Predicting the risk of iliofemoral vascular complication in complex transfemoral-TAVR using new generation transcatheter devices

Abstract

ObjectiveDesign a predictive risk model for minimizing iliofemoral vascular complications (IVC) in a contemporary era of transfemoral-transcatheter aortic valve replacement (TF-TAVR).BackgroundIVC remains a common complication of TF-TAVR despite the technological improvement in the new-generation transcatheter systems (NGTS) and enclosed poor outcomes and quality of life. Currently, there is no accepted tool to assess the IVC risk for calcified and tortuous vessels.MethodsWe reconstructed CT images of 516 propensity-matched TF-TAVR patients using the NGTS to design a predictive anatomical model for IVC and validated it on a new cohort of 609 patients. Age, sex, peripheral artery disease, valve size, and type were used to balance the matched cohort.ResultsIVC occurred in 214 (7.2%) patients. Sheath size (p = 0.02), the sum of angles (SOA) (p < .0001), number of curves (NOC) (p < .0001), minimal lumen diameter (MLD) (p < .001), and sheath-to-femoral artery diameter ratio (SFAR) (p = 0.012) were significant predictors for IVC. An indexed risk score (CSI) consisting of multiplying the SOA and NOC divided by the MLD showed 84.3% sensitivity and 96.8% specificity, when set to >100, in predicting IVC (C-stat 0.936, 95% CI 0.911–0.959, p < 0.001). Adding SFAR > 1.00 in a tree model increased the overall accuracy to 97.7%. In the validation cohort, the model predicted 89.5% of the IVC cases with an overall 89.5% sensitivity, 98.9% specificity, and 94.2% accuracy (C-stat 0.842, 95% CI 0.904–0.980, p < .0001).ConclusionOur CT-based validated-model is the most accurate and easy-to-use tool assessing IVC risk and should be used for calcified and tortuous vessels in preprocedural planning.

The role of external iliac artery diameter indexed to BSA score in predicting vascular access complications after transfemoral transcatheter aortic valve implantation

“…The further search for a perfect predictor of vascular events led to a series of studies describing potential candidates [ 28 ]. The iliofemoral tortuosity (IFT) score [((true vessel length/ideal vessel length) – 1) × 100] demonstrated a good positive correlation with access and bleeding complications [ 29 ].…”

See It Best: A Propensity-Matched Analysis of Ultrasound-Guided versus Blind Femoral Artery Puncture in Balloon-Expandable TAVI

“…In our study (as for our daily practice), we have chosen the femoral puncture site according to the standard pre-operative CT features, focusing most on the absolute diameter of the vessel, tortuosity, calcium burden (anterior versus posterior wall), and femoral bifurcation height [ 11 ].…”

Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits

“…It is important for attention to be paid, particularly during the analysis of the common femoral and iliac arteries, to their caliber (that should be at least 5.5 mm, ideally 6.5 mm for a 18F delivery system), the presence and extension of atherosclerosis and calcifications, and the degree and extension of vessel tortuosity [26]. In cases of concentric significant calcifications located anywhere from the aorto-iliac bifurcation to the femoral bifurcation, even if there is satisfactory caliber, it could potentially account for a contraindication for TF access, and then the heart team should discuss alternative routes [18].…”

“…cations, and the degree and extension of vessel tortuosity [26]. In cases of concentric significant calcifications located anywhere from the aorto-iliac bifurcation to the femoral bifurcation, even if there is satisfactory caliber, it could potentially account for a contraindication for TF access, and then the heart team should discuss alternative routes [18].…”

“…However, in cases of ilio-femoral lesions, it is shown in the literature that ad hoc percutaneous angioplasty at this level can be combined in order to achieve a proper lumen and optimal sheath advancement, also known as the "paving and cracking technique", a feasible, safe, and effective option to guarantee a TF approach for TAVI in such challenging anatomies . It is of paramount importance to properly assess the caliber of the iliac artery, as the optimal balloon size should be selected when transient occlusion is needed in the event of hemorrhagic complications [26]. Potential challenges such as tortuosity, the presence of aneurysms, thrombotic appositions, or extreme calcifications should definitely be identified via cautious exploration of the aorta, as all these anatomic features are possible prospective sources of peripheral embolization, reasons for vascular adverse events, and may hinder equipment delivery [2].…”