Version May 2024
INTRODUCTION — Percutaneous procedures, including both diagnostic and interventional, begin with access to an artery. Depending on the procedure planned, vessels of the upper or lower extremities, or both, are used. The artery can be accessed either in a retrograde or antegrade manner in relation to the flow.
Relevant arterial anatomy and techniques for vascular access related to these procedures are reviewed.
The complications associated with arterial access techniques include bleeding, hematoma, pseudoaneurysm, arterial dissection, arterial thrombosis, embolism, and perforation. These are reviewed separately. (See "Access-related complications of percutaneous access for diagnostic or interventional procedures".)
PERCUTANEOUS ACCESS — A variety of access sites are used to treat a multitude of conditions using instrumentation designed to regain lumen diameter (eg, angioplasty, stenting, atherectomy), remove thrombus (thrombolysis, mechanical thrombectomy), cause vascular occlusion (angioembolization for bleeding, coil embolization of aneurysm), deliver intravascular devices or medications, or retrieve foreign bodies.
Diagnostic and interventional procedures for specific disease pathologies are discussed in separate topic reviews.
●Neurovascular intervention (See "Overview of carotid artery stenting" and "Percutaneous carotid artery stenting" and "Intravenous thrombolytic therapy for acute ischemic stroke: Therapeutic use" and "Treatment of cerebral aneurysms", section on 'Endovascular therapy'.)
●Aortic aneurysmal disease (See "Endovascular repair of abdominal aortic aneurysm" and "Endovascular repair of the thoracic aorta".)
●Cardiac diagnosis and intervention (See "Preparing patients for cardiac catheterization and possible coronary artery intervention" and "Percutaneous coronary intervention with intracoronary stents: Overview" and "Transcatheter aortic valve implantation: Periprocedural and postprocedural management".)
●Visceral intervention (See "Surgical and endovascular techniques for mesenteric revascularization" and "Treatment of visceral artery aneurysm and pseudoaneurysm" and "Renal artery aneurysm".)
●Peripheral intervention (See "Endovascular techniques for lower extremity revascularization" and "Surgical and endovascular repair of popliteal artery aneurysm" and "Intra-arterial thrombolytic therapy for the management of acute limb ischemia".)
●Cardiac support and extracorporeal circulation (See "Extracorporeal life support in adults: Management of venoarterial extracorporeal membrane oxygenation (V-A ECMO)" and "Intraaortic balloon pump counterpulsation".)
SITE SELECTION — The arterial access site for percutaneous arterial procedures is placed in the upper or lower extremity depending on the location of the pathology being treated and the procedure planned. In general, requirements for good access vessels include:
●Proximity of the artery to the skin
●Diameter sufficient to accept the planned interventional sheath
●The ability to provide adequate pressure at the completion of the procedure to aid with hemostasis of the puncture site
Suitable vessels commonly used for access are discussed below. (See 'Specific access sites' below.)
By location of arterial pathology
●Lower extremity – For most lower extremity percutaneous procedures, the common femoral artery is selected, using either an antegrade or retrograde (up and over the aortic bifurcation) approach. Depending on patient anatomy (eg, occluded contralateral iliac system) and planned procedure, access via the upper extremity may also be considered using brachial or radial arterial access. (See 'Common femoral artery' below and "Endovascular techniques for lower extremity revascularization", section on 'Arterial access'.)
●Iliac vessels – Similarly, for most iliac artery interventions (eg, iliac stenting, iliac aneurysm stent-grafting, iliac embolization), femoral access is most commonly used. This can be either retrograde on the ipsilateral side of the lesion or antegrade (up and over the aortic bifurcation) from the contralateral side. (See "Surgical and endovascular repair of iliac artery aneurysm" and "Endovascular techniques for lower extremity revascularization", section on 'Arterial access'.)
●Abdominal aorta – For the abdominal aorta, femoral access is selected; however, on occasion dual access using a combined femoral and brachial access approach may be used. This can be helpful in patients undergoing fenestrated endovascular repair or those receiving renal or visceral stents in the same setting as the abdominal aortic repair. (See "Endovascular repair of abdominal aortic aneurysm", section on 'Vascular access'.)
●Mesenteric/renal vessels – Brachial artery access is appealing for interventions on the mesenteric vessels because of the often-downward angle of these arteries from the aorta (particularly the superior mesenteric artery). Depending on the anatomy, these mesenteric/renal vessels may also be approached from femoral access, particularly if steerable sheaths are used. (See "Surgical and endovascular techniques for mesenteric revascularization", section on 'Endovascular techniques'.)
●Thoracic aorta – Femoral artery access is usually selected. Historically, large diameter access sheaths were required for these procedures, which necessitated open cutdown. However, later-generation, lower-profile devices and percutaneous closure techniques have allowed this procedure to be performed percutaneously as well. (See "Endovascular repair of the thoracic aorta", section on 'Vascular access'.)
