title: Mastering the antegrade femoral artery access in patients with symptomatic lower limb ischemia: learning curve, complications, and technical tips and tricks.
abstract: BACKGROUND
  Antegrade femoral access is fraught by technical challenges and steeper learning curve, in comparison with retrograde contralateral femoral access. We appraised learning curve, complications, and technical aspects inherent in the adoption of antegrade approach.
  
  
  METHODS
  Consecutive cases in which antegrade access was attempted by a cardiologist experienced in retrograde access, but inexperienced in antegrade, under supervision of an operator with anterograde expertise, were collected. The primary end-point was the occurrence of antegrade access failure or local complications. Major complications were defined as those life-threatening, requiring transfusion, percutaneous, or surgical repair.
  
  
  RESULTS
  Anterograde access was attempted in 120 patients. The primary end-point occurred in 14 (11.6%) cases, but according to the learning curve, in 12 (20%) for first 60 cases vs 2 (3.3%) for the last 60 cases (P = 0.008). Access failure in the hands of the in-training operator was similarly found in all cases but one during the first 60 cases. No major complications occurred, while minor complications were found in 9 (7.5%) patients, again with all but two of them occurring in the first 60 cases. These included peri-adventitial extravasation in 8 patients (6.7%), and perforation of a small branch in one (0.8%); all these complications were conservatively and successfully managed. Obesity was the only significant predictor of access failure/complication (P = 0.004).
  
  
  CONCLUSIONS
  This work, the first to report on the learning curve of the antegrade approach, supports the feasibility and safety of this access site even for an in-training operator, if supervised. A minimum caseload of 60 procedures is likely needed to master this technique.
authors.affiliation: Hemodynamics and Cardiovascular Interventions Service, Abano Terme Hospital, Abano Terme, Italy. gbiondizoccai@gmail.com
authors.forename: Giuseppe G L
authors.initials: GG
authors.lastname: Biondi-Zoccai
authors.forename: Pierfrancesco
authors.initials: P
authors.lastname: Agostoni
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Sangiorgi
authors.forename: Luca
authors.initials: L
authors.lastname: Dalla Paola
authors.forename: Fabio
authors.initials: F
authors.lastname: Armano
authors.forename: Simone
authors.initials: S
authors.lastname: Nicolini
authors.forename: Josef
authors.initials: J
authors.lastname: Alek
authors.forename: Massimiliano
authors.initials: M
authors.lastname: Fusaro
mesh_terms: D000368:Aged; D001157:Arterial Occlusive Diseases / Q000601:surgery*; D002406:Catheterization, Peripheral / Q000009:adverse effects / Q000379:methods*; D002983:Clinical Competence; D004502:Education, Medical, Continuing / Q000379:methods*; D005260:Female; D005263:Femoral Artery / Q000601:surgery; D006801:Humans; D007511:Ischemia / Q000601:surgery; D007866:Leg / Q000098:blood supply; D023821:Limb Salvage / Q000193:education*; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000193:education; D009765:Obesity / Q000150:complications; D016491:Peripheral Vascular Diseases / Q000601:surgery*