Impact of the Use of Transradial Versus Transfemoral Approach as Secondary Access in Transcatheter Aortic Valve Implantation Procedures

Objectives: to understand the role of a transradial (TR) secondary approach during complex percutaneous interventions. Background: The value of the TR route for ancillary vascular approach has not been adequately validated in this setting, and there is scant data on its role in reducing bleeding complications. Methods: In the present study we retrospectively included patients undergoing the following interventions requiring two vascular approaches at nine high-volume centers in Italy: structural cardiac interventions, complex PCI, endovascular aortic repair (EVAR) and complex lower limb angioplasty. We compared procedural outcomes according to the type of ancillary vascular approach selected, namely TR or transfemoral/transbrachial (TF/TB). Primary endpoints of the study were procedural success and in-hospital BARC grade 3-5 bleedings. Results: We included 906 patients, 433 receiving TR and 473 TF/TB ancillary approaches. Baseline characteristics did not differ significantly. Patients underwent the following types of intervention: structural 50%, complex coronary PCI 37%, EVAR 11%, peripheral angioplasty 2%. Procedural success was similar (90% in TR and 92% TF/TB, P 5 NS). In-hospital BARC 3/5 bleedings were more common in TF/TB group as compared to TR group (19.7% vs. 6.7%,P < 0.001). In TF/TB group we also observed a higher postprocedural hemoglobin drop (1.92 vs 1.13 g/dl, P 5 0.008) and longer hospital stay as compared to TR group. Similar results were observed in a propensity scorematched population of 450 patients. Conclusions: In our study TR ancillary approach was associated with a significant reduction in the risk of major bleedings, without jeopardizing the success of complex structural, coronary, and peripheral percutaneous interventions. The value of the transradial route for ancillary vascular approach during percutaneous interventions has not been adequately validated yet. We retrospectively

Section: Discussionmentioning

confidence: 81%

Transradial versus transfemoral ancillary approach in complex structural, coronary, and peripheral interventions. Results from the multicenter ancillary registry: A study of the Italian Radial Club

Cortese

Rigattieri

Aranzulla

et al. 2017

“…In parallel, new generation devices have increased the precision, safety and deliverability of the percutaneous heart valves. The rates of vascular complications are currently as low as 3–6% with approximately 1/4 of vascular access site complications (1/3 of major vascular complications) in TAVR being related to the TF secondary access …”

Section: Introductionmentioning

confidence: 99%

“…The rates of vascular complications are currently as low as 3-6% 3 with approximately 1/4 of vascular access site complications (1/3 of major vascular complications) in TAVR being related to the TF secondary access. 7 Simultaneously, the transradial approach (TRA) for coronary angiography and percutaneous coronary angioplasty has become widely used worldwide and is currently being adopted as the dominant approach because of improved patient comfort, reduction of staff workload, earlier ambulation as well as a dramatic reduction in vascular complications compared with the TF approach. [5][6][7][8][9][10][11][12] Therefore, given that our center adopted the radial approach in the early nineties, implementing a radial approach instead of a contralateral femoral approach for TAVR seemed a logical strategy.…”

Section: Introductionmentioning

confidence: 99%

Implementation of the transradial approach as an alternative vascular access for transcatheter aortic valve replacement guidance: Experience from a high‐volume center

