The wire not advancing further. What is the next best step?

1. Call vascular surgery

2. Switch to radial access

3. Deploy covered stent

4. Retract and redirect wire

The wire not advancing further. What is the next best step?

1. Call vascular surgery

2. Switch to radial access

3. Deploy covered stent

4. Retract and redirect wire

Figure 1. Guidewire in deep circumflex iliac artery

Correct Answer: Retract and redirect wire The lateral course of the guidewire suggests that is located in the deep circumfex iliac artery (Figure 2). Inserting a sheath over the guidewire into this small branch could result in perforation. Simple wire redirection was successful in advancing the guidewire into the right external iliac artery (Figure 3).

Common femoral

Inf. epigastric

Deep femoral(profundis)

Superficial femoral

Deep circumflex

iliac

Figure 3. Wire retracted and redirectedFigure 2. Femoral access angiographic anatomy

Option 1: Calling vascular surgery is not necessary unless a perforation is confirmed with contrast extravasation that cannot be controlled in the cath lab.

Option 2: Switching to radial access is possible, but will likely not be necessary if simple wire redirection achieves the goal of safely obtaining femoral arterial access.

Option 3: Covered stent deployment is also not required, since no perforation has occurred; moreover, stent implantation in the common femoral artery is suboptimal as it is prone to fracture.