●Upper extremity – A femoral access site can be used; however, intervention on the more distal vasculature may be limited by the length of available catheters. Proximal lesions (such as the subclavian artery) may be treated in a retrograde fashion from the brachial artery.
●Carotid/cerebral – The femoral artery is often selected; however, the radial artery is increasingly being used. Percutaneous carotid access has been reported but is rarely used given the inability to easily compress the artery due to its location, as well as potentially devastating outcomes with complications. Endovascular procedures that use carotid access more commonly use an open cut-down to allow direct repair of the arterial puncture site. (See "Overview of carotid artery stenting", section on 'Approach to carotid artery stenting' and "Transcatheter aortic valve implantation: Periprocedural and postprocedural management", section on 'Alternative approaches'.)
●Coronary circulation – A radial access site is often selected to reduce access site complications associated with femoral artery access, though a definitive advantage of one site over another has not been demonstrated. (See "Periprocedural complications of percutaneous coronary intervention", section on 'Radial artery access'.)
Lower versus upper extremity access — As devices have become smaller, some procedures can be performed equally well through either a lower extremity (femoral) or upper extremity access site (brachial, radial). When either lower or upper extremity access is deemed appropriate from a technical standpoint, early studies suggested lower complication rates for radial access compared with femoral access; however, later trials have reported that vascular complications were similar, possibly related to improvements in femoral artery access techniques including the use of ultrasound guidance and micropuncture techniques [1,2].
Based on randomized trials, a radial rather than femoral access site may be preferred for patients with acute coronary syndromes undergoing percutaneous coronary intervention [2-7]. This issue is discussed separately. (See "Primary percutaneous coronary intervention in acute ST-elevation myocardial infarction: Periprocedural management", section on 'Radial versus femoral approach'.)
The risk of stroke comparing lower extremity versus upper extremity sites has also been studied. In one large database review of patients undergoing percutaneous coronary intervention, the risk of stroke was lower for radial compared with femoral access (odds ratio 0.33, 95% CI 0.16-0.71); the overall risk of stroke was 0.3 percent [8].
GENERAL PRINCIPLES — Arterial interventions are typically performed in an angiography suite, hybrid operating room, or alternatively using an operating table suitable for radiographic imaging and a portable C-arm fluoroscopy unit.
Positioning and anesthesia — Positioning of the patient depends upon the proposed access site with the appropriate access area prepared and draped. Regardless of the approach, it is important to ensure proper positioning to avoid complications. (See "Patient positioning for surgery and anesthesia in adults".)
●For femoral artery access, the patient is generally placed supine.
●For upper extremity access, the arm is usually abducted and externally rotated.
●For popliteal artery access, the patient is placed prone.
Depending on the procedure planned, many patients will be given intravenous sedation. Lidocaine injected with a 21-gauge needle is often used to anesthetize the access site. (See "Considerations for non-operating room anesthesia (NORA)".)
Dynamic ultrasound guidance — Prior to needle access, the selected artery is identified using physical examination using appropriate anatomic landmarks and pulse, combined with imaging techniques such as ultrasound or fluoroscopy.
Based upon randomized trials, we recommend dynamic ultrasound guidance during needle placement in the artery (any site) rather than using landmark techniques or fluoroscopy techniques alone. Ultrasound reduces bleeding complications (eg, hematoma) and incidental venipunctures and improves first-pass success rates [9-15].
●In a meta-analysis of five trials (1552 patients), the use of ultrasound reduced the rate of vascular access-related complications compared with using only landmarks (1.9 versus 4.3 percent, odds ratio [OR] 0.44, 95% CI 0.24-0.81) [10]. In an earlier meta-analysis (four trials), ultrasound guidance was associated with 42 percent improvement in the likelihood of first-attempt success (relative risk 1.42, 95% CI 1.01-2.00).
●In a randomized trial that included 635 patients undergoing femoral access, cannulation success was increased with ultrasound guidance compared with fluoroscopy (93 versus 86 percent), as was first-attempt success (74 versus 42 percent) [15]. Fewer inadvertent venipunctures occurred in the ultrasound group (2 versus 10 percent). However, complication rates for ultrasound guidance versus fluoroscopy were similar at 24 hours (1 and 1 percent) and nonsignificantly less at 30 to 90 days (4 and 2 percent, respectively).
Ultrasound also helps identify aberrant anatomy, small vessel size, and calcified or diseased segments of the artery to avoid and ensures that the access site is at a location that will allow for adequate compression following completion of the procedure.
