- Email: [email protected]
Technical report: Use of a directional needle for antegrade guide wire placement when performing femoropopliteal angioplasty
Clinical Radiology (1993) 48, 278 279
Technical Report: Use of a Directional Needle for Antegrade Guide Wire Placement When Performing Femoropopliteal Angioplasty H. G. T H O M A S and C. H. W O O D H A M
Department of Radiology, John Radcliffe Hospital, Headington, Oxford We tJescribe the use of a needle with a pencil point tip and a bevelled distal side hole as an effective and cheap method of directing a guide wire into the superficial femoral artery.
Thomas, H.G. & Woodham, C.H. (1993). Clinical Radiology 48, 278 279. Technical Report: Use of a Directional Needle for Antegrade Guide Wire Placement When Performing Femoropopliteal Angioplasty
Cannulating the superficial femoral artery (SFA) for antegrade femoropopliteal angioplasty or thrombolysis can sometimes be difficult and time-consuming, particularly in obese patients, in those with disease at the origin of the SFA, and in those with a high bifurcation of the common femoral artery (CFA) which leaves little room for manipulation from the puncture site to the SFA origin. We describe the use of a needle with a pencil point tip and a bevelled distal side hole for directing a guide wire into the SFA. We have used this needle successfully on 20 patients without requiring additional catheters or guide wires. There have been no significant complications. This directional needle is an effective and cheap alternative to the use o f mutiple catheters, sheaths or guide wires sometimes required in these patients. MATERIALS AND METHODS
The positions of the femoral artery and inguinal ligament are established by palpation and those of the superior and inferior surfaces of the femoral head using fluoroscopy. The level of the CFA bifurcation is also established from prior angiography if available and the point of entry used is as high in the CFA as possible whilst staying below the line of the inguinal ligament. After sterilization of the puncture site, local anaesthetic (lignocaine hydrochloride 1%, 5 ml) is injected around the CFA. An 18G 80 mm needle with a sharp pencil point tip and single side hole with a Tuohy bevel designed for epidural puncture (Perican R, B. Braun Medical Ltd, Aylesbury, Bucks) is used to cannulate the CFA (Fig. 1). This needle allows the guide wire to emerge from the tip at an angle of approximately 18~ (Fig. 2). Either a single anterior wall puncture with the plastic trocar removed or the standard Seldinger double wall puncture technique can be used with slight antegrade angulation of the needle. In the latter case the central plastic trocar is then removed and the cannula slowly withdrawn with its hub angled to lie more horizontally. When free flow of arterial blood is obtained, a 0.035 in diameter flexible-tipped guide wire is introduced with the side hole of the needle directed Correspondence to: Dr Hywel G. Thomas, Department of Radiology, Musgrove Park Hospital, Taunton, Somerset TAI 5DA.
antero-medially towards the SFA origin. A notch on the hub of the needle indicates the position of the side hole. A test injection of contrast can be made prior to guide wire insertion if required. The guide wire is advanced into the SFA under fluoroscopic screening, being withdrawn and the needle rotated slightly if the profunda femoris artery (PFA) is selected. When the guide wire is positioned well down the SFA, the cannula and guide wire are withdrawn together slightly until the needle tip is clear of the skin. With the guide wire fixed at the groin, the cannula is removed in a smooth continuous large curved arc over the guide wire to prevent inadvertent shearing. A dilator, catheter or sheath can then be advanced over the guide wire directly into the SFA for the procedure to continue. We have used this needle successfully in 20 patients and performed a small prospective randomized evaluation compared with our standard needle on 16 patients undergoing antegrade femoropopliteal angioplasty. The patients were allocated the Perican cannula or our standard cannula on a random number basis. All procedures were performed by the same radiologist (HT) of senior registrar grade and having completed 6 months on the angiography rotation. We analysed the time taken and the number of passes required to gain access to the common femoral artery, the time taken to select the SFA with the guide wire, and noted if additional equipment was used in the latter procedure.
Fig. 1 The Perican R cannula with a sharp pencil point tip and single side hole with a Tuohy bevel designed for epidural puncture.
GUIDE WIRE PLACEMENT IN FEMOROPOPLITEAL ANGIOPLASTY
279
where a safety wire is placed in the PFA so preventing the sheath from being inadvertently withdrawn, whilst a second curved wire is manipulated into the SFA. Another technique uses a movable core guide wire with its tip lodged in the PFA and the core being withdrawn until the coreless portion flops over the bifurcation into the SFA
[l].
