World Journal of Cardiovascular Diseases, 2013, 3, 569-572 WJCD Published Online December 2013 (
Excellent femoral outcomes when all access attempts and
closure devices are performed by experienced cardiologists
Kevin S. Kang, Quentin Orlando, Robert Maholic, Richard Petrella, Gurjaipal S. Kang*
UPMC Hamot Hospital, Erie, USA
Email: *
Received 25 September 2013; revised 27 October 2013; accepted 16 November 2013
Copyright © 2013 Kevin S. Kang et al. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Femoral access is considered less safe for access site
complications than the radial access. Cardiovascular
procedures have not been studied taking operator
experience, defined as American Board of Internal
Medicine, Interventional Cardiology certification or
equivalent qualification in another country, into ac-
count. We hypothesize that the procedural results are
operator dependent and excellent results are obtained
when procedures are performed by experienced op-
erators. Femoral access is higher risk than radial ac-
cess based on American College of Cardiology (ACC)
guidelines. Femoral access is less forgiving, as oppos-
ed to radial, as it is an end-artery, lacks easy com-
pressibility and is more likely to cause morbidity
when injured. Hence, radial is recommended over the
femoral approach according to ACC practice guide-
lines. These guidelines are often based on the rando-
mized studies from academic centers where trainees,
with variable arterial access experience, perform the
initial access stick and arterial closure device deploy-
ment. Methods: We performed a single center retro-
spective review of 32,446 consecutive patients under-
going invasive cardiovascular procedures done from
the femoral approach using American College of
Cardiology/National Cardiovascular Data Registry
(ACC/NCDR) from January 1, 2006 to June 30, 2013.
Only experienced operators performed the actual ac-
cess site stick and the reminder of the invasive pro-
cedure. Results: Total bleeding and vascular compli-
cations were less than 1%. We define outcomes as ex-
cellent if the total bleeding and vascular complication
risk is less than 1% based on previous studies dis-
cussed in the ACC guidelines. Conclusion: Excellent
outcomes can be obtained from the femoral access if
experienced cardiologists perform the procedure.
Hence, radial arterial access over the femoral access
may be selectively rather than universally recom-
mended considering the possibility of varying level of
femoral access expertise of different practices.
Keywords: Operators; Access; Complications
Cardiac diagnostic and interventional procedures have
historically been performed using femoral arterial access
[1]. Associated risks include access site bleeding and
major vascular complications [2]. Radial access is favor-
ed to decrease the vascular complication risk during
these cardiovascular procedures [3,4]. However, there
are also some limitations pertaining to the radial artery. It
is associated with an increased radiation exposure to the
operator [5] and a higher risk of procedural failure due to
the smaller size and tortuous nature of the vessel [6]. It
may be harder to palpate the vessel in hypotensive pa-
tients and impossible to use with large diameter devices.
The American College of Cardiology (ACC) guidelines
increasingly recommend the use of the radial approach
[4]. The ACC guidelines are based on studies done ex-
clusively at academic centers where often a trainee, in-
stead of a board certified interventional cardiologist,
sticks the access artery and performs the closure device
procedure. These studies comparing femoral and radial
accesses fail to take the operator experience into account
when reporting outcomes [3]. We defined an experienced
operator as a board certified interventional cardiologist
because of three reasons. Firstly, a board certified cardio-
logist on average is more likely to have performed grea-
ter number of proc edures compared to a trainee. Second-
ly, the board certified attending cardiologist assumes full
responsibility of patient outcomes as opposed to trainees
or other staff where the ultimate responsibility still re-
sides with the attending cardiologists in the training pro-
gram. Also, board certification assures a complete know-
*Corresponding author.