Despite results showing benefits for ultrasound guidance, it is underused. In a review of over 43,000 procedures across the 18 Vascular Quality Initiative (VQI) regions, the average rate of ultrasound usage was 71 percent [14]. A higher use of ultrasound-guided access was associated with significantly fewer access site complications.
Access needle and initial sheath placement — Percutaneous arterial access is initially obtained with an arterial access needle, either an 18- or 21-gauge hollow beveled needle through which a wire is placed after the artery is accessed. An 18-gauge needle will accommodate a 0.035-inch guidewire, while a 21-gauge needle is typically used with a 0.018-inch guidewire.
Because of the lower profile of the wire, a 21-gauge needle is often referred to as a micropuncture needle (picture 1). Use of these smaller needles and wires lowers vascular complication rates when compared with standard needles [16].
After access is obtained under direct ultrasound guidance (see 'Dynamic ultrasound guidance' above), the wire is advanced through the needle into the artery, and the needle is removed to allow placement of a sheath with its dilator over the wire. With micropuncture access, a micropuncture 4 or 5 Fr sheath and introducer are used, which then allows for exchange to a 0.035-inch wire and placement of a standard (working) sheath.
●For extremity and peripheral artery work, these sheaths usually range in size from 5 to 7 Fr.
●For thoracic or abdominal aortic procedures, sheath sizes ranging from 16 to 24 Fr may be used.
For sheath sizes larger than 8 Fr, a suture-mediated percutaneous closure device is commonly used. (See 'Vascular closure devices' below.)
The dilator is removed, and the sheath is flushed with heparinized saline. An access arteriogram may be performed at this time to confirm the location of the puncture within the artery.
SPECIFIC ACCESS SITES
Common femoral artery — The common femoral artery is the primary entry point for most percutaneous peripheral vascular procedures because it easily provides access to:
●The ipsilateral lower extremity via antegrade access
●The contralateral lower extremity via retrograde access by going up and over the aortic bifurcation
●The thoracic and abdominal aorta
●The neck, head, and upper extremities via the aortic arch vessels
●The visceral vessels through the use of curved catheters or steerable sheaths
The common femoral artery was once the most frequent access site for percutaneous coronary procedures; however, the use of the radial artery, particularly when managing acute coronary syndrome, has increased. (See 'Radial artery' below and 'Lower versus upper extremity access' above.)
Femoral artery anatomy — The common femoral artery is the continuation of the external iliac artery below the level of the inguinal ligament beginning distal to the inferior epigastric and lateral circumflex branches of the external iliac artery and ending at the bifurcation of the profunda femoris and superficial femoral artery.
The common femoral artery lies between the femoral nerve (laterally) and common femoral vein (medially) within the common femoral sheath (figure 1) and provides flow to the lower extremity via the profunda femoris artery posterior laterally in the thigh (figure 2) and the superficial femoral artery to the leg.
The inguinal ligament extends from the anterosuperior iliac spine to the pubic tubercle, which can be identified by palpation on examination, and forms the superior border of the femoral triangle (figure 1). The medial border is formed by the adductor longus muscle medially, and the lateral border is formed by the sartorius muscle. Because the inguinal ligament is not seen with angiography, the inferior epigastric artery is frequently used as a marker for the origin of the common femoral artery. The femoral head lies posterior to the femoral triangle and may be identified radiologically at the time of access and is useful as a point against which to compress the artery at the completion of the procedure. As such, this location is the ideal puncture site for common femoral access.
Femoral access techniques — Access to the common femoral artery may be either retrograde (directed towards the iliac arteries/head) or antegrade (directed towards the superficial femoral artery/ipsilateral foot). When performed appropriately, the risks associated with each approach are low and similar. In a large database study comparing antegrade and retrograde femoral access, no significant differences were reported for hematoma formation, reintervention, or access site occlusion [17]. Regardless of approach, the ideal location for arterial puncture is the middle of the vessel cephalad to the origin of the profunda femoris artery and caudal to the inguinal ligament.
●Retrograde – A retrograde approach provides access to the ipsilateral iliac arteries and the aorta and also allows the operator to select the contralateral iliac artery to perform interventions on the contralateral lower extremity via an "up and over" technique (image 1). This technique allows visualization (and potentially treatment) of the contralateral limb from the common iliac artery to the toes. (See 'Retrograde approach' below.)
●Antegrade – An antegrade approach provides access to the ipsilateral lower extremity below the inguinal ligament. While visualization is limited to the common femoral artery and below, this approach provides a mechanical advantage with more "pushability" of devices by providing a more stable platform for intervention; shortens the access-to-target distance, which may extend the treatment zone of shorter-length device catheters in tall patients; and allows treatment of patients with anatomic considerations that preclude retrograde access [18]. This may include a complete contralateral iliac occlusion, prior kissing iliac stents or endovascular aneurysm repair, or a scarred groin from previous access. (See 'Antegrade approach' below.)
