Peripheral Vascular Access Complications After Percutaneous Procedures: A Single-Center Experience

The Seldinger technique is a widely used percutaneous method for vascular and hollow organ access in numerous medical specialties, including interventional radiology, cardiology, cardiovascular surgery and vascular surgery.

Peripheral vascular access is fundamental in cardiovascular surgery, enabling hemodynamic monitoring, drug administration, mechanical circulatory support, and device-based interventions. Despite its necessity, vascular access is frequently associated with complications that may adversely affect outcomes. Complications can occur with both peripheral and central venous cannulation, including arterial puncture, hematoma, infection, and thrombosis, underscoring the need for careful technique selection and management strategies.¹ Central venous catheter insertion, for instance, has evolved with approaches such as posterior access to the internal jugular vein to reduce adverse events, though procedural risks remain.²

In the context of percutaneous coronary interventions, vascular access site complications can significantly influence procedural success and patient prognosis. Advances in percutaneous techniques have improved safety; however, bleeding, vascular injury, and access-site failure are still reported, especially in complex cases.³ Similarly, extracorporeal membrane oxygenation (ECMO) requires large-bore vascular cannulation, which carries risks of ischemia, bleeding, and vessel injury. These complications are associated with increased morbidity and mortality, and require vigilant monitoring and timely management.⁴

Transcatheter aortic valve implantation (TAVI) is another cardiovascular intervention during which vascular complications are common and clinically relevant. Studies have shown that vascular injury during transfemoral TAVI not only complicates the procedure but is also associated with higher mortality.^5,6 Broader reviews of vascular access complications emphasize the importance of early diagnosis and structured management approaches to mitigate these risks.⁷ Similarly, complications after other valvular interventions demand multidisciplinary strategies for optimal outcomes.⁸

The challenge is further compounded by the growing use of temporary percutaneous mechanical circulatory support devices, which also introduce unique vascular risks, particularly in patients with cardiogenic shock.⁹ Moreover, delayed vascular complications, such as those seen after ECMO, highlight the importance of long-term surveillance and tailored management strategies.¹⁰ Even routine diagnostic procedures such as coronary angiography can carry vascular risks, including dissection, perforation, and access-related bleeding, necessitating preventative measures and contingency planning.¹¹

Recent case reports and series have added nuance to our understanding of access-related and adjunct complications. For example, a case of unilateral pulmonary edema occurring after minimally invasive mitral valve surgery required peripheral venoarterial ECMO and independent lung ventilation for its resolution, illustrating how accesssite or access-adjacent complications may escalate into life-threatening situations if not managed promptly.¹² Another report described endoscopic mitral surgery in a patient with Noonan syndrome, underscoring how anatomical or genetic factors may complicate otherwise routine vascular access or surgical exposures.¹³

Given the increasing reliance on peripheral vascular access across a wide range of cardiovascular interventions, understanding the spectrum of complications and developing evidence-based management strategies are critical. This paper aims to review the management of complications associated with peripheral vascular access in cardiovascular surgery, integrating insights from contemporary literature across diverse procedural contexts.

In this in-hospital study, carried out at the Emergency Institute for Cardiovascular Diseases and Transplantation in Târgu Mureş, Romania, we examined a cohort of 81 patients admitted between 2017 and 2024, who had severe vascular complications that required surgical interventions for vascular axis reconstruction after cardiovascular procedures using the Seldinger vascular technique, including peripheral cannulations, ECMO, TAVI, coronary angiography, and angioplasty.

In our center, approximately 3,000 percutaneous interventions are performed annually, amounting to a cumulative total of 23,370 procedures in the studied period, including 592 TAVI procedures. Among these, only 81 patients (0.35%) experienced vascular complications related to peripheral vascular access that required surgical intervention as definitive therapy. Of this cohort, 73 patients (90.1%) presented with complications involving the femoral artery, whereas 8 patients (9.9%) developed complications at the radial artery. Given the predominance of femoral access-related complications, the present analysis focuses on this subgroup.

Statistical analysis was performed using Microsoft Excel and IBM SPSS 25. Descriptive analysis was conducted, and group comparisons were made using the chi-squared test. The level of statistical significance was set at p < 0.05.

