-To examine the relationship between iatrogenic femoral artery
injuries and the anatomical site of arterial entry.
Materials and methods
-Vascular ultrasound studies and charts were retrospectively
reviewed for 19 patients with groin complications following
femoral artery catheterization between September 1994 and
November 1995. The arterial entry site was determined in each
case. Clinical data, including the weight and anticoagulation
status of each patient, was ascertained. Size of catheters and
duration of groin compression were also noted when
-Pseudoaneurysms and arteriovenous fistulas were the primary
iatrogenic injuries identified. The superficial femoral artery
and the profunda femoris artery were found to be the sites of
arterial entry primarily resulting in the formation of
arteriovenous fistulas. Similarly, the majority of the
pseudoaneurysms were formed when the superficial femoral artery
or the profunda femoris artery was used as the site of arterial
entry, whereas a smaller proportion were the result of femoral
artery bifurcation punctures. Approximately one-half of the
lesions identified were treated surgically; ultrasound-guided
compression and expectant management were employed for the
remainder of the lesions.
-Use of the femoral crease as a landmark results in a low and
aberrant arterial entry site, with attendant morbidity,
particularly in heavyset patients with altered hemostasis. This
could be avoided by meticulous attention to the arterial entry
site using fluoroscopy.
The incidence of post-catheterization pseudoaneurysms, or
arteriovenous fistulas involving the femoral artery, has been
reported to be 0.02 to 0.2%.
In recent years, the incidence has been at the upper end of this
range, likely secondary to the large size of catheters used and to
These complications lead to significant morbidity, with possible
sequelae including pain, infection, compression of adjacent
structures, rupture, distal arterial insufficiency, and congestive
heart failure due to arteriovenous fistulas.
Diagnosis of these complications are easily accomplished using
However, attention should be focused on trying to prevent these
complications in the first place. In the study described herein, we
attempted to correlate the arterial entry site to the incidence of
Materials and methods
We retrospectively reviewed vascular ultrasound studies and
clinical charts in 19 patients with groin complications following
femoral artery catheterization between September 1994 and November
1995. The arterial entry site was determined based on the vascular
ultrasound study in each case. Clinical data, including weight and
anticoagulation status, were obtained from the patient's
Periprocedural anticoagulation was used in all patients. Of the
cases reviewed, either a 5-F or 7-F catheter was introduced into
the femoral artery. At our institution, we routinely compress the
groin proximal to the cutaneous puncture site to ensure adequate
control of the femoral artery, accounting for discrepancies between
the skin entry and the actual arteriotomy site. Duration of groin
compression is typically 20 minutes following femoral artery
catheterization; however, documentation of the precise length of
time of groin compression for each case is unavailable.
An ultrasound demonstrates a fistulous communication between the
superficial femoral artery [SFA] and the superficial femoral vein
(A) An ultrasound demonstrates a fistulous communication between
the profunda femoris artery [PFA] and the superficial femoral
vein. (B) An arteriogram shows a similar arteriovenous fistula
between the profunda femoris artery and the superficial femoral
This ultrasound demonstrates a pseudoaneurysm arising from the
superficial femoral artery.
This ultrasound image demonstrates a bilobed pseudoaneurysm
arising from the profunda femoris artery.
A retrospective review of 19 groin complications following
femoral artery catheterization at our institution revealed 10
arteriovenous fistulas and 11 pseudoaneurysms. The arterial entry
site was aberrant in all arteriovenous fistulas and 82% of the
pseudoaneurysms, as determined by ultrasound and color-flow Doppler
analysis (figures 1,2A,3,4) and angiography (figure 2B). The
average weight of the patients was 183 pounds (range 141-297
pounds). Sixteen of the 21 lesions identified required either
surgical intervention or ultrasound compression.
According to classic anatomic description, the common femoral
vein is medial to the common femoral artery at the level of the
inguinal ligament, but it assumes a more lateral position as they
course distally (figure 5).
Another report, based on CT evaluations, suggests that the common
femoral artery partially overlaps its accompanying vein in 65% of
the individuals studied, and veins accompanying the deep femoral
artery tend to lie anterior to it (figure 6).
Distal puncture is likely to pierce both artery and vein as they
align themselves in the anterior/posterior position.
In addition, a distal puncture does prevent adequate vascular
compression at the end of the procedure due to the lack of a firm
structure deep to the point where pressure is applied.
This diagram illustrates the anatomic relationship between the
femoral artery and vein as they course below the inguinal
An ultrasound image demonstrates the superficial femoral vein
positioned between the superficial femoral artery and the
profunda femoris artery.
Some angiographers and cardiologists who perform invasive
procedures use the femoral crease as a landmark for common femoral
artery puncture (figures 7,8).
A study by Lechner at al
demonstrated that the bifurcation of the femoral artery lies below
inguinal crease in 20%, at the level of the inguinal crease in
3.5%, and above the inguinal crease in 76.5% of patients.
Additionally, the inguinal crease is an unreliable landmark, as the
position of the crease, relative to the underlying vessels, is
highly dependent on body habitus (figure 9).
This diagram illustrates the anatomic relationships of the
femoral head, inguinal ligament, and femoral crease.
This image demonstrates the use of fluoroscopic guidance to
identify the femoral head for groin puncture.
This fluoroscopic image demonstrates how using the femoral crease
as a landmark for common femoral artery puncture can erroneously
determine the level of the femoral head.
We have found that the use of the inguinal crease in heavyset
patients was more likely to result in groin complications than in
smaller patients for two reasons. The first is that the inguinal
crease (and the panniculus) in larger patients was lower in
relation to the femoral head than in thinner patients, and hence
resulted in more aberrant arterial entry sites. The second reason
for higher rates of groin complications following femoral artery
catheterization in obese patients is that groin compression is
technically easier in smaller patients, as femoral arterial
pulsations are more easily palpated in thinner patients, and
adequate compression can be achieved.
The relatively high incidence of arteriovenous fistulae
following coronary angiography has been reported in the past.
This may be related to the simultaneous arterial and venous
punctures in some patients and to utilization of large caliber
catheters and anticoagulation in these patients.
However, we believe significant contributory factors also include
the distal location chosen for arterial entry resulting from the
use of the femoral crease as a landmark for the location of the
common femoral artery. All patients with arteriovenous fistulae in
our study had aberrantly low arterial entry sites.
Similarly, a perivascular hematoma, formed when a femoral
puncture site which appears to communicate with the arterial lumen
via a neck or track fails to heal, has been labeled a
It stands to reason that because healing of a femoral puncture site
is dependent upon adequate compression,
a low arterial entry site compromises this.
Again, our study corroborates that contention. Of the 11
pseudoaneurysms found, the arterial entry site was at or below the
level of the femoral bifurcation in nine patients. The use of
anticoagulation and larger caliber catheters compounds the problem
and definitely contributes to the incidence of these complications.
In addition, compression is more difficult in obese patients.
The femoral crease is an unreliable landmark to identify the
position of the common femoral artery.
Ideally, for all angiographic and interventional procedures, we
recommend the distal common femoral artery overlying the femoral
head as the arterial entry site because the relatively consis tent
relationship between the femoral artery and the lower aspect of the
femoral head has been well documented. Meticulous attention to the
arterial entry site by fluoroscopic means prior to establishing
arterial entry will contribute significantly in decreasing these