KEY CLINICAL MESSAGE
In challenging common femoral artery assess scenarios, the “wall
PIERCE” technique, which utilizes a larger puncture needle to pierce
the vessel wall along the guidewire, facilitates sheath insertion. This
method proves successful in two cases without any complications,
presenting a valuable addition to strategies for addressing challenging
sheath insertion scenarios.
Keywords: wall PIERCE technique, puncture, endovascular
therapy, trans femoral approach, common femoral artery
INTRODUCTION
With the evolution of devices, medical procedures involving less
invasive approach sites, such as transradial access, distal radial
access, and tibiopedal arterial (tibiopedal arterial minimally invasive
retrograde revascularization), have become preferred in percutaneous
coronary intervention (PCI) and endovascular therapy
(EVT).1-3 However, the common femoral artery (CFA)
approach remains necessary for procedures requiring large-diameter
sheath, such as an 8Fr for PCI or EVT below the inguinal region. Even
when successfully accessed and a 0.035-inch guidewire is inserted,
inserting the sheath through the CFA can sometimes be difficult. This is
particularly common in cases with severe calcification of the vessel
wall of the CFA, cases with a history of multiple CFA approaches for
chronic limb-threatening ischemia (CLTI), or accessing the CFA after
endarterectomy. Typically, these challenges are addressed by first using
a bougie with a dilator attached to the sheath, replacing the guidewire
with a sturdier 0.035-inch guidewire, or replacing the sheath with a
smaller-diameter sheath. If sheath insertion remains difficult, the
puncture or approach site should be changed.
We have recently encountered two cases in which a sheath was
successfully inserted using the ”wall PIERCE” technique. This technique
involves using a larger puncture needle to pierce the vessel wall along
the guidewire. In this case series, we present these two cases.
CASE 1
Case history and examination
A man in his 60s presented with Rutherford class 5 lower-extremity
artery disease with resting pain and an ischemic ulcer on his left
fourth toe. He had a history of diabetes mellitus and was undergoing
hemodialysis. A few years prior, he underwent an endarterectomy for a
calcified lesion in the left CFA (Figure 1A). Duplex ultrasonography
revealed a chronic total occlusion of the left distal superficial
femoral artery.
Differential diagnosis, investigations, and treatment
We opted for an ipsilateral approach from the left CFA and accessed it
using an 18GA puncture needle. The insertion was performed successfully,
and the 0.035-inch guidewire advanced into the superficial femoral
artery. However, the sheath could not follow the guidewire owing to the
hardened vessel wall resulting from the prior endarterectomy of the CFA
(Figure 1B). To overcome this challenge, we employed the “wall PIERCE”
technique, which involves inserting a 12GA puncture needle (BD
AngiocathTM IV Catheter 12GA×3.00IN; BD Bioscience,
Franklin Lakes, NJ, USA) along the guidewire to penetrate the vessel
wall of the CFA, thereby facilitating the subsequent passage of the
sheath (Figure 1C). After performing the “wall PIERCE” technique, the
sheath was inserted successfully (Figure 1D). Figure 1E shows the BD
AngiocathTM IV Catheter 12GA×3.00IN (left upper
panel). A puncture needle without a catheter was used in the wall PIERCE
technique (left, lower panel).
CASE 2
Case history and examination
A woman in her 70s with Rutherford class 5 lower-extremity artery
disease presented with resting pain and gangrene in her left third and
fifth toes. She had a history of diabetes mellitus and was undergoing
hemodialysis.
Differential diagnosis, investigations, and treatment
We opted for an ipsilateral approach from the left CFA and punctured
with an 18 GA puncture needle. Fluorography revealed severe
calcification at the insertion site in the left CFA (Figure 2A). The
artery was accessed successfully, and the 0.035-inch guidewire advanced
into the superficial femoral artery. However, the sheath could not
follow the guidewire, as the vessel wall was hardened owing to severe
calcification (Figure 2B-D). The “wall PIERCE” technique was
accordingly used to penetrate the vessel wall of the CFA, thereby
facilitating the subsequent passage of the sheath (Figure 2E). After
performing the “wall PIERCE” technique, the sheath was inserted
successfully (Figure 2F).
DISCUSSION
In some scenarios, transfemoral access is selected when performing PCI
or EVT procedures. However, dense calcifications at the puncture site or
blood vessel wall stiffening after endarterectomy can hinder sheath
advancements, even if the puncture needle and guidewire are successfully
inserted. We believe, based on our experience, that the “wall PIERCE”
technique is effective in these cases.
Nakama et al. reported an inner PIERCE technique for advancing through
hard lesions such as calcifications.4 This method
involves modifying a highly calcified lesion using a retrograde long
puncture needle when the guidewire passes through the infrapopliteal
lesion and a pull-through is achieved, but the balloon does not pass
through. This modification is highly effective and allows the balloon to
pass through, facilitating balloon expansion. We applied this technique
at the CFA puncture site. A 12GA needle is used. Piercing with a 12GA
needle creates a hole equivalent to 2 mm around the guidewire (Figure
1E, right panel), effectively accommodating a 4Fr sheath. Piercing the
blood vessel wall with this 12GA needle facilitates subsequent sheath
insertion. In addition, even if a 5Fr sheath is inserted, there is no
leakage around the sheath during EVT. Another advantage of this
technique is the cost-effectiveness of the puncture needle.
However, the needle is relatively bulky. Therefore, it is recommended to
change the guidewire to a 0.035-inch support-type guidewire to prevent
potential injury to the guidewire by the needle and its subsequent
rupture. Notably, at our hospital, we used the “wall PIERCE” technique
in nine cases between January 2021 and January 2024, and sheath
insertion was successful in all cases, with no complications such as
guidewire rupture or hematoma (Table 1).
The “wall PIERCE” technique has been mainly used only for EVT cases;
however, we believe that it can also be utilized when inserting a PCI
sheath. Although we exclusively used the BD AngiocathTM IV Catheter 12GA
x 3.00IN, we believe the same procedure can be performed with other
needles close to 12GA in size.