Femoral artery access is a cornerstone in interventional radiology and cardiology, enabling endovascular interventions such as angiography, stent placement, and embolisation. Despite the advent of alternative access sites like the radial and brachial arteries, given reduced radiation exposure, the femoral artery remains a preferred choice for large-bore catheters and complex procedures due to its ease of access and direct route to the central vasculature ^1,2.

Indications

Femoral artery access is indicated for a wide variety of diagnostic and therapeutic procedures ^{3, 4}:

• peripheral angiography and intervention

• endovascular aneurysm repair (EVAR)

• cardiac catheterisation, especially in the absence of suitable radial access

• embolisation procedures

• large-bore catheter placement, e.g. intra-aortic balloon pump, Impella devices

Contraindications

• local infection or groin haematoma

• severe peripheral arterial disease at the access site

• uncorrectable coagulopathy

• previous extensive groin surgery, e.g. femoral bypass grafts

• allergy to procedural materials, e.g. contrast agent

Procedure

Preprocedural evaluation

• withholding anticoagulants pre-procedure if not contraindicated

• patient positioned supine with the hip extended and externally rotated

• sterile field and septic technique to minimise infection risk

• anatomic localisation of the puncture site

  • the common femoral artery (CFA) midpoint is the ideal puncture site to minimise complications related to arterial bifurcation or inguinal ligament puncture ⁵

  • palpate the femoral pulse +/- use ultrasound guidance to visualise the CFA and its bifurcation

Technique

Three puncture techniques of femoral artery access are reported: best pulse, fluoroscopy-guided, and ultrasound directed. Compared to fluoroscopy-guided technique, ultrasound-guided femoral artery access has a higher first pass success rates, reduced mean time to access, and reduced rates of access related complications ⁶.

A combined ultrasound/fluoroscopy technique is as follows ³:

1. Local anaesthetic: Short-acting local anaesthetic is injected under real-time ultrasound visualisation.

2. Needle insertion: Using a 21 G or 18 G needle, puncture the CFA under real-time ultrasound guidance, ensuring the needle is inserted at a 30–45° angle.

3. Guidewire insertion: Advance a guidewire through into the CFA, confirming intraluminal placement using fluoroscopy.

4. Sheath placement: Insert the arterial sheath over the guidewire, ensuring smooth passage without resistance.

Postprocedural care

• haemostasis can be achieved via manual compression, closure devices, or mechanical compression systems ^{4, 7-8}

• observe for signs of bleeding, haematoma, or pseudoaneurysm ⁷

• standard post-procedure protocols typically involve 2–6 hours of bed rest, depending on anticoagulation use ^{7, 9}

Complications

Femoral artery access can have complications in both the immediate and delayed settings ^{5, 7, 10}.

Immediate complications

• bleeding, haematoma

• arterial dissection or occlusion

• pseudoaneurysm formation

• local infection

Delayed complications

• arteriovenous fistula

• retroperitoneal haemorrhage

• chronic arterial insufficiency

Practical points

• real-time ultrasound visualisation reduces complications and improves first-pass success rates

• puncture site selection: avoid the CFA bifurcation and inguinal ligament to minimise complications

• operator experience: adequate training and supervision are crucial for minimising adverse events