INTRODUCTION

It is often said that restenosis is the ‘Achilles heel’ of percutaneous intervention. With this threat now rapidly receding thanks to drug-eluting stents (see Chapter 13) it is time for the arterial puncture site to step forward as the rightful owner of this classical metaphor.

Any regular PCI operator will have a number of stories of cases where a coronary triumph has been marred or completely overshadowed by a problem relating to the arterial access site. At the time of writing, the femoral artery is by far the most common access site used for percutaneous intervention, with over 80% of all procedures being performed from this site. The reasons are many: the artery is large, easy to cannulate and allows the insertion of large bore sheaths. Moreover the majority of coronary guide catheters are designed for use from the femoral route.

This ease of use comes at a price, however, complications relating to the femoral artery occur in up to 9% of cases, and very rarely may be fatal.¹ A full working knowledge of the correct procedure for sheath removal and groin site aftercare is, therefore, essential for operators using this route.

Whilst much is made of the after-care of the femoral access site, many complications can be avoided by careful arterial puncture. Ideally the anterior wall of the common femoral artery should be punctured below the inguinal ligament, but above the bifurcation of the profunda femoris and the superficial femoral artery. Too high and bleeding complications are difficult to control with manual pressure, too low and the risk of vessel trauma and pseudo aneurism formation increases.

Given that brachial access is no longer a first choice access site and the radial artery is covered in detail elsewhere, the rest of this chapter will focus on the complications relating to, and the closure techniques used for, the femoral artery.

As with all invasive medical procedures, the complication rate from femoral access can be minimised by careful case selection: increased complications are seen in patients with peripheral vascular disease, advanced age, repeat procedures and aggressive anti-thrombotic regimens.² Similarly increased operator experience reduces complication rates. Further to this, complications can be limited by selection of the smallest diameter sheath that will allow effective coronary intervention. Downsizing from 8 French is associated with reduced adverse events.³

Complications relating to the femoral access site can be haemorrhagic (haematoma, pseudo-aneurism and retroperitoneal bleeding), related to compression from haematomas, embolic or infective. These complications are covered in detail in Chapter 12 (Complications of PCI).

SHEATH REMOVAL