Fig. 2 The guide wire emerging from the cannula tip at an angle of approximately 18~
RESULTS There were seven patients in the Perican cannula group, five male and two female. There were nine in the standard cannula group, two male and seven female. The age ranges were 46-82 and 38-87 with means of 64.9 and 68.6 years respectively. The weights of the patients ranged from 50-102 and 45-76 kg in the two groups respectively. The average number of passes (3.4) was identical and the time taken from making the skin incision to placing a guide wire in the CFA was similar in both groups (4 min 17 s with the Perican cannula and 3 min 34 s with our standard cannula). Added to this the average time to cannulate the SFA with the Perican cannula was 1 min 12 s and with the standard needle 5 min 29 s. Additional catheters were required in two patients in the standard cannula group, a multipurpose in one and a femorovisceral in the other. DISCUSSION lpsilateral antegrade puncture of the c o m m o n femoral artery is thepreferred route to gain access to the SFA to perform femoropopliteal angioplasty, thrombolysis, selective embolization or infusion of chemotherapeutic agents. This route allows straight vector forces to be applied if traversing narrowed or occluded arteries and allows easier catheter manipulation compared with the contralateral retrograde 'up and over' technique where the catheter may buckle up into the aorta [1]. There is, however, a tendency for the guide wire to enter preferentially the P F A due to the deeper branching angle of this artery [2]. I f this occurs it is not u n c o m m o n to lose entry into the C F A during withdrawal and manipulation, especially when the puncture site is just above the bifurcation [3]. This may then lead to dissection and haematoma, This method, using a directional needle from the outset, obviates the need for additional, more expensive equipment. The use of directional dilators [3], frog leg position, curved catheter or torque steerable guide wire [4] as well as a needle set including a catheter sheath with a 30 ~ preshaped tip and steering device at the tip [2] have been reported. Techniques have been described to reposition a guide wire into the SFA if the P F A has been selected. These include the use of a double guide wire single sheath [5],
The use of a shaped guiding catheter from the contralateral approach has also been described when ipsilateral C F A puncture is not possible [6]. A further method [7] is to perform a direct puncture of the SFA using a target guide wire placed in the SFA from the contralateral retrograde approach in patients who have a high bifurcation or in those where direct puncture of the P F A m a y have occurred. Direct SFA puncture had been previously reported to be associated with an increase in pseudoaneurysm formation [8], but Berman et al. [7] had not encountered difficulties in their technique. Further technical notes have described techniques for converting retrograde C F A puncture into antegrade catheterization of the SFA. These include the use of a double curved, triangular catheter [9], a sidewinder catheter [10] and a directional accordion catheter [11]. Hawkins et al. [12] described the use of a directional needle developed for antegrade guide wire placement using a vertical arterial puncture. This needle is not commercially available in the U K and would be more expensive (personal communication E-Z-EM). The technique described here provides easy antegrade access to the SFA at reduced time and cost and we suggest is extremely useful, even in experienced hands.
REFERENCES 1 Bishop AF, Berkman WA, Palagallo GL. Antegrade selective catheterization of the superficial femoral artery using a movablecore guide wire. Radiology 1985;157:548. 2 Kikkawa K. A new antegrade femoral artery catheter needle set. Radiology 1984;151:798. 3 Saddekni S, Srur M, Cohn D J, Rozenblit G, Wetter EB, Sos TA. Antegrade catheterization of the superficial femoral artery. Radiology 1985;157:531 532. 4 Greenfield AJ. Femoral, popliteal and tibial arteries: percutaneous transluminal angioplasty. American Journal of Radiology 1980;135:927 935. 5 Teitelbaum GP, Joseph GJ, Matsumoto AH, Barth KH. Double guide wire access through a single 6-F vascular sheath. Radiology 1989;173:871 873. 6 Kaufman SL. Angioplasty from the contralateral approach: use of a guiding catheter and coaxial angioplasty balloons. Radiology 1990;177:577 578. 7 Berman HL, Katz SG, Tihansky DP. Guided direct antegrade puncture of the superficial femoral artery. American Journal of Radiology 1986; 147:632-634. 8 Rapoport S, Sniderman KW, Morse SS, Proto MH, Ross GR. Pseudoaneurysm: a complication of faulty technique in femoral artery puncture. Radiology 1985;154:529 530. 9 Patel YD. Catheter for conversion of retrograde to antegrade femoral artery catheterization. American Journal of Radiology 1990;154:179 180. 10 Shenoy SS. Sidewinder catheter for conversion of retrograde into antegrade catheterization. Cardiovascular and lnterventional Radiology 1983;6:112-113. 11 Miles SG, Siragusa R, Hawkins IF Jr. New directional accordion catheter for converting a retrograde puncture into an antegrade catheter placement. American Journal of Radiology 1988; 151 : 197199. 12 Hawkins JS, Coryell LW, Miles SG, Giovannetti M J, Siragusa R J, Hawkins IF Jr. Directional needle for antegrade guide wire placement with vertical arterial puncture. Radiology 1988; 168:271-272.
