Fishes live in the sea, as men do a-land; the great ones eat up the little ones
William Shakespeare
Thanks to major procedural refinements and technological developments, transcatheter aortic valve implantation (TAVI) continues to expand its clinical role for patients with severe aortic stenosis. From its original validation in patients at prohibitive or very high surgical risk, TAVI is now considered a mainstay in the management of subjects with high or intermediate risk, and studies are under way to appraise its comparative safety and effectiveness. Yet, TAVI still entails the use of large vascular sheaths, which may be difficult to safely and effectively manage even with current generation devices. In the light of ongoing collaboration between industry and physicians, new devices to manage large arteriotomies, such as the Manta collagen plug (Essential Medical, Exton, PA, USA), with favourable preliminary findings have been introduced.
In this issue of the Journal, Hoffmann et al.1 provide the first description of a late pseudoaneurysm after Manta use for TAVI. In their case report, the authors describe the case of a 73 year old gentleman who had undergone uneventful TAVI with left femoral access haemostasis by means of a 14F Manta. He presented five weeks later with pain and claudication like symptoms in the left leg. Prior medical history included hypertension, diabetes, and atrial fibrillation. Computed tomography angiography showed a significant pseudoaneurysm in the left common femoral artery (CFA). Vascular surgery was successfully performed, with favourable results up to the three month follow up.
This appears to be the first ever late complication following successful use of the Manta vascular closure device, and it is even more clinically relevant considering that, despite the affected patient having had extensive calcification in the pelvic arteries, the left CFA was not extensively diseased and the acute angiographic results appeared quite favourable. Accordingly, and in light of prior reports of potential adverse events occurring during or early after using the Manta device,2, 3 it remains important to maintain active vigilance for late access site complications such as pseudoaneurysms after TAVI, having a low threshold for imaging tests in patients presenting with discomfort from the arterial access site or distally in the affected extremity, especially whenever vascular closure devices are used for large arteriotomies.
Conflict of interest
Prof. Biondi-Zoccai has consulted for Abbott Vascular and Bayer.
Funding
None.
References
- 1.Hoffmann P, Al-Ani A, von Lueder T, Skoe ØW, Tran TT, Opdah A. Late pseudoaneurysm after access site closure with Manta in transfemoral aortic valve implantation. 2018. 10.1016/j.ejvssr.2018.10.003. [DOI] [PMC free article] [PubMed]
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