617 Percutaneous Aortic Valve Replacement - improved vascular outcomes with a fully percutaneous procedure

Role of Preprocedural Computed Tomography in Transcatheter Aortic Valve Implantation

“…However, as a result of the use of smaller delivery systems and better patient selection, the rates of vascular complications could be significantly lowered [44]. Relevant arteriosclerosis, vessel course, and the diameter of the delivery system in relation to the minimum diameter of the access path are associated with vascular complications [44,45].…”

Transcatheter aortic valve replacement

“…Further, a transfemoral transcatheter valve is more difficult to position than a valve inserted via a more direct approach. 38,39,41,42,46,48 Some studies have reported a higher incidence of neurologic events with the transfemoral route, which is probably because the sheath has to pass through the curved aortic arch, but others could not support these findings. 40,49,50 Introducing the valve through the left-ventricular apex is performed via a left anterior thoracotomy through the fifth or sixth intercostal space.…”

“…Risk factors include peripheral artery disease, severely calcified and tortuous vessels, circumferential calcifications, and an external sheath diameter larger than the minimal luminal diameter of the access vessel. 38,41,42 As is to be expected, vascular complications are significantly more frequent when a transarterial route is used compared with when a transapical approach is used (3.4% vs 14.2%). 40 When comparing the SAPIEN valve and CoreValve for the transarterial route, the risk of vascular damage is higher with the former (22.3% vs 10.8%), which is probably related to the larger introducer sheaths used for the first-generation SAPIEN valve.…”

“…Additional predictors of vascular complications are concentric calcifications and calcifications surrounding more than 180° of the vessel circumference. 38,39,41,42 Similarly, the lower the atherosclerotic burden, the higher the accepted vessel tortuosity. A flexible vessel will stretch during advancement of the sheath, even with kinking angles over 90°.…”

“…However, more detailed information on luminal diameter, atherosclerosis, and vessel tortuosity can be gained by multidetector computed tomography (MDCT). 39,41 MDCT allows measuring luminal diameter at an exactly orthogonal plane to the vessel by using multiplanar reconstructions. 38 The high risk of vascular injury in TAVR via a peripheral access is due to the large introducer sheaths, though a substantial reduction in sheath diameter has been achieved over the last few years.…”