For either approach, the patient's bilateral groins are prepared and draped, and the operator stands on the side of the bed with which they are most comfortable. If right-handed, this is often to the patient's right (if retrograde access) or left (if antegrade access), as it allows use of the dominant hand in a forehand technique for arterial puncture. Conversely, standing ipsilateral to the artery being punctured provides the benefit of standing closer to the access site.
Retrograde approach — The location of the inguinal ligament is identified by bony landmarks (pubic tubercle medially and anterior superior iliac spine laterally), and the pulse is palpated below this point. The point of maximal pulsation has been shown to be associated with the common femoral artery in over 90 percent of patients [19]. If the femoral pulse cannot be easily palpated, the course of the vessel is typically halfway between the pubic symphysis and the anterior superior iliac spine and is identified using ultrasound.
The femoral head may be identified radiologically and marked on the skin, and using a vascular linear array probe, the artery is interrogated at this location. The use of ultrasound allows identification of the profunda femoris artery as well as any anterior arterial plaque that may hinder easy access. A location on the common femoral artery is identified with ultrasound that is cephalad to the profunda femoris artery and caudal to the inguinal ligament, ideally with a soft anterior arterial wall free of plaque. Access to the central portion of the common femoral artery is critical, as low, high-middle, and high femoral punctures have been associated with greater than 70 percent of vascular access complications [20].
The operator must estimate the distance from the planned access site and the puncture site of the skin. A steep needle angle may provide the additional force needed to puncture a scarred or calcified vessel, but the wire may not track easily through the needle. Conversely, a needle placed in a shallower trajectory may be deflected by the vessel, particularly if calcified, resulting in access failure. As such, a good rule of thumb is to plan access with the needle held at approximately 45 degrees. Under ultrasound guidance, the needle tip is identified anterior to the planned puncture site on the common femoral artery, which is entered under direct ultrasound vision.
Once the tip of the needle is identified within the lumen of the vessel and there is return of blood through the needle hub, a 0.018 guidewire with floppy tip is advanced through the needle into the common femoral artery. The wire should pass freely with minimal resistance and should not be forced if resistance is felt. Fluoroscopy should identify the wire in a path consistent with the external iliac artery. The skin is next incised with scalpel to a size consistent with the final planned sheath size, and a 4 or 5 French micropuncture catheter with dilator is advanced over the wire. The dilator is removed, and pulsatile bleeding should be noted from the microcatheter. A medium-stiff flexible wire with a floppy or J-tip is then advanced through the microcatheter, which is removed with gentle pressure over the arterial access site, and then the working sheath with its dilator is placed over this wire. The dilator is removed, and the sheath is flushed with heparinized saline. An access arteriogram may be performed at this time to identify the puncture site of the common femoral artery. This is performed by rotating the c-arm ipsilateral to the side of access and deflecting the sheath to the contralateral side, which allows identification of the profunda femoris artery as well as the entry point of the sheath in relation to the femoral head.
Antegrade approach — Identification of bony landmarks and ultrasound identification of the common femoral artery is performed as with retrograde approach. The skin access site is typically cephalad to the inguinal ligament to allow puncture of the common femoral artery at its midportion based on access using a 45-degree needle angle. Use of a micropuncture catheter followed by working sheath is done in the same manner as above. Because of its posterior direction off the common femoral artery, the microwire often preferentially enters the profunda femoris artery rather than the superficial femoral artery. In this event, the wire should be manipulated under radiologic guidance into the superficial femoral artery before placement of the micropuncture catheter. Placing the image intensifier into ipsilateral oblique orientation, obtaining a roadmap image through the needle with contrast, or using a directional catheter may help achieve this goal.
Brachial artery — The brachial artery can be used to reach targets in the arm or the chest, abdomen, lower extremities via the aorta, and occasionally, the distal upper extremity. Brachial artery access is particularly appealing for interventions on the mesenteric vessels given the often-downward angle at which these arteries (particularly the superior mesenteric artery) originate from the aorta.
The location of brachial access affects the rate of complications. Distal brachial artery access is associated with lower rates of hematoma and subsequent nerve compression compared with more proximal access. While a distal brachial approach is acceptable for percutaneous access using small sheaths, as sheath size increases to >5 Fr, the risk of complications increases, doubling for 6 and 7 Fr sheaths [21]. Often for more complex procedures and fenestrated devices, a large sheath is necessary (12 Fr), which will limit the distal brachial approach, as the artery generally is not large enough to accommodate the larger sheaths. In these situations, judicious use of brachial artery cutdown can be performed; however, even with open brachial artery access, there is still risk for brachial sheath hematoma [21-23]. (See "Access-related complications of percutaneous access for diagnostic or interventional procedures", section on 'Axillary/brachial sheath hematoma'.)