Fernández-López

Chevalier

Lefèvre

et al. 2018

Objective This study sought to assess the potential benefits of the transradial approach (TRA) as an alternative vascular access to the classical contralateral femoral approach for transcatheter aortic valve replacement (TAVR). Background Vascular and bleeding complications in TAVR have gradually decreased owing to operator experience and downsizing of the delivery system. However, about 1/4 of vascular access site complications are related to the transfemoral (TF) secondary access. Methods We compared the outcomes at 30 days according to VARC‐2 after TAVR of a prospective cohort of 217 consecutive patients undergoing right or left TRA as the second vascular access (TRA‐TF TAVR) and a retrospective cohort of 194 consecutive patients undergoing TF approach as a second vascular access (TF‐TF TAVR). Results Baseline clinical characteristics and risk scores were well matched in both groups. Procedural success rate was 99.7%. Fluoro time was significantly lower in the TF‐TF TAVR group (16.9 ± 7.2 vs. 19.1 ± 7.8 min, P = 0.003); however, there was no significant difference in x‐ray exposure, procedure time or amount of contrast used. In the TRA‐TF TAVR group, there were no complications related to the TRA access and there were less vascular and bleeding complications (18.0% vs. 9.7%, P = 0.014; 17.0% vs. 9.2%, P = 0.026, respectively), although blood transfusion requirement or hospitalization duration stay were similar in both groups. Conclusions TRA approach as alternative secondary vascular access in TAVR is safe and feasible and is associated with a significant decrease in vascular and bleeding complications. Further, large‐scale studies are warranted to confirm the potential benefit of this approach.

Section: See Abovementioning

confidence: 99%

“…However, and this is what being a physician is all about, the rate of significant bleeding was significantly lower in the TR group as compared to TF/TB group (6.7% vs. 19.7%; P < 0.001), and the TR approach was associated with significantly reduced length of hospital stay, and a reduced need for transfusions (P < 0.001). This was not surprising based on previous TR to TF reports in coronary and transcatheter aortic valve intervention (TAVI) procedures [1][2][3].The longer procedural time was actually an average of 30 min and may reflect some learning as it has for most radialists in their early experience. However, it may also reflect some limitations with regard to positioning during complex cases as well as the use of suboptimal catheters for procedures far from the intended treatment sites (e.g., iliac interventions).…”

mentioning

confidence: 99%

One arterial puncture: Radial, please; if two? Make one radial, please

Butman

2018

There is less bleeding with a radial approachThere is less bleeding with a radial approach See aboveThe authors, from nine high-volume cardiovascular interventional centers in Italy, went back and reviewed cases requiring two vascular approaches for either structural cardiac intervention, complex percutaneous coronary intervention (PCI), endovascular aortic repair (EVAR), or complex lower limb angioplasty.The radial approach (TR) was used in a long list of structural, coronary, valvular, aneurysm, and peripheral interventions, all complex in nature by any standard. Most cases were structural interventions; mostly being transcatheter aortic valve implantation, while complex coronary interventions and EVAR/peripheral interventions represented the remainder. While not unexpected, the TR approach was associated with significantly longer procedural and fluoroscopy times than the transbrachial/transfemoral (TB/TF) group. However, and this is what being a physician is all about, the rate of significant bleeding was significantly lower in the TR group as compared to TF/TB group (6.7% vs. 19.7%; P < 0.001), and the TR approach was associated with significantly reduced length of hospital stay, and a reduced need for transfusions (P < 0.001). This was not surprising based on previous TR to TF reports in coronary and transcatheter aortic valve intervention (TAVI) procedures [1][2][3].The longer procedural time was actually an average of 30 min and may reflect some learning as it has for most radialists in their early experience. However, it may also reflect some limitations with regard to positioning during complex cases as well as the use of suboptimal catheters for procedures far from the intended treatment sites (e.g., iliac interventions). What, if anything, is the downside? The physicians involved were exposed to additional radiation. While statistically significant, the mean fluoroscopy time differed by only 7 min and the longest procedure times only differed by 4 min. These limitations are easily remedied as the change to radial interventions becomes more the norm and equipment will be developed to address some technical and length limitations, respectively. The latter already is already happening.As expected, bleeding events were more frequent with femoral ancillary needs compared to cases where a radial site was employed.This could be blamed on the larger bore catheters used in the patients where the femoral rather than radial approach was implemented, 6.6 Fr versus 5.9 Fr (P < 0.001). This was not a randomized trial, after all, but this should not dissuade anyone who does not believe that technical advances will make "larger bore" devices smaller in the years to come (i.e., radial approach possible).Bleeding and the transfusions that follow increase the risk of post-procedural death [4]. This has been shown to be true in multiple other trials. We should only be asking ourselves the following questions? How soon this will be the norm, why are we not doing so currently or at a minimum, why are we not planning to do ...