Relationship of the inguinal ligament to pelvic radiographic landmarks: anatomic correlation and its role in femoral arteriography

ULTrasound-guided TRAnsfemoral puncture in COmplex Large bORe PCI: study protocol of the UltraCOLOR trial

INTRODUCTION

Although recently published evidence favours transradial access (TRA) when using large-bore guiding catheters for percutaneous coronary intervention (PCI) of complex coronary lesions, the femoral artery will still be used in a considerate proportion of patients undergoing complex PCI, especially in PCI of chronic total occlusions (CTO). Ultrasound-guided puncture of the femoral artery may reduce clinically relevant access site complications, but robust evidence is lacking up to date.

METHODS AND ANALYSIS

A total of 542 patients undergoing complex PCI, defined as PCI of CTO, complex bifurcation, heavy calcified lesion or left main, in which the 7-F or 8-F transfemoral access is required, will be randomised to ultrasound-guided puncture or fluoroscopy-guided puncture. The primary outcome is the incidence of the composite end-point of clinically relevant access site related bleeding and/or vascular complications requiring intervention. Access site complications and major adverse cardiovascular events up to 1 month will also be compared between both groups.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee ('Medisch Ethische Toetsing Commissie Isala Zwolle') for all Dutch sites, 'Comité Medische Ethiek Ziekenhuis Oost-Limburg' for Hospital Oost-Limburg, 'Comité d'éthique CHU-Charleroi-ISPPC' for Centre Hospilatier Universitaire de Charleroi and 'Ethik Kommission de Ärztekammer Nordrhein' for Elisabeth-Krankenhaus). The trial outcomes will be published in peer-reviewed journals of the concerned literature. The ultrasound guided transfemoral access in complex large bore PCI trial has been administered in the ClinicalTrials.gov database, reference number: NCT03846752.

REGISTRATION DETAILS

ClinicalTrials.gov identifier: NCT03846752.

Position Statement on Vascular Access Safety for Percutaneous Devices in AMI Complicated by Cardiogenic Shock

In the United States, the frequency of using percutaneous mechanical circulatory support devices for acute myocardial infarction complicated by cardiogenic shock is increasing. These devices require large-bore vascular access to provide left, right, or biventricular cardiac support, frequently under urgent/emergent circumstances. Significant technical and logistical variability exists in device insertion, care, and removal in the cardiac catheterization laboratory and in the cardiac intensive care unit. This variability in practice may contribute to adverse outcomes observed in centers that receive patients with cardiogenic shock, who are at higher risk for circulatory insufficiency, venous stasis, bleeding, and arterial hypoperfusion. In this position statement, we aim to: 1) describe the public health impact of bleeding and vascular complications in cardiogenic shock; 2) highlight knowledge gaps for vascular safety and provide a roadmap for a regulatory perspective necessary for advancing the field; 3) propose a minimum core set of process elements, or "vascular safety bundle"; and 4) develop a possible study design for a pragmatic trial platform to evaluate which structured approach to vascular access drives most benefit and prevents vascular and bleeding complications in practice.

Perclose Proglide™ for vascular closure

In the past 20 years, numerous percutaneous vascular closure devices have been tested and compared with manual compression and to surgical cut-down. The suture-mediated closure device Perclose ProGlide™ system (Abbott Vascular, CA, USA) emerged as a safe and effective alternative for many procedures requiring either small or large bore vascular accesses. In this review, we will discuss the characteristics of this vascular closure device and the main studies that proved its potential to reduce vascular complications, time to deambulation, time to discharge and patient discomfort.

Redefining the fluoroscopic landmarks for common femoral arterial puncture during cardiac catheterization: Femoral angiogram and computed tomography angiogram (FACT) study of common femoral artery anatomy

BACKGROUND

The mid-femoral head (F₅₀ ) is a common fluoroscopic target for common femoral artery (CFA) puncture during cardiac catheterization. Punctures above the inguinal ligament (marking the proximal end of CFA) increase the risk of retroperitoneal hemorrhage and are classified as high punctures.

METHODS

We retrospectively analyzed 114 CT angiograms for the anatomic relationship of the inguinal ligament to the femoral head (FH) and inferior epigastric artery (IEA). We analyzed 114 CT angiograms and 500 femoral angiograms, for the relation of the mid-point of CFA to F₅₀ and F₇₅ (the junction of upper 3/4th and lower 1/4th of FH).

RESULTS

The proximal third of femoral head (F₃₃ ) (-1.4 mm) and IEA nadir (-2.9 mm) were closer approximations to the inguinal ligament than the IEA origin (-12.8 mm) or cranial end of FH (-15.2 mm). The inguinal ligament correlated better with the IEA nadir than F₃₃ (R²  = 0.49 vs. 0.001). F₇₅ was a closer approximation for the mid-point of the CFA than F₅₀ (0.3 mm vs. -9.2 mm). Using F₇₅ as the target for CFA puncture carried the lowest risk for non-CFA punctures (18.6%), while using F₅₀ had a 41.2% risk for non-CFA punctures. F₇₅ had an increased risk for low punctures (14.2%) but F₅₀ had a far higher risk for high punctures (36.6%).