●Brachial artery anatomy – The brachial artery is the main artery supplying the upper extremity and is the continuation of the axillary artery (figure 3) beyond the border of teres major muscle. The brachial artery is anatomically related to the median nerve. Proximally, the median nerve is lateral to the brachial artery; however, the median nerve crosses medially and lies anterior to the brachial artery at the elbow (figure 4) [24]. The nerve artery and vein are bounded by the relatively rigid brachial sheath. Bleeding within this space (ie, brachial sheath hematoma) can result in nerve compression with profound neurologic deficits. In the antecubital fossa, the brachial artery divides into the radial and ulnar arteries, which run through the forearm. In some individuals (8 to 15 percent), the artery bifurcates earlier in the course, resulting in radial and ulnar arteries that originate above the antecubital fossa of the arm [24,25].
●Technique – The brachial artery is typically accessed a few centimeters cephalad to the antecubital fossa. The arm is supinated to facilitate distal brachial artery access. At this location, the brachial artery is easily palpable and the distal portion of the humerus lies posteriorly, which can be used to aid compression at the completion of the procedure.
Needle entry into the artery should be at the olecranon process lateral to the brachial muscle. Care should be taken to avoid entry into a high radial artery takeoff in this location in patients with aberrant anatomy. Ultrasound, which is used to guide most brachial accesses, can facilitate access in helping to identify arterial anatomy and these variants. Access into small brachial or radial arteries can increase the risk of complications.
At the completion of imaging/intervention, it is important to check the activated clotting time (ACT) and let it normalize or reverse heparin anticoagulation with protamine at the time of sheath removal, as it has been shown that protamine may be protective against access site complications at this location [13]. Hemostasis is often achieved with manual compression, although this may be complicated by thrombosis if a small brachial artery is completely occluded from excessive pressure or there is compression of the artery due to a brachial sheath hematoma or pseudoaneurysm formation from inadequate pressure. The adequateness of manual pressure can be checked by placing continuous pulse oximetry on the ipsilateral hand or by performing intermittent pulse checks of the radial artery. Given the risk of brachial sheath hematoma and difficulties with holding pressure on the arm, for a sheath size >6 Fr, some providers will routinely cut down on the brachial artery and fix the puncture site surgically with interrupted suture closure.
Radial artery — The radial artery is frequently used for coronary diagnostic and interventional procedures and is often selected due to its ease of hemostasis and minimal risk of bleeding. Similarly, radial access is increasingly being used for infrainguinal interventions in the lower extremity using longer, lower-profile devices [26,27]. Due to the vessel diameter, the radial artery is usually only able to accommodate devices up to 6 Fr sheath. Use of the radial artery should be performed by properly trained operators. (See 'Site selection' above.)
The complication most commonly associated with radial artery access is thrombosis related to spasm or compression while obtaining hemostasis at the completion of the procedure. (See "Access-related complications of percutaneous access for diagnostic or interventional procedures", section on 'Arterial thrombosis'.)
Radial artery occlusion occurs in approximately 5 percent of patients undergoing radial artery access. A potential clinical consequence is the inability to use the radial artery for future access.
Radial artery anatomy — The radial artery originates at the bifurcation from the brachial artery usually at the antecubital fossa. It runs distally on the anterior forearm and separates the anterior from posterior compartments of the forearm (figure 5). It continues laterally around the wrist and passes through the anatomic snuff box into the hand [24]. The artery is usually accessed distally, at which point the vessel runs over the distal portion of the radius bone (figure 6). Radial loops are an uncommon but challenging vascular anomaly that can be difficult to navigate; conversion to an alternative access sites may be required [28-30].
Assessment of hand circulation — Prior to obtaining radial artery access, the adequacy of the circulation to the hand should be assessed and documented in the medical record.
The modified Allen test assesses the adequacy of collateral blood supply from the ulnar artery to the hand via the palmar arches (figure 6) and has been used to identify patients at increased risk from radial artery catheterization. However, many centers now use pulse oximetry (figure 7) and plethysmography.
The test consists of the following steps:
●The patient's hand is initially held high while the fist is clenched and both radial and ulnar arteries are compressed; this allows the blood to drain from the hand.
●The hand is then lowered, and the fist is opened.
●After pressure is released over the ulnar artery, color should return to the hand within six seconds, indicating a patent ulnar artery and an intact superficial palmar arch. The test is considered abnormal if 10 seconds or more is required for color to return.
