Arteriotomy site complication during transcatheter aortic valve replacement: Ipsilateral wire protection and bailout

Transcatheter Aortic Valve Replacement: Full Unilateral Access Using the Ipsilateral Superficial Femoral Artery Is Effective

BACKGROUND

Access site complications are very common complications in transcatheter aortic valve replacement (TAVR). Usually, a second arterial sheath is placed either in the contralateral femoral artery or in the radial artery as a simplified approach. This study aimed to investigate the safety and effectiveness of a full unilateral access using the ipsilateral superficial femoral artery (iSFA) in TAVR and to determine whether it simplifies the procedure.

METHODS

This single-center retrospective audit analyzed the first 100 TAVR cases between February 2022 and January 2023 using iSFA as default secondary access. The primary outcomes included 30-day device success, bleeding, and vascular access-related complications. The last 100 bilateral cases and all bilateral cases (n = 656) served as controls.

RESULTS

Of the 143 transfemoral TAVRs performed during the study period, 43 patients were excluded. The remaining 100 patients (median age, 84 years; interquartile range, 80-89 years; median EuroSCORE II, 2.46; interquartile range, 1.65-3.97) were analyzed. The vascular access-related complication rates were 11% (main access, 55%; secondary access, 45%), with a 97% device success rate. In the control group of all bilateral cases, device success and vascular access-related complication rates were 93% and 17%, respectively. In the experimental group, access complications were promptly managed in the catheterization laboratory. All cases requiring interventions other than manual compression were successfully managed using iSFA.

CONCLUSIONS

The total unilateral approach using iSFA was safe and effective, shortening the time to address main access complications, providing ergonomic advantages for operators, and enhancing patient comfort.

Tips and Tricks for Successful Trans-EVAR TAVR: Buddy up!

Described is challenging trans-catheter aortic valve replacement (TAVR) procedure done via tortuous iliofemoral access with prior endovascular aneurysm repair. Detailed pre-procedural planning enabled the operators to overcome the challenges while employing the following 4 strategies: Although trans-EVAR TAVR remains somewhat unpredictable, especially these 4 strategies may simplify and reduce the inherent failure rate of such procedures.

[TAVR : Imaging for an optimal femoral approach]

Both computed tomography (CT) angiography and vascular ultrasound have a major role before and during a transfemoral approach to TAVR. CT angiography will determine whether the patient is eligible for a femoral approach. Peri-procedural arterial ultrasound will be helpful to improve safety and optimize results during the femoral approach. Being able to interpret both of these imaging modalities is of paramount importance for any interventional cardiologist who practices structural interventions.

Pledget-assisted hemostasis to fix residual access-site bleedings after double pre-closure technique

BACKGROUND

The use of pre-closure suture-based devices represents a widely access-site hemostasis technique in percutaneous transfemoral transcatheter-aortic-valve-replacement (TF-TAVR); yet this technique is associated with the risk of a device failure that may result in clinically relevant residual bleeding. Thus, a bailout intervention is needed. So far, the best management of pre-closure device failure has not been recognized.

AIM

To report the first clinical results obtained using a novel bailout hemostasis technique for patients with double suture-based vascular closure device failure in the setting of TF-TAVR.

METHODS

We developed a "pledget-assisted hemostasis" technique to manage residual access-site bleeding. This consists of the insertion of a surgical, non-absorbable, polytetrafluoroethylene pledget over the sutures of the two ProGlide (Abbott Vascular, CA, United States). The ProGlide's knot-pushers are used to push down the pledget and the hand-made slipknot to seal the femoral artery leak. This technique was used as a bailout strategy in patients undergoing TF-TAVR with a systematic double pre-closure technique. Post-procedural access-site angiography was systematically performed. In-hospital complications were systematically detected and classified according to Valve Academic Research Consortium-2 criteria.

RESULTS

Out of 136 consecutive patients who underwent TF-TAVR, 15 patients (mean age 80.0 ± 7.2 years, 66.7% female) with access-site bleeding after double pre-closure technique failure were treated by pledget-assisted hemostasis. In the majority of patients, 16F sheath was used (n = 12; 80%). In 2 cases (13%), a peripheral balloon was also inflated in the iliac artery to limit blood loss during pledget preparation. Angiography-confirmed hemostasis (primary efficacy endpoint) was achieved in all patients. After the procedure, 1 patient required blood transfusion (2 units), and no other bleeding or major ischemic complication was noticed.

CONCLUSION

The "pledget assisted hemostasis" might be considered as a possible bailout technique to treat patients with residual access site bleeding. Further studies are needed to compare this approach with other bail-out techniques.

Iliofemoral peripheral orbital atherectomy for optimizing TAVR access: An innovative strategy in the absence of alternative access options

Suboptimal iliofemoral artery access requiring alternative trans-catheter aortic valve replacement (TAVR) access is still encountered in 10-20% of subjects undergoing TAVR. Attempting suboptimal vascular access may result in excessive vessel injury, bleeding and even death. Reported is an innovative procedure to address suboptimal heavily calcified iliofemoral access by using Diamondback 360 peripheral orbital atherectomy (POA) to ablate heavy endoluminal vascular calcifications followed by balloon angioplasty. This approach enabled us to successfully deploy TAVR in extremely challenging iliofemoral anatomies that would otherwise be rendered prohibitive. The technical aspects of this procedure are delineated accompanied by a descriptive case of such procedure.