Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

Abstract

BACKGROUND The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject. OBJECTIVE To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature. METHODS A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures. RESULTS The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication. CONCLUSION The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays.

Access-site complications in ultrasound-guided endovascular thrombectomy: a single-institution retrospective cohort study

“…However, the incidence of major complications (2.51%) in our cohort was greater than those previously reported by Oneissi et al for these three groups (0.92%, 0.21%, and 0.83%, respectively). 14 On the other hand, rates of groin pseudoaneurysm and arterial dissection in patients from our cohort were 0.83% (4/479) and 1.04% (5/479), respectively, lower than those reported previously. A 2018 review of 8 RCTs reported groin/puncture site hematoma rates of 3.6%, a groin pseudoaneurysm rate of 1%, and an arterial dissection rate of 2%, 21 and a 2020 review of 7 prospective trials of EVT with transfemoral access reported a major access-site complication rate of 1.67% and a total complication rate of 4.59%.…”

“…Disaggregated, access-site complications in our retrospective cohort treated with EVT using US-guided puncture (4.18%) were comparable with a 2020 systematic review of 16 randomized controlled trials (RCTs) and 17 observational studies, in which the incidence of complication with no US guidance was reported as 5.13% and 2.78%, respectively. 14 Furthermore, our incidence of minor complications (1.67%) was markedly lower than rates previously reported in RCTs (4.07%) and observational studies with or without VCDs (2.05% and 2.85%, respectively). However, the incidence of major complications (2.51%) in our cohort was greater than those previously reported by Oneissi et al for these three groups (0.92%, 0.21%, and 0.83%, respectively).…”

“…The present study also offers a univariate analysis of the effect of US guidance on access-site complication rates in EVT, but it must be noted that other variables factor into these rates, including the concomitant use of anticoagulation or tPA thrombolysis, 35 as well as closure devices. 14 Finally, the overall rarity of access-site complications in EVT presented obstacles to the robust subgroup analysis of potential complication associations with other factors such as patient age, body habitus, comorbidities, and specific equipment.…”

“…To allow for direct comparison with previous reports of groin complications in EVT, we applied the same categorization schema for access-site complication severity used by Oneissi and colleagues. 14 Specifically, minor complications were defined as groin hematomas and groin hemorrhages, while major complications included retroperitoneal hematomas, arteriovenous fistulae, artery pseudoaneurysms, artery dissections, nerve injuries, arterial occlusions, and wound infections.…”

“…Access-site complications account for the most common adverse events across all peripheral vascular interventions (occurring in 1%-11% of these procedures). 13 For EVT, access-site complications have been reported to occur in between 2.78% and 5.13% of cases 14,15 and represent a common and actionable target for improvement in all interventions requiring transfemoral access. Outside of interventional neuroradiology, the use of ultrasound (US) to guide femoral access has garnered attention as one possible means of curtailing these complications.…”