K. S. Kang et al. / World Journal of Cardiovascular Diseases 3 (2013) 569-572
ledge base of invasive cardiovascular procedures. For the
purpose of our study, we define an excellent outcome as
a complication risk of less than 1%. We chose a number
of less than 1% total vascular complication risk as an
indicator on an excellent outcome based on the prior re-
sults from radial access studies and guideline recom-
mendations [3,4]. Coronary and carotid stenting pro-
cedures are dependent on operator volume [7,8]. We hy-
pothesize that any invasive cardiovascular procedure is
operator dependent and excellent results are possible
with femoral access when conducted by experienced
operators. The prior randomized studies may have favor-
ed the radial approach because the arterial access was
obtained by the trainees in academic centers where such
studies were conducted. This lack of experience of a
trainee may be associated with arterial injury to radial or
the femoral artery, leading to further complications and
less than excellent outcomes. We define arterial injury as
causing arterial dissection, perforation or emboli during
the course of access or closure device placement. How-
ever, such vascular injuries in the case of radial artery
may be asymptomatic. This is because the radial artery
access may be a forgiving approach to cardiac inter-
ventional and diagnostic procedures because it is super-
ficial, easily compressible and is not an end artery [9]. If
a trainee with minimal experience in arterial access in-
jures the radial artery, the clinical outcomes are not
likely to be affected. However, a femoral arterial injury
is more likely to result in symptomatic post procedure se-
quel, such as severe bleeding or ischemic complications.
Femoral artery is an end artery and is not easily com-
pressible for hemostasis. Prior studies comparing the two
access sites have favored radial over femoral without
accounting for operator experience [3]. If an injury, such
as dissection, of the femoral artery is avoided, the vas-
cular outcomes with femoral artery access should be ex-
cellent. Operator experience may be important in avoi-
ding femoral artery injury. Femoral artery may be prefer-
red in several settings because of its larger diameter, fre-
quent lack of tortuosity and easier palpation in hypo-
tensive patients [9]. When experienced operators conduct
femoral access procedures, total bleeding and vascular
complications may be less than 1%. The training level of
the operator can greatly mitigate the bleeding and groin
complication risks in patients undergoing femoral ap-
proach invasive procedures [7,8].
All patients, presenting between January 1, 2006 and
June 30, 2013, that underwent an invasive cardiovascular
procedure through femoral access were included in our
study. The total number of consecutive patients who
were accessed via the femoral artery was 32,446. A
board certified interventiona l cardiologist does all patient
arterial access in our institution and the study was
exclusively done at our institution. The data reported in
this study is taken from the American College of Car-
diology/National Cardiovascular Data Registry (ACC/
NCDR). The NCDR Registry is an initiative of the
American College of Cardiology (ACC) and the Society
for Cardiovascular Angiography and Interventions and
has been previously described [10]. ACC committee pro-
spectively defined the variables, which are available at (AUGUST 2013). The ACC/ NCDR has
specific definitions for endpoints such as bleeding,
dissection, emboli, fistula and pseudo-aneurysm, and
such definitions are available on the website and are
summarized below. Bleeding Complication: Blood loss
at the site of arterial or venous access, or due to per-
foration of a traversed artery or vein requiring transfu-
sion and/or prolonging the hospital stay, and/or causing a
drop in hemoglobin of >3.0 g/dL. Bleeding attributable
to the vascular site could be retroperitoneal (retroperi-
toneal bleeding), a local hematoma >10 cm with femoral
access, >2 cm with radial access, or >5 cm with bra-
chial access (hematoma bleeding), or external (entry site
bleeding). Vascular Complication: This category in-
cluded the presence of any one of the following vascu lar
complications pertaining to the percutaneous access site:
occlusion, defined as total obstruction of the artery by
thrombus, usually at the site of access requiring surgical
repair; embolization, defined as loss of distal pulse, pain
and/or discoloration (especially the toes); dissection, de-
fined as a disruption of an arterial wall resulting in split-
ting and separation of the intimal (subintimal) layers;
pseudoaneurysm, defined as the occurrence of a disrup-
tion and dilation of the arterial wall without identifi-
cation of the arterial wall layers at the site o f the catheter
entry demonstrated by arteriography or ultrasound; or
AV fistula, defined as a connection between the access
artery and the accompanying vein demonstrated by
arteriography o r ultrasound and most often characterized
by a continuous bruit. Bleeding or Vascular Complica-
tion: Either one or the other, or both. For the purpose of
our study, we use the NCDR/ACC registry limited to
data reported from our single institution. The study data
is limited to our center where only the nursing staff,
trained in the NCDR registry, is allowed to enter data.
