Conversations in Cardiology: Should I do a femoral angiogram prior to my closure device in everyone?

Note: Audio commentary to this article from Dr. Morton Kern is available with the online version of this article.

A colleague asked, “Should I do femoral angiography prior to closure device in everyone, and if I do not and I have a complication, am I practicing below the standard of care? 

“One operator in my lab does not do femoral angiography, because when he was an investigator [for femoral closure devices] he learned it was of little concern. When told of this, I just shook my head, especially since that operator had a major groin bleed. I know of another cardiologist who also never shoots the groin. To not do angiography always struck me as silly, given the complete lack of benefit of closure device regarding safety and the risk of an untoward complication, [a risk] which only worsens by not following the instructions for use (IFU). Are we at risk for not doing the femoral angiogram?”

Given what we now understand about closure devices and femoral angiography, I found it strange that this question would come up, but I put it out to my colleagues on the “Cath List” to see what the conversation might be. As you will read below, the respondents were unanimous in the view that femoral angiography should always be performed before a closure device at the minimum and perhaps always, whether a closure device is used or not. Here’s one of the rare conversations in which there is consensus, but still some variance on how the images might be best obtained.

Mort Kern, Long Beach, California:  Since the questions are usually sent to me, I’m usually the first to answer. My view is, always do a femoral angiogram. It costs little in terms of time, energy, and dollars, and provides potential safety information regarding the correct location for implanting a device, particularly for revealing an unsuspected femoral high bifurcation.  

Kenneth Rosenfield, Boston, Massachusetts: [Femoral angiography is the] Standard of care. Period. 

Would anyone place a pressure wire without seeing where you are putting it? Why is the peripheral vasculature any different? The common femoral and iliac arteries give us the privilege of using them for access to the heart…should we not give them the courtesy of knowing that we have not “violated” them, and that we are in the right spot?

Mike Ragosta, Charlottesville, Virginia:  It is the practice at the University of Virginia and considered our “standard of care” to always shoot femoral angiogram prior to use of a closure device. It seems foolish not to; it takes 2 minutes and 2 cc of contrast and [saves] a lot of aggravation later. I have been asked by defense attorneys to review several malpractice cases involving retroperitoneal hemorrhages where the operator did not do an angiogram and used a closure device. It’s not easily defensible and the plaintiff attorneys drool over such cases.

David Cohen, Kansas City, Missouri:  I agree with Ken Rosenfield. I always do it [femoral angiography] before starting the case — just in case I might change my strategy based on the anatomy and the stick.

Mladen I. Vidovich, Chicago, Illinois:  [Femoral] angiography prior to closure should be standard of care. No question.

Not infrequently, I access [the femoral artery] with 4 French (Fr) micro puncture and take a confirmatory angiogram prior to placing the larger procedure sheath to confirm access above the profunda.

Richard Bach, St. Louis, Missouri: I suspect like many others, with the concern that the Proglide (Abbott Vascular) stitch may catch and occlude the ostium of an adjacent significant branch, or that the Angio-Seal occluder (St. Jude Medical) might cover one, or simply if there is extensive disease where the occluder would take up precious lumen, I always do a femoral angiogram, and elect not to close if the anatomy is less than suitable. I’m surprised more by the idea of not doing it...

David Rizik, Scottsdale, Arizona: It takes 5 seconds and 5 cc of contrast. Is this really a question? 

[Editor’s Note:  Yes, David, believe it or not, some operators do not believe femoral angiography is of value. Here we have a consensus, but unfortunately, those not in agreement often do not comment to us. MK]

Kenneth Rosenfield, Boston, Massachusetts:  This [issue of femoral artery angiography] is NOT one of those cases of “what you don’t know won’t hurt you”. It definitely will…someday, somehow! Knowledge of the anatomy and the arteriotomy site can be incredibly useful and beneficial for patient care. By the way, it is important to know how best to look…usually 40-50 degrees ipsilateral angulation, with the sheath pulled slightly medially. If that does not show the femoral bifurcation, then go opposite, with contralateral angulation at about 60 degrees, and sheath pulled laterally.

John Bittl, Ocala, Florida:  A femoral angiogram performed before percutaneous coronary intervention (PCI) helps to define optimal access management after the procedure. 

Prashant Kaul, Chapel Hill, North Carolina:  I absolutely always do a femoral angiogram prior to closure device. No exceptions.  A calcified CFA [common femoral artery], high bifurcation or other relative contraindication to closure device must be established. Personally, I do not think it is defensible to implant a device and then have a complication without having documented the CFA anatomy and arteriotomy site. We are talking about 5 cc of contrast. In my mind, not doing an angiogram would be absolutely below standard of care. In fact, I heard of an operator who had a serious vascular complication after attempted Angio-Seal placement, which subsequently required vascular surgery repair. A femoral angiogram had not been done. Suffice it to say, litigation did not go well for the operator. At open repair the vessel was both heavily calcified and had a high bifurcation.

