Access, Femoral

How to safely perform femoral arterial access is the first step of any transfemoral angiography (Case 1, Case 2). In patients with difficult anatomies, bedside ultrasound can be utilized for the guidance of the puncture (Case 3). Pre-interventional imaging such as CTA/MRA are sometimes of tremendous help, however, knowing the patient's anatomy remains a key step to avoid complications (Case 4, Case 5).

Extensive atherosclerotic disease indicates a higher risk of stroke via transfemoral approach (Case 3). According to the CREST study[1], compared with carotid endarterectomy, stroke was more likely after transfemoral carotid-artery stenting. TCAR bypasses the aortic arch and subclavian/CCA origins, and is branded to have a lower peri-operative stroke rate.



(A): This patient has a venous access catheter (black arrow) in the right common femoral vein, which travels towards the heart to the right of the spine. The arterial puncture site is lateral to this venous catheter, and the 0.021'' microwire (yellow arrowheads) from the micropuncture kit travels from the lateral side to the medial side of the venous catheter and then crosses the midline to the left of the spine, indicating arterial access. (B): DSA showed that the arterial puncture site is in the common femoral artery, above the bifurcation (red double arrow).


Ideally, the sheath entry site (black double-arrow) should be between the origin of the inferior epigastric artery (yellow arrow) and the common femoral artery bifurcation (red arrow) to lower the risks of retroperitoneal hematoma (too proximal) or pseudoaneurysm/AVF (too distal).[2]


Common femoral artery calcifications can often be seen in patients with systemic atherosclerotic disease, particularly those presented for the evaluation of internal carotid artery stenoses. On ultrasound imaging, calcified tissues are hyperechoic/echogenic/bright (red arrow) with clean posterior acoustic shadowing (yellow arrow),[3] which should be avoided when performing puncture.

Extensive atherosclerotic changes are seen on this 3D reconstruction of CTA neck imaging, especially at the aortic arch and major arterial origins.


This patient has a history of a renal transplant. The right common femoral artery run cleared depicted two kidneys in the vicinity. As this is a known history, caution should be taken when advancing the wire under fluoroscopy or even roadmap to avoid injury to either of the renal arteries.


This patient developed diffuse intracranial vasospasm in the setting of subarachnoid hemorrhage due to a ruptured aneurysm. (A): A 6F 11 cm flexible Arrow sheath[4] was placed for repetitive intra-arterial vasodilation therapy, with its tip in the external iliac artery (yellow arrowhead). A stenotic segment (red arrow) was noticed at the CFA, impeding distal flow. (B): Gentle withdrawal of the sheath under fluoroscopy until the tip was distal to the stenosis improved distal flow of the CFA, preventing distal limb ischemia. The left-in sheath was then sutured to the skin and maintained on continuous drip. Black double-arrow: catheter entry site of the CFA.

  1. Stenting versus Endarterectomy for Treatment of Carotid-Artery Stenosis | NEJM ↩︎

  2. Cureus | Assessment of Femoral Artery Bifurcation Level with Conventional Angiography | Article ↩︎

  3. Diagnostic Approach to Benign and Malignant Calcifications in the Abdomen and Pelvis | RadioGraphics ↩︎

  4. Super Arrow-Flex® Sheaths | US | Teleflex ↩︎