The study included 73 patients with a mean age of 65.7 ± 13.3 years, comprising 87.6% who were over 50 years old, the majority being men (60.2%). The major modifiable cardiovascular risk factors identified were hypertension (42.4%), diabetes mellitus (36.9%), dyslipidemia (35.6%), and smoking (34.2%). Among the associated diseases, the following stand out: cardiopathies (97.5%), anemia (67.1%), peripheral arterial disease (32.8%), coagulopathies (28.7%), chronic kidney disease (26.0%), and liver diseases (9.5%). Patients with previous vascular interventions experienced a higher incidence of vascular complications (45.2%) compared to those without such a history (42.9%). The chi-squared test confirmed a statistically significant association between previous procedures and the risk of complications in future interventions (p < 0.001). Analysis of post-puncture vascular complications indicated that the most frequent were pseudoaneurysm (43.8%), followed by hematoma and fistula. When comparing distribution by sex, pseudoaneurysm was present in 40.91% of men and 48.28% of women (p = 0.7042). The most frequently used surgical intervention was arterial suturing (67.1%). When comparing distribution by sex, suturing was performed in 61.36% of men and 75.86% of women (p = 0.3003).

The demographic and clinical features of the study population, including age, sex distribution, BMI categories, and prevalence of comorbidities, are presented in Table 1. Procedural details, complications, and anesthetic approaches are presented in Table 2.

Peripheral vascular access in cardiovascular interventions carries substantial risks, and complications remain a significant contributor to morbidity and mortality‥ The incidence of severe access-site complications requiring surgical intervention was low in our center, with only 81 cases among 23,370 percutaneous procedures (0.35%), of which 73 involved femoral artery access. Considering the high volume of coronary interventions and the substantial number of large-bore procedures such as TAVI and ECMO, this rate is comparable to contemporary reports from high-volume cardiovascular institutions.^3,9 Femoral artery pseudoaneurysms are among the most frequent complications following catheterization, with risks heightened by anticoagulation, large sheath sizes, and repeated punctures. In our study, pseudoaneurysm was the most frequent severe complication requiring surgery (43.8%), which is consistent with published data. Management has evolved from surgical repair toward less invasive strategies such as ultrasound-guided compression and thrombin injection, which have become standard due to their safety and efficacy. However, surgical intervention remains necessary in cases of rupture, infection, or failed percutaneous management.¹⁴ The clinical profile of the cohort, however, reflects a population at inherently high risk for vascular injury. The prevalence of anemia (67.1%), peripheral arterial disease (32.8%), chronic kidney disease (26.0%), coagulopathies (28.7%), and obesity (38.36%) underscores the fragility of these patients. Each of these comorbidities is independently associated with impaired vessel wall integrity, delayed hemostasis, and increased susceptibility to bleeding complications. When analyzing complications by sex, pseudoaneurysm was identified in 40.91% of men and 48.28% of women (p = 0.7042). Hematomas and pseudoaneurysms were likewise more frequently observed in female patients, although without statistical significance. Simple arterial suturing represented the most common surgical approach (67.1%), performed in 61.36% of men and 75.86% of women (p = 0.3003). Although women exhibited a slightly higher proportion of access-site complications, this difference did not substantially alter the overall distribution of surgical management strategies. The predominance of cases managed by primary arterial suturing suggests that most defects were limited in extent and did not involve major arterial ruptures. This observation further supports the assumption that many of these lesions might have been amenable to treatment with vascular closure devices (VCDs). Consequently, the failure of VCDs in this cohort may be attributed to several factors, including operator experience, device malfunction, unfavourable femoral arterial anatomy, or suboptimal puncture site selection, preventing proper deployment of the closure system. In contrast, the cases requiring patch angioplasty or bypass grafting were associated with extensive arterial ruptures, situations in which currently available VCDs are inherently ineffective and cannot provide adequate hemostasis.

In transcatheter aortic valve implantation, access-site complications such as bleeding, arterial rupture, and dissection are strongly associated with adverse outcomes, necessitating meticulous pre-procedural risk assessment, advanced imaging, and appropriate device selection to minimize procedural risk.¹⁵ These considerations are particularly relevant given that TAVI is predominantly recommended for elderly patients, typically those older than 70 years, and individuals with significant comorbidities who are at increased surgical risk. Our results align with this clinical profile, as 87.6% of the patients in our cohort were older than 50 years, and comorbidities were highly prevalent, further supporting the vulnerability of this population to access-site complications. Prevention of vascular complications in TAVR is critical, with strategies including sheath-to-artery ratio optimization, meticulous puncture technique, and prompt recognition of bleeding or vessel injury. Recent studies have highlighted that procedural techniques can further influence outcomes. Predilatation does not significantly affect long-term survival, whereas postdilatation may be associated with a trend toward increased mortality, independent of transprosthetic gradient. Furthermore, CT-derived anatomical assessment did not predict acute complications after TAVI, emphasizing the importance of careful procedural planning and operator experience in achieving safe outcomes.^16,17