Fred Resnic, Boston, Massachusetts:  Much useful information is to be gained, at very little incremental risk or cost. From my perspective, it should be done at the beginning of any transfemoral procedure to have an understanding of the ilio-femoral status, and to potentially avoid anticoagulating an elective patient with an unexpected high stick. 

Joseph Babb, Greenville, North Carolina:  As above, femoral angiography before closure device to me is the standard of care. Also, as several have stated, doing this immediately upon femoral access is the better choice than at the end of the case before using a closure device. By doing it up front, one can opt not to proceed if the puncture is high or in the profunda. As you note, Mort, closure devices have no evidence of reducing complications and are purely for operator comfort (I don’t have to apply pressure for 15-20 minutes and talk to the patient) and earlier ambulation for the patient. Hence, as always, safety first and angiogram everyone.

Andy Michaels, Eureka, California: I agree that a femoral angiogram should not only be done prior to closure device use, but immediately after the femoral sheath is in. My first angiogram is always the femoral (prior to the coronaries). First, you immediately know if anticoagulation is safe (prior to any PCI). Second, you know if a longer sheath is needed. Third, you know if there is low cardiac output, from the femoral flow pattern. Fourth, you already know if you can upsize the sheath, and what the closure plan is from the start of the case. Also, starting with the femoral angiogram provides a good road test for the manifold hemodynamics system. If there is a transducer problem or a bubble in the manifold system, it is much better to sort that out with the femoral artery, rather than the left main. Since I’m going to do the femoral angiogram in every femoral case, I have always thought it is better to know all these factors right at the beginning. [Editor’s Note: See Figure 1.]

Bob Applegate, Winston-Salem, North Carolina:  In a training program, femoral angiography provides immediate feedback to the operator, and helps shape the decision to proceed with the case. In some instances, we have seen leaks at the insertion site that were corrected immediately, usually by upsizing the sheath. 

Digital subtraction angiography, too?

David Kandzari, Atlanta, Georgia: The real issue is not whether a femoral angiogram should be performed prior to closure (and most commonly at the end of the case), but rather should it be performed at the beginning of every case, irrespective of closure? My answer is yes, at the onset of every case and indifferent to use of closure. There have been rare cases where despite localization under fluoro, the access was inadvertently above the inguinal ligament, and other cases with side branch hemorrhage where I have postposed PCI for concern over RP [retroperitoneal] bleeding. Why would an interventionalist not want to know what he/she is up against from the outset rather than wait for the complication to occur? Renal failure and radiation exposure should not be an issue. Do the angiogram with diluted contrast and under fluoro save. 

Prashant Kaul, Chapel Hill, North Carolina:  I do not believe there is a need for digital subtraction. I don’t think it adds anything and have actually seen very small oozes be subtracted out of the picture, not to mention the higher radiation. A fluoro save picture is adequate. But more importantly, one of the main reasons to do this is to see the vessel/arteriotomy in relation to the bony landmarks. I see no reason to subtract the bones out.   

Obligatory oblique views?

Peter Block, Atlanta, Georgia:  Always do the angiogram first to know where you stuck. As for which view, the RAO [right anterior oblique] vs AP [anteroposterior] views, I always rely on the AP view to see where the sheath/stick is in relation to the femoral head. The RAO is only useful to see the bifurcation better, but not always needed. If the bifurcation is clearly seen on the AP, I’m done. If not, do an RAO, but an RAO alone does not tell you much about “height” [above the bifurcation].

Herb Aronow, Ypsilanti, Michigan:  I use a modification of Peter Block’s technique. I fluoro the micropuncture needle/wire upon gaining vascular access and save single frame in AP projection to confirm compressibility of puncture site (no contrast needed); I then shoot an ipsilateral oblique angiogram to lay out CFA bifurcation, thus eliminating the need for a second angiogram.  [Editor’s Note: See Figures 2 and 3.]

Guidewire in place and micropuncture?

Zoltan Turi, New Brunswick, New Jersey:  It is nice to see that this issue is no longer controversial (although it is for some reason in some parts outside the U.S.). The standard of care is clearly angiography before closure device use — something of a no-brainer, given that generally it’s in the IFUs. Unfortunately, it has not risen to standard of care to do femoral angiography for all femoral access WHETHER OR NOT a closure device is used.  

