RESUMEN
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.
Asunto(s)
Estenosis de la Válvula Aórtica/cirugía , Cateterismo Periférico/efectos adversos , Técnicas Hemostáticas/efectos adversos , Reemplazo de la Válvula Aórtica Transcatéter/efectos adversos , Procedimientos Quirúrgicos Vasculares , Lesiones del Sistema Vascular/cirugía , Anciano , Anciano de 80 o más Años , Colombia Británica , Cateterismo Periférico/instrumentación , Toma de Decisiones Clínicas , Femenino , Prótesis Valvulares Cardíacas , Técnicas Hemostáticas/instrumentación , Humanos , Masculino , Selección de Paciente , Estudios Retrospectivos , Medición de Riesgo , Factores de Riesgo , Factores de Tiempo , Reemplazo de la Válvula Aórtica Transcatéter/instrumentación , Resultado del Tratamiento , Dispositivos de Acceso Vascular , Dispositivos de Cierre Vascular , Procedimientos Quirúrgicos Vasculares/efectos adversos , Lesiones del Sistema Vascular/diagnóstico por imagen , Lesiones del Sistema Vascular/etiologíaRESUMEN
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.