January 2013

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After its first introduction by Seldinger, percutaneous vascular access through the common femoral artery (CFA) has become the most widely used route of access to the arterial system for peripheral percutaneous vascular interventions. This article discusses anatomical aspects related to CFA puncture, choosing the optimal puncture site, and methods to increase the efficacy and safety of the CFA puncture.

PUNCTURE SITE AND PUNCTURE TECHNIQUES

Relevant Anatomy
The CFA is the continuation of the external lilac artery after the take-off of the inferior epigastric artery and after crossing the inguinal ligament that forms an anatomical landmark and runs from the anterosuperior iliac crest to the pubic bone (an imaginary line drawn between these bony structures indicates the location of the inguinal ligament; Figure 1A).^1-3 Here, the artery lies midway between the anterosuperior crest of the iliac bone and the pubic bone and runs parallel with the medial aspect of the femoral head. It descends almost vertically down toward the adductor tubercle of the femur and ends at the opening of the adductor magnus muscle in the so-called femoral triangle. At its origin, the femoral artery is accompanied by the anterior crural nerve laterally and the femoral vein medially and is covered anteriorly by the inferior extension of the fascia of the transverse abdominal and iliac muscles (the so-called femoral sheath).

The femoral sheath is funnel-shaped and fuses with the adventitia of the vessels at the site where the greater saphenous vein joins the femoral vein.4 The presence of the femoral sheath that encloses the CFA assists in preventing pseudoaneurysm formation after puncture. The deep femoral artery branches 2.5 to 5 cm distal from the origin of the CFA. The most superficial part of the CFA lies at the level where the artery passes in front of the femoral head.⁴ The center of the CFA lies anterior to the common femoral vein. A portion of the CFA overlaps the corresponding vein in the anteroposterior plane in 65% of cases (Figure 1B). This relationship is important in preventing the development of arteriovenous fistulas.⁵ Many variations of this anatomy have been described, but an extensive discussion on this topic is beyond the scope of this article.

Relative to palpable bony structures, the course of the femoral artery is indicated by the upper two-thirds of the line drawn between the midpoint of the anterosuperior iliac spine and symphysis pubis to the prominent tuberosity on the inner condyle of the femur with the thigh abducted and rotated outward.⁶

The association between low puncture sites and both pseudoaneurysms and arteriovenous fistulas is well known, as is the high risk of retroperitoneal bleeding in cases of high puncture sites. The bleeding may be massive because of the presence of only loose connective tissue in the retroperitoneal space.⁷

Choice of Puncture Site and Technical Aspects
The inguinal crease is frequently used as a landmark, based on the belief that the level of the inguinal crease is closely related to the inguinal ligament.^8,9 However, the distance between the inguinal crease and the inguinal ligament is highly variable, ranging from 0 to 11 cm (mean, 6.5 cm), and the bifurcation of the CFA is above the inguinal crease in 75.6% of patients.⁹ Another frequently used landmark, the maximal femoral pulse, is over the CFA in 92.7% of limbs, and the CFA is projected over the medial aspect of the femoral head in 77.9% of limbs. This indicates that the level of the strongest femoral pulse is a more reliable means of localizing the CFA than the level of the inguinal crease. Therefore, although popular, the use of the inguinal skin crease should be considered an unreliable guide for CFA puncture.