Implementation of the Universal Femoral Access Protocol Decreases Complications of Peripheral Vascular Interventions.

Abstract

Objectives: Common femoral artery (CFA) is the most common access site for peripheral vascular interventions (PVI). Ultrasound (US) use has been shown to decrease access-related complications. However, the recommended site for femoral artery puncture has not been well defined, and the access technique varies significantly based on the operator specialty and training. This study describes the development of a multidisciplinary universal femoral access (UFA) protocol and its implementation at a tertiary care centre.

Methods: Femoral artery access zones in relation to the femoral head were described based on prior cadaveric groin dissection study. The UFA was developed with an emphasis on dual image guidance using US and fluoroscopy for optimal access. A technical video was created and shared with the specialists and trainees performing PVI, and via online platforms. A single center retrospective review of pre-UFA patients from September 2020 to November 2020 and post-UFA patients from September 2022 to November 2022 was conducted. The institutional Vascular Quality Initiative database was used to compare patient characteristics and access complications before the development of the UFA (pre-UFA) and after its implementation (post-UFA). All fluoroscopic images of the procedures were retrospectively reviewed to assess the needle location and use of dual imaging guidance during PVI.

Results: A total of 375 procedures were analysed with 63.2% in the pre-UFA group (n=237). After the implementation of the UFA, the rate of overall access complications significantly decreased from 12.7% pre-UFA vs 5.1% post-UFA, p=0.019. There was a statistically significant decrease in thrombotic complications (3.7% pre-UFA vs 0% post-UFA, p=0.029), with a trend towards a decrease in the bleeding rates without reaching a statistical significance (9.3% pre-UFA vs 5.1% post-UFA, p=0.154). A significant increase in the use of dual image guidance was observed in the post-UFA group (27.4% pre-UFA vs 55.8% post-UFA, p<0.001).

Conclusions: The UFA protocol emphasizing use of dual image guidance and a comprehensive understanding of femoral anatomy can reduce access site complications during PVI. Expansion of the UFA to other procedures using femoral artery access and to other institutions can improve patient care.

Clinical relevance: CFA access can lead to limb or life-threatening complications. Understanding of the femoral anatomy, and optimization of access technique with dual imaging can reduce complications. This study highlights the importance of establishing a standardized femoral access protocol to improve patient outcomes.