Ultrasound-guided femoral vascular access in adult congenital heart disease patients undergoing catheter ablation on uninterrupted oral anticoagulation

Clinical Research in Cardiology https://doi.org/10.1007/s00392-026-02935-1 ORIGINAL PAPER Ultrasound‑guided femoral vascular access in adult congenital heart disease patients undergoing catheter ablation on uninterrupted oral anticoagulation Marta Telishevska1 · Sarah Lengauer1 · Theresa Reiter1 · Hannah Krafft1 · Miruna Popa1 · Fabian Bahlke1 · Florian Englert1 · Nico Erhard1 · Isabel Deisenhofer1 · Gabriele Hessling1 Received: 28 July 2025 / Accepted: 28 April 2026 © The Author(s) 2026 Abstract Background Data on ultrasound-guided vascular access (UGVA) to reduce vascular access complications in adult congenital heart disease (ACHD) patients undergoing catheter ablation (CA) on uninterrupted oral anticoagulation (OAC) are limited. Objective Comparison of UGVA to a standard approach with regard to vascular access complications in ACHD patients. Methods We retrospectively analyzed 477 consecutive ACHD patients (52% male, mean age 46 ± 14 years) with simple (n = 166), moderate (n = 133), and complex (n = 178) congenital heart disease (CHD) who underwent 639 CA procedures for atrial tachycardia or fibrillation between 2014 and 2024. UGVA (243 patients, 271 ablations) was compared to a conventional approach (234 patients, 368 ablations) regarding vascular access complications under uninterrupted OAC (DOAC or VKA). Results Access was obtained via the femoral vein (n = 321), both femoral vein and artery (n = 311), or jugular vein with femoral artery (n = 7). UGVA significantly reduced overall vascular access complications compared to the standard approach (4.1% vs. 13.5%; p < 0.001). Major complications occurred only in the conventional group (n = 4; AV fistula = 2, retroperitoneal hematoma = 2; p = 0.086). Minor complications—hematomas > 5 cm, small AV fistulas treated conservatively, or pseudoaneurysms treated by compression or ultrasound-guided thrombin injection—were also significantly lower with UGVA (4.1% vs. 12.5%; p < 0.001). Conclusions UGVA significantly decreases vascular access complications in ACHD patients undergoing CA on uninterrupted OAC and may be advantageous for routine use in clinical practice. * Marta Telishevska 1 German Heart Center Munich, Munich, Germany Vol.:(0123456789) Clinical Research in Cardiology Graphical Abstract Ultrasound-guided femoral access in ACHD undergoing catheter ablation on uninterrupted OAC Key Question: Does ultrasound-guided access reduce vascular complications in ACHD? Conventional access 2014–2019 n = 234 patients 13.5% vascular complications Ultrasound-guided access 2020–2024 n = 243 patients 4.1% vascular complications Conclusion: Ultrasound-guided access reduces vascular complications in ACHD Keywords Ultrasound-guided vascular access · Adult congenital heart disease · Catheter ablation · Atrial arrhythmias · Vascular access complications Abbreviations UGVA Ultrasound-guided vascular access ACHD Adult congenital heart disease CA Catheter ablation CHD Congenital heart disease AF Atrial fibrillation OAC Oral anticoagulation DOAC Direct oral anticoagulation TSP Transseptal puncture ACT Activated clotting time VKA Vitamin K antagonist n.s. Non-significant Introduction Cardiac arrhythmias in ACHD patients have increasingly come into focus over the last two decades due to an ageing patient population with an earlier arrhythmia onset compared to patients without CHD [1–4]. CA for atrial arrhythmias is recommended as first-line therapy in ACHD patients regardless of CHD complexity [5, 6]. However, cardiac anatomy and previous cardiac surgery might present technical challenges and a higher recurrence and redo ablation rate has been described [7]. Vascular complications are among the most common complications of CA as procedures are performed under oral anticoagulation and heparin and the insertion of multiple sheaths is required. ACHD patients have often undergone (multiple) previous cardiac catheters or electrophysiological studies with vascular access using the groin vessels. The incidence of major vascular complications in non ACHD is reported in the range of 0.2% to 1.5% [8–10]. In patients with atrial fibrillation (AF) without CHD, vascular complications rates are reported between 2 and 4% [11]. Recent data in non-ACHD patients suggest in non-randomized trials that ultrasound-guided vascular access (UGVA) is a useful method to reduce major and minor vascular complications [12–14]. It allows direct visualization of venous and arterial anatomy and reveals anatomical variants. In an earlier study from our group with ACHD patients on uninterrupted oral anticoagulation undergoing CA for atrial arrhythmias, we had observed a major bleeding/vascular access complication rate of 1.1% and a minor complication rate of 12.5% [15]. Based on this experience, we changed our conventional femoral access approach to a UGVA strategy in 2020. Here, we report our outcomes before and after this change of practice. Clinical Research in Cardiology Methods Study population and design A retrospective analysis of 477 consecutive ACHD patients (52% male, mean age 46 14 years) who underwent 639 catheter ablation procedures for atrial flutter/tachycardia or AF between 2014 and 2024 was performed. In 2020, we had changed our clinical practice from a conventional vascular access approach to UGVA. UGVA was used in 243 patients (51%) with 271 ablations (42%) and compared to the conventional approach in 234 patients (49%) with 368 ablations (58%) with regard to vascular access complications. Clinical data, including arrhythmia type, medical history, OAC regimen, ablation strategy, and peri-procedural complications, were extracted from the institutional database. Medical history included heart failure (LV ejection fraction ≤ 45%), CHA_2DS_2-VASc score, hypertension, diabetes, prior stroke/TIA, vascular/ coronary disease, and body mass Index. All ablations were performed on uninterrupted OAC (DOAC or VKA). Arrhythmias were defined as paroxysmal or persistent AF and typical (cavo-tricuspid isthmus dependent) or atypical atrial flutter/atrial tachycardia. The UGVA group (patients treated from 2020 onward) underwent fewer ablation procedures per patient (on average ~ 1.12 procedures/ patient) compared to the conventional group (2014–2019 era, ~ 1.57 procedures/patient). This discrepancy arises largely from the longer follow-up period in the conventional group: patients in the earlier cohort had more time to experience arrhythmia recurrences and thus return for repeat ablations. Additionally, some complex ACHD patients in the conventional cohort underwent multiple procedures before 2020. The study was approved by the institutional ethics review board. Vascular access strategies All patients were treated according to an identical institutional protocol, ensuring procedural comparability. For femoral venous access, all patients received either one 6 F and two 8 F sheaths or three 8 F sheaths. In cases requiring transseptal or baffle (...truncated)