These nurses have no financial affiliation with the opera-
tors. Our institution is a private, non-teaching hospital
and all operators who stick the arterial access site are
board certified interventional cardiologists rather than
cardiology fellows or other non-physician staff. The
study was limited to patients undergoing invasive cardio-
vascular procedures through femoral arterial access over
a 6 1/2 year period. No patients were excluded from this
group. Attempts are not made to directly compare this
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K. S. Kang et al. / World Journal of Cardiovascular Diseases 3 (2013) 569-572 571
study with previous studies using statistical means be-
cause of differences in patient populations involved in
previous studies ev en though this is possible.
Patients selected for our single-center retrospective re-
view had inpatient follow up as required by NCDR [10].
32,446 patients were selected from January 1, 2006 to
June 30, 2013 with no exclusion criteria except for un-
dergoing invasive cardiovascular procedure from femoral
access. Greater than 50% of the femoral access patients
had Perclose or Starclose Closure Device deployment in
the end. Only board certified cardiologists were allowed
to attempt arterial access and closure device deployment
at our center. Our results reveal that there was low mor-
tality (<0.9%) in this large patient population undergo-
ing femoral access by experienced operators. Vascular
complications recorded were limited to bleeding (0.6%),
dissections (0.1%), occlusions (0.0%), pseudo-aneury-
sms (0.1%), emboli (0.0%) and fistulae (0.0%). The
overall risk of vascular complications with femoral ac-
cess was less than 1% and numerically lower than the
risk reported in previous studies [3]. The largest rando-
mized study, RIVAL, that compared the two access sites
reported vascular complications for radial access at 1.4%
and femoral access at 3.4% [3]. The complication risk in
our study involving femoral access patients was less than
1%. In our study, the patients were noted to have no
femoral infections. Table 1 lists values for bleeding and
vascular complications.
ACC/AHA guidelines advocate radial access over the
femoral access to reduce the vascular complication risk
[4]. A lot of prior data in the radial versus femoral litera-
ture has been collected from teaching hospitals where
Table 1. Complications of invasive procedures done from
the femoral access.
Total invasive femoral access procedures 32,446
Mortality 0.9%
Bleeding 0.6%
Dissection 0.1%
Occlusion 0.0%
Pseudoaneurysm 0.1%
Emboli 0.0%
Fistulae 0.0%
Total Bleeding and Vascular Complications 0.8%
trainees with minimal experience may attempt arterial
access and closure devices under the supervision of ex-
perienced cardiologists. The trainees may perform the
actual arterial access stick. The impact of trainees in get-
ting arterial access for cardiovascular procedures has not
been studied, to our knowledge, but in other specialties,
such as general surgery, the effect of trainees may in-
crease the complication risk [11]. Major studies compar-
ing outcomes with different types of arterial access were
done in teaching hospitals where trainees often get arte-
rial access and perform part of the invasive procedure
albeit under supervision [3]. The ACC/AHA guidelines
are based on such studies and recommend radial access
[4]. The guidelines are then applied to all types of prac-
tice patterns regardless of the training experience of the
operators. We realized that major studies like RIVAL
may not apply to our hospital. Our institution is unique
because only board certified cardiologists perform all
invasive procedure and closure devices. We decided to
look exclusively at our own hospital data so we could
learn more about the femoral vascular complication re-
sults in cardiology practices similar to ours where only
experienced operators performed the procedures. As far
as we know, similar data have not been published before.
