CathLabHub complications toolkitcathlabhub.com/toolkit/large-bore-accessIn review, October 24, 2026
Recognize
The signs on the monitor, the image and the patient.
Act now
In the order the operator does them. The first three come first, whatever else is happening.
- Keep the wire across the access; never pull the last wire after a closure failure.
- Inflate a balloon from the contralateral side over the bleeding point or proximal to it 1.
- Call for help: second operator, vascular surgery, blood bank.
- Resuscitate and reverse heparin once the bleeding is controlled 1.
- Seal with a covered stent across the hole, self expanding in the common femoral artery 1.
- Iliac rupture: occlusion balloon proximal to it, then a covered stent; an aortic occlusion balloon for massive bleeding.
- Occlusion or dissection limiting flow: balloon and stent from the other side, or surgery 1.
- Surgery when stenting fails or is unsuitable, such as at the femoral bifurcation 1.
Equipment
From the complications cart. Linked items open in the equipment directory.
- Large bore sheathsDirectory: Sentrant introducer sheath, DrySeal Flex introducer sheath, eSheath+ introducer set.
- Closure devicesTwo sutures preclosed at 10 and 2 o'clock for an Impella sheath 2. Directory: Perclose ProStyle, MANTA vascular closure device.
- Crossover sheath and cathetersDirectory: Pinnacle Destination guiding sheath.
- Peripheral balloons for tamponadeDirectory: Armada 35, Mustang.
- Aortic occlusion balloonDirectory: Coda balloon catheter.
- Covered stentsDirectory: Viabahn VBX, Viabahn.
- Stiff 0.035 inch wiresDirectory: Amplatz Super Stiff, Lunderquist extra stiff.
Drugs
Adult doses as the cited source gives them. Check your formulary and the label.
- ProtamineReverse heparin once the hole is controlled 1.Weight based dose in the Cath Med App
- Blood productsPer the massive transfusion protocol.
Who to call
The escalation ladder, first call first.
- Second operator: contralateral access and balloon.
- Vascular surgery: at the first sign.
- Anesthesia: for resuscitation and the airway.
- Blood bank: massive transfusion.
- Heart team surgeon: in TAVR cases.
The bailout step by step
Crossover balloon occlusion and covered stent 1
- Contralateral access; crossover sheath over the aortic bifurcation.
- Wire through the injured segment, ideally the safety wire already placed.
- Inflate a compliant or peripheral balloon at the hole or above it at low pressure.
- Angiogram around the balloon to define the injury.
- Size and deliver a covered stent: balloon expandable for precision, self expanding where the artery flexes 1.
- Deflate, completion angiogram, check the distal pulse.
- Failure: keep the balloon up and go to surgery.
Prevent
- CT of the iliofemoral arteries: a sheath to femoral artery ratio of 1.05 or more predicted major vascular complications in TAVR 3.
- The Impella CP 14 Fr sheath needs iliofemoral arteries over 5 mm without severe calcification or tortuosity 2.
- Ultrasound guided puncture, femoral angiography before upsizing, and preclose 2.
- A contralateral safety wire or catheter for large bore closure.
After care and documentation
- Classify bleeding and vascular events by VARC-3 in TAVR cases 4.
- Limb checks, hemoglobin, and an access ultrasound if in doubt.
- Document the sheath size, the artery size, the closure and the repair.
Practice
No emergency simulator case for large bore access yet; the mechanical support cases include access steps. Browse the case library.
References
- Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 29, Vascular access complications.
- Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 14, Hemodynamic support.
- Hayashida K, Lefevre T, Chevalier B, et al. Transfemoral aortic valve implantation: new criteria to predict vascular complications. JACC Cardiovasc Interv 2011;4:851-858.
- VARC-3 Writing Committee: Genereux P, Piazza N, Alu MC, et al. Valve Academic Research Consortium 3: updated endpoint definitions for aortic valve clinical research. J Am Coll Cardiol 2021;77:2717-2746.
Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/large-bore-access. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.