Femoral Artery Access Outcomes and Technical Considerations in Vascular Ehlers-Danlos Syndrome

Femoral artery access in vascular Ehlers-Danlos syndrome (VEDS) poses unique technical challenges due to structurally fragile arteries. This study evaluated femoral access-related complications in patients with genetically confirmed VEDS and sought to identify procedural and biologic factors that may inform access planning for endovascular procedures.

A cross-sectional analysis of patients with pathogenic/likely pathogenic COL3A1 variants who underwent endovascular procedures requiring femoral artery access. Data were obtained from the global GEN-VEDS Natural History Study and a retrospective single center cohort. Demographics, genotype, procedural indication, access and closure techniques, access-related complications, and outcomes were abstracted from clinical record. Major access-related complications were defined as femoral artery dissection, pseudoaneurysm, rupture, or closure device failure requiring open operative repair.

A total of 117 femoral artery access sites were used in 105 endovascular interventions among 60 patients between 1989 and 2025. Median age at intervention was 39 years, and 53.3% of patients were male. Among 99 procedures with known access modality, 84 were performed percutaneously and 15 involved planned open femoral exposure. Manual compression was used in 33 percutaneous access sites, with no major access-related complications. Percutaneous closure devices were used in 39 access sites; major complications occurred in 5 access sites across 5 procedures, all requiring unplanned surgical exposure and repair. One additional percutaneous access site required unplanned open repair for access-related arterial injury and external iliac artery dissection before any closure device was attempted. Of percutaneous closure device failures, Perclose ProGlide and Starclose had the highest rate of failure (18.8% and 33.3% respectively). Three of four affected patients had large amino acid substitutions or exon skip mutations; the remaining patient had a small amino acid substitution but underwent 16-Fr sheath placement. No access-related complications occurred after planned open exposure.

Femoral artery access in VEDS requires deliberate individualized planning. In this cohort, manual compression for smaller-caliber access (<6 Fr) was associated with favorable outcomes, whereas major complications occurred predominantly following attempted percutaneous closure. Planned open exposure, despite use in procedures involving larger sheath sizes, was not associated with access-related complications and may warrant consideration in selected circumstances, including procedures requiring larger sheath sizes, known prior closure-related arterial injury, and high-risk genotypes.