Fellows Course: Best Practices in Large-Bore Access

Rajiv Tayal, MD, MPH, FSCAI reviews best practices for large-bore femoral and axillary access. Dr. Tayal is director of structural heart disease at Newark Beth Israel Medical Center. This discussion was part of Abiomed’s MCS & Complex Coronary Intervention virtual fellows course held on September 26, 2020.

First, Dr. Tayal reviews best practices for femoral access, beginning with a brief review of femoral anatomy to help identify common vascular and boney landmarks that aid in insertion. He highlights the “functional” zone for insertion. “It’s not just about being below the inferior epigastric and above the bifurcation of the SFA and profunda, but rather being in those areas, but also directly over the bony landmarks.” This, he explains, is important if manual compression is needed to facilitate hemostasis at the end of a procedure.

Dr. Tayal emphasizes the importance of routine ultrasound guidance to facilitate improved outcomes in not just large bore, but all femoral access. Ultrasound guidance has been shown to reduce the number of attempts needed to obtain access, improve the rate of first attempt access, and reduce the time to sheath insertion. Dr. Tayal discusses the importance of obtaining a 35 to 40-degree stick angle and explains that ultrasound needle guides can be helpful tools for pre-determining the angle of access. He also discusses the routine use of micropuncture technique to help reduce blood loss.

Dr. Tayal then provides a step-by-step overview of femoral access, including pre-closure with 2 Perclose ProGlide™ vascular closure devices, exchange of the J-wire for a stiffer wire (eg, Lunderquist®, Amplatz Super Stiff™, Supra Core™) prior to using larger dilators, use of fluoroscopy while advancing the large-bore sheath, and use of ipsilateral angiography through the large-bore sheath to evaluate distal flow. He reviews primary access site considerations related to vascular size, tortuosity, and calcification, as well as severe obesity, which he notes is “one of the most underappreciated complicating factors with regard to large-bore access.”

Dr. Tayal briefly mentions subclavian and transcaval alternative access sites and the increasing use of Shockwave intravascular lithotripsy (IVL) to facilitate large-bore access. He explains that IVL “has really changed the landscape and the way that we look at alternative access and options for access” and that it is an important tool as the single-access for high-risk PCI (SHiP) technique—use of secondary access point through Impella CP® sheath—becomes more widely adopted.

Dr. Tayal concludes with a discussion of percutaneous axillary insertion, beginning with an overview of axillary anatomy and stepwise axillary insertion using ultrasound guidance. He advocates for routine use of dry closure—low-pressure inflation of a peripheral balloon prior to removal of the large-bore device—in axillary and femoral access, noting the multiple studies have shown that it reduces the rates of vascular complications.

Lunderquist is a registered trademark of Cook Medical

Amplatz Super Stiff is a registered trademark of Boston Scientific

SupraCore is a registered trademark of Abbott