด้วยเทคนิค Shadowing จากวิดีโอ: Femoral access: step-by-step and troubleshooting - Mazen Abu-Fadel, MD

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