Femoral access in 100 consecutive subarachnoid hemorrhage patients: The "craniotomy" of endovascular neurosurgery

Background. Femoral access is a fundamental element of catheter-based cerebral angiography. Knowledge of location of the common femoral artery (CFA) bifurcation is important as the risk of retroperitoneal bleeding is increased if the puncture is superior to the inguinal ligament and there is an increased risk of thrombosis and arteriovenous fistula formation if the puncture is distal into branch vessels. We sought to characterize the location of the CFA bifurcation along with the presence of significant atherosclerosis or iliac tortuosity in a contemporary series of subarachnoid hemorrhage (SAH) patients. Findings. The records of a prospective single-center aneurysm database were reviewed to identify 100 consecutive SAH patients. Using an oblique femoral arteriogram, the presence of significant atherosclerosis, iliac tortuosity, and the CFA bifurcation were assessed. The CFA bifurcation was graded according to its position with respect to the femoral head: below (grade 1), lower half (grade 2), and above the upper half (grade 3). We found a CFA bifurcation grade 1 in 50 patients (50%, mean age 51.2 years), grade 2 in 40 patients (40%, mean age 55.5 years), and grade 3 in 10 patients (10%, mean age 58.2 years). Whereas 30 of 90 patients with CFA grades I or II were male (33%), only 10% with grade 3 were male (1 of 10, p = 0.12). Mean age for significant atherosclerosis was 65.5 2.6 years versus 50.9 1.6 years (p < 0.001) without, and iliac tortuosity was 64.9 2.4 years versus 50.3 1.6 years (p < 0.001) without. Conclusions. Although a requisite element of endovascular treatment in SAH patients, femoral access can be complicated by a high common femoral artery bifurcation and the presence of atherosclerotic disease and/or iliac artery tortuosity. In this study, we found a grade 3 (above the femoral head) CFA bifurcation in 10% patients, with 90% of these patients being female. We also found the presence of atherosclerotic disease and iliac tortuosity to be significantly more likely in patients older than 65 years of age.