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J Am Coll Cardiol, 2008; 51:1416-1417, doi:10.1016/j.jacc.2007.12.028 © 2008 by the American College of Cardiology Foundation |
* Central Maine Medical Center, Lewiston, Maine 04240 (Email: wphillips{at}cmhc.org).
We would liken this practice to secondary prevention. As important as that is, most of us would like to achieve primary prevention and prevent incorrect sheath location. To achieve that, it has been widely recommended that pre-procedure fluoroscopy of the femoral head would help to reduce inaccurate sheath insertion and lower complication rates.
Unfortunately, the authors do not even mention the most accurate method of sheath insertion: the use of needle-guided vascular ultrasound imaging. Invasive and interventional cardiologists relying on surface or fluoroscopic landmarks depend upon normal anatomy and palpation to guide their punctures. In percutaneous coronary intervention procedures this is uncomplicated about 98% of the time, as noted in the article and by the NNECVDG (Northern New England Cardiovascular Disease Study Group) Registry.
In our experience, routine ultrasound use can substantially lower this small but costly complication rate. It has long been advocated in the anesthesia community for safe and successful central venous access. Prospective data to prove this claim are, unfortunately, not yet available for femoral access.
In the cardiac catheterization laboratory, ultrasound is sometimes used for the "difficult patient," relegating it to a situation that disrupts the flow of the procedure and may be frustrating, since rare use on the most difficult patients makes for a long learning curve. Routine ultrasound use, however, can be done very quickly and confidently. Good technique is rapidly achieved, making the difficult patient much easier. The artery can almost always be punctured at the 12 o’clock position, above the bifurcation, below the inferior epigastric, and on the first attempt. The presence of plaque and calcification can be visualized, and if a clean site cannot be located alternative entry sites can be proactively selected. An expanding hematoma during an emergency procedure can significantly ruin the day (or night). Many of us have seen patients who have died as a result of a serious vascular complication.
No "state of the art" paper on vascular closure should ignore the importance of vascular access. It seems that the cardiology community might benefit from the lessons learned in anesthesia. In a 1999 editorial about ultrasound venous access, D.H.T. Scott quoted the philosopher Erasmus: "In the country of the blind, the one-eyed man is king" (2).
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