In two large series of patients undergoing cardiac catheterization, an abnormal Allen test result was obtained in 6 and 27 percent [31,32]. The importance of an abnormal test was evaluated in a study of 55 patients undergoing coronary angiography [33]. After 30 minutes of subsequent radial artery occlusion, the patients with an abnormal test had significantly reduced blood flow to the thumb and an elevated thumb capillary lactate. Based upon such observations, radial artery catheterization is usually not performed in patients with an abnormal modified Allen test. However, the results of the modified Allen test can be altered by several factors, including overextension of the wrist, skin tension over the ulnar artery, and operator error. As a result, an appreciable number of false positive and false negative results have been reported [31]. As an alternative, many centers use a more direct assessment of blood flow to the thumb during radial artery occlusion, which can be accomplished with pulse oximetry and plethysmography [31,34].
In a consecutive series of 1010 patients referred for diagnostic cardiac catheterization, the modified Allen test was compared with pulse oximetry and plethysmography [31]. The modified Allen test was considered abnormal if palmar blanching persisted for ≥10 seconds after release of ulnar compression. Plethysmography was observed for two minutes during radial artery compression. Plethysmography was characterized as follows:
●A – No change in the amplitude of the pulse tracing during compression
●B – Reduction in amplitude with compression
●C – Loss of pulse tracing with initial compression, but recovery of flow during two minutes of compression (signifying development of collateral flow)
●D – Loss of pulse tracing with no recovery
Patients in categories A, B, and C were considered to have a patent palmar arch and therefore eligible for radial catheterization. The modified Allen test was abnormal in significantly more patients than plethysmography (6.3 versus 1.5 percent). The authors concluded that plethysmography more accurately demonstrated the adequacy of the palmar arch and that the modified Allen test may unnecessarily exclude some patients from radial artery catheterization. However, the number of patients who underwent radial artery catheterization was not reported, and the value of either test for predicting ischemic complications following radial artery catheterization was not assessed.
Radial access technique — Access is achieved via anatomic landmarks and arterial pulse palpation or more commonly ultrasound-guided access to the distal artery in the anatomic snuff box or more proximally at the wrist. Techniques are similar to those described above regarding ultrasound-guided access.
Because of the vasoreactivity of the radial artery, spasm is common, occurring in up to 20 percent of cases, more commonly in women and in those with small-diameter vessels [35]. Administration of intra-arterial calcium channel blockers, intra-arterial nitroglycerine, and heparin and use of hydrophilic sheaths have been used to prevent spasm and thrombosis [36,37].
Popliteal artery — Retrograde popliteal access is an option for imaging/intervention in patients with isolated superficial femoral or popliteal artery disease in whom retrograde or antegrade common femoral artery access has been unsuccessful. This may include patients with superficial femoral lesions that are flush with the common femoral artery or those with extensive infrainguinal disease. Patients selected for this approach should have popliteal vessels ideally greater than 5 mm in diameter without calcification. While popliteal access may provide similar benefits to pedal access regarding the direction of the access, the popliteal artery may have advantages in crossing occlusions in this area, as the vessel is larger and closer to the lesions of interest, which may allow increased support and a mechanical advantage particularly for crossing complete occlusions.
●Popliteal artery anatomy – The popliteal artery is the continuation of the superficial femoral artery deep (figure 8) within the popliteal fossa that extends posterior to the knee (picture 2). Its point of origin is the adductor canal of the distal thigh. The vessel terminates below the knee at the lower edge of the popliteus muscle where the anterior tibial artery branches off laterally, and the popliteal artery continues as the tibioperoneal trunk, giving rise to the posterior tibial artery and peroneal artery.
●Technique – Popliteal access can be done with the patient in the prone position or with a modified medial or anterolateral modified approach depending on body habitus and disease distribution [38,39]. Using ultrasound guidance, the micropuncture needle should be directed under direct vision usually at or above the knee [40]. Once back bleeding through the needle is confirmed, a microwire and microcatheter are placed in combination like descriptions above form common femoral access. In a large database study, retrograde popliteal access was found to have a lower overall success rate when compared with antegrade common femoral access for isolated superficial femoral or popliteal disease but similar rates of primary patency and complications, including arterial dissection, access site hematoma, or distal embolization [41].
Pedal artery access — Use of the pedal arteries for retrograde arterial access is increasingly used for treatment of chronic total occlusions of the lower extremity arteries resulting in chronic limb-threatening ischemia (see "Management of chronic limb-threatening ischemia"). Its use is most described in patients with long-segment, heavily calcified lesions in which antegrade crossing has been unsuccessful. Technical success rates have been shown to be as high as 88 percent in complex lesions, but in the setting of increased major adverse limb events and higher complication rates (11 percent) [42,43].
●Tibial and pedal artery anatomy – Below the level of the knee, the popliteal artery gives off the anterior tibial artery laterally and the tibioperoneal trunk medially, from which arise the posterior tibial and peroneal (or fibular) arteries (figure 8). All three arteries have been used for pedal access.
