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CardioVascular and Interventional Radiology Springer-Verlag New York, Inc 1998 Cardiovasc Intervent Radiol (1998) 21:512-513 TECHNICAL NOTE An Improved Reversal Technique from Retrograde to Antegrade Femoral Artery Cannulation George Hartnell Department of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, One Deaconess Road, Boston, MA 02215, USA Abstract Converting retrograde femoral access to antegrade access may be required following diagnostic arteriography to perform an interven- tional procedure. This technical note describes a modification of a previously described technique that allows reliable catheter reversal which was successful in 27 attempted procedures. There were no complications. Key words: Antegrade catheterization--Transluminal angio- plasty--Arteries, femoral--Interventional procedures When the need to convert a retrograde to an antegrade femoral artery puncture arises, avoiding a separate antegrade puncture is advantageous, particularly in patients requiring anticoagulation or thrombolytic therapy. A variety of techniques for conversion from a retrograde to an antegrade approach have been described [1-5]. These have varying degrees of technical difficulty, and some re- quire equipment which may not readily be available to angiogra- phers [3-5]. We present a simple modification of the "shepherd's crook" method [1] for reversing direction which uses readily avail- able catheters and guidewires. Technique When contemplating this reversal technique, a near vertical puncture over the femoral head is used to minimize the length of the subcutaneous tract, reduce the stretch on the punctured vessel, and allow easier compression of the puncture site after the procedure. Following diagnostic angiography, using a retrograde common femoral artery puncture, a 5 Fr Sos-shaped catheter (5 Fr Sos 2 or 3 or Omni-Flush; Anglo Dynamics, Queensbury, NY, USA) is inserted through a 5 Fr sheath over a conventional guidewire (Fig. 1). The loop of the Sos catheter is fornted in the lower aorta. The catheter is withdrawn into the origin of the ipsitateral common lilac artery and contrast is injected to confirm that the tip of the catheter is engaged within the origin of that vessel. An angled glidewire (0.035" Glidewire, Meditech, Watertown, MA, USA) is inserted and the distal 4-6 cm of the glidewire is pushed out of the end of the catheter. The catheter and glidewire are withdrawn together with the tip of the glidewire manipulated first into the external iliac artery and then into the superficial femoral artery (SFA). Once the origin of the SFA has been accessed by the tip of the glidewire (Fig. 2), the glidewire is advanced further into the SFA, ensuring that the stiff part of the glidewire shaft has passed through the loop of the Sos catheter. The Correspondence to: G.G. Hartnell, Department of Radiology, Johns Hop- kins Hospital, 600 North Wolfe Street, Baltimore, MD 21287, USA catheter and glidewire are pulled back together until the secondary curve of the catheter reaches the end of the sheath. This may be required before the glidewire can be pushed further down into the target vessel. Continuing withdrawal of the catheter, sheath, and glidewire together then leads to a position where the loop of the catheter arrives at the level of the femoral artery puncture. This can be felt as a slight "thump" as the loop becomes unwound. At this stage, it is possible to advance the catheter, and then the sheath, directly down the glidewire into the SFA (Fig. 3). Bypass grafts, including occluded grafts, are accessed in the same way. This technique does not require the use of any unusually shaped cath- eters. It has been used in 27 reversal procedures in 24 patients (26 limbs). In all cases, reversal was successful, allowing rapid access to the SFA or a femoral bypass graft on all but one occasion. There was one failure to enter an occluded distal bypass graft arising from a proximal SFA which was distorted as a result of prior surgery. There were no complications and no loss of access. The technique has been easy to teach to other stall, residents, and fellows. Comments During the evolution of this technique various combinations of "shepherd's crook"-shaped catheters and guidewires were used. Important considerations included a match between the stiffness of the guidewire and catheter to prevent straightening of the catheter during guidewire manipulation. The steerable quality of an angled glidewire is required to allow selection of the origin of the SFA or graft. The stiffness of the 0.035" glidewire (conventional "floppy" type) was found to frequently produce displacement and straight- ening of 4 Fr catheters, although this is not a problem with 5 Fr catheters. The classical "shepherd's crook"-shaped catheters (Sim- mons 1, 2, and 3) were also difficult to use due to the length of the catheter tip and the radius of the secondary curve (Fig. 1); these were usually too tight to fit easily into the confines of the common femoral artery/SFA confluence leading to frequent catheter dis- placement and straightening or failure to respond appropriately to manipulation. The Sos 2 or 3 (either seems acceptable) configuration with its tighter secondary curve and shorter tip was found to be much easier to use in this area and was unlikely (when using the 5 Ft version) to straighten out during guidewire manipulation. It was also found that manipulation through a short arterial sheath reduced the risk of losing arterial access and allowed easier advancement of the cath- eter after turning, especially in obese patients. The technique we describe is a development of the use of a "shepherd's crook" (Simmons) catheter for SFA access de- scribed by Shenoy [1]. We previously employed this widely used technique but for the reasons given above, it was often unsatis-