Iatrogenic complications may also arise from technical errors, such as guidewire retention, which, although rare, highlight the risks of procedural oversight and the importance of strict adherence to protocols to mitigate preventable harm.¹⁸ More broadly, cardiac catheterization itself is associated with vascular trauma, bleeding, embolism, and arrhythmic events, reinforcing the need for meticulous patient selection, procedural planning, and complication preparedness.¹⁹ Complication risks are amplified in complex cases of percutaneous coronary intervention (PCI). Consensus-derived management algorithms now provide structured responses to vascular perforation, dissection, and access-site bleeding, ensuring rapid and systematic intervention.²⁰ Previous vascular interventions were strongly associated with the occurrence of complications (p < 0.001), reinforcing the concept of cumulative arterial injury. Repeated femoral punctures, progressive atherosclerosis, and previous endovascular or surgical manipulations contribute to structural weakening of the arterial wall. Patients with repeated access should thus be systematically considered high-risk, warranting ultrasound-guided puncture, meticulous access planning, and careful selection of closure devices.

Although transradial access reduces bleeding compared with femoral approaches, it is not without risk. Complications such as radial artery occlusion, spasm, and perforation remain clinically relevant, requiring careful sheath selection, adequate anticoagulation, and post-procedural surveillance.²¹ This is supported by our finding that only eight radial complications over 8 years required surgery, highlighting the rarity of severe radial injuries. For femoral access, vascular injuries, including pseudoaneurysm, arteriovenous fistula, and retroperitoneal hemorrhage, are increasingly treated with endovascular approaches such as covered stents and coil embolization, which offer effective minimally invasive management.²² Long-term multicenter experience supports the safety and durability of percutaneous techniques for vascular access complications when appropriately applied.²³ Nevertheless, surgical repair continues to play a role in cases where endovascular treatment is not feasible, such as in extensive vessel rupture, infection, or hemodynamically unstable patients.

Vascular closure devices (VCDs) represent an essential component in minimizing femoral access-related complications. In our cohort of 73 patients requiring surgical revision for hemostatic failure, VCDs (AngioSeal VIP, ProGlide) had been used in 23 cases (31.51%), whereas 50 patients (68.49%) initially underwent manual compression. In all cases included in the study, these hemostatic techniques, whether device-assisted or manual, ultimately failed, leading to the development of clinically significant femoral artery complications. Despite this, the overall complication rates associated with femoral access remain low, with failure rates consistently reported to be higher following manual compression compared with VCD-assisted hemostasis.

Manual hemostasis in the femoral region is technically challenging, particularly in obese patients, where increased adipose tissue and deeper vessel location diminish the effectiveness of external compression. In such patients, first-intention hemostasis using VCDs is generally recommended due to superior efficacy and reduced failure rates. Conversely, in normal-weight individuals, manual compression or external compression systems may be acceptable alternatives, particularly in settings where closure devices are unavailable.

In our cohort, obesity classification further highlighted this discrepancy. Among patients with BMI 30–34.9 kg/m² (n = 22), VCDs were used in 8 cases (38.09%), whereas 13 patients (61.90%) underwent manual compression. In patients with BMI 35–39.9 kg/m² (n = 5), manual compression was used exclusively (100%), and the same was observed in the single patient with BMI ≥ 40 kg/m². These findings indicate that, despite evidence favoring deviceassisted hemostasis in obese individuals, the majority of overweight and obese patients in our study initially received manual compression. This observation underscores the need to prioritize VCD use as the first-line hemostatic strategy in obese patients, in whom manual compression is inherently less reliable and more frequently associated with hemostatic failure. Studies confirm their role in lowering bleeding and vascular injury rates during PCI, although improper use can itself cause arterial stenosis, infection, or device failure.^24,25 Contemporary reviews emphasize that risk reduction depends on both device type and operator expertise, highlighting the necessity of tailored strategies based on patient and anatomical factors.²⁶ In TAVR, prevention of vascular complications is equally critical, with strategies including sheath-to-artery ratio optimization, meticulous puncture technique, and prompt recognition of bleeding or vessel rupture.²⁷

