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Vascular access and closure for cardiovascular intervention
  1. Stephen H Dorman1,
  2. Daniel R Obaid2
  1. 1Bristol Heart Institute, Bristol, UK
  2. 2Swansea University Medical School and Morriston Cardiac Centre, Swansea, UK
  1. Correspondence to Dr Stephen H Dorman, Bristol Heart Institute, Bristol, BS2 8HW, UK; Stephen.Dorman{at}UHBristol.nhs.uk

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Learning objectives

  • To choose the most appropriate access site for a cardiovascular intervention.

  • Learn how to gain access and achieve closure of the radial and femoral arteries.

  • Learn how to minimise vascular complications.

Introduction

Selective coronary angiography initially required surgical cut down to access the brachial artery.1 Subsequently, in 1967 Melvin Judkins described a direct percutaneous approach via the femoral artery,2 an easily palpated vessel with high procedural success that would go on to become the default arterial access route. However, despite decades of experience with femoral access, vascular complications and bleeding remain a concern and are still a significant cause of mortality in cardiovascular intervention.3 Percutaneous coronary intervention (PCI) via the radial artery was first described by Kiemeneij in 1993,4 and early studies appeared to show a virtual elimination of access site complications.5 Initially the technique remained a niche interest of early radial pioneers, but usage in the United Kingdom has increased from 14% in 2005 to 84% in 2016 replacing the femoral artery as the most popular access site for intervention.6

Selection of radial or femoral arterial access

Radial artery access reduces vascular complications across all patient groups7 and is now recommended as the standard route for PCI.8 However, there are groups where the benefit is more pronounced. The superficial course and small calibre of the radial artery simplifies haemostasis allowing early ambulation9 and reducing cost10 making it ideal for patients who cannot tolerate prolonged bed rest, on anticoagulants or are undergoing PCI in the day case setting. A mortality benefit for radial access has been shown in patients with acute coronary syndrome and ST elevation myocardial infarction in both large randomised controlled trials11 and meta-analysis12 making this a strong indication for radial PCI. However, there remain procedural reasons when femoral access is required (large-bore access for transcatheter …

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