Synopsis
Select and obtain safe vascular access, navigate vessels with controlled wire and catheter technique, choose embolic strategies by flow and anatomy, recognise non-target injury and verify haemostasis and distal perfusion.
- Choose access from the target, vessel calibre and disease, required sheath size, device length, ability to compress the artery and the consequences of occlusion; recent cross-sectional imaging and ultrasound should inform the choice.
- Real-time ultrasound shows lumen, plaque, bifurcation, vein and needle tip and is the recommended first approach for common femoral arterial puncture in the CIRSE arterial-access standard.
- The Seldinger sequence requires free blood return, gentle guidewire passage, wire position confirmation, tract dilation and sheath placement while continuously controlling the wire.
Key red flags
An enlarging groin or arm haematoma with tachycardia, hypotension or falling haemoglobin requires immediate compression and evaluation for active arterial bleeding.
New limb pain, pallor, paraesthesia, weakness or loss of pulses after access or closure suggests acute arterial occlusion or dissection and needs urgent revascularisation assessment.
Back, flank or abdominal pain with hypotension after femoral access can indicate retroperitoneal haemorrhage even when the skin puncture looks dry.
Abrupt pain or neurological, bowel, renal, cardiac or respiratory dysfunction during embolic delivery suggests reflux, shunting or non-target embolisation and requires injection to stop immediately.
A wire should advance without force along the expected vessel course; resistance, buckling, pain or an unexpected fluoroscopic path requires withdrawal and reassessment for subintimal passage, dissection or extravascular position.
New pulse loss, coolness, delayed capillary refill, pain, paraesthesia or weakness beyond the access site may follow thrombosis, embolus, dissection or an occlusive closure device and requires urgent action.
Unexpected embolic reflux, passage through a shunt, loss of normal branch opacification or abrupt symptoms in another vascular territory indicates unintended delivery and may cause irreversible infarction.
Reasoning priorities
Map target and access anatomy, disease, tortuosity, aneurysm, stenosis, occlusion and possible collateral routes.
Imaging helps choose side and entry vessel, predicts catheter reach and rescue options, but interval thrombosis, spasm and haemodynamic change can alter anatomy by procedure time.
Worked reasoning
A haemodynamically supported patient has active upper-abdominal bleeding on CTA from a small branch pseudoaneurysm; the parent artery supplies viable tissue through limited collaterals.
- Define the clinical aim as urgent haemostasis while preserving parent-artery flow, review CTA for access vessels, culprit branch, inflow and outflow, and activate transfusion and surgical backup appropriate to the physiology.
- Use real-time ultrasound to puncture a suitable common femoral artery segment, pass the wire gently under fluoroscopy and place a sheath after confirming intraluminal position; document baseline distal pulses.
- Perform selective angiography and advance a microcatheter close to the pseudoaneurysm without crossing or injuring it, checking for non-target branches and choosing a focal mechanical agent whose size and deployment can be controlled.
- Occlude the relevant inflow and, when anatomy permits, outflow around the pseudoaneurysm rather than filling the sac blindly; pause before each deployment and maintain catheter stability.
- Verify exclusion of the pseudoaneurysm and cessation of extravasation with preserved essential parent flow, then remove access and achieve haemostasis.
- Recheck observations, haemoglobin trend, abdominal findings, access site and distal perfusion; recurrent instability triggers urgent repeat imaging or angiography because collateral rebleeding can occur.