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Obtaining Vascular Access

The femoral artery is the most commonly used arterial site of access in the United States while the radial artery access is currently gaining popularity. In 2018, radial artery access was used in 40.7 percent of procedures in the U.S.

To perform percutaneous intervention, the first step is to obtain a perfect vascular access. While a “high” sheath insertion above the inguinal ligament could increase the risk of retroperitoneal bleeding, a “low” sheath insertion into the profunda femoris or the superficial femoral artery (SFA) could result in arteriovenous fistula, pseudoaneurysm, or limb ischemia.

While the standard size (18G) or micro access needle (21G) with ultrasound or angiographic guidance can be used to obtain arterial access, the latter would be a better choice for vascular access with ultrasound guidance. The ideal location for femoral artery access is the segment of common femoral artery below the inguinal ligament [1–2 cm below the line traced from the anterosuperior iliac spine to the pubic tubercle].

In radial artery access can be done by using 20-22 gauge needle with Glide sheath catheter.

Sheaths

  • It is a plastic tube through which the equipment and various devices are delivered to perform percutaneous coronary intervention.
  • The standard sheath size is 6-8 French with different lengths (10, 25, and 45 cm).
  • Long sheath (6/7F and 45 cm in length) is particularly useful in cases that need additional support.
Femoral sheath size by different procedure type
PROCEDURE
Diagnostic cardiac catheterization
SHEATH SIZE
5 Fr
PROCEDURE
PCI – most PCIs including orbital atherectomy and rotational atherectomy burr 2mm
SHEATH SIZE
6 Fr
PROCEDURE
PCI – most PCIs including orbital atherectomy and rotational atherectomy burr up to 2mm
SHEATH SIZE
7 Fr
PROCEDURE
Rotational atherectomy burr of 2.15mm or 2.25mm
SHEATH SIZE
8 Fr
PROCEDURE
Balloon aortic valvuloplasty
18 mm balloon
SHEATH SIZE
10 Fr
PROCEDURE
Balloon aortic valvuloplasty
20 mm balloon
SHEATH SIZE
11 Fr
PROCEDURE
Balloon aortic valvuloplasty
22 mm balloon
SHEATH SIZE
12 Fr
PROCEDURE
Balloon aortic valvuloplasty
23–25 mm balloon
SHEATH SIZE
13 Fr
PROCEDURE
Impella
2.5
SHEATH SIZE
13 Fr
PROCEDURE
Impella
CP
SHEATH SIZE
14 Fr
PROCEDURE
Impella
5.0
SHEATH SIZE
21 Fr
PROCEDURE
Impella
LD
SHEATH SIZE
21 Fr
PROCEDURE
Transcatheter aortic valve replacement
Core valve - Evolut
SHEATH SIZE
18 Fr
PROCEDURE
Transcatheter aortic valve replacement
Edwards SAPIEN valve
SHEATH SIZE
22-24 Fr

The Impella 2.5®, Impella CP®, Impella 5.0®, and Impella LD® Catheters, in conjunction with the Automated Impella Controller™ (collectively, “Impella® System Therapy”), are temporary ventricular support devices intended for short term use (≤ 4 days for the Impella 2.5 and Impella CP, and ≤ 14 days for the Impella 5.0 and Impella LD) and indicated for the treatment of ongoing cardiogenic shock that occurs immediately (< 48 hours) following acute myocardial infarction, open heart surgery, in the setting of cardiomyopathy such as peripartum cardiomyopathy, myocarditis.

The intent of Impella therapy is to reduce ventricular work, providing the circulatory support necessary to allow heart recovery and early assessment of residual myocardial function.

Diagnostic Wires

The access wire is designed to overcome standard clinical challenges providing necessary support to introduce the sheath and catheters. The wire is usually made of stainless steel or nitinol along with PTFE coated or polymer jacket cover.

A Glidewire with hydrophilic coating is mostly used to navigate through tortuous lesions while extra support wires are useful to deliver the sheath especially in tortuous and angulated vessels.

Case ExamplesEducational Content

ATHERECTOMY COMPLICATIONS

Case ExamplesEducational Content

BYPASS GRAFT COMPLICATIONS

Left Main DK Crush Video ID