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Arterial access and arteriotomy site closure devices

Nature Reviews Cardiology volume 13, pages 641–650 (2016)Cite this article

Subjects

Key Points

  • Cardiac catheterization begins with arterial access and ends with access-site closure, both of which are fundamental to the safe performance of diagnostic and interventional procedures

  • The preferred arterial access site and method of arteriotomy have evolved over 70 years from brachial to femoral and radial access, and from surgical cut-down to percutaneous puncture

  • Compared with femoral artery access, radial artery access results in fewer access-site bleeds, more rapid time to ambulation, and greater patient comfort, and is, therefore, preferred by many patients and an increasing number of operators

  • Femoral and radial vascular closure technique and devices (active and passive) have also been evolving, resulting in more rapid time to haemostasis and reduced local complications

  • Novel arterial access routes are being investigated, and new closure systems are being developed for interventions requiring large-calibre devices

  • Expertise in both femoral and radial artery access and intervention is essential for contemporary interventional cardiologists

Abstract

Arterial access and haemostasis are fundamental aspects of procedures performed in the cardiac catheterization laboratory. The first description of arterial access for cardiac catheterization was in 1948, when surgical cut-down was used to access the radial artery. Over the next 2 decades, the preferred arteriotomy method transitioned from the Sones approach of brachial artery cut-down to the Seldinger and Judkins technique of percutaneous femoral artery access. Compared with the femoral approach, percutaneous transradial access results in reduced access-site bleeding, faster time to ambulation, and greater patient comfort. Several large-scale, randomized trials have also reported a survival advantage in patients with acute coronary syndromes treated with radial compared with femoral access. However, inconsistencies exist between the completed trials, and the underlying mechanism of a reduction in mortality with radial access is uncertain. Femoral artery haemostasis can be achieved with either manual compression or vascular closure devices, with recent studies suggesting improved outcomes with the use of active closure systems. Radial artery haemostasis is achieved through the use of wristbands that mimic manual compression, and 'non-occlusive' haemostasis reduces the risk of radial artery occlusion. Newer arterial access routes and closure approaches for large-bore devices are being actively investigated. Expertise in both femoral and radial artery access and intervention is essential for contemporary interventional cardiologists.

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Figure 1: Anatomy of the femoral artery.
Figure 2: Basic steps of micropuncture arterial access technique.
Figure 3: Ultrasound-guided femoral artery access.
Figure 4: Four types of ulnopalmar arch patency based on the use of plethysmography and oximetry.
Figure 5: Anatomical variations of the radial artery.

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Authors and Affiliations

  1. The Duke Clinical Research Institute, 508 Fulton Street (111A), Durham, 27705, North Carolina, USA

    Sunil V. Rao

  2. Columbia University Medical Center and the Cardiovascular Research Foundation, 1700 Broadway, 8th Floor, New York, 10019, New York, USA

    Gregg W. Stone

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Both authors researched data for the article, discussed its content, wrote the manuscript, and reviewed/edited it before submission.

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Correspondence to Gregg W. Stone.

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S.V.R. declares being a consultant for Medtronic and Terumo International Systems. G.W.S. declares no competing interests.

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Rao, S., Stone, G. Arterial access and arteriotomy site closure devices. Nat Rev Cardiol 13, 641–650 (2016). https://doi.org/10.1038/nrcardio.2016.133

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