General Description

The most common vascular access approach used for diagnostic cerebral angiography and neuroendovascular interventions is the common femoral artery (CFA). Understanding the anatomy of the femoral artery and related anatomic structures is fundamental to any neurointerventionist to minimize complications during vascular access.

Indications

Femoral artery access is indicated for any diagnostic cerebral angiogram. It is also indicated for most neuroendovascular procedures that require a 7 French (F) or larger sheath for access.

Neuroendovascular Anatomy

The CFA is a continuation of the external iliac artery. The transition from the CFA to the external iliac artery is marked by the inguinal ligament that extends from the bony anterior superior iliac spine to the pubic tubercle. The CFA extends from the inguinal ligament and crosses at the medial third of the femoral head. At the junction of the femoral neck and lesser trochanter, it bifurcates into the superficial femoral artery (SFA) and profunda femoral artery (PFA). Small branches from the external iliac artery, such as the circumflex iliac and deep epigastric, should be identified to avoid placing the access sheath within them and causing vessel rupture and retroperitoneal hematoma.

Specific Technique and Key Steps

It is important to obtain the patient’s history of previous femoral artery access, femoral bypass, stent placement, or surgery at the inguinal region. A complete examination of the groin area with documentation of the femoral, popliteal, and pedal pulses is essential. To maximize the efficiency of neuroendovascular procedures, we routinely obtain percutaneous access through the right femoral artery ( Fig. 1.1–1.3 and Video 1.1–1.3 ), unless a contraindication exists (i.e., scarring from a previous surgery, absence of a femoral pulse, multiple previous punctures/closure device, or pseudoaneurysm formation).

1. 
   

   After the groin is prepared and draped in sterile fashion, the site of puncture is identified using bony landmarks and confirmed radiographically with an X-ray ( Fig. 1.2, 1.3 and Video 1.2, 1.3 ). The anteri- or superior iliac spine and the pubic symphysis are connected by the inguinal ligament, which marks the superior border of the CFA. This can be palpated in most individuals.

   
   
2. 
   

   The CFA runs medial to the center of the femoral head. This site is found under X-ray using a hemostat for localization and marked. The lower third of the femoral head is the ideal site for vessel puncture.

   
   
3. 
   

   The CFA pulse is elicited, and local anesthesia is infiltrated in the skin and subcutaneous tissue. A single wall puncture of the CFA is performed with a microneedle (21-gauge micropuncture kit) at a 45° angle with the bevel facing up. A single anterior wall puncture technique is used.

   
   
4. 
   

   Once pulsatile bright red blood is encountered, a microwire (0.010-inch diameter Cope Mandril, Cook Medical) is advanced through the microneedle. If resistance is noted, the process is halted, and the microwire trajectory is confirmed with an X-ray. After the trajectory is confirmed, the wire is advanced up and to the left toward the iliac artery and abdominal aorta, avoiding the small lateral side branches. The microneedle is removed and an intermediate dilator (4–5F microsheath) is inserted. The introducer is removed and a 30-cm J-wire is inserted. The intermediate dilator/microsheath is exchanged for a sheath (4–6F). For diagnostic cerebral angiography, a 5F sheath is used for adult cases, and a 4F sheath is used for pediatric cases. Longer femoral sheaths (>25 cm) are considered for patients who are obese or those with very tortuous anatomy ( Fig. 1.1 , Video 1.1 ).

   
   
5. 
   

   If a larger diameter femoral sheath is required (7–9F), an intermediate dilator and a longer, stiffer wire should be used ( Fig. 1.2 and Video 1.2 ).

   
   
6. 
   

   After arterial access is established, a femoral artery angiogram (run) is performed before proceeding with the case. We assess for femoral artery patency, stenosis, and dissection, as well as possible extravasation. The groin run is needed to determine whether the arteriotomy can be closed percutaneously with a closure device (e.g., AngioSeal, St. Jude Medical; Perclose, Abbott Vascular; Mynx, Cardinal Health; or Catalyst, Cardiva Medical) ( Fig. 1.1–1.6 and Video 1.1–1.6 ).