The standard of care, unfortunately, is not the same as good care, and [there are still] many or most operators who don’t do femoral angiograms unless a vascular closure device is contemplated. Three pieces of information you get from the femoral angiogram: 1. Location of puncture; 2. Size of vessel; and 3. Presence or absence of atherosclerotic disease, not to mention the occasional incidental finding of a lacerated inferior epigastric artery, etc. You get some but not all of this with ultrasound, but few operators or labs use this. A lot of retroperitoneal hemorrhages wouldn’t happen if people just didn’t anticoagulate and [not] proceed to PCI if they knew they had high sticks. 

As already mentioned, doing the angiogram at the start of the case will let you avoid a lot of trouble later — especially if you plan to anticoagulate. For patients with renal failure, a little dilute contrast, especially with digital subtraction angiography, if you have it, will do the trick. 

Finally, do the angiogram with the guide wire still in place. It helps avoid an occasional dissection caused by the tip of the sheath being up against a tortuous arterial wall. Now, if you just add micropuncture for all femoral sticks… [You’d have it all, says ZT].

Gus Pichard, Washington, DC:  Through TAVR [transcatheter aortic valve replacement], I have learned to image before placing the [large bore] sheath. I do not use it as frequently, since I do mostly radial procedures. I have seen some major heart centers in the U.S. who DO NOT routinely image the femoral artery before device closure. I have asked them and they report “no problems”!!!

Keep the fingers out of the field!

Jon Tobis, Los Angeles, California: At UCLA, we all shoot the femoral artery after the procedure and before any closure device. The only thing that bothers me is some people put their hand in the field to wiggle the introducer sheath to confirm the entry point. I think this is a violation of radiation safety. The fellow should be taught not to do this for their own well-being.

Kim Skelding, Harrisburg, Pennsylvania:  While femoral angiography should be done in all cases, sometimes it is difficult to see the bifurcation if the sheath is completely overlying the vessel, especially in the AP projection. One needs to carefully and gently pull the sheath to the ipsilateral side to see the bifurcation clearly. Keeping your hands out is the right way to do it, but sometimes it is a challenge to do this and be sure the sheath stays exactly where it was placed (something that makes me especially nervous with junior fellows.)

Jeff Marshall, Atlanta, Georgia:  We often use a plastic hemostat to hold the side port of the sheath out laterally. This avoids having hands in the field.

Ultrasound?

Peter Ver Lee, Bangor, Maine:  I always do femoral angiogram in 30 RAO for the right, 30 LAO for the left. I also ALWAYS put femoral sheaths in with ultrasound guidance. Angiography usually confirms what I saw on US [ultrasound], but gives additional information such as location of the inferior epigastric artery, bleeding, location and size of the vein. The appearance of the femoral artery on US also dictates the kind of closure device I use. When there is heavy calcification or a deep vessel, I prefer Angio-Seal, otherwise, Perclose (Abbott Vascular). 

Duane Pinto, Boston, Massachusetts:  How does one defend an interventionalist who “didn’t save the femoral angio” after an Angio-Seal complication? The lack of a femoral angiogram would be a huge deal in such a case. Given the obligate risk in the best of hands with closure, I would suggest saving the angiogram or an ultrasound picture. It strikes me that if one isn’t willing to do a femoral angiogram, you probably aren’t doing ultrasound access either.

Bottom line

For safety, understanding the risk, selection of devices, identification of complications, and best practices, femoral angiography at the beginning or at least at the end of the procedure is the standard of care. While contemplating your practice and the use of femoral angiography, it’s still worthwhile to give another thought to radials as well.  

My great appreciation to my expert colleagues and contributors to this conversation in cardiology.

Contributors:

• Robert Applegate, Winston-Salem, North Carolina
• Herb Aronow, Ypsilanti, Michigan
• Joseph Babb, Greenville, North Carolina
• Richard Bach, St. Louis, Missouri
• John Bittl, Ocala, Florida
• David Cohen, Kansas City, Missouri
• David Kandzari, Atlanta, Georgia
• Prashant Kaul, Chapel Hill, North Carolina
• Jeffrey Marshall, Atlanta, Georgia
• Andrew Michaels, Eureka, California
• Gus Pichard, Washington, D.C.
• Duane Pinto, Boston, Massachusetts
• Mike Ragosta, Charlottsville, North Carolina
• Fred Resnic, Boston, Massachusetts
• David Rizik, Scottsdale, Arizona
• Kenneth Rosenfield, Boston, Massachusetts
• Kimberly Skelding, Harrisburg, Pennsylvania 
• Jon Tobis, Los Angeles, California
• Zoltan G. Turi, New Brunswick, New Jersey 
• Mladen  I Vidovich, Chicago, Illinois
• Peter Ver Lee, Bangor, Maine