In addition to access site complications associated with
operator experience, closure device complications may
also be operator dependent. The previously published
studies often had trainees placing closure devices possi-
bly leading to higher risk of vascular femoral site com-
plications. So, we expect that the overall vascular out-
comes associated with femoral access may be dependent
on the initial access stick and the final closure device
technique. Our results as noted above confirm our excel-
lent outcomes with femoral approach in an especially
high-risk population. The excellent outcomes of <1%
complication risk in our study, as predicted, may be due
to differences in the operator skill. Our operators were
board certified interventional cardiologists and no train-
ees or other non-physician staff was allowed to stick or
close the artery. Our study demonstrates that when only
board certified cardiologists perform access arterial stick,
the injury to the femoral artery may be decreased and as
a consequence, vascular and bleeding outcomes are ex-
Retrospective nature of the study and based in only one
We conclude that if only experienced operators stick an
access site and personally perform the entire procedure,
excellent outcomes in patients with femoral access are
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K. S. Kang et al. / World Journal of Cardiovascular Diseases 3 (2013) 569-572
Copyright © 2013 SciRes.
possible. Our recommendation would not generalize the
clinical trial results from training centers to every cardi-
ology practice worldwide and endorse radial over the
femoral approach but acknowledge differences between
practices’ expertise in a particular access site.
[1] Gruentzig, A. (1978) Transluminal dilatation of coro-
nary-artery stenosis. Lancet, 1, 263.
[2] Doyle, B.J., Rihal, C.S., Gastineau, D.A. and Holmes,
D.R., Jr. (2009) Bleeding, blood transfusion, and in-
creased mortality after percutaneous coronary intervene-
tion: implications for contemporary practice. Journal of
the American College of Cardiology, 53, 2019-2027.
[3] Jolly, S.S., Yusuf, S., Ca irns, J., et al. (2011) RIVAL trial
group. Radial versus femoral access for coronary an-
giography and intervention in patients with acute coro-
nary syndromes (RIVAL): A randomized, parallel group,
multicenter trial. Lancet, 377, 1409-1420.
[4] Levine, G.N., Bates, E.R., Blankenship, J.C., et al. (2011)
ACCF/AHA/SCAI Guideline for percutaneous coronary
intervention: A report of the American College of Cardi-
ology Foundation/American Heart Association Task
Force on Practice Guidelines and the Society for Cardio-
vascular Angiography and Interventions. Journal of the
American College of Cardiology, 58, e44-e122.
[5] Jolly, S.S., Cairns, J., Niemela, K., et al. (2013) Effect of
radial versus femoral access on radiation dose and the
importance of procedural volume: A substudy of the mul-
ticenter randomized RIVAL trial. JACC: Cardiovascular
Interventions, 6, 258-266.
[6] Biondi-Zoccai, G., Sciahbasi, A., Bodí, V., Fernández-
Portales, J., et al. (2013) Right versus left radial artery
access for coronary procedures: An international collabo-
rative systematic review and meta-analysis including 5
randomized trials and 3210 patients. International Jour-
nal of Cardiology, 166, 621-626.
[7] Gray, W.A., Rosenfield, K.A., Jaff, M.R., et al. (2011)
Influence of site and operator characteristics on carotid
artery stent outcomes: Analysis of the CAPTURE 2 (Ca-
rotid Acculink/Accunet Post Approval Trial to Uncover
Rare Events)clinical study. Journal of the American
College of Cardiology, 4, 235-246.
[8] Kastrati, A., Neumann, F.J. and Schömig, A. (1998) Op-
erator volume and outcome of patients undergoing coro-
nary stent placement. Journal of the American College of
Cardiology, 32, 970-976.
[9] Nicholas, R., Balaji, P. and Shah, B. (2011) Radial artery
catheterization. American Heart Association, 124, e407-
[10] Rao, S.V., Ou, F.S., Wang, T.Y., et al. (2008) Trends in
the prevalence and outcomes of radial and femoral ap-
proaches to percutaneous coronary intervention: A report
from the National Cardio-vascular Data Registry. JACC:
Cardiovascular Interventions, 1, 379-386.
[11] Kiran, R.P., Ahmed Ali, U., Coffey, J.C., et al. (2012)
Impact of resident participation in surgical operations on
postoperative outcomes: National surgical quality impro-
vement program. Annals of Surgery, 256, 469-475.
ACC: American College of Cardiology
NCDR: National Cardiovascular Data Registry