•The anterior tibial artery passes from the popliteal fossa through the interosseus membrane between the tibia and fibula before coursing between the tibialis anterior and extensor digitorum muscles in the anterior compartment of the leg and terminating in the dorsalis pedis artery into the foot.
•The posterior tibial artery travels medially in the posterior compartment of the leg and passes posterior to the medial malleolus of the tibia anterior to the Achilles tendon into the tarsal tunnel of the foot.
•The peroneal artery supplies the lateral compartment of the leg and passes through the deep posterior compartment of the leg to its termination above the ankle.
●Techniques – The anterior tibial artery is usually the easiest vessel for pedal access and is typically entered on the dorsum of the foot as it becomes the dorsalis pedis artery. The posterior tibial artery runs a bit deeper but can be accessed posterior to the medial malleolus. Access to the peroneal artery has been described but is not commonly done.
Dynamic ultrasound guidance is used to access the tibial arteries, and smaller sheath sizes and wires are needed to prevent arterial complications. Similar to transradial access, patients are usually given an antispasmodic cocktail after placement of the sheath that includes nitroglycerin, a calcium channel blocker, and heparin. One dosing regimen is 200 microg of nitroglycerine, 2.5 mg of verapamil, and intravenous heparin at 70 units/kg patient weight. Vessels used for access are determined by preoperative imaging, most commonly from an up-and-over angiogram performed from contralateral access. This allows visualization of angiosomal distributions that need revascularization depending on the location of the wound, as well as the size of the candidate vessels. The dorsalis pedis artery on the dorsum of the foot or the posterior tibial artery behind the medial malleolus are most commonly accessed in soft noncalcified areas [44].
HEMOSTASIS AT THE ACCESS SITE — Hemostasis at the completion of the procedure can be obtained using manual compression at the access site or by using a closure device.
Mechanical c-clamp compression was used in the past to reduce time and effort to achieve hemostasis. While more commonly used following cardiac interventional procedures, these devices were not widely adopted for peripheral vascular intervention. The increased use of vascular closure devices has largely supplanted their use, particularly among patients in whom a longer time to hemostasis is anticipated or those being maintained on antithrombotic therapy.
Manual compression — Traditionally, hemostasis at the end of percutaneous arterial access is obtained with manual pressure at the site until a clot has formed at the arterial puncture site. The duration of pressure is usually between 15 and 20 minutes but depends upon many variables including the size of sheath used and the patient's coagulation parameters (eg, activated clotting time [ACT]), which may be elevated if heparin was used during the procedure. After this period, the patient is placed at bedrest to prevent bleeding complications, with a longer length of time used for larger diameter sheaths. Manual compression times can be reduced with the adjunct use of closure devices.
Because radial access has been associated with arterial occlusion, a technique termed "nonocclusive hemostasis" appears to reduce the incidence of radial artery occlusion [45-47]. The technique involves using the least amount of compression needed to prevent bleeding while still maintaining flow through the radial artery [48]. Plethysmography can be used to assess adequacy of compression.
Vascular closure devices — Vascular closure devices aim to decrease bedrest times and allow earlier ambulation as well as to decrease the amount of time spent achieving hemostasis, which may improve patient comfort by limiting the duration of compression. Many vascular closure devices are available for use (eg, Perclose, Angio-Seal, ProGlide, Vascade, Mynx, MANTA). These work by either actively closing the puncture site with suture or clips or by promoting thrombosis at the puncture site via collagen or sealant plugs (figure 9) [49-52]. While these devices are designed for transfemoral access site closure, their use has been described at other access sites with mixed results [53-55]. Instructions for use (IFU) for each device dictate what sheath sizes may be closed for a given device.
Prior to using a femoral closure device, an angiogram of the femoral artery should be performed. Use of closure devices should be avoided if a hematoma has formed during the procedure, in the presence of severe iliofemoral vascular disease, and when the access site is below the bifurcation of the superficial and profunda femoral arteries. Failure of a closure device can usually be managed with manual compression. Other complications (eg, pseudoaneurysm, arteriovenous fistula) associated with closure devices are reviewed separately. (See "Access-related complications of percutaneous access for diagnostic or interventional procedures".)
Vascular closure devices decrease the time to hemostasis when compared with manual compression; however, in two separate systematic reviews, similar efficacy and overall complication rates were reported, but with slightly higher risks of infectious and thrombotic complications for closure devices compared with compression [56,57].
Whether to select a vascular closure device and which specific device to use depends upon the specific procedure, device availability, and operator preference.
