Bifurcating Profunda Artery With a High Common Femoral Bifurcation: A Cause of Low Ultrasound-Guided Access for Coronary Angiography

Abstract:

We present the case of an 81-year-old male in which an anatomical variant of extraordinarily high common femoral bifurcation misled optimal femoral access despite ultrasound guidance during routine coronary angiography. Arterial ultrasound at the midpoint of the femoral head identified an arterial bifurcation thought to be the common femoral artery branching into the superficial and profunda arteries.

In reality, the bifurcation identified on ultrasound was a lateral circumflex femoral artery branching from the profunda femoris artery continuing distally. Femoral angiogram revealed that the patient had an unusually high bifurcation of the superficial and profunda arteries at the most superior aspect of the femoral head. This unique case accentuates the importance of confirmatory femoral angiography in the procedural workflow to anticipate and reduce periprocedural complications.

Femoral access remains an indispensable skill in the catheterization laboratory, particularly for cases requiring large-bore access (i.e., structural heart intervention, mechanical circulatory support, or high-risk coronary interventions) or in patients with contraindications for transradial access. Safe percutaneous femoral artery access involves a stepwise approach that involves multimodal planning with fluoroscopy and ultrasound, access with micropuncture needle, and confirmation of entry with femoral angiography.^1-3 These techniques improve rates of optimal sheath placement and decrease vascular complications. Here, we share a case of a patient with a high right common femoral artery bifurcation that misled optimal femoral access despite ultrasound guidance.

Case Presentation

An 81-year-old veteran with quadriplegia, type 2 diabetes, hypertension, and hyperlipidemia was admitted for substernal squeezing chest pain concerning for unstable angina that required nitroglycerin infusion. Troponin was not elevated with an electrocardiogram (EKG) during a chest pain episode that demonstrated old, large anteroseptal Q waves unchanged from an EKG from 2 years prior. This was consistent with a pharmacologic nuclear stress test at that time with a large, fixed anteroseptal wall defect and global hypokinesis with akinesis at the apex in the same region of the perfusion deficit. Given the presentation and history, coronary angiography was recommended, but was delayed for treatment of urosepsis. After completion of antibiotic course and return to previous clinical baseline, a new finding of heart failure with mid-range ejection fraction was noted on echocardiography.

Arterial access for this patient was complicated by bilateral arm contractures. The intended area of right common femoral artery access was identified using the anterior iliac spine and pubic symphysis as landmarks, and a radiopaque instrument was visualized under fluoroscopy to confirm optimal site of arterial entry at the midpoint of the femoral head. Using ultrasound guidance at this site, a bifurcation was identified, and the artery proximal to the meeting point of this bifurcation was visualized and accessed using micropuncture needle. A femoral angiogram was then performed, revealing that the patient had an unusually high bifurcation of the superficial and profunda arteries at the most superior aspect of the femoral head (Figure 1). This made evident that the vessels distal to the bifurcation visualized on ultrasound were actually large branches from the profunda femoris artery (Figure 2). With knowledge that site of entry was in the profunda femoris artery, decision was made to proceed with upsizing to 6 French sheath. The remainder of the procedure was performed without further difficulties. Findings were significant for distal left anterior descending (LAD) coronary artery stenosis that was moderate in severity on coronary angiography, and for apical aneurysm and reduced ejection fraction on left ventriculogram.

A vascular closure device could not be safely utilized in this case due to location of arteriotomy in the proximity to the bifurcation of the profunda artery. Therefore, manual pressure was applied with adequate hemostasis. There were no postoperative complications, and the patient was discharged a few days following the cardiac angiogram, with addition of guideline-directed medical therapy for coronary artery disease and heart failure.

Discussion

A careful assessment to identify the optimal location of femoral arteriotomy is of particular importance to reduce vascular complications and improve patient outcomes. A 2011 study of femoral artery access identified that 38 (13%) of the patients had access sites located outside the optimal location, which is above the femoral bifurcation, but below the border of the inferior epigastric artery. Vascular complications were significantly more frequently encountered in patients with femoral access in suboptimal locations when compared to those with optimal access (18% vs 4%, P<.001).⁴

It is exceedingly rare to encounter a case with an extremely high common femoral artery bifurcation; a study of 200 patients had previously demonstrated that only 3 (1.5%) of these patients had the common femoral bifurcation located above the midline of the femoral head.⁵ The multicenter Femoral Arterial Access With Ultrasound Trial (FAUST) trial demonstrated improved common femoral artery (CFA) cannulization in patients with high CFA bifurcations (83% vs 69.8%, P<.01).¹ However, cases like these further highlight the importance of femoral angiography immediately after micropuncture catheter insertion to confirm optimal arteriotomy site.

Conclusion

Operators should incorporate femoral angiography into their workflow prior to upsizing to larger sheaths, even when ultrasound images appear to clearly delineate the vessel anatomy. In cases of high common femoral bifurcation, branches from the profunda femoris artery may be misleading on ultrasound due to their shift upwards to the anticipated level of the common femoral bifurcation.

References

1. Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femoral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access With Ultrasound Trial). JACC Cardiovasc Interv. 2010; 3(7):751-758.

2. Ben-Dor I, Sharma A, Rogers T, et al. Micropuncture technique for femoral access is associated with lower vascular complications compared to standard needle. Catheter Cardiovasc Interv. 2021; 97(7):1379-1385.

3. Sandoval Y, Burke MN, Lobo AS, et al. Contemporary arterial access in the cardiac catheterization laboratory. JACC Cardiovasc Interv. 2017; 10(22):2233-2241.

4. Pitta SR, Prasad A, Kumar G, et al. Location of femoral artery access and correlation with vascular complications. Catheter Cardiovasc Interv. 2011; 78(2):294-299.

5. Schnyder G, Sawhney N, Whisenant B, et al. Common femoral artery anatomy is influenced by demographics and comorbidity: implications for cardiac and peripheral invasive studies. Catheter Cardiovasc Interv. 2001; 53(3):289-29

Disclosures: Dr. Wu and Dr. Johl report no conflicts of interest regarding the content herein. Dr. Kern reports he is a speaker for Abbott Vascular, Boston Scientific, Philips, OpSens Medical, and ACIST Medical.

The authors can be contacted via Perry Wu, MD, at wu.y.perry@gmail.com