Treatment Algorithm Demonstrates Favorable Outcomes for Endovascular Repair of Access Site Complications

Large bore percutaneous access has been increasingly performed, which can result in access site complications such as bleeding, dissection, thrombosis, and pseudoaneurysms. Given the greater risks and longer length of stay with open vascular repair, covered stent-grafts can potentially treat these situations much more rapidly. We have proposed a treatment algorithm for access site-related complications. During a 60-month period, we performed nine femoral artery repairs, including endarterectomy, profundaplasty, and patch repair or interposition grafts. We placed 68 Viabahn or Viabahn VBX (W. L. Gore & Associates, Flagstaff, Ariz) stent-grafts across the inguinal ligament in emergent settings to treat access site complications, including bleeding and hemorrhagic shock, arterial dissection, pseudoaneurysms, and iatrogenic arteriovenous fistulas. No stents had compromised flow to either the deep or superficial femoral artery. We retrospectively reviewed our technical success, which was defined by complete arterial repair, open conversion, and in-hospital and 30-day mortality. We examined the incidence of blood transfusions and wound complications and compared both techniques with our historical controls from open vascular repair. We followed up the patients using duplex ultrasound and computed tomography angiography. Nine open repairs were performed. We had placed 26 Viabahn and 42 Viabahn VBX stents in the distal external iliac artery and proximal common femoral artery in 40 men and 34 women. The indications were bleeding in 38 patients (52%), flow limiting dissection in 32 patients (41%), and a symptomatic arteriovenous fistula in 4 patients (7%). None of the deployed stents had compromised flow to the deep or superficial femoral artery. None of the patients who had undergone endovascular repair required open conversion or evacuation of hematomas. The transfusion requirement and hospital stay were shorter than those for the historic controls. At the 30-day follow-up, stent patency was 100%, and no stent fractures or kinks were found. The midterm follow-up (50 of 74 patients) showed 100% patency with no evidence of stent fracture, stenosis, or kinking. Using our algorithm, Viabahn and Viabahn VBX stents can be placed safely and effectively in the distal external iliac and common femoral arteries across the inguinal ligament with little or no vascular complications, preserving the outflow vessels (superficial and deep femoral arteries). These stent-grafts reduce the need for open surgery, blood transfusions, and hospital length of stay. In the midterm-related follow-up, these stent-grafts performed well. No kinking or thrombosis had developed and no open revisions had been required. Longer term follow-up is required.