Technical Report: Use of a Directional Needle for Antegrade Guide Wire Placement When Performing Femoropopliteal Angioplasty H. G. T H O M A S and C. H. W O O D H A M
Department of Radiology, John Radcliffe Hospital, Headington, Oxford We tJescribe the use of a needle with a pencil point tip and a bevelled distal side hole as an effective and cheap method of directing a guide wire into the superficial femoral artery.
Thomas, H.G. & Woodham, C.H. (1993). Clinical Radiology 48, 278 279. Technical Report: Use of a Directional Needle for Antegrade Guide Wire Placement When Performing Femoropopliteal Angioplasty
Cannulating the superficial femoral artery (SFA) for antegrade femoropopliteal angioplasty or thrombolysis can sometimes be difficult and time-consuming, particularly in obese patients, in those with disease at the origin of the SFA, and in those with a high bifurcation of the common femoral artery (CFA) which leaves little room for manipulation from the puncture site to the SFA origin. We describe the use of a needle with a pencil point tip and a bevelled distal side hole for directing a guide wire into the SFA. We have used this needle successfully on 20 patients without requiring additional catheters or guide wires. There have been no significant complications. This directional needle is an effective and cheap alternative to the use o f mutiple catheters, sheaths or guide wires sometimes required in these patients. MATERIALS AND METHODS
The positions of the femoral artery and inguinal ligament are established by palpation and those of the superior and inferior surfaces of the femoral head using fluoroscopy. The level of the CFA bifurcation is also established from prior angiography if available and the point of entry used is as high in the CFA as possible whilst staying below the line of the inguinal ligament. After sterilization of the puncture site, local anaesthetic (lignocaine hydrochloride 1%, 5 ml) is injected around the CFA. An 18G 80 mm needle with a sharp pencil point tip and single side hole with a Tuohy bevel designed for epidural puncture (Perican R, B. Braun Medical Ltd, Aylesbury, Bucks) is used to cannulate the CFA (Fig. 1). This needle allows the guide wire to emerge from the tip at an angle of approximately 18~ (Fig. 2). Either a single anterior wall puncture with the plastic trocar removed or the standard Seldinger double wall puncture technique can be used with slight antegrade angulation of the needle. In the latter case the central plastic trocar is then removed and the cannula slowly withdrawn with its hub angled to lie more horizontally. When free flow of arterial blood is obtained, a 0.035 in diameter flexible-tipped guide wire is introduced with the side hole of the needle directed Correspondence to: Dr Hywel G. Thomas, Department of Radiology, Musgrove Park Hospital, Taunton, Somerset TAI 5DA.
antero-medially towards the SFA origin. A notch on the hub of the needle indicates the position of the side hole. A test injection of contrast can be made prior to guide wire insertion if required. The guide wire is advanced into the SFA under fluoroscopic screening, being withdrawn and the needle rotated slightly if the profunda femoris artery (PFA) is selected. When the guide wire is positioned well down the SFA, the cannula and guide wire are withdrawn together slightly until the needle tip is clear of the skin. With the guide wire fixed at the groin, the cannula is removed in a smooth continuous large curved arc over the guide wire to prevent inadvertent shearing. A dilator, catheter or sheath can then be advanced over the guide wire directly into the SFA for the procedure to continue. We have used this needle successfully in 20 patients and performed a small prospective randomized evaluation compared with our standard needle on 16 patients undergoing antegrade femoropopliteal angioplasty. The patients were allocated the Perican cannula or our standard cannula on a random number basis. All procedures were performed by the same radiologist (HT) of senior registrar grade and having completed 6 months on the angiography rotation. We analysed the time taken and the number of passes required to gain access to the common femoral artery, the time taken to select the SFA with the guide wire, and noted if additional equipment was used in the latter procedure.
Fig. 1 The Perican R cannula with a sharp pencil point tip and single side hole with a Tuohy bevel designed for epidural puncture.
GUIDE WIRE PLACEMENT IN FEMOROPOPLITEAL ANGIOPLASTY
279
where a safety wire is placed in the PFA so preventing the sheath from being inadvertently withdrawn, whilst a second curved wire is manipulated into the SFA. Another technique uses a movable core guide wire with its tip lodged in the PFA and the core being withdrawn until the coreless portion flops over the bifurcation into the SFA
[l].
