Interventional Treatment of Access Site Complications During Transfemoral TAVI: A Single Center Experience

Abstract

Introduction: Transcatheter aortic valve implantation (TAVI) has rapidly developed over the last decade and is nowadays the treatment of choice in the elderly patients irrespective of surgical risk. The outcome of these patients is mainly determined not only by the interventional procedure itself, but also by its complications.Material and Methods: We analyzed the outcome and procedural events of transfemoral TAVI procedures performed per year at our institution. The mean age of these patients is 79.2 years and 49% are female. All the patients underwent duplex ultrasonography of the iliac arteries and inguinal vessels before the procedure and CT of the aorta and iliac arteries.Results: Transfemoral access route is associated with a number of challenges and complications, especially in the patients suffering from peripheral artery disease (PAD). The rate of vascular complications at our center was 2.76% (19/689). Typical vascular complications (VC) include bleeding and pseudoaneurysms at the puncture site, acute or subacute occlusion of the access vessel, and dissection or perforation of the iliac vessels. In addition, there is the need for primary PTA of the access pathway in the presence of additional PAD of the common femoral artery (CFA) and iliac vessels. Balloon angioplasty, implantation of covered and uncovered stents, lithoplasty, and ultrasound-guided thrombin injection are available to treat the described issues.Conclusion: Interventional therapy of access vessels can preoperatively enable the transfemoral approach and successfully treat post-operative VC in most of the cases. Training the heart team to address these issues is a key focus, and an interventional vascular specialist should be part of this team.

Vascular access site complications after transfemoral transcatheter aortic valve implantation: a comparison of open and percutaneous puncture approaches

“…Additionally, our study showed that the average EIA diameter was approximately 0.5 mm smaller than the CFA diameter; insertion of large-diameter sheaths may have caused EIA injuries as well. Although CFA dissection may be treated endovascularly ( 20 ), all CFA dissections in our study required surgical repair because balloon dilation failed to improve the associated stenosis. CFA stenosis is frequently caused by tight ligation of the closure device or purse-string suture ( 20 ).…”

“…Although CFA dissection may be treated endovascularly ( 20 ), all CFA dissections in our study required surgical repair because balloon dilation failed to improve the associated stenosis. CFA stenosis is frequently caused by tight ligation of the closure device or purse-string suture ( 20 ). In the inguinal region, surgical repair is generally preferable because hip flexion may cause occlusion of an endovascular stent.…”

“…Bleeding from an EIA injury may occur in patients with a highly calcified and narrow EIA and is treated promptly with balloon occlusion, covered stent grafting, or artificial graft replacement. EIA dissection is typically treated with endovascular repair using a non-covered stent ( 20 ). In our study, although most EIA injuries were treated with a covered stent graft, one patient required an artificial graft to replace the CIA and EIA in conjunction with balloon occlusion of the abdominal aorta because of the large extent of injury.…”

TAVI after More Than 20 Years

“…Prompt and efficient diagnoses and management are necessary for achieving bleeding control, which is usually carried out via crossover angiography from the contralateral femoral artery or, more recently, from the radial artery. Limited dissection or perforation can usually be managed with prolonged occlusive balloon inflation, whereas percutaneous deployment of a stent, thrombin injection or surgical repair can be used in cases with more extensive, flow-limiting dissection or bleeding, or in cases with hemodynamic instability or threatened limb circulation [30].…”

A 20-year journey in transcatheter aortic valve implantation: Evolution to current eminence

“…Percutaneous deployment of a covered stent or surgical repair is indicated for more extensive flow-limiting dissection or bleeding or in cases with hemodynamic instability or threatened limb circulation. Both options are associated with good outcomes, but the percutaneous option is usually preferred over surgical repair, especially when the injury is above the inguinal ligament as the latter might require laparotomy and TAVI patients are usually old, frail, and have high perioperative risk ( 80 , 95 , 96 ).…”