Should We Use Ultrasound Routinely to Guide Transfemoral Access?

Currently, transfemoral access (TFA) is used in large-caliber procedures and when transradial access fails. The introduction of ultrasound (US) to guide access has emerged as a technique that allows for precise channeling, avoiding accesses above or below the inguinal ligament. However, evidence regarding the use of this tool has shown diverse results. Two surveys conducted among interventional cardiologists revealed that only 13-27% of them use US, despite 88% indicating that this technology was available in the cath lab.

The aim of this meta-analysis was to compare the use of US to guide TFA versus its absence.

The primary endpoint (PEP) was a composite of major vascular complications (including pseudoaneurysms, arteriovenous fistulas, retroperitoneal bleeding, hematomas with diameter >5 cm, limb ischemia requiring intervention or surgery) or major bleeding according to BARC classification 3 or 5. The secondary endpoint (SEP) was a composite of major vascular complications, major or minor bleeding, and major vascular complications, exclusively.

The analysis included a total of 2441 patients; 1208 of them were randomized to the US-guided access group and 1233 to the non-US-guided access group. Mean patient age was 65.5 years, and most subjects were men. Overall, 12% of patients had peripheral vascular disease, and 34% underwent coronary transluminal angioplasty. A 6-Fr catheter was used in approximately 80% of cases, and percutaneous device closure was applied in half of the cases.

Read also: Short-Term Outcomes of TAVR in Asymptomatic or Minimally Symptomatic Patients.

In terms of results, the incidence of major vascular complications or major bleeding was lower in the US-guided group (2.8% vs 4.5%; odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.39-0.94; p=0.026). In the subgroup of patients who received closure devices, those randomized to the US-guided arm experienced a reduction in the rates for major bleeding or major vascular complications (2.1% vs 5.6%; OR: 0.36; 95% CI: 0.19-0.69), while there was no benefit for patients in the subgroup without closure device (4.1% vs 3.3%; OR: 1.21; 95% CI: 0.65-2.26).

Conclusion

This meta-analysis showed that the use of US to guide TFA is associated with a lower risk of major bleeding or major vascular complications in coronary procedures. In addition, this strategy may be useful in preventing vascular complications in patients receiving closure devices. Routine incorporation of ultrasound to guide transfemoral access should be considered.

Dr. Andrés Rodríguez.
Member of the Editorial Board of SOLACI.org.

Original Title: Ultrasound guidance for transfemoral access in coronary procedures: an individual participant-level data meta-analysis from the femoral ultrasound trialist collaboration.

Reference: Marc-André d’Entremont, MD, MPH et al EuroIntervention 2023;19-online publish-ahead-of-print October 2023.

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