Fig. 2 The guide wire emerging from the cannula tip at an angle of approximately 18~
RESULTS There were seven patients in the Perican cannula group, five male and two female. There were nine in the standard cannula group, two male and seven female. The age ranges were 46-82 and 38-87 with means of 64.9 and 68.6 years respectively. The weights of the patients ranged from 50-102 and 45-76 kg in the two groups respectively. The average number of passes (3.4) was identical and the time taken from making the skin incision to placing a guide wire in the CFA was similar in both groups (4 min 17 s with the Perican cannula and 3 min 34 s with our standard cannula). Added to this the average time to cannulate the SFA with the Perican cannula was 1 min 12 s and with the standard needle 5 min 29 s. Additional catheters were required in two patients in the standard cannula group, a multipurpose in one and a femorovisceral in the other. DISCUSSION lpsilateral antegrade puncture of the c o m m o n femoral artery is thepreferred route to gain access to the SFA to perform femoropopliteal angioplasty, thrombolysis, selective embolization or infusion of chemotherapeutic agents. This route allows straight vector forces to be applied if traversing narrowed or occluded arteries and allows easier catheter manipulation compared with the contralateral retrograde 'up and over' technique where the catheter may buckle up into the aorta [1]. There is, however, a tendency for the guide wire to enter preferentially the P F A due to the deeper branching angle of this artery [2]. I f this occurs it is not u n c o m m o n to lose entry into the C F A during withdrawal and manipulation, especially when the puncture site is just above the bifurcation [3]. This may then lead to dissection and haematoma, This method, using a directional needle from the outset, obviates the need for additional, more expensive equipment. The use of directional dilators [3], frog leg position, curved catheter or torque steerable guide wire [4] as well as a needle set including a catheter sheath with a 30 ~ preshaped tip and steering device at the tip [2] have been reported. Techniques have been described to reposition a guide wire into the SFA if the P F A has been selected. These include the use of a double guide wire single sheath [5],
The use of a shaped guiding catheter from the contralateral approach has also been described when ipsilateral C F A puncture is not possible [6]. A further method [7] is to perform a direct puncture of the SFA using a target guide wire placed in the SFA from the contralateral retrograde approach in patients who have a high bifurcation or in those where direct puncture of the P F A m a y have occurred. Direct SFA puncture had been previously reported to be associated with an increase in pseudoaneurysm formation [8], but Berman et al. [7] had not encountered difficulties in their technique. Further technical notes have described techniques for converting retrograde C F A puncture into antegrade catheterization of the SFA. These include the use of a double curved, triangular catheter [9], a sidewinder catheter [10] and a directional accordion catheter [11]. Hawkins et al. [12] described the use of a directional needle developed for antegrade guide wire placement using a vertical arterial puncture. This needle is not commercially available in the U K and would be more expensive (personal communication E-Z-EM). The technique described here provides easy antegrade access to the SFA at reduced time and cost and we suggest is extremely useful, even in experienced hands.
REFERENCES 1 Bishop AF, Berkman WA, Palagallo GL. Antegrade selective catheterization of the superficial femoral artery using a movablecore guide wire. Radiology 1985;157:548. 2 Kikkawa K. A new antegrade femoral artery catheter needle set. Radiology 1984;151:798. 3 Saddekni S, Srur M, Cohn D J, Rozenblit G, Wetter EB, Sos TA. Antegrade catheterization of the superficial femoral artery. Radiology 1985;157:531 532. 4 Greenfield AJ. Femoral, popliteal and tibial arteries: percutaneous transluminal angioplasty. American Journal of Radiology 1980;135:927 935. 5 Teitelbaum GP, Joseph GJ, Matsumoto AH, Barth KH. Double guide wire access through a single 6-F vascular sheath. Radiology 1989;173:871 873. 6 Kaufman SL. Angioplasty from the contralateral approach: use of a guiding catheter and coaxial angioplasty balloons. Radiology 1990;177:577 578. 7 Berman HL, Katz SG, Tihansky DP. Guided direct antegrade puncture of the superficial femoral artery. American Journal of Radiology 1986; 147:632-634. 8 Rapoport S, Sniderman KW, Morse SS, Proto MH, Ross GR. Pseudoaneurysm: a complication of faulty technique in femoral artery puncture. Radiology 1985;154:529 530. 9 Patel YD. Catheter for conversion of retrograde to antegrade femoral artery catheterization. American Journal of Radiology 1990;154:179 180. 10 Shenoy SS. Sidewinder catheter for conversion of retrograde into antegrade catheterization. Cardiovascular and lnterventional Radiology 1983;6:112-113. 11 Miles SG, Siragusa R, Hawkins IF Jr. New directional accordion catheter for converting a retrograde puncture into an antegrade catheter placement. American Journal of Radiology 1988; 151 : 197199. 12 Hawkins JS, Coryell LW, Miles SG, Giovannetti M J, Siragusa R J, Hawkins IF Jr. Directional needle for antegrade guide wire placement with vertical arterial puncture. Radiology 1988; 168:271-272.