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Endovascular therapy has evolved steadily throughout the past two decades. Devised as a form of minimally invasive therapy, it has often replaced or complemented open surgical therapy. From the initial descriptions of balloon angioplasty to treat peripheral vessel disease, endovascular therapy has expanded into more complex procedures involving practically every vessel in our body. To understand and confidently manage endovascular therapy, we have to start from the basic principles and learn the different access options and devices that can be used to treat a wide array of diseases.


The very first step of any endovascular procedure is to choose the best-suited access for the intervention. Depending on the site of intervention, type of disease, and diameter of devices, there can be numerous different access possibilities.

Femoral Artery

The common femoral access is the most versatile arterial access.

Through this artery, we can perform upper extremity, cerebrovascular, thoracic, abdominal, and lower extremity interventions. Most of the ancillary elements for endovascular therapy have been designed with the femoral access as the entry point.

Given its usual big diameter (8–9 mm),1 it can accommodate most devices, even large bore diameter sheaths (up to 26 Fr).

Access can be either percutaneous or open. Based on previous images or intraoperative ultrasound (US), the exact point of entry is chosen to avoid calcified plaques.

US-guided puncture is highly recommended, gaining access to the anterior aspect of the artery, below the inguinal ligament and above the femoral bifurcation (which can be easily recognized under US). In this position, the artery lies in front of the femoral head, so manual pressure can be applied for hemostasis after sheath removal. Other less-useful guiding techniques involve radiographic guidance based on the femoral head or the presence of calcium in the artery.

When the puncture is too low, there is a risk of puncturing the superficial femoral artery (SFA) or the profunda femoral artery, which can be troublesome for hemostasis given the lack of a bone prominence to hold the artery against. Such a low entry might also occlude the origin of the vessel with some closure devices (Figure 12-1).


White arrow showing the adequate position for arterial puncture in the common femoral artery. Puncture cannot be above the inguinal ligament (white line) where potential hemorrhagic complications can occur due to the lack of bony structures to hold pressure after sheath removal.

After gaining needle access, it is important to carefully advance the guidewire under fluoroscopy and observe its smooth advancement. If any resistance is met, there should be liberal use of contrast angiography to assess the plaque burden in the iliac arteries to avoid dissections and false lumen ...

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