Antegrade Bailout Repair of Large Bore Arteriotomy Site

Introduction: Arteriotomy site vascular complications is the most common vascular complications encountered in TAVR and other large bore arterial sheaths interventions. Contralateral retrograde access, wiring, imaging, and if needed intervention was adopted by some TAVR operators. This strategy may fail due to inability to cross over due to hostile calcified aortic bifurcations or trapping of the retrograde wire by the double-Proglide pre-closure.

Method: Reported are 4 cases in which this technique strategy was employed as a bailout antegrade (after failed retrograde attempts) to address femoral arteriotomy site occlusion or bleeding. A 21G needle is used to access the superficial femoral artery (SFA) under fluoroscopy or ultrasound 3 cm caudal to the TAVR arteriotomy site. An 0.018” (V-18) or 0.014” (Whisper) wire is advanced under fluoroscopy across the injured arteriotomy site up to the descending aorta. A 6 or 7 French radial sheath is advanced on the wired across the arteriotomy site to allow stenting or covered stents deployment while using antegrade and retrograde contrast injections to guide the procedure.

Results: All 4 arteriotomy sites were repaired within a few minutes with resolution of bleeding and femoral artery flow. None of the femoral sites required reintervention.

Conclusion: Antegrade arteriotomy site repair is easy to perform, does not require specialized equipment and minimizes the risk of proximal vessel injury. It should be practiced as a bail out method in cases in which the retrograde approach is challenging. Antegrade pre-wiring may facilitate such procedure.