Presentations

Abstract

Introduction:

Transcatheter aortic valve replacement (TVAR), a minimally invasive intervention for symptomatic aortic stenosis, is a procedure that involves replacing the aortic valve via the common femoral artery (CFA) access route. While typically safe, transfemoral TVAR is not devoid of complications, such as mechanical device malfunction, cardiac anomalies, and vascular complications at the CFA puncture site.

Case Information:

W.F. is a 27 year old female admitted for transfemoral TVAR due to severe bioprosthetic aortic stenosis and aortic insufficiency. Left CFA access was employed for temporary pacemaker placement, while right CFA access facilitated catheter and guidewire insertion for the TVAR procedure. Subsequent to the successful valve replacement, the right CFA access site underwent repair through employment of a Perclose ProGlide suture-mediated closure system. Contrast angiography at the iliac bifurcation confirmed successful right CFA closure, indicating no vascular stenosis or extravasation. The left CFA access point was secured utilizing an Angio-Seal vascular closure device. Following intraoperative closure, the patient experienced hypotension, necessitating chest compressions and epinephrine administration, culminating in the restoration of spontaneous circulation (ROSC). After reassessment and intervention, a stent was placed due to compromised blood flow in the left main coronary artery ostium.The patient was transferred to the Cardiac Surgical Intensive Care Unit, where she continued to improve and remained hemodynamically stable. The patient was discharged on anticoagulation two days following the TVAR.

One day after discharge, W.F. presented to the emergency department with left groin pain, left lower quadrant tenderness, and dyspnea. Ultrasound confirmed left femoral deep vein thrombosis, prompting a pulmonary embolism (PE) assessment. Although CT angiography detected no PE, it unveiled active extravasation within the left CFA alongside a compressive hematoma encasing the left femoral vein. This led to surgical vascular exploration and repair. The patient remained remained hemodynamically stable and was subsequently discharged.

Discussion:

The most common TVAR complications are vascular, which are categorized into major, minor, and percutaneous closure device failure. Historically, vascular complications have ranged from 10-20%, but current rates may be as low as 4%. Major and minor complications include ischemia, vessel injury (dissection, stenosis, hematoma), with major complications precipitating death, life-threatening hemorrhage, and end-organ impairment.

Abdominal CTA of W.F. demonstrated left retroperitoneal hemorrhage extending into the pelvis, small active extravasation anterior to the distal left external iliac vessels, and narrowing of the proximal left femoral vein lumen extending to the external iliac due to mass effect from an adjacent left pelvic sidewall hematoma. These findings were consistent with a major vascular complication (life-threatening bleeding) in left CFA.

This vascular injury may have occurred during the initial left CFA puncture for TVAR or when reestablishing after ROSC. Most likely, the left CFA injury occurred while reestablishing access when the patient developed obstructive shock. The active extravasation likely remained minimal and the patient remained relatively hemodynamically stable following ROSC. Her fluid status may have been masked by the administration of levophed and saline in the SICU, further delaying symptoms. Starting anticoagulation following discharge likely exacerbated the hemorrhage, which led to rapid deterioration and readmission.

Conclusion:

This case highlights the intrinsic susceptibility to vascular complications accompanying TVAR and transfemoral procedures, with a focal point on the left CFA. Intraoperative angiography serves as a critical tool for assessing vascular integrity. Post-procedure, vigilant observation of patients displaying symptoms suggestive of active hemorrhage, particularly in those undergoing anticoagulation, necessitates expeditious dedicated lower extremity and pelvic CT angiography evaluation.