Page 9 - Carotid and peripheral vascular interventions textbook
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                 STEP-BY-STEP TECHNIQUE                          CONTRALATERAL FEMORAL (CROSSOVER)

                 VASCULAR ACCESS                                     Arterial access may be obtained contralateral or

                                                                 ipsilateral to the target lesion. Commonly, contralateral
                     The selection of access location is left to the     vascular access is preferable. This approach allows a
                 operator’s  discretion. The  most  common  vascular     suitable working length for imaging and treating sequential
                 access for femoropopliteal intervention is the CFA.   lesions located within the distal external iliac, femoral
                 Most interventionists are usually familiar with the    and popliteal arteries, and also it is frequently used for
                 CFA puncture. However, it may be challenging in     below-knee interventions. This approach is associated
                 patients with diminished or absent palpable pulse,     with less access-related complications while allowing
                 calcif ed  CFA  disease,  obese  patients,  and  high     the easier application of closure devices when indicated.
                 bifurcation.  In  these  diff cult  cases,  f uoroscopy-      When contralateral access is gained, a guide wire is
                 guided puncture or using ultrasound-guidance should     forwarded retrograde along the iliac arteries and aorta using
                 be  used  to  reduce  multiple  punctures  and  the    f uoroscopic guidance. For SFA angioplasty, the sheath sizes
                 complication rates. The suitable point for puncture     may vary between 4- and 7-French (Fr). When in placed,
                 is the inner lower third of the femoral head, because    the vascular sheath needs f ushing with heparinized saline.
                 the femoral head contributes a solid surface to support   Through the vascular sheath, a diagnostic catheter (e.g., Judkins
                 CFA compression which is required for hemostasis.    right (JR), internal mammary (IM), Sos Omni, Simmons,
                 Besides  CFA  access,  in  selected  cases,  radial  or     or Cobra) is advanced over a 0.035”, angle-tip angled
                 brachial artery (antegrade approach) or popliteal or   Glidewire  (Terumo) into the distal abdominal aorta. Then
                 pedal artery (retrograde approach), can be used for     DSA of the aorta with the iliac arteries is then performed,
                 an additional access (Fig. 12-6). Table 12-1 summaries     except when this area has been already surveyed by MRA or
                 the  vascular  access  sites  commonly  used  for     CTA. This angiography helps to assess the inf ow and to
                 femoropopliteal intervention and its features.   facilitate crossing the aortic bifurcation into contralateral limb.

                 A                                    B                                     C



                 Figure 12-6. Vascular access for femoropopliteal intervention. A: Common femoral artery (retrograde and antegrade access); B: Brachial
                 and radial artery (retrograde access); C: Popliteal artery (retrograde access); D: Dorsalis pedis or tibial artery (retrograde access).
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