Vascular Access Complications and Clinical Outcomes of Vascular Surgical Repairs Following Transcatheter Aortic Valve Implantation (TAVI).

BACKGROUND: Transcatheter aortic valve implantation (TAVI) procedures have revolutionized the treatment of aortic stenosis. However, due to large sheaths, improperly deployed closure devices, and the comorbidities and challenges innate to this population, vascular access complications can be devastating. The objective of this study is to evaluate vascular access complications in one of the largest TAVI sites in North America. METHODS: This was a retrospective single center review between January 2014 and December 2018 of vascular access complications necessitating operative intervention by vascular surgery. Patient demographics and preoperative comorbidities were collected. Type of vascular access complication, types of repair, closure device used, and postoperative outcomes were analyzed. RESULTS: A total of 37 cases out of a total of 985 TAVI procedures were identified. TAVI was carried out in the operating suite (70%) or the catheterization lab (30%). Consults to vascular surgery were requested intraoperatively (60%), immediately postoperative (14%), later in the day of the TAVI (20%), and on postoperative day 1 (6%). The location of injury included common femoral artery (49%), superficial femoral artery (11%) and external iliac artery (41%), with some cases injuring multiple vessels. Closure devices were found in the subcutaneous tissue (26%), anterior wall (37%), posterior wall (11%), intra-arterial (11%), closing the anterior to the posterior wall (16%), and in the inguinal ligament (5%). Injuries included tears (11%), dissections (38%), and vessel rupture (19%). The majority of repairs were done primarily (64%), with patch (28%) and bypass (8%) less frequently. Four patients died perioperatively (11%), 2 from hemorrhage, 1 from cardiac arrest, and 1 from progressive respiratory disease. CONCLUSIONS: Access complications during TAVI procedures predispose complex patients to increased risk of morbidity and mortality. Careful patient selection, proper access techniques, and performing high risk patients in the operating suite with vascular surgery are fundamental in minimizing complications.

Removing the infected aortofemoral graft using a two-stage procedure with a delay between the stages.

This study describes the results of a procedure for removing the infected aortofemoral graft using a two-stage procedure with a delay between the stages. The objective was to lessen the morbidity and mortality associated with removing an infected graft through a single operation. Eight consecutive patients were treated in this manner over a 6-year span. The indications for surgery were infected groin false aneurysms in three, chronic draining sinuses involving the prosthetic graft in four, and an open groin infection involving graft in one. There were five males and three females, with ages ranging 47-83 years (mean = 63). The mean operative time of the first-stage operation was 5.1 hr (range 3.0-7.7), and the mean blood transfusion requirement was 1.7 units. The mean operative time of the second stage operation was 3.5 hr (range 3.5-7.6), and the mean blood transfusion requirement was 2.5 units. In six patients, the hospital course was uncomplicated, with a mean hospital stay of 8.4 days for the initial stage and 9.2 days for the second stage. Two patients had complicated postoperative courses with hospital stays of >30 days. There was no operative or graft-related late mortality. No patients were lost to follow-up. One patient died of unrelated causes with a patent graft at 22 months postsurgery. All other patients remain well with patent grafts, without requiring revisions at a mean follow-up of 33 months (range 6-73). A two-stage approach with a delay between the stages may reduce the morbidity and mortality associated with the removal of an infected aortobifemoral graft.

Results of prosthetic-vein composite graft with remote popliteal arteriovenous fistula in infragenicular bypass.

OBJECTIVE: The purpose of this study is to report the results of a novel procedure for femoral-distal bypass grafting using a composite graft with an adjunctive remote popliteal fistula distal to the prosthetic portion of the graft. This reconstruction was developed for use in limb salvage in the absence of satisfactory autogenous vein. METHOD: Data were collected prospectively on all patients undergoing this procedure from January 1, 1993 to December 31, 1999. Graft patency was determined from follow-up duplex scanning. Patient survival was determined by clinic follow-up. RESULTS: A total of 43 procedures were performed in 38 patients. In 34 patients, 72 previous arterial operations had been previously performed on the ipsilateral limbs. There were 20 men and 18 women with a mean age of 72 years. The indication for surgery was limb salvage in all, with rest pain in 30, and tissue loss in 13. The outflow artery was the below-knee popliteal artery in 10 and a tibial artery in the remainder. Operative mortality was 6.8%. Mean follow up was 26.9 months. The primary patency was 54% at 12 months. Six reconstructions were revised for a primary assisted patency of 60% at 16 months. Secondary patency was 69% at 16 months. Patient survival was 62% at 2 years and 26% at 5 years. CONCLUSIONS: The technique of composite grafting with remote popliteal arteriovenous fistula may be a useful alternative in infragenicular bypass when a satisfactory autogenous vein is not available.