CONCLUSIONS

The nadir of IEA is the best landmark for identifying the inguinal ligament (the proximal end of CFA) and defining high punctures. F₇₅ is a more accurate target for successful CFA puncture than F_50.

Poorly recognized age-related downward deviation of the inguinal ligament

Objective:

To determine factors affecting actual inguinal ligament course in live human subjects.

Introduction and hypothesis:

Although the expected inguinal ligament course is supposedly a straight line extending from anterior superior iliac spine to pubic tubercle, the actual inguinal ligament course is frequently depicted a priori by a downward bowing dotted line. There are no studies in a live subject supporting this assumption. We hypothesized this assumption is indeed valid and is related to among other factors a lifelong effect of gravity and lax abdominal musculature on the inguinal ligament course.

Methods:

We retrospectively reviewed 54 consecutive computed tomography scans of the abdomen and pelvis randomly distributed across all age groups. Actual inguinal ligament course was visualized by reconstructing images using Terracon software. Vertical distance from the lowest point of actual inguinal ligament course to the expected inguinal ligament course was measured. We used multiple linear regression analysis to study the correlation between degree of inguinal ligament deviation and several variables.

Results:

Actual inguinal ligament course was below the expected inguinal ligament course in 52 of 54 patients. The mean deviation was 8.2 ± 5.9 mm. Advanced age was significantly associated with greater downward bowing of the inguinal ligament (p = 0.001).

Conclusion:

Actual inguinal ligament course is often well below the expected inguinal ligament course; this downward bowing of the inguinal ligament is especially pronounced with advancing age. Operators need to be mindful as this downward bowing can lead to supra-inguinal sticks causing vascular complications.

Comparison of ultrasound guidance with the traditional palpation and fluoroscopy method for the common femoral artery puncture

OBJECTIVES

To compare the success and complication rates of ultrasound-guided or palpation-guided punctures of the common femoral artery in a prospective randomized study.

BACKGROUND

Percutaneous femoral arterial access is sometimes difficult to perform and is the source of complications. It has not been established whether ultrasound-guided puncture of the common femoral artery is the standard practice for angiography.

MATERIALS AND METHODS

Two hundred and eight patients were randomized into two groups. One had ultrasound-guided puncture and the other had palpation-guided puncture of the common femoral artery. The technical success, first pass success rate, total number of attempts required for access, time to sheath insertion, pain during puncture, and access-related complication were compared.

RESULTS

Technical success tended to be higher and the complication rates tended to be lower in the ultrasound-guided group but the difference did not reach statistical significance (P = 0.052 and P = 0.052). The first pass success rate was higher, total number of attempts required for access and time to sheath insertion were lower in the ultrasound-guided group. Atheromatous plaques on the common femoral artery, iliac artery obstructive lesion, previous ipsilateral puncture of the common femoral artery, obesity, and blood pressure during puncture did not change the outcome.

CONCLUSIONS

Ultrasound guidance improves secondary outcomes of the common femoral artery puncture when compared to palpation-guided puncture. Technical success and complication rates seem lower in the presence of ultrasound guidance but larger study populations are needed to verify the result.

Ultrasonography of the femoral vessels in the groin: implications for vascular access

The femoral artery and vein are commonly used for access to the circulation. Accidental puncture of one vessel whilst attempting to cannulate the other is a common complication. Identification of relevant surface anatomical landmarks and ultrasonography of both groins was performed on 50 consecutive adult patients admitted to the intensive care unit. In most patients there was overlap of the artery over the vein far closer to the inguinal ligament than conventional anatomical texts would indicate. The frequency and degree of overlap increased as the vessels descended distally towards the knee. Surface anatomical landmarks were not useful in predicting the underlying anatomy. The side-by-side relationship of artery and vein is commonest close to the inguinal ligament. Therefore, to avoid damage to the neighbouring vessel, percutaneous access should be undertaken just below the inguinal ligament.

Percutaneous femoral puncture for endovascular treatment of occlusive arterial lesions

BACKGROUND

Percutaneous femoral arterial access is a most important and difficult aspect of endovascular intervention, and the source of most complications.

METHODS

A retrospective review was made of the authors' 9-year experience with 755 femoral punctures for the endovascular treatment of occlusive disease. The main focus was the evolving success rate with percutaneous arterial entry and the incidence of access-related complications.

RESULTS

Cutdowns were frequent during the first 2 years, 54% and 17%, respectively, decreasing to 5% or lower by the third year. The incidence of femoral hematoma and other complications mirrored the same learning curve. After cutdown, wound infections and lymph leakage occurred in 2.4% each, and prolonged significant pain in 5%.

CONCLUSIONS

Percutaneous puncture is a crucial skill in endovascular intervention. Practicing vascular surgeons can expect a significant learning curve. Performance can be optimized through intensive basic and advanced training and preceptorship. The cutdown approach is neither necessary nor acceptable for most endovascular procedures.