●For endovascular repair of aortic aneurysm (thoracic, abdominal), percutaneous access (rather than cutdown) has become the norm at many institutions given the increased availability of later-generation, large-bore closure devices. These are placed before the introduction of the large bore sheath (ie, pre-close technique). (See "Endovascular repair of abdominal aortic aneurysm", section on 'Percutaneous access' and "Endovascular repair of the thoracic aorta", section on 'Vascular access'.)
●For percutaneous lower extremity procedures performed with femoral artery access, use of closure devices has become commonplace. (See "Endovascular techniques for lower extremity revascularization", section on 'Percutaneous access'.)
●For percutaneous coronary procedures, the incidence of complications related to vascular closure devices may be increased for interventional compared with diagnostic procedures likely related to ongoing anticoagulation [58,59].
The use of closure devices may increase the risk of local infection or endarteritis [60,61]. Although this complication is infrequent (0.3 percent in one series [61]), it can be serious when it occurs. Periprocedural antibiotics can be considered in immunocompromised patients following prolonged arterial access, or when sterility has been breached when a closure device is used. It may also be prudent for the operator to change gloves prior to using an arterial closure device. (See "Complications of diagnostic cardiac catheterization", section on 'Infection'.)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (See "Patient education: Endovascular surgery (The Basics)" and "Patient education: Stenting for the heart (Beyond the Basics)".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Occlusive carotid, aortic, renal, mesenteric, and peripheral atherosclerotic disease" and "Society guideline links: Aortic and other peripheral aneurysms" and "Society guideline links: Percutaneous coronary intervention".)
SUMMARY AND RECOMMENDATIONS
●Arterial access – Arterial access is necessary for percutaneous diagnostic or interventional vascular procedures to place a sheath through which to position the necessary wires, catheters, and devices. (See 'Introduction' above.)
●General characteristics – Suitable access sites are those with good proximity of the artery to the skin, sufficient diameter to accept the planned interventional sheath, and tissue (usually bone) against which to provide adequate compression to aid with hemostasis at the completion of the procedure. (See 'Site selection' above.)
●Ultrasound guidance – When equipment and expertise are available, we recommend dynamic ultrasound guidance during needle placement in the artery, rather than using landmark techniques or fluoroscopy alone (Grade 1B). When compared with the use of anatomic landmarks or fluoroscopy, ultrasound reduces complications, including bleeding, hematomas, and incidental venipunctures and improves first-pass success. (See 'Dynamic ultrasound guidance' above.)
●Specific access sites – The access site is selected based upon the location of the pathology being treated and the planned procedure. (See 'By location of arterial pathology' above and 'Specific access sites' above.)
•Common femoral artery – The common femoral artery is selected for most percutaneous cerebrovascular, aortic, visceral, lower extremity, and proximal upper extremity procedures. Access can be retrograde (directed toward the head) or antegrade (directed toward the feet). For vascular lesions below the knee, antegrade access provides a more stable platform, shortens the access-to-target distance, and extends treatment to patients in whom retrograde access is not possible (eg, iliac occlusion).
•Brachial artery – Distal brachial artery access is often selected for mesenteric procedures given the often downward angle at which these arteries (particularly the superior mesenteric artery) originate from the aorta. The diameter of sheath the brachial artery can accommodate is limited to 5 Fr. The risk of complications increases for larger sheaths. Brachial sheath hematoma is a serious complication at this access site that can lead to nerve dysfunction. (See 'Brachial artery' above.)
•Radial artery – The radial artery is commonly used for percutaneous cardiac procedures, particularly intervention, and is increasing in popularity for peripheral procedures. The radial artery is associated with lower rates of local complications; however, vasospasm is an issue occurring in up to 20 percent of cases and can lead to radial artery thrombosis. Administration of intra-arterial vasodilators and heparin and use of hydrophilic sheaths have been used to help prevent spasm and thrombosis. (See 'Radial artery' above.)
•Popliteal artery – Popliteal access is useful for patients in whom retrograde or antegrade common femoral artery access has been unsuccessful (eg, flush superficial femoral artery lesion). The popliteal artery should ideally be larger than 5 mm in diameter and have no calcification. Advantages of this approach include increased support and a mechanical advantage, particularly for crossing complete occlusions, because of the proximity of the access to the lesion(s) of interest. (See 'Popliteal artery' above.)
•Pedal arteries – Pedal access is useful when access at other sites has been unsuccessful. This occurs predominantly with attempts to cross long-segment, heavily calcified chronic total lower extremity occlusions. (See 'Pedal artery access' above.)
●Postprocedure hemostasis – Hemostasis at the completion of the percutaneous procedure can be obtained using compression at the access site or by using a closure device. The use of a closure device has not been proven to reduce access site complications; however, the duration of compression and time to ambulation are both reduced. (See 'Hemostasis at the access site' above.)
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