Device Selection

1. 
   

   4–6F femoral sheath requires the following:

   
   
   
   
   1. 
      

      Micropuncture kit (microneedle, microwire, microsheath, intermediate sheath, J-wire).

      
      
   2. 
      

      4–6F femoral sheath.

   
   
2. 
   

   7–9F femoral sheath requires the following:

   
   
   
   
   1. 
      

      Micropuncture kit (microneedle, microwire, microsheath, intermediate sheath, J-wire).

      
      
   2. 
      

      Intermediate dilator (7F).

      
      
   3. 
      

      Longer, stiffer wire (i.e., short Amplatz wire, Stiff Glidewire).

Closure Device Selection

1. 
   

   The AngioSeal device utilizes a collagen sponge that is sandwiched between the inner and outer vessel wall ( Fig. 1.4 and Video 1.4 ). We typically use this device for larger arteriotomies (i.e., 8–9F) and in patients with hemostasis-related issues.

   
   
2. 
   

   The Mynx percutaneous closure device is used for smaller (i.e., 5–6F) arteriotomies typically after diagnostic procedures ( Fig. 1.5, 1.6 and Video 1.5, 1.6 ). The device utilizes an extravascular sealant, and some manual pressure is usually required after placement. In very thin patients, the sealant can extrude to the skin and must be wiped away and more manual pressure applied. The Catalyst device is also utilized for smaller arteriotomies; it requires removal of the device 10 minutes after placement and the application of manual pressure for 20 minutes thereafter.

   
   
3. 
   

   The Perclose device is designed to deliver a prolene stitch at the arteriotomy site. This device is commonly used for 6F openings. The patient is typically given one dose of antibiotics as the stitch is nonabsorbable.

Pearls

• 
  

  Prepare and drape both groins in patients with weak or nonpalpable femoral pulses or patients with possible difficult access (i.e., obese or peripheral vascular disease) ( Fig. 1.2 and Video 1.2 ). With the use of ultrasound imaging, identify the femoral artery; use an echogenic insulated ultrasound needle for this purpose.

  
  
• 
  

  If resistance is encountered while advancing the microwire or needle wire, stop! Inadvertent advancement within a dissection flap or small caliber vessel is likely when microwire resistance is encountered. Advance the wire under fluoroscopy. Use a nitinol wire; these wires are longer and firmer.

  
  
• 
  

  For pediatric cases, use ultrasound imaging for identification of the femoral artery ( Fig. 1.3 and Video 1.3 ). In these cases, it is not uncommon to puncture the posterior wall inadvertently because of the small artery size. Some interventionists prefer not to use a sheath, and to use the diagnostic catheter directly.

  
  
• 
  

  For obese patients, use long sheaths. Short sheaths can become kinked or may pull out inadvertently.

  
  
• 
  

  Avoid puncturing femoral artery stents. Obtain access above or below the stent or the contralateral femoral artery. Puncture of vascular grafts is acceptable, but special care should be taken with sterile technique and closure. If access was gained through a vascular graft, closure often requires an extra amount of manual compression. We do not recommend the use of any closure device for these cases.

  
  
• 
  

  Pulsatile masses over previous puncture sites should be evaluated with computed tomography angiography of the pelvis or abdomen to determine whether a pseudoaneurysm is present. Another possibility for the evaluation of these masses involves puncturing the contralateral groin and performing a formal femoral angiogram on the suspicious side. Treatment options for pseudoaneurysms include ultrasonic compression, ultrasonic compression with thrombin injection, stenting, and, last, vessel reconstruction.

  
  
• 
  

  Postoperative back pain should be taken seriously as this can be a sign of retroperitoneal hematoma, often from a high-level puncture in which it was difficult to achieve hemostasis. Immediate evaluation with computed tomography imaging is needed.

Case Overview: CASE 1.1 Femoral Artery Access

• 
  

  A 35-year-old woman presents for evaluation of nonruptured brain arteriovenous malformation. She has no significant past medical history.

  
  
• 
  

  Patient requires a diagnostic cerebral angiogram for further evaluation.

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