Expanding Hematoma at the Start of Transcatheter Aortic Valve Implantation Procedure

An 82-year-old woman with symptomatic severe aortic stenosis was scheduled for elective transcatheter aortic valve implantation (TAVI). The suitability of vascular access via the transfemoral approach was confirmed using computed tomography (CT) with the femoral bifurcation just below the level of the lower-femoral head.

Ultrasound guidance was used to obtain anterior wall puncture of the right common femoral artery with successful insertion of 5F sheath. The puncture site was subsequently prepared using blunt dissection technique after infiltrating local anesthetics to introduce two percutaneous closure devices (Proglide, Abbot vascular). Sheath position was confirmed through femoral angiography which reveals extensive contrast extravasation extending over the femoral bifurcation and distal common femoral artery [Figure 1, Panel A]. A small hematoma was noted, and manual pressure was applied. Nonetheless, bleeding continued despite continuous manual pressure. On close inspection, it transpired that contrast was exiting the sheath very early and suggesting that the bleeding site was within the sheath itself [Video 1]. The sheath was exchanged, and repeat angiography confirmed the absence of contrast extravasation with no signs of active bleeding at the puncture site [Figure 1, Panel B and Video 2]. The sheath was subsequently upsized to 14F eSheath and 23 mm S3 Sapien Ultra balloon-expanding valve (Edwards, lifescience) was implanted with no complication. The site was closed with good hemostasis. The patient was discharged on the following day with no events.

Figure 1.

Contrast extravasation upon checking sheath position (a)with subsequent hemostasis when applying a new sheath (b)

Vascular complication is a recognized challenge during TAVI procedure. Its incidence became less frequent over the years. This was mainly driven by improvements in the design of valve delivery systems, smaller sheath sizes, and the high use of CT imaging to assess the suitability of femoral vasculature, in addition to operator's experience.[1]

Recent randomized clinical trials reported an incidence of 2%–4% of vascular complications in patients who were considered at low surgical risk.[2,3] In our case, understanding the mechanism of the vascular complication allowed us to maintain the same access site for TAVI procedure. Bleeding from a branch was a possible alternative explanation. The uncontrolled nature of bleeding, despite continuous manual pressure, might have necessitated a contralateral puncture to tamponade the main vessel or emergency surgical repair. More importantly, early identification of the vascular complication enabled us to achieve successful implantation of the valve and early discharge of the patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.