Chief of Vascular Surgery Oregon Health & Science University (OHSU) Portland, Oregon
Objectives: Femoral artery access for endovascular intervention in individuals with vascular Ehlers-Danlos syndrome (VEDS) has been associated with severe access-related complications, yet endovascular therapy is often unavoidable. We evaluated femoral artery access strategies and outcomes in patients with genetically confirmed VEDS to inform a selective, biology-informed approach to arterial access.
Methods: This is a cross-sectional cohort study of patients with genetically confirmed VEDS undergoing endovascular procedures requiring femoral arterial access between 1989 and 2025. Abstracted data included patient demographics, COL3A1 variant, procedural characteristics (including sheath size and closure method), technical success, and access-site complications. The primary outcome was major access-related complications, defined as femoral artery dissection, pseudoaneurysm, or rupture requiring operative repair and percutaneous closure device failure requiring open repair. Outcomes were compared by closure method (manual compression, percutaneous closure device, or planned surgical exposure and repair) and sheath size ( < 6 or ≥6 French).
Results: Among a cohort of 392 patients with VEDS, 59 (15.1%) underwent endovascular procedures requiring femoral artery access (53% male; 86% White), accounting for 111 femoral access sites during 99 index procedures (mean age 41.5±11.4 years). Data were available for 94 femoral artery access sites (84% percutaneous, 16% surgical exposure). Three patients (5 femoral sites) did not achieve closure for reasons unrelated to access. Femoral artery closure was achieved in 89 sites: 29 (32.6%) manual compression (sheath size range 4-7.5Fr), 39 (43.8%) percutaneous closure devices (sheath size range 5-16Fr), and 16 (18%) surgical closures (sheath size range 5-22Fr), and 5 (5.6%) unknown closure methods). Technical success was 100%, 87.2%, and 93.8% in the manual compression, percutaneous closure, and surgical exposure and repair groups respectively (p=0.03). No major access-related complications occurred among femoral access sites using < 6 Fr sheaths (n=40), regardless of closure method. In contrast, major access-related complications occurred in 6 (13.3%) access sites (3 proglide, 1 starclose, 1 angioseal, 1 emergent surgical exposure) in 5 patients using ≥6 Fr sheaths (3 major bleeding, 3 dissection and acute limb ischemia), and all required open exposure and repair. Of these, COL3A1 variants included 1 exon skip, valine, 1 aspartic acid, 1 cystine, 1 serine.
Conclusions: These findings support a biologically-informed approach to femoral access in VEDS. Percutaneous femoral artery access is generally safe when small-bore sheaths are used, with planned surgical exposure reserved for larger sheath requirements (Figure 1 and 2).