High-risk scenarios such as percutaneous mechanical circulatory support (pMCS) further amplify vascular access risks due to the use of large-bore sheaths. Here, sheath management protocols and closure systems play a vital role in reducing bleeding and vessel trauma, with growing emphasis on pre-closure techniques.²⁸ Recent comparative analyses of plug-based versus suture-based closure systems suggest both approaches can mitigate complications, though device choice should be individualized based on operator familiarity and patient anatomy.²⁹ Updated reviews reinforce the importance of proper deployment technique to minimize risk of stenosis, infection, and late bleeding.^30,31 In our surgically treated cohort, arterial suturing represented the primary therapeutic approach (67.1%), followed by patch angioplasty (31.5%) and bypass grafting in a minority of cases (1.4%). The distribution of complications included pseudoaneurysm in 43.80% of patients, hematoma in 36.99%, and arteriovenous fistula in 20.5%. Pseudoaneurysms and hematomas may occasionally be treated conservatively, particularly when they are small, stable, and responsive to targeted compression, yet in most cases that progress to surgical referral, the arterial wall defect is sufficiently large or unstable to require open repair. Arteriovenous fistulas, on the other hand, exhibit a distinct clinical course: small femoral AV fistulas may close spontaneously, especially when the communication is narrow and flow is low. However, larger fistulas rarely undergo spontaneous closure and typically necessitate surgical intervention, as was the case in our series.

Emerging evidence supports new-generation closure technologies designed to improve hemostasis and enable early ambulation without increasing complication risk.³² Bioabsorbable systems have demonstrated favorable real-world outcomes, although vigilance is required for rare but serious device-related complications.³³ Notably, An-gio-Seal, one of the most widely used VCDs, carries risks of arterial occlusion, infection, and embolization if misapplied, underscoring the need for careful monitoring and readiness to intervene surgically or endovascularly in the event of device failure.³⁴

Large-bore sheath management represents another critical frontier in complication prevention. Risk factors such as improper puncture site, sheath size mismatch, and suboptimal anticoagulation are directly linked to vascular injury and bleeding. Standardized protocols emphasizing ultrasound-guided puncture, careful anticoagulation control, and staged sheath removal have been shown to minimize complication rates.³⁵ Still, in severe cases, such as uncontrolled retroperitoneal bleeding or catastrophic vessel rupture, open surgical repair remains the definitive treatment and must be rapidly available in centers performing complex cardiovascular interventions. The management data in our study where arterial suturing was the most frequent surgical technique underscores the need for available and prompt surgical expertise.

While our observations generally correspond with existing studies, they also provide new insights into vascular complications in high-risk patients (Table 3).

This study has several limitations. It is a retrospective, single-center analysis, which may limit generalizability, and the small sample size (n = 73) restricts statistical power for subgroup and multivariate analyses. The inclusion of diverse cardiovascular procedures (TAVI, ECMO, angiography, angioplasty, cannulation) adds heterogeneity. Although no short-term complications were detected during the immediate postoperative period, minor complications managed conservatively were not captured, potentially biasing toward more severe cases. Some clinical parameters, such as sheath size, puncture technique, anticoagulation, and closure device, were inconsistently documented, limiting assessment of their impact. Finally, causal relationships cannot be established; prospective, multicenter studies with standardized data and long-term follow-up are needed to validate these findings and refine risk stratification.

Taken together, the literature demonstrates that while vascular access complications remain a persistent risk in cardiovascular surgery and intervention, their incidence can be significantly reduced by careful patient selection, risk stratification, procedural planning, and the use of structured management algorithms. Advances in closure devices, adoption of minimally invasive rescue techniques, and readiness for surgical intervention when percutaneous management fails are key to optimizing outcomes in this high-risk domain.

This single-center retrospective study of 73 surgically managed complications provides quantifiable evidence for enhanced risk stratification in peripheral vascular access.

We confirmed that prior vascular interventions are a statistically significant risk factor for severe access failure requiring surgery. The high-risk cohort is characterized by advanced age and extensive comorbidities, particularly cardiopathies. The most frequent complication necessitating operative intervention was pseudoaneurysm, primarily managed by arterial suturing.

The underutilization of VCDs in obese patients may therefore represent a contributing factor to hemostatic failure and the need for surgical revision.

These findings underscore that while preventative measures are essential, centers performing complex procedures must incorporate these specific risk factors into their planning. Furthermore, they highlight the critical, ongoing necessity of rapid surgical expertise as the definitive management for severe access complications that frequently resist percutaneous treatment in this vulnerable population.