血管通路是最初的,非常重要,血管内手术的步骤。各种进入部位包括股总动脉,肱动脉,桡动脉,pop动脉,和胫骨远端血管(足动脉)。成功的动脉通路需要先进的解剖学知识,以及适当的培训和经验。今天,应使用实时获得血管通路,超声引导以减少访问时间,患者不适,和穿刺相关的并发症,包括夹层,动静脉通讯,和出血。然而,在外周手术中支持这一建议的高水平证据有限,A级数据主要来自仅研究桡动脉和股骨入路的随机心脏试验.用于股骨通路的血管闭合装置(VCD)可大致归类为主动闭合装置。压缩辅助装置,和外部/局部止血装置。有高水平的证据表明,它们的使用与更少的步行时间和增加的患者满意度有关。然而,现有数据未能清楚地证明在外周血管内动脉手术中与标准手动压迫相比在并发症方面的益处,VCD使用后报告的血栓性和感染性并发症仍然是一个问题。文献中提到的异质性,由各种各样的设备引起的,访问站点,护套尺寸,临床情景,和程序,给数据分析和未来研究设计带来了困难。因此,目前建议对≥5Fr股动脉通路进行个性化的VCD使用,这不仅是为了缩短止血和下床活动的时间,也是为了提高患者的舒适度,但也减少出血并发症的情况下,股骨入路出血风险增加,紊乱的凝血,和大口径通道,尽管支持这一后来建议的大量证据是有限的.关键点:美国的指导是强烈建议股骨入路,是强制性的,以获得更具挑战性的访问。使用VCD进行股骨止血通常是安全的,有效,目前有一级证据支持。正确的培训和正确的VCD选择,根据患者的个体特征,必须优化结果。
Vascular access is the initial, very important, step of endovascular procedures. Various access sites include the common femoral artery, brachial artery, radial artery, popliteal artery, and distal tibial vessels (pedal arteries). Successful arterial access requires advanced knowledge of anatomy, as well as proper training and experience. Today, vascular access should be obtained using real-time, ultrasound guidance to reduce access time, patient discomfort, and puncture-related complications including dissection, arteriovenous communication, and bleeding. Nevertheless, high-level evidence to support this recommendation in peripheral procedures is limited and level A data are mainly derived from randomized cardiac trials investigating only radial and femoral access. Vascular closure devices (VCDs) for femoral access can be broadly categorized as active closure devices, compression assist devices, and external/topical hemostasis devices. There is high-level evidence demonstrating that their use is related to less time for ambulation and increased patient satisfaction. However, available data failed to clearly demonstrate a benefit in complications compared to standard manual compression in peripheral endovascular arterial procedures, and thrombotic and infectious complications reported following VCD use remain an issue. Heterogeneity noted in the literature, caused by the vast variety of devices, access sites, sheath sizes, clinical scenarios, and procedures, poses difficulties in data analysis and future study design. As a result, an individualized VCD use is currently suggested for ≥ 5 Fr femoral artery access not only to reduce time to hemostasis and ambulation and to improve patient comfort, but also to reduce bleeding complications in cases of femoral access with increased bleeding risk, deranged coagulation, and large-bore access, though a high level of evidence to support this later recommendation is limited. KEY POINTS: US guidance is strongly recommended for femoral access and is mandatory to obtain more challenging access. The use of VCDs for femoral hemostasis is generally safe, effective, and currently supported by level I evidence. Proper training and correct VCD choice, based on the patient\'s individual characteristics